Cheyenne County Consultative Visit ... - The Montrose...

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Emergency Medical and Trauma Services Consultative Visit Montrose County, Colorado

Table of Contents Executive Summary…………………………………………………………………………..……….…….….…….2 Introduction and Project Overview ................................................................................. 3 Montrose County Geography and Demographics ........................................................4 Emergency Medical and Trauma Services Providers ................................................... 5

Basin Clinic ................................................................................................... 5 CareFlight .................................................................................................... 5 Montrose County Sheriff's Posse ........................................................................... 5 Montrose Fire Protection District .......................................................................... 6 Montrose Memorial Hospital ............................................................................... 7 Montrose Regional Communication Center ............................................................... 7 Norwood Fire Protection District .......................................................................... 7 Nucla-Naturita Fire Protection District and Ambulance ................................................ 8 Olathe Fire Protection District ............................................................................. 8 Paradox Fire Protection District ........................................................................... 9 TransCare Ambulance ....................................................................................... 9

Analysis of Montrose County EMS System Elements…..……………………………………….10 Legislation and Regulation ................................................................................ 10 System Finance .............................................................................................. 11 Human Resources ........................................................................................... 14 Medical Direction ........................................................................................... 18 Clinical Care ................................................................................................. 19 Education Systems .......................................................................................... 22 Public Access ................................................................................................ 25 Communications ............................................................................................ 26 Information Systems ........................................................................................ 27 Public Education ............................................................................................ 28 Prevention ................................................................................................... 29 Mass Casualty ............................................................................................... 30 Integration of Health Services ............................................................................ 30 Evaluation .................................................................................................... 32

Summary of Recommendations……………… ............................................................. …....36 Appendix A: 2014 EMS Statistics……………………………………….…………………………..….…45 Appendix B: List of Stakeholders Interviewed ………….……………………………………….54 Appendix C: Pre-Visit Survey Results ........................................................................ 55 Appendix D: Montrose County Service Map ............................................................ 61

Appendix E: Assessment Team Biographical Information ...................................... 62 Herb Brady ................................................................................................... 62 Roger Coit .................................................................................................... 62 Ray Jennings Jr. ............................................................................................. 62 Tom Soos .................................................................................................... 63 Matt Skwiot .................................................................................................. 63 Phyllis Uribe ................................................................................................ 64 Matt Concialdi ............................................................................................... 64 Eric Schmidt ................................................................................................. 65

References ....................................................................................................... 65

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Executive Summary In April 2015, the Colorado Department of Public Health and Environment, along with six EMS and trauma services experts, performed a consultative visit at the request of the Montrose County Board of Commissioners. The purpose of the visit was to review and evaluate the components of the EMS and trauma system in order to provide recommendations for system improvement and enhancement.

The Montrose County EMS and trauma system includes the Montrose Fire Protection District, Nucla-Naturita Fire Protection District and Ambulance, Norwood Fire Protection District, Olathe Fire Protection District, Paradox Fire Protection District, TransCare Ambulance, St. Mary’s CareFlight, Montrose Memorial Hospital, Basin Clinic and the Montrose County Regional Communications Center. Delta Ambulance District and Classic Aviation are nearby and provide mutual aid coverage when requested.

Montrose County is located on the western slope and is composed of a predominately rural environment that poses challenges to the EMS and trauma system. Mutual aid can be 30 to 45 minutes away depending upon weather and resource availability. The pre-visit survey showed that the stakeholders rated the overall effectiveness of the system as above average, with a caveat that the more urban environment of Montrose is much different than the rural areas of Olathe, Nucla, Naturita and Paradox. It was evident that the various communities in the county are passionate about the ambulance services and will do what it takes to sustain emergency medical and trauma services in their area. The EMTS system in Montrose County is experiencing many of the problems typical to rural areas that are developing more urban and suburban characteristics. Population growth, technological changes and other extrinsic factors strain existing systems and increase the need for more formalized organizational structures to effectively communicate among the EMTS stakeholders, maintain compliance with legal requirements and meet the service expectations of the community.

In addition, budgets are too tight for any agency to stand alone and it is important to recognize this interdependence to create governance structures that foster mutual respect and substantive participation in policy decisions. Although it is often difficult to justify the resources to create and sustain these structures, policy makers should understand they are essential to form a strong foundation for continued evolution of the EMTS system. This compelling need is demonstrated by the recommendation to establish an EMTS Council to advise the Board of County Commissioners on EMS and trauma matters and provide the stakeholders a forum to voice concerns and collaborate on effective solutions. Another recommendation in this report advocates the formation of a communications advisory board composed of representatives from EMS, fire services, law enforcement and other stakeholders to participate in operational and fiscal policy decisions that affect each user agency.

Financial challenges are a staple in EMS especially for agencies operating in a rural environment. The Montrose County EMS agencies do a good job given the resources at their disposal and they participate in grant funding opportunities when able. This report provides short-, medium- and long-term recommendations for consideration by the stakeholders to enhance effectiveness of the EMTS system in Montrose County. These suggested recommendations are found within the various sections of the report and are listed in an appendix at the conclusion of the analysis report. A map of the county along with 2014 EMS run data reported by each agency is provided in the appendix section.

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Introduction and Project Overview

In February 2014, the Board of County Commissioners of Montrose County requested grant funding from the Colorado Department of Public Health and Environment (the department) to provide an assessment and review of the county’s emergency medical and trauma services system. The department awarded system improvement funding to support the consultation in July 2014.

Under Colorado law, the Board of County Commissioners is the ground ambulance licensing authority as defined by C.R.S. § 25-3.5-301 and

C.R.S. § 30-11-107(q). The primary EMS agencies within the Montrose County system are the Montrose Fire Protection District, Nucla-Naturita Fire Protection District and Ambulance, Olathe Fire Protection District, Norwood Fire Protection District, Paradox Fire Protection District, St. Mary’s CareFlight and TransCare Ambulance. Delta Ambulance District and Classic Aviation based in Moab, Utah provide mutual aid coverage as needed. The primary hospital in the area is Montrose Memorial Hospital, a Level III trauma center located on the eastern side of the county. Approximately 86 miles away on the south-west side of the county is the Basin Clinic, a rural health clinic. All agencies are dispatched by the Montrose County Regional Communications Center. The county commissioners along with the EMS and trauma services stakeholders agreed to participate in the consultation process in order to develop viable long-term strategies to ensure high-quality EMS services are provided to the citizens and visitors of Montrose County.

The Emergency Medical and Trauma Services Branch, pursuant to declaration and authority to assist local jurisdictions provided in C.R.S. § 25-3.5-102 and 603 respectively, recruited an emergency medical and trauma services consultative visit team to evaluate the Montrose County EMS and trauma system and to make recommendations for system improvement. Analysis of the current system involved interviews with primary stakeholders and a review of available system data. The state of the current system was analyzed using elements derived from the original 14 EMS system components contained in the 1996 EMS Agenda for the Future, published by the National Highway Traffic Safety Administration, in addition to one Colorado-specific component. These attributes serve as the basis for a number of statewide and regional planning activities and are further referenced in 6 CCR 1015-4, Chapter Four. A list of short-, medium- and long-term recommendations with guidance for implementation is provided in this report for consideration to improve the overall Montrose County EMS and trauma system, including the pre-hospital treatment, ground ambulance transportation, communication and documentation subsystems addressed in C.R.S. § 25-3.5-101 et seq.

The system improvement grant authorized approximately $35,000 to conduct the review in conjunction with a similar assessment in Ouray County. The department developed a contractual relationship with the Western Regional Emergency Medical and Trauma Advisory Council (RETAC) to serve as the fiscal agent for the project. The system development coordinator at the department and the Western RETAC coordinator, Terri Foechterle, provided project management for the consultative visit. All the team members were selected based on their expertise in rural EMS and trauma systems and were approved jointly by the RETAC and the department.

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Montrose County Geography and Demographics

Montrose County is located on the western slope bordering Utah to the west, Mesa and Delta Counties to the north, Gunnison County to the east, San Miguel County to the south and Ouray County to the south east. The major townships within Montrose County are: Bedrock, Maher, Montrose (county seat), Naturita, Nucla, Olathe and Paradox. The county spans 2,240 square miles with a 2013 population estimate of 40,713, a 17.85 percent increase since 2000.1 With a population density of 18.4 persons per square mile, the median house hold income is $45,718 with a median house

price of $193,700.1 The City of Montrose is the most densely populated town with a 2010 census of 19,132 persons contrasted with small rural towns like Paradox that has a population of approximately 200 persons.

Montrose County was created in 1882 from a portion of Gunnison County. The name originates from Sir Walter Scott’s novel, A Legend of Montrose. The original courthouse was an adobe building purchased in 1882.2 In November 1918, the county decided to build a new courthouse to fulfill the counties growing needs and serve as a memorial for those who served in World War I. The stone courthouse was built in stages and officially completed in October of 1923. The courthouse was used until November of 1998 when the new Justice Center Complex was built.

“Montrose has often been described as the Hub of Western Colorado because it truly is located in the middle of everything, including an unbelievably vast selection of outdoor and indoor activities. Thus the slogan ‘Stay here, play everywhere.’”2 The City of Montrose rests in the heart of the Uncompahgre Valley 30 minutes from the San Juan Mountains. The lush land is prime for farmlands where ranchers raise cattle, sheep and horses alongside grazing elk, deer and antelope. The lion’s share of the county consists of National Forest, Bureau of Land Management or National Park lands.3 During the summer months, the Black Canyon of the Gunnison National Park creates an epic exploring avenue for hiking, biking, rafting, kayaking and rock climbing.2 The Black Canyon is known for its spectacular sheer walls creating average depths of 2,000 feet of narrow canyon openings. In and around the City of Montrose, visitors can enjoy rounds of golf with breathtaking views. During winter months, the canyon becomes a glorious place to cross-country ski or snowshoe.

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Emergency Medical and Trauma Service Providers

Basin Clinic The Basin Clinic has provided primary care services to the communities of Naturita, Nucla, Redvale, Norwood, Paradox and surrounding areas since 1979. The clinic was originally part of the “combined clinic” along with the Uncompahgre Medical Center (UMC) in Norwood. When the two organizations separated, the Basin Clinic board decided to remain independent in order to provide 24/7 urgent care services, which UMC could not provide due to its Federally Qualified Health Centers status. In 2000, the clinic

affiliated with Montrose Memorial Hospital but the affiliation was terminated in 2013. As of August 2013, the clinic operates as a not-for profit independent certified rural health clinic. Funding sources come from Montrose County, the Town of Nucla, insurance payments, private pay and grants. The clinic has a seven member Board of Directors overseeing the operation.

Being a rural health clinic nearly 100 miles away from the nearest hospital, the clinic does not operate an emergency department; however, they do accept patients urgently and will receive ambulance transports. The goal of the clinic is to treat as possible, stabilize, then evaluate whether the patient needs to be transported to tertiary care either by helicopter or ground ambulance. The clinic staffs a total of 12 persons including a nurse practitioner, physician assistant, physician medical director, licensed practical nurse, part-time registered nurse/diabetic educator and three medical assistants. The clinic also contracts with two different physicians who come in on a weekly basis. Services include urgent care, general practice, lab, podiatry and internal medicine. The clinic in 2014 saw a total of 4,949 patients, 434 of those came through the urgent care.

CareFlight As of April 1, 2015, St. Mary’s CareFlight replaced Tri-State CareFlight as the air medical resource in Montrose. The helicopter base is in partnership with Montrose Memorial Hospital. The Eurocopter AS 350 B3 (AStar) helicopter is housed on top of the hospital for rapid scene response or interfacility air transport. The primary response range is within a 50 mile radius of the hospital. During inclement weather, the helicopter can be relocated to the hanger at Montrose Regional Airport. During down time the on duty crew floats throughout the ICU and emergency department assisting with various tasks. The crew is made up of a contract pilot (Air Methods Corporation), certified critical care paramedic and a critical care flight nurse. The paramedic and nurse work 24 hour shifts and the pilot is on a 12 hour rotation. Based on the information provided by the previous air medical provider,

approximately 300 scene and interfacility flight transports are anticipated. Being a non-profit agency through St. Mary’s Hospital, funding predominately comes through user fees and donations.

Montrose County Sheriff’s Posse The Montrose County Sheriff’s Posse was established in 1964 as a 501 (c) 3 non-profit corporation designed to provide support for search and

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rescue, wildfires, mutual aid and various other services. Funding comes strictly from private fund raising and grants. The posse has 14 volunteer EMS members on the east side, 12 are emergency medical responder (EMR) and two are EMT trained. On the west end of the county, there are seven volunteers. For wildland firefighting, the posse has a total of five brush trucks, with three housed on the east side and two on the west end. Some of the posse members have their wildland Red Card, while others do not. The posse will handle low angle rescues but will use mutual aid from Ouray or Telluride for high angle rescues. In 2014, the posse recorded 26 call outs with 2,481 volunteer hours.

Montrose Fire Protection District The Montrose Fire Protection District is a Title 32 Special District providing both fire and EMS services to a total population of 36,000 within 1,100 square miles in portions of Montrose, Ouray and Gunnison Counties. Established originally in 1888 as a municipal department, a rural fire protection district was established to provide fire suppression services to areas outside the city limits in 1946. In 1978, the city fire department was merged into the fire protection district. In 1999 the district became responsible for providing ambulance services to the City

of Montrose and surrounding areas after purchasing the assets of a local private ambulance service. Montrose FPD staffs three full time fire stations consisting of four ambulances, three fire engines, three brush trucks, one ladder truck, one tender, four quick response vehicles, one mass casualty truck, two all-terrain vehicles with transport capabilities and one special operations trailer. The district responds to approximately 3,200 calls a year, and roughly 2,400 of those requests for service are EMS related.

The district receives an 8.813 mill levy on property within the district boundaries that generates about 77 percent of the annual revenue. Approximately 12 percent of the revenue comes from ambulance transports and the remainder comes from grants and miscellaneous sources. The department responds to all requests for service at the ALS level and has a total of 48 service members, the majority of which are full time with a handful being part-time and volunteer to support the full-time staff members.

Montrose Memorial Hospital Montrose Memorial Hospital is designated as Level III trauma center receiving EMS patients from Gunnison, Lake City, Montrose, Naturita, Nucla, Olathe, Ouray, Ridgway, Silverton, Telluride and regional air medical transports. The hospital offers a medical destination for all agencies within the Western RETAC. Since 1987 the hospital has been managed through Quorum Health Resources and is set up as a non-profit facility with the main funding sources coming from user fees and donations. A local board oversees the hospital functions. The primary

service area the hospital covers is 45,000 persons. With 75 inpatient beds, 12 of which are emergency department beds, the emergency department sees roughly 16,350 patients a year. The emergency department is supported by the hospital and its 23 subspecialties, which makes Montrose Memorial the leading healthcare facility in the Uncompahgre Valley. The emergency department is staffed during

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peak time with four nurses, one physician and one technician. The on-duty flight crew will assist with trauma cases, starting difficult IVs, and other assigned tasks to support the ED staff.

Montrose Regional Communication Center (MRCC) Before 1998, the Montrose County Sheriff’s Office only dispatched for the Ouray County Sheriff during business hours; after hours dispatch ran through the Colorado State Patrol. In 1998 the Montrose County Sheriff’s Office took over as the regional communications center for approximately 22 EMS, fire and law enforcement agencies within the area including Montrose Police Department, Montrose Fire Protection District, Nucla-Naturita Fire/EMS, Paradox Fire/EMS, Olathe Police, Olathe Fire and EMS, Telluride Fire Protection District, Telluride

Marshal, Mountain Village Police Department, Ouray EMS, Ridgway Fire, Ouray Sheriff, Ouray Police and Ouray Fire just to name a few. In addition, the communication center also provides dispatching for various city and county utilities setting the total agencies to dispatch for at approximately 32.

Funding for the service comes through agency fees based on percent of use, grants, Colorado Department of Local Affairs (DOLA) grants, Montrose Emergency Telephone Service Authority and gifts from other dispatch centers. The communications center is authorized for 19 full time employees, two communication leads and one director. At time of the report there were only 13 full time employees, three trainees, one lead and a director. Shift rotations range from 8, 10 and 12 hour shifts with five or six dispatchers on during peak times and two or three dispatchers on during low volume times. The center handles approximately 20,000 9-1-1 calls each year with approximately 103,000 800 MHz radio transmissions.

The dispatch system being used is the Motorola MCC7500 with VHF paging and various frequencies for fire and EMS communications. The main radio system used for EMS, fire and law enforcement is the 800 MHz Digital Trunked Radio system. The phone system is Cassidian (Airbus) Vesta 911 with CodeRed being the emergency notification system (reverse 9-1-1). The communication center can handle seven 9-1-1 calls at once. Starting the end of April 2015 the center will be able to receive incoming 9-1-1 text messages. All dispatchers are emergency medical dispatch (EMD) trained through Association of Public-Safety Communications Officials (APCO) and all medical aid requests for service get EMD. The communication center does utilize Active 9-1-1 notification for the agencies that are set up to receive.

Norwood Fire Protection District The Norwood Fire Protection District is located in San Miguel County; however, it covers 35 square miles of Montrose County. The district was formed in 1953 with a coverage area of 70 square miles consisting of Norwood and Redvale. In 2008 the district was expanded to include a total of 380 square miles. The fire protection district covers a total of 380 square miles with an estimated population served of 2,500. Being a Title 32 Special District, the district receives a 5.895 mill levy with additional funding sources of user fees, subscription fees, grants, private

fundraising and gifts/donations. The district responds to approximately 133 to 170 EMS requests for service, transporting 60 to 80 patients a year with 55 to 80 fire related responses. The district is a

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volunteer department with 40 members consisting of eight first responders, eight EMTs, four EMT-Intermediates and two paramedics. Currently there are three volunteers enrolled in an EMT class. The EMS service members will get a stipend for transports to a hospital. There are two stations: Norwood and Redvale that house two Type I ambulances, five fire fighting apparatus equipped to handle structure, vehicle and wildland fires, two water tenders and a command vehicle. Due to the location, Norwood Fire Protection District has the ability to provide mutual aid and ALS intercept services to the west end of Montrose County.

Nucla-Naturita Fire Protection District and Ambulance The Nucla-Naturita Ambulance serves a population of 2,125 persons within a 210 square mile service

area. During business hours, the Basin Clinic is used as a stopping point for the service to stabilize any critically ill or injured trauma patients before they are transferred to Montrose or Grand Junction. Transport to a designated emergency department is typically two hours by ground. The typical call time is 5-6 hours up to 7-8 hours depending upon the location and destination.

The structure of the service is a fire department based Title 32 Special District with funding derived through a 5.582 mill levy and ambulance

transport user fees. The service is made up of 18 volunteer EMTs with one paid full time EMT-Intermediate, eight EMTs and the remainder are ambulance operators. Approximately half the EMTs are intravenous authorized. The EMTs and drivers get a small stipend for a transport. The EMS division of the district responds to approximately 200 to 250 requests per year. Three of the district EMTs have previously received a Phoenix Live Saving Award. The fleet consists of three Type I 4x4 ambulances, 2004 and 2007 Fords and a 2013 Dodge.

Olathe Fire Protection District The ambulance service in Olathe originally was privately owned, and then was under the control of the Montrose Fire Department until 2002 when the special district was established. The fire protection district covers an estimated 65 square miles with a permanent population of 4,800 within Montrose County. The service area spans from Ida Road south, 51.00 Road west, Peach Valley Road east and Delta County line to the north. Olathe EMS will respond to calls if requested west to the Uncompahgre Plateau and east into the Gunnison

Gorge National Conservation Area as they are the closest agency.

The district is set up as a Title 32 Special District in which funding comes from a mill levy and user fees for ambulance transport. Currently the special district receives 4.2 mills of which about 22 percent (1 mill) is allocated to the EMS department. There are 12 service members including two drivers who are emergency medical responders (EMR), seven EMTs, two EMT-Intermediates and one paramedic. Employees receive a small amount per

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hour that they are on-call plus a larger hourly rate when they are sent to a call. The district has two Type III ambulances, 2002 and 2008 Fords, three fire engines, three brush trucks, one brush trailer and one water tender. In 2014, the EMS branch of the district responded to 384 EMS requests for service.

Paradox Fire Protection District The Paradox Fire Protection District provides both fire and EMS response to approximately 500 square miles in Montrose County from the Utah state line to Montagram Road (west to east) and Highway 141 to Bull Canyon (north to south). The formal district itself covers 180 square miles. The population served in the area is approximately 200 persons. The district was formed in 1983 by Jack Lee and at that time only fire services were offered. In 1998, the ambulance service was formed under the district; however, the two services are different departments within the district. The service is set up as a Title 32

Special District in which it receives 7 mills and collects user fees from transports. The service is made up of a fire department with 17 members and an ambulance service with seven members all of whom are volunteers. The service is strictly BLS with two EMTs with intravenous authorization.

The fire department houses one brush truck, two fire engines and two water tenders. The ambulance quarters house two Type I ambulances, a 1994 Chevrolet and 2002 Ford, both purchased used. The district responds to approximately 15 to 35 EMS requests for service a year.

TransCare Ambulance TransCare Ambulance is a private for-profit interfacility transport ambulance service licensed in Montrose and Delta counties. They maintain an operation base in the City of Montrose and the town of Silt. The service provides critical care, ALS, BLS ambulance and wheelchair transportation. In 2008, TransCare Ambulance expanded to Montrose at the request of Montrose Memorial Hospital to provide interfacility transport to remove the burden from Montrose Fire Protection District. The service has occasionally provided back-up 9-1-1 response when

requested to fills gaps in coverage for western Montrose County. Currently the operation has four Ford Type 1 ambulances and one ambulette with wheelchair lifts in each division (Montrose and Silt). Funding comes solely from fees for service from ambulance and wheelchair transports. There is a total of 55 employees company-wide: three full time service members consisting of one nurse, an EMT and a paramedic, and 23 part time employees in the Montrose division ranging from EMTs, intermediates, paramedics and nurses.

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Analysis of Montrose County EMS System Elements Prior to and during the consultative visit, key participants from the countywide EMS response system and local health care facilities were asked to complete a survey rating the current EMS and trauma services and relationships in the county. In addition, county commissioners and EMS and trauma system stakeholders were interviewed during the county visit. The following sections take into consideration the pre-visit survey, interviews and factual data from various reports.

Legislation and Regulation

In Colorado, counties are required to license ambulance services, and are authorized to adopt regulations and develop an EMS system framework that meets or surpasses the requirements contained in state regulations. Most counties establish their EMS system and licensing policies through a resolution or ordinance. The Montrose County Board of County Commissioners is the ambulance licensing authority as defined by C.R.S. § 25-3.5-301. The county also has the power to organize, own, operate, control, direct, manage, contract for or furnish ambulance services, pursuant to C.R.S. § 30-11-107(q).

Montrose County revised its ambulance resolution substantially in January of this year. During the consultative team’s interviews, numerous stakeholders expressed dissatisfaction with the process to enact the resolution because they were not provided opportunity for comment as initially proposed at the outset of the process. Although there is no statutory requirement to have input or approval from any agency, the process appears to have left the emergency response community feeling that the lack of opportunity to provide input negatively impacted relationships and trust.

Recommendations

Enact a resolution to form a council to advise the Board of County Commissioners on emergency medical and trauma services. This would promote continuity of communications, team building and cooperation among the agencies. The council should have representation from every agency in the county that participates in the emergency medical services system, including the communications center, first response agencies, ground and air ambulance providers, fire and rescue services, health care facilities, law enforcement and the coroner. This council can also serve as a forum to enhance coordination and address issues within the system among the agencies involved. Once formed, the council should diligently serve as advisors to the Board of County Commissioners and keep the commissioners apprised of the status of the EMS system in the county, reporting the successes as well as working together to address the challenges.

Revisit the EMS Resolution and deliberately consider stakeholder concerns. The EMS Resolution should be reviewed at least biannually and the EMS Council should take the lead in making recommendations for changes to ensure an effective, coordinated system remains in place to keep pace with changes imposed by new laws governing health care delivery and public safety as well as variations in the demand for services within the county.

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System Finance

Prehospital Services Montrose County is a beautiful environment with an outstanding array of EMS professionals dedicated to serve their communities. Montrose County has a strong base of providers adapting to the changing world and realizing the needs of their communities. The most difficult aspect is the financial constraints to enhance the EMS response. It is interesting the community authorized a public safety sales tax and, it would appear from the stakeholder interview conversations and documents provided in the 2015 county budget, that only $15,000 from the proceeds is going to support EMS. It was unclear to the consultative visit team how these monies are allocated throughout the rest of the county.

In general, the fire districts are trying to find adequate funding to support EMS. Property taxes appear to be the primary mechanism for funding EMS through mill levies. It is worth noting the foresight of the past fire board directors for Nucla-Naturita Fire Protection District to place monies into a money market account to help provide for the future. In addition to mill levy support, the fire districts bill for services to help offset the cost for EMS in their respective communities.

In conversations with the various EMS stakeholders, it was apparent there is considerable value for Montrose County to develop some form of an advisory council to advise the Board of County Commissioners and bring all of the agencies to the table on a regular basis. This council should have a direct line of communication to advise the Board of County Commissioners on emergency medical services issues. The idea of all of the agencies serving Montrose County coming together would benefit the EMS system and also bring forth information, knowledge and understanding with the Board of County Commissioners. It is apparent the Board of County Commissioners has an interest in the EMS system and would like to bring a positive message toward the continued success of EMS for the future. The meetings would help to identify constraints and could facilitate a stronger team approach in developing answers, sharing results and creating a more unified EMS system.

It would be nice to say there is a single solution to the financial effects of the current economy but, unfortunately, this is not the case. The future for all agencies is uncertain as the local and national economy and needs of the community continue to evolve. A good place to begin seeking financial success in order to achieve community goals is to assess the current needs and determine what resources are needed to continue providing services over the next year, three years and five years.

Understanding and knowing what major impacts are on the horizon is key to preparing for the future. The Board of County Commissioners can be a wealth of information given their expertise and role in the county government. Individual agencies can gather information on issues they expect to impact the community in the future. Combining all of this information can develop a vision or strategic plan assisting everyone with greater financial understanding. How the future of healthcare reform will change the EMS system in Montrose County is a significant question that cannot be immediately answered today. Working together to understand the changes is important while collaborating to vet out issues will help to provide the best possible solutions. This is the one of the primary reasons that developing a county EMS Council is essential.

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Montrose Memorial Hospital Montrose Memorial Hospital is a community not-for-profit hospital serving the citizens of Montrose, Ouray and San Miguel counties since 1949. The hospital considers it is the primary provider for 45,000 persons, and the secondary service area for an additional 55,000 persons in Delta and San Miguel counties.

Quorum Health is the management company for Montrose Memorial Hospital, and this has been a stable arrangement for many years. Over the past five years there have been changes in the hospital’s ownership and board of trustees, including changes in the relationship with Montrose County. These dealings are outside of the scope of this report, and reportedly have not adversely affected patient care or the day-to-day operations of the facility. For a period of time the hospital withdrew its participation from the Western RETAC, but they are currently active participants and the hospital trauma coordinator is an appointed member of the council.

Montrose Memorial Hospital is licensed for 75 inpatient beds and provides healthcare services including an emergency department, surgery, intensive care, medical and surgical floors, joint replacement and other orthopedic services and family care including obstetrics. There are 12 bays in the emergency department, with an average of 50 patients per day. There are eight intensive care beds, six telemetry beds and 24 medical-surgical beds. Four operating rooms allow approximately 2,400 surgeries each year. The hospital has a Level I neonatal intensive care unit, an interventional cardiac catheterization lab and is designated as a Level III trauma center. The hospital reported 100,000 outpatient visits in 2014.

In addition to the services listed above, Montrose Memorial Hospital operates an acute rehabilitation unit, which provided 2,603 days of patient care for 210 patient admissions in 2013. Outpatient services include medical imaging, cardiology, pulmonology, oncology services, physical therapy, occupational therapy, speech therapy, cardiopulmonary rehabilitation and general laboratory services.

Per the 2013 published tax return, Montrose Memorial Hospital ended the year with $53,372,453 in net assets. Charity care provided in 2013 was reported to be $10,267,629. County commissioners were concerned that the hospital provided less charity care in 2014, possibly due to the change in ownership. However, the administrative team stated that the decrease in charity care from six percent to two percent was related to the Affordable Care Act, and was accompanied by a marked increase in the number of Medicaid patients seen. The facility works with patients to find other state and city resources to help pay the hospital bill before writing an amount off as charity care.

Montrose Memorial Hospital has recently established a joint venture with St. Mary’s Hospital in Grand Junction for a helicopter air medical transport service based in Montrose. This change in service is too new to know if it will be more financially advantageous than the previous affiliation with Tristate Care Flight, or if it will result in additional patients coming to the hospital. The change was reportedly made to improve the integration of care, as St. Mary’s is the hospital’s primary referral choice, and also to maintain a community focus.

In the past Montrose Memorial Hospital owned clinics in Olathe and Norwood, and had a financial interest in the Basin Clinic. It was determined that those relationships were no longer viable, and the hospital no longer provides financial support to them.

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The hospital is appropriately billing for trauma patients who are admitted through the emergency department. Unfortunately fifty percent or more of the emergency department patients arrive by private vehicle, which is a factor in their ability to charge and collect a trauma activation fee to help recoup some of the costs of maintaining Level III readiness for trauma care.

Basin Clinic The Basin Clinic is a rural health center located in the town of Naturita. The clinic has provided primary care services since 1979 to several surrounding communities: Naturita, Nucla, Redvale, Norwood and Paradox. The clinic has gone through several iterations since inception, including being part of a combined clinic with Uncompahgre Medical Center and being affiliated with Montrose Memorial Hospital from 2000 through July 2013. Since Aug. 1, 2013 the clinic has operated independently, offering services from 8 a.m. to 5 p.m. during the week.

Basin Clinic is financed through insurance or private pay for medical services provided (46 percent) and receives 33 percent of the budget from Montrose County ($300,000), 21 percent from a combination of $173,000 from a Colorado Health Foundation grant, health fair donations, and 1 percent sales tax from the town of Nucla. Operating costs are over $700,000 per year and administration is looking at ways to improve income. Strategies include increasing the number of employee physicals done for the Department of Transportation, blood alcohol and breathalyzer testing, and other community health services. They are also working to improve care coordination for Rocky Mountain Prime Medicaid patients; there are 60 such patients on the roster and there is a $30/month capitation. Thirty percent of the clinic patients are on Medicare and 40 percent are on Medicaid.

The clinic is not eligible to bill trauma charges for the patients who are brought by ambulance for evaluation. One consideration might be to apply for Level V trauma center designation, which does not require 24/7 services.

The clinic needs new radiology equipment and general refurbishing (carpet and similar amenities). The staff is aware there may be grants available for some assistance, but there is a lack of time and expertise to pursue them. Suggestions made included accessing the Western RETAC grant writer, and looking for potential funding sources from the Colorado Rural Health Center and Caring for Colorado.

Recommendations

Make use of the Western RETAC for grant writing assistance. The Basin Clinic is in need of new radiology equipment and other updates for the facility. Work with the grant writer from Western RETAC to seek out and apply for various grant opportunities from the Colorado Rural Health Center, Caring for Colorado and federal or state programs for funding assistance.

Continue to seek grant funding and other revenue streams to support all EMS agencies throughout Montrose County. Using the Western RETAC for grant writing assistance and researching various EMS and fire related grants can help fill in financial gaps to purchase needed equipment or fund staffing positions.

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Human Resources

Prehospital Given the current state of affairs, utilization of volunteers is vital for agencies to maintain the continued ability to answer calls for help or emergencies. It is the responsibility of each fire district to develop and determine proper rules, policies and position descriptions for each role of the agency. It is also the responsibility of each agency to complete a vetting process to fully understand Fair Labor Standard Act (FLSA) rules. This process includes defining how a member is reimbursed for reasonable expenses, benefits, or a nominal fee or any combination thereof. There are guidelines for reimbursing volunteers through stipends that can be found by reviewing Fair Labor Standards Act 553.100. If there is a question on how an agency provides any type of compensation, the agency may request an opinion letter from the United States Department of Labor. Agencies also have the ability to collaborate with their legal counsel, and/or as a member of VFIS or Colorado Technical Services Inc. This is vital to preserve a healthy volunteer force within the agency and for the leadership including the governing board to be informed and understand the work rules for volunteers.

Volunteer Response Timeframe One of the agencies interviewed discussed the time allowance for individuals to respond is five minutes as a volunteer. The consideration is to check the Fair Labor Standards Act for proper alignment with the agencies response policies. FLSA rules indicate persons who are on-call need to have an amount of ability / freedom or they are considered on-duty (engaged to be waiting clause), as opposed to be considered off-duty (waiting to be engaged). The United States Department of Labor website breaks these clauses down under the FLSA Hours Worked Advisor topic. This item should be reviewed to prevent a negative personnel issue in the future.

EMS Service Job Descriptions It is important to have appropriate descriptions for each position in the organization whether the agency is paid, volunteer or mixed. Professional volunteer organizations, just as their counterparts, need the job descriptions to allow a clear understanding of each person’s role. This is a positive incentive for the organization to promote the importance of the volunteer and how that role is vital to the success of the agency. The process for developing an adequate job description is easily found on the web, along with different examples of various job descriptions. There is no need to reinvent the wheel as many agencies have developed job descriptions that can be applied and modified until a job description that meets the organization’s standards has been developed. The job descriptions would ideally be approved by the governing board and a reviewed every three to five years.

Job descriptions provide a working understanding of the expectations of the professional volunteer as well as the management team. Position descriptions also provide a framework to develop a review or performance evaluation for the volunteer on a regular basis, at least annually. This is a tool that can be used by the volunteer to understand and realize successes and by supervisors in the situation when a volunteer may not be performing at an acceptable level and may need corrective action.

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Policies, Procedures and Documentation The fire protection agencies should have a current policy and procedure manual or employee handbook that answers the frequently asked questions, how to, who, why, and what of the agency. They should include information as to the expectations for performance of job duties and what and how the volunteer is allowed to do and not allowed to do. Providing information on how to become a member and how to achieve different levels in the agency is a proactive

approach to an agency’s success for the future. The policy and procedure manual or employee handbook is also a guide and a historical reference for future generations to see and understand the agency’s roots.

There should be information as to how and what is considered as the expectations and what and how the volunteer is allowed to do and not allowed to do. Providing information on how to become a member and how to achieve different levels in the agency is a proactive approach to an agency’s success for the future. A policy book is also a guide for future generations to see and understand the agency’s history.

It is necessary to develop personnel files of all staff members. The agency can use work records to understand workflows or patterns for how to staff during certain periods of time. The work records can also be used to document how much time each paid and volunteer staff member is providing for the community. Work records are necessary in the event of a workers’ compensation claim as well. Overall, work records provide a wealth of information about the agency’s current staffing, staffing needs and retention. In the agencies with paid staff it is necessary to maintain work records to demonstrate the amount of time full-time staff are working and to insure they are being compensated correctly. It is not hard for dedicated professionals to work beyond their duty hours but it is the responsibility of the agency to insure they are compensated correctly. The need to pay appropriately for overtime or comp time becomes a matter of Fair Labor Standard Act rules. It is for this reason each agency should have a proper documentation and written rules for how the paid staff is utilized, scheduled and compensated. The work rules should be vetted by the governing board as well as legal counsel.

Accurate records are essential in the modern world. Today it does not matter if you are paid professional or a volunteer professional; the agency has a responsibility to provide a fair and equitable workplace. The documentation of proper policies, training on the policies and the documentation of work records are necessary to protect the agency’s reputation, the management team, the volunteer staff and the governing board.

Montrose Memorial Hospital Montrose Memorial Hospital uses a flexible staffing model to staff the 75 beds in a most efficient manner. The Chief Nursing Officer is a hospital employee, but the other three members of the administrative team are employed by Quorum Health, an outside management company. Patient satisfaction scores are reported through Avatar and are described as above the ninetieth (90th) percentile. Strategic planning processes to maintain and improve scores include focus groups to develop a community needs assessment.

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The emergency department is staffed with two physicians during the day and one at other times. There are no midlevel providers used and staff includes two day, two night, and two swing nurses, an EMT or Licensed Practical Nurse for both day and night shifts. Mental health services are lacking in the community but the hospital is adding space for an on-site evaluator to expedite the process. There are currently no detox capabilities locally.

Although the administrative team reported no significant staffing issues for physicians or registered nurses, the emergency department nursing director reported that recruiting registered nurses is a challenge and the department is currently using two nurses from a traveler agency. This is partly attributed to lower wages than nearby communities offer. The hospital uses a “grow your own” recruitment process. However, they do not accept nursing students in the emergency department for clinical rotations, which seems to contradict that philosophy. (EMS students are accepted for clinical rotations.)

The hospital assists physician practices in the community with recruitment within the confines of the Stark laws. They also assist with recruitment for the Olathe, Basin and Norwood clinics, and maintain a cordial working relationship with them in spite of no longer being financially affiliated. Specialty and outpatient physician access for patients is reported as a problem, with long waits for an office appointment. Cardiology, pulmonology and medical oncology are specialties that were described as being employed by the hospital, but other physicians are contracted for hospital coverage.

Radiology coverage is provided by local physicians during the day and by a contracted Night Hawk service after hours. Digital images are transmitted to St. Mary’s Hospital to facilitate easy consultation for patients requiring transfer to a higher level of care.

The emergency department relationship with EMS is described as good, with an especially good working relationship with Montrose Fire Department. Interaction is more challenging with outlying agencies and there is less predictability in what will happen with patient care prior to the patient’s arrival. EMS patient care record access is variable, being described in a range from good to challenging. The Montrose County west end agencies leave a handwritten report. It was noted that EMS agency verbal handoff reports are inconsistent, and an opportunity for standardization and improvement likely exists. Incoming telephone calls are usually made via mobile phone, and there were inconsistent opinions regarding whether it is a recorded line. There is no EMS liaison identified for the emergency department. Physicians provide quarterly case reviews for EMS. Representatives from Montrose Fire Protection District and CareFlight attend the monthly trauma meetings for performance improvement.

Opportunities for improvement with EMS include finding a way to receive ECG tracings and formalizing the stroke alert process to facilitate faster assessment and care.

Basin Clinic The Basin Clinic currently employs twelve people including the healthcare providers. There is a clinic manager and an office manager, both of whom wear many hats due to the small staff. The healthcare providers include a physician’s assistant, a nurse practitioner, two registered nurses, one licensed practical nurse and four medical assistants or EMTs. In 2014 there were 4,900 clinic visits. There is a

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requirement that there must be a midlevel practitioner on duty at least 50 percent of the time. One goal is to increase services by adding an internal medicine practitioner on a weekly schedule.

The medical director for the clinic is a family practitioner from Montrose and is on-site every other week. His main responsibility is clinic oversight; however, he does see patients at the clinic occasionally. There are two other physicians: one is an internal medicine doctor who sees patients at least twice a month with the goal of increasing to a weekly schedule, and the other sees patients two times a week.

The clinic has three regular exam rooms, one pediatric exam room, and one urgent care room with two beds. A newer resource for the community is access to the Center for Mental Health. Basin Clinic is providing office space in the annex for this service. The clinic recently received new monitors; however, the staff was unsure if the monitors are compatible with the EMS monitors. The clinic uses Amazing Charts as the vendor for electronic medical records and there is a staff call-down list for mass casualty events. Practitioners occasionally do house calls, as there are no hospice services in the community. A representative from the clinic makes the effort to attend RETAC meetings.

Recommendations

Develop job descriptions for each position to include the EMS director, full-time paramedics, part-time paramedics, intermediates and the professional volunteer EMS provider for the agencies that do not currently have job descriptions in place.

Continue to use the CREATE grant as well as the EMS Provider grant systems. The CREATE grant process is an excellent opportunity to assist in the financial ability to provide and promote training of the staff. The EMS Provider grant can also provide assistance for staffing in the short-term by helping to offset the initial cost of hiring someone as well as provide backfill when sending staff to training programs. The backfill option could make sending someone to paramedic school more affordable since it reduces the cost for coverage during their absence.

Seek out resources and tools to aid in recruitment and retention. In recruitment and retention of staff there are tools, education and training available from numerous resources including the National Fire Academy, American Ambulance Association (AAA) and Volunteer Fireman’s Insurance Services (VFIS). These organizations have developed a number of programs to provide leadership training, organizational training and professional development. The National Fire Academy has specific courses applicable to EMS in addition to their courses designed for both fire and EMS. The American Ambulance Association provides a number of tools for free to its members as well as making them available to non-members for a fee. VFIS is well known to fire and emergency services agencies for its insurance products and has developed a number of courses from safety training through human resources training and information. The various Montrose County agencies may be able to access information and training from VFIS through the area fire departments in a cooperative manner. Below are some website links for more information.

• http://www.usfa.fema.gov/training/nfa/

• www.the-aaa.org/

• www.vfis.com

http://www.usfa.fema.gov/training/nfa/

http://www.the-aaa.org/

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Medical Direction

The Montrose County EMS agencies have adopted the regional protocols developed by the Western Regional EMS Leadership Council. All agencies throughout the county have a relatively stable medical direction process and are pleased with the amount of interaction that they have with their medical director. From the medical directors’ perspective, all feel that they have a satisfactory involvement with their agencies. It was brought to the team’s attention that the medical director for Nucla-Naturita and Paradox EMS volunteers his time, which shows a great sense of dedication to

assisting rural/frontier agencies.

The medical directors throughout the county appear to be part of a well-functioning group within the Western RETAC. The Western Regional EMS Leadership Council gets together twice a year to discuss clinical practices and case reviews. The physician serving as the regional medical director is currently working with the agency medical directors to adopt quality management programs that include the components required to invoke the confidentiality protections enacted by the Colorado legislature in 2014. This will enhance the quality assurance and quality improvement review process. Regular meetings among the individual agencies where quality assurance and quality improvement activities are performed are the norm for this region, and most agencies do a review every four months with their respective medical director.

The relationships between the Montrose Board of County Commissioners and the EMS agencies appear to have been strained recently over the adoption of the new ambulance licensing resolution. This has resulted in the reduction of collaborative efforts and an increased tension. It appeared to the team that some agencies believed the Western Regional EMS Leadership Council meeting was an “EMS Council” to assist in dealing with Montrose County with respect to the ambulance licensing resolution. During the Western Regional EMS Leadership Council meeting attended by the review team, the group expressed they should be considered more of a subject matter expert/medical resource for the local political leaders.

Medical Direction Challenges At the regional level there is a significant variation of training, collaboration and care. This is due largely to the variation of resources and geographical isolation. Increased collaboration among the agencies and their medical directors could help this situation. It is also advised that the Western Regional EMS Leadership Council and the Montrose Board of County Commissioners actively work on strengthening their relationship as this will only help the community.

Concerns regarding training availability were voiced several times during the consultative visit by various agencies. Training is a vital component of EMS agencies’ health and can be easily overlooked in a limited resource environment. Quality assurance and quality improvement are also essential components to a medical direction program, and it was apparent that the agencies within Montrose County do this well. Adopting quality management programs that include the components required to invoke the confidentiality protections enacted by the Colorado legislature in 2014 will increase the value of quality assurance and quality improvement activities while providing decreased exposure to professional liability.

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Recommendations

Adopt consistent quality management programs across all agencies that include the components required to invoke the confidentiality protections enacted by the Colorado legislature in 2014.

Increase collaboration among agencies. Look to develop a roving paramedic program among the ALS agencies to cover service area gaps that exist. This can be done through an “adopt an agency” program where the larger departments help the smaller agencies. This approach could also be adapted to assist with quality management, peer review and training programs. Another way to increase collaboration is through regional trainings with rotating locations so that the agencies can learn from each other while decreasing the need to always have to travel to a distant location.

Increase collaboration among EMS leaders and political leaders. Develop some form of an advisory council to advise the Board of County Commissioners and bring all of the agencies to the table on a regular basis. This council should have a direct line of communication to advise the Board of County Commissioners on emergency medical services issues. The idea of all of the agencies serving Montrose County coming together would benefit the EMS system and also bring forth information, knowledge and understanding with the Board of County Commissioners. It is apparent the Board of County Commissioners has an interest in the EMS system and would like to bring a positive message toward the continued success of EMS for the future. The meetings would help to identify constraints and could facilitate a stronger team approach in developing answers, sharing results and creating a more unified EMS system. This would also promote continuity of communications, team building and cooperation among the agencies.

Promote current teleconference opportunities using WebEx or similar technology to facilitate medical director interactions with outlying agencies. Travel can be difficult for volunteers to access training and EMS meeting opportunities. Using video and teleconferencing capabilities allows outlying agencies the ability to interact over streaming video and gain real time feedback. This allows the volunteers the ability to receive high quality training from their medical director and neighboring agencies without having to drive outside their area.

Clinical Care

Montrose County has a wide variety of clinical care needs and resources. The town of Montrose has approximately 20,000 people and appears to have good clinical care resources. There is a Level III trauma center and a well functioning fire-based EMS system that utilizes paramedics. There is also a rotor wing air ambulance stationed at the hospital. There is a private EMS service (TransCare) that primarily is utilized for inter-facility transports. Overall the EMS clinical care based in the town of Montrose appears to be excellent.

The Town of Olathe is smaller and has fewer resources as a

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fire-based EMS system. Given the close proximity to adjacent cities, Montrose Fire and Delta County Ambulance can provide mutual aid when needed. The EMS clinical care appears to be very good, given the limited resources.

The west end of Montrose County, including Nucla, Naturita, Paradox and Redvale is very rural and isolated. There are three primary agencies providing EMS service: Nucla-Naturita Fire Protection District, Paradox Fire Protection District and Norwood Fire Protection District. The Basin Clinic is a rural health clinic that is primarily staffed by a physician assistant; however, there is a physician who sees patients at the Basin Clinic occasionally. The clinic previously provided urgent and afterhours care but has discontinued this service due to limited resources. Due to the remote locations of the west end towns, the local EMS agencies work closely with the clinic. It was mentioned during the stakeholder interviews that it is policy to transport to the clinic during business hours for stabilization, treatment or transfer direction whether flight, ALS or BLS. There are two main rotor-wing resources available: CareFlight in Montrose and Classic Aviation in Moab, Utah. Montrose Fire and TransCare have provided mutual aid to the west end as well, including ALS intercepts. There appears to be a significant disconnect among the EMS agencies in the area creating significant silos. This accentuates the inherent difficulties in providing rural healthcare.

Protocols All agencies in Montrose County except for TransCare Ambulance Service have adopted the regional protocols developed by the Western Regional EMS Leadership Council. TransCare has specialty protocols through their medical director due to the focus on critical care transports between facilities and the use of nurses on the ambulance. The Western Regional EMS Leadership Council protocols were adapted from the Denver Metro protocols and modified to fit the rural needs. These are reviewed semiannually at the Western Regional EMS Leadership Council meetings.

Quality Assurance/Quality Improvement (QA/QI) The quality assurance/quality improvement process is not standardized throughout the region, and it is up to each agency to implement. However, it was mentioned during the Western Regional EMS Leadership Council meeting that the regional medical director is working on an enhanced quality assurance/quality improvement process.

Montrose Fire utilizes 100 percent paramedic chart review. The encounters that drop out per their audit filters will then go up the chain of command to the agency medical director. They report that this seems to work well but are looking for new ideas. Olathe reports that they use 100 percent chart review but that their process is relatively informal. West end agencies utilize a process for 100 percent medical director review of cases every four months. TransCare utilizes 100 percent medical director review on a regular basis.

Alerts/Activations Montrose Memorial Hospital is a Level III trauma center with a functioning, standardized trauma alert protocol in which EMS may activate a trauma alert in the field. There do not appear to be significant issues outside of lack of means of communication in outlying areas. There are significant gaps in radio and cell phone coverage in large areas that can delay early notification.

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The regional protocols have provisions for cardiac alerts and stroke alerts. The EMS providers appear comfortable with their use. However, Montrose Memorial Hospital does not have standardized protocols for responding to these alerts. As part of the continuum of care, the fact that there is not reliable evidence based protocol at the hospital level unnecessarily increases variation in the care patients receive. Several studies have shown that evidence based guidelines significantly reduce medical errors and unnecessary care. Montrose Memorial Hospital is close to developing a STEMI (cardiac) alert but is awaiting cardiologist input. Montrose Memorial Hospital does not have the capability to receive an electronic ECG image currently but during the stakeholder interviews a few of the stakeholders stated they would like to see this capability added to the system. The ability to transmit an EMS ECG while transporting would facilitate STEMI alerts. There does not appear to be a significant effort toward developing a stroke alert protocol; however, Montrose Memorial Hospital did state they are looking into it down the road. Increased hospital focus on alerts or activations will encourage pre-hospital agencies efforts.

Recommendations

Review agency quality management programs to ensure they reflect the most current research and best practices, and thoroughly assess system and individual performance.

Update agency quality management programs to incorporate all components required to invoke the confidentiality protections enacted by the Colorado legislature in 2014.

Implement a STEMI alert protocol at Montrose Memorial Hospital. Completion of a STEMI alert protocol will serve to increase the reliability of emergent cardiac care and may see positive outcomes in cardiac patient recovery.

Develop a Stroke alert protocol at Montrose Memorial Hospital. Consider following American Heart Association/American Stroke Association Guidelines for Early Management of Adults with Ischemic Stroke or ACLS. Seek referral neurologist input. Having a stroke alert protocol may increase the recovery outcomes of stroke patients.

Look at improving EMS communications to expedite alerts and activations for critical syndromes as described in the communications section.

Evaluate the potential for EMS to send ECG transmissions and Montrose Memorial Hospital’s ability to receive those transmissions. There is good evidence that pre-arrival to the hospital identification of STEMI via telemetry can reduce mortality and morbidity in systems that have cardiac catheterization facilities available. Collaboration between EMS agencies and the hospital should take place in order to lessen the financial costs associated with this technology. Seeking various grants through the Colorado Rural Health Center, Caring for Colorado, Centers for Medicare and Medicaid system improvement grant, and the Colorado Department of Public Health and Environment may also decrease the financial burden. Seeking a CMS system improvement grant may be a viable option in that the grant could be set up for a hospital cardiology program establishing a STEMI program with EMS capabilities to transmit ECG from the field in order to decrease mortality in cardiac patients.

Increase the collaboration of Nucla-Naturita Fire Protection District and Paradox Fire Protection District. This would be a high yield move that would likely help improve health care

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quality and access. Collaborative trainings, improving mutual aid and facilitating professional interactions could assist in breaking down the silos that exist in this isolated valley.

Consider implementing regional trainings. This would assist the rural agencies with their training. This is also likely to increase the collaboration of the region. Electronic aids such as WebEx could be utilized.

Consider improving funding of rural agencies. This could be accomplished by reallocation of local funding or dedicated mill levies, but focusing on grants for underserved, rural healthcare may prove beneficial. In addition, agencies should look to Western RETAC for help with additional funding opportunities provided by the state and federal grant programs for fire departments and EMS agencies.

Education Systems

Within Montrose County, emergency medical responders generally enjoy good availability of EMS education for both continuing education and initial provider class offerings. Additional resources exist nearby to supplement continuation offerings up to the paramedic level. Other educational outlets such as regional conferences and private EMS education providers round out the list. There are two separate worlds in this system, rural volunteer versus paid urban providers, and the overall education system appears to be divided along these familiar lines. The small population dispersed across a large area outside the city limits of Montrose becomes a real barrier to maintaining the best provider education.

Delta Montrose Technical College is recognized as a key regional EMS educational institution providing a wide array of core courses as well as numerous specialty offerings. Delta Montrose Technical College generally remains engaged with the EMS community and has a record of providing remote courses for rural agencies as requested. They acknowledge hurdles caused by the recent economic downturn combined with mine closures affecting population and decreasing school district tax revenues.

EMS educational opportunities are also available through several other organizations, including but not limited to: Montrose Fire Protection District, Professional EMS Education, individual EMS agency in-house programs and occasional offerings from Montrose Memorial Hospital and St. Mary’s CareFlight. The west end agencies also look to organizations such as Classic Air Medical in Moab to provide training. The Western RETAC has worked hard to provide access to state and regional EMS training conferences and continuing education opportunities through grants provided by the Colorado Resource for Emergency and Trauma Education (CREATE) program.

Western RETAC has taken on an important role in supporting the educational needs of community EMS providers, and they are developing an expanded webpage to advertise availability of training offerings in the region. Western RETAC also has a strong grant writing program and has been awarded CREATE grants and other funding to send more than 60 local providers to conferences and other educational offerings this past year, typically at little or no cost to providers. In spite of these successes, the fact remains that these opportunities do not always mean equal participation by EMS providers from across

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the county. Some agencies do not always take advantage of these opportunities, and it may be difficult for volunteer providers to commit the time to travel long distances for training excursions even when most of the cost is paid.

As the singular, paid-career EMS agency in the county, Montrose Fire Protection District lacks little as far as provider clinical training. Their firefighter EMTs are well trained and are a part of an agency that devotes significant amounts of time and energy to maintaining a

high level of clinical competency. Providers benefit from a relatively large number of patient contacts and maintain skills and knowledge as a result. Montrose Fire Protection District acts as something of a regional educational resource, often opening up their training sessions to area providers. Additionally they act as a clinical site for EMS training center students who are completing their field internship practicums.

The real educational challenge that faces this system is the volunteer EMS providers who staff the rural and frontier agencies. These providers, for all intents and purposes, commit their time and energy to their communities above and beyond their regular jobs and family life. Although efforts are regularly made to provide training in these more remote areas and funding is often made available through grants, there still exist some real roadblocks to developing new providers and maintaining competencies in current providers. Simply making funds available for these rescuers may not answer the entire question on training needs.

The rural medical directors interviewed were found to be actively engaged with their agencies, and this group uniformly described a common list of complications facing the training mission. This list of complications was also largely shared by the rural agency providers and managers themselves. There was no lack of dedication or commitment to the training mission in these groups. The challenges come from the pressures of real-life, and it was apparent in the real frustration expressed in their stories. Rural volunteers encounter trials in dedicating time to simply being on-call or on extended patient transports, let alone making themselves available for additional training sessions. Recruiting a community member into their ambulance corps, providing them with initial EMT training, and then maintaining the required minimum continuing education is no small task. The difficulty of maintaining clinical skills for current providers in the context of low call volume remains, and this is particularly acute for ALS level providers.

This system should look to unique solutions to keeping current providers trained and also supplement or magnify current activities to improve new provider recruitment. Current training practices are good but are not answering some large problems; this evaluation may present an opportunity for change.

Recommendations

Engage rural EMS service managers and medical directors collectively and individually in best practices evaluation of EMS education models for their agencies and the rural regions. This should include polling pre-hospital providers as to what the roadblocks are to initial training, continuing education and certification advancement.

Evaluate how grant funds are applied to the rural training problem. Western RETAC, along with agency medical directors and managers, should review gaps in funding and seek to provide

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ways to obtain grants for training opportunities. Consider developing and seeking funds for alternative educational strategies or partnerships outside of the more traditional conference scholarships and standard classes. Work to create innovative solutions and approach foundations and other grant providers to fund a more comprehensive rural EMS education model.

Work to improve coordination of training offerings in rural areas. Increase communication between rural agencies in order to maximize cost efficiencies and to avoid duplication of efforts (e.g. an initial EMT class offered in the rural areas should always be widely advertised and made available to multiple agencies and communities). Whenever possible, work to develop joint training sessions.

Continue to promote the idea of an “adopt an agency” program for educational support of rural providers. Travelling guest presenters have generally been well received by rural providers, and they offer exposure to current clinical practices and consistency of training message. Opportunities exist for the larger coordination of this program through the regional medical director group and the Western RETAC.

Work in general to improve access and availability of initial and continuing education to rural volunteer providers. Volunteer agency educational delivery is best when held locally and when it meets volunteer personnel availability (e.g. evenings, weekends, considerations for childcare and seasonal agricultural activities, etc.). Rural agency leadership, particularly in fire-based EMS agencies, must place a premium on the educational support of their medical providers. Departments should fully fund the educational activities of their providers and strive to provide, at a minimum, enough access to training to maintain provider medical certification. Providers should not be expected to pay out of pocket for any significant portion of training activities.

Employ online educational offerings as an example of innovative delivery models. High quality online continuing education offerings can be contracted through several national providers and can fill gaps in needed continuing education. This should not be considered the sole or primary method of training delivery but it can serve as a cost-effective supplement to a larger educational scheme.

Enhance integration of emergency dispatch center personnel with greater EMS community education. Participating in some shared training initiatives may enhance cooperation between field providers and dispatchers and may help patient outcomes by improving benchmarked clinical care issues. An example of this could be implementation and ongoing evaluation of a new STEMI alert program.

Increase the use of distance learning methods and the hybrid (part online and part live instruction) course model. This delivery model can reduce student travel time but retain valuable direct instructor contact opportunities for students. Some additional competency may need to be developed in the instructor pool to use this delivery method effectively.

Ensure that specialized training is provided for agency managers/supervisors, both urban and rural, that enhances their leadership skill-set and avoids a “Peter Principle” system of promotion. The Montrose County EMS system should embrace the idea of growing new leaders within their ranks.

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Consider creating a regional training coordinator position. The existing efforts of Western RETAC, the Western Regional EMS Leadership Council and others toward providing and improving educational opportunities in the region has been very good but may benefit from a focused-role approach. This role could provide an overall coordination of efforts and could act as an advocate for the more rural agencies.

Look to Montrose Memorial Hospital and St. Mary’s CareFlight to play an increased role in county EMS education efforts. The hospital is the cornerstone of emergency medical care in the community and the opportunity exists to play a lead role in the EMS system. The hospital should work to provide leadership and become a focus for clinical practice example for prehospital providers. An example of this could be the implementation and educational support of a new STEMI or stroke alert system. Efforts should be coordinated with the Western Regional EMS Leadership Council and could extend into many clinical practice areas such as maintenance of ALS skills for rural providers through access to clinical experiences in the emergency department or operating room.

Work to tie quality improvement issues and benchmarking of clinical care fundamentals in developing educational priorities. Planning of educational offerings, both system-wide and within individual agencies, should go beyond the standard fare of courses geared toward maintenance of certification and the occasional “hot topic” class. Topics of focus in the educational realm should be identified through the quality improvement process. The key to engaging in this level of coordination is to acknowledge the connection of quality improvement data analysis and the identification of educational needs. Development of a regional quality improvement initiative through the Western Regional EMS Leadership Council would be an excellent format for its growth and implementation. Additionally, some form of outreach to smaller, more rural agencies could be integrated with regionally coordinated educational activities.

Investigate acquiring a mobile, high-fidelity training lab for the region. In the absence of frequent patient contact experiences provider clinical competency wanes. There is now good science in support of the use of human simulators for developing and maintaining provider skills in the absence of numerous patient contacts. This mobile lab could be used as a regional resource to extend critical patient care practice to the more rural, lower call volume providers. Efforts to this end should be led by Western RETAC and done in consultation with training centers serving the region.

Public Access

The universal 9-1-1 emergency access number is currently available in all portions of Montrose County, ringing into the Montrose County Regional Dispatch Center. The dispatch center maintains 24/7/365 coverage. Most providers and community members felt that the quality of the dispatching services is good. Cellular service access surrounding the largest population center of Montrose was not considered a problem for persons utilizing the 9-1-1 system. There are areas of the county where cellular service is unreliable or nonexistent. This is

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primarily due to the large geographic area of the county, physical features of the terrain and a relatively small and widely dispersed population. Problems with cellular service in those areas were discussed as having an impact on the public’s ability to contact 9-1-1.

Emergency Medical Dispatching The Montrose County Regional Dispatch Center utilizes the Association of Public-Safety Communications Officials (APCO) EMD Program. Dispatchers are certified to this standard and the center maintains quality assurance processes. The survey reflects that high quality instructions services are given to callers.

Communications

Currently the Montrose County Regional Dispatch Center provides services to the following agencies in and around Montrose County: Montrose County Sheriff’s Office, Montrose Airport Fire Department, Paradox Fire & EMS, Nucla-Naturita Fire & EMS, Montrose Police & Animal Control, Montrose Fire & EMS, Olathe Police, Olathe Fire & EMS, Log Hill Fire, Ouray Police, Ouray Fire, Ouray EMS, Ouray Sheriff’s Office & Mountain Rescue, Horsefly Fire, Ridgway Fire, Ridgway Marshal, Mountain Village Police, Telluride Marshal, Telluride Fire Protection District and the National Park Service.

Montrose Regional Dispatch Center currently employs 13 full time communication technicians, one full time lead communication technician, one director and three communication technician trainees. As with many communications centers, they are currently short staffed and are requiring personnel to work mandatory overtime. The communication center was authorized for three additional full time technicians for a total of 19 full time communication technicians, two full time lead communication technicians and one director staffing positions.

During the consultative visit team interview the communication staff was very knowledgeable, professional and a credit to the center. An immediate concern would be that continued forced overtime may lead to employee burnout causing an even greater staff shortage. When discussing the service provided with user agencies, they were satisfied with the service the communication technicians were providing. It was mentioned that on the west end of the county there have been some units dispatched to calls when in fact the actual call was not in their area. This is caused in part by duplicate addresses in the county.

By far the largest concern was the increased cost of services. Prior to this year Montrose County had subsidized the center. At the same time as the subsidy ended the center was approved for three more full time employees, which further increased the costs to the local agencies, many of them small rural department with very limited budgets. Due to increased costs, not quality of service, it was brought up that some agencies are actively exploring other avenues for communication service. Losing any of the current users will increase costs even further unless personnel cuts are made. Another issue raised was that the users have no control over cost or policy and are required to pay a percentage of the overall costs based on percentage of use.

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Recommendations

Engage all the stakeholder agencies and work to resolve the current issues including increased operating costs. Efforts should be made to keep current agency users from seeking services elsewhere.

Form a standalone communications center overseen by a communications board composed of representatives of the user agencies. Since the user agencies fund the center they should have a voice in the budget of the center and other issues that could substantially increase their costs. As active participants in the process user agencies will have a better understanding of the constraints affecting the operation and finances for the communications center.

Ensure automatic number identification and automatic location information are correct in the database. Establish a comprehensive procedure to verify that addresses in the database correspond to the actual physical location of the telephone and have all of the correct response agencies assigned. Establish procedures to identify duplicate addresses, or addresses with similarities that could be mistaken, and dispatch responders to all locations unless the actual physical location can be determined. Consider review of the street address system county wide and change street names or address ranges to eliminate duplicates.

Information Systems

The Montrose County EMS system is generally using modern technology in the conduct of patient care reporting and data collection. The region has variable access to reliable broadband Internet with connectivity being more robust in the more populous areas and sporadic to no access in the more rural and frontier areas.

Although all county agencies describe using electronic patient care reporting (ePCR) software and provide workers with modern hardware on which to complete this task, there was some variation reported in the degree of success in its implementation. Some rural agencies are still struggling with provider adoption of the modern systems and complain that this remains a point of contention between agency managers, medical directors and the field staff.

Most agencies have relied on state EMTS Provider Grant funding to purchase ePCR software and the associated hardware platforms. Several agencies use the ImageTrend Field Bridge® ePCR software available directly from the state without charge. All Montrose County ground transport agencies are compliant with state reporting requirements and are eligible for EMTS Provider and CREATE grants for needed system resources. Although all agencies are using ePCR software and are collecting data, it was apparent that only a few are using analysis of that data toward system improvement ends.

Patient care reports are typically provided at the time of patient delivery to Montrose Memorial Hospital with only occasional poor compliance. It was also noted that the ability for the hospital to reliably access agency reports securely online would be very helpful in a continuity of care and trauma data reporting perspective.

Communications between field units and the hospital

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emergency department are accomplished via mobile phone with ready access to emergency physicians for consultation and orders. It was universally noted though that there is no recording of telephone communications between field units and the hospital emergency department and, therefore, provide no access for follow-up quality or compliance review.

Recommendations

Work to identify key performance indicators for agency activities both operationally and in clinical care, and use them as a driver for the quality improvement program and provider education efforts. Devise processes to ensure that data input by field providers is valid and being entered correctly. This should be performed with the understanding that data can change clinical practice and improve patient outcomes. It should be noted that efforts along these lines will likely require some additional specialized training for staff charged with this responsibility. This training can often be accomplished by informational visits with larger agencies who have dedicated staff performing this function.

Implement a recorded phone line to capture communications between field providers and hospital medical direction. This information is highly valuable for quality improvement activities and risk management for agencies and medical directors.

Investigate providing online access through agency ePCR systems for agency medical directors to review patient care reports remotely and securely. This will help ease chart review workload for the medical director covering the more rural agencies.

Investigate providing online access through agency ePCR systems for receiving facility trauma coordinator. This could serve to improve the continuum of care as well as enhance trauma data collection and system data analysis.

Provide electronic documentation training to rural agencies struggling with provider reporting compliance. Investigate initiatives within these agencies to promote provider acceptance of this important practice.

Investigate cooperative information technology support services amongst the rural agencies.

Public Education

There are a variety of public education topics provided throughout the county by EMTS agencies. Most of the public education is directed toward injury prevention activities. Montrose Fire Protection District provides on-site public education with station tours and safety messages. An opportunity exists, especially in the smaller communities within the county, to educate the public about the EMS community and the role they play. This could also help recruit volunteers, who may not realize what is involved.

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Prevention

Most of the programs in Montrose County focus on injury prevention efforts, but more opportunities exist. Montrose Memorial Hospital offers or supports various health initiatives including smoking cessation, nutrition and diabetes education, and multiple support groups. Staff at both the hospital and Montrose Fire indicated interest in a fall prevention program but the program is said to be on hold presently. Various other programs around the county exist, which are described below.

Child Safety Seats Injuries suffered in a motor vehicle traffic collision are the leading cause of death among children in the United States. Numerous studies including a 2010 NHTSA Study Children Injured in Motor Vehicle Traffic Crashes conclude that use of child safety seats are effective in reducing the incidence rates of incapacitating injuries in any motor vehicle traffic crash type. Presently the Colorado Department of Transportation (CDOT) website lists the Colorado State Patrol and Montrose Fire as the only Child Safety Seat inspection stations in Montrose County. Montrose Fire, however, reports having only one certified Child Passenger Safety technician. The Colorado State Patrol reports they have two certified technicians and a class is scheduled to be offered in June or July 2015 to train additional technicians. Montrose Memorial Hospital reports having staff who are able to install car seats for infants being discharged from the hospital after birth.

Fall Prevention According to the Centers for Disease Control (CDC), falls are the leading cause of fatal and nonfatal injuries among adults age 65 and older. Given the access that EMS agencies have to patient’s homes, and the expertise of medical providers in assessing a patient’s fall risk, a partnership between the hospital and fire/EMS organizations in an initiative such as the Stopping Elderly Accidents, Deaths & Injuries (STEADI) program through the CDC should have an immediate and sustainable positive impact on the communities. The STEADI program provides tools and educational materials to help prevent elderly fall and accidents.

Recommendations

Increase the number of car seat technicians in the area. Concern was expressed that the program devolved to more of a “free car seat” program; however, a comprehensive inspection and installation program does not need to include a free car seat component. Programs can obtain coupons from local businesses that incentivize parents to purchase a new seat. Given the remoteness of the west end of Montrose County, a suggestion is to support one or more paid EMS providers and a resident Montrose County Sheriff Deputy to obtain Child Passenger Safety Technician certification. Successful programs have also partnered with local car dealerships to increase access to car seat inspections.

Launch a community-wide awareness and carbon monoxide detector program through the various fire and EMS agencies in Montrose County. This type of program is not only highly effective, but it offers the opportunity for agencies to work together with the goal of having

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every household in Montrose County protected with a carbon monoxide detector. Private foundations such as The Lauren Project offer grants and assistance to agencies. (http://www.laurensproject.org/)

Mass Casualty

The county hired a new emergency manager just a little over a year ago and he is diligently working to improve the planning process in the county. Emergency management is currently in the process of updating the mass casualty plan for the county. The greatest challenge in finalizing the county mass casualty plan is getting individual agencies to update their plans and submit them for inclusion in the county plan. Due to the size and varied resources, response to a mass casualty incident would be quite different in the west end of the county than in the city.

As with counties throughout the state, many of the stakeholders need to conduct or participate in mass casualty exercise to comply with regulations or grant funding requirements. For example, hospitals and airports are required to have exercises on a regular basis. It is often difficult for small rural departments to travel out of their area to participate in an exercise and still have adequate coverage; hence, many of the smaller agencies in Montrose County do not regularly participate.

Recommendations

Develop a county mass casualty incident plan dividing the county into regions based on capability rather than individual jurisdictional boundaries. Define what constitutes a mass casualty incident in each of those regions and develop an automatic aid response for incidents that meet the established threshold.

Develop a comprehensive Training and Exercise Plan (TEP) for the entire county for the next three to five years. This would allow the emergency manager to request state assistance to provide training within the county. It would also increase the efficiency of exercise planning by designing exercises to meet the needs of multiple agencies.

Conduct mass casualty incident exercises in all areas of the county on a rotating basis to ensure all agencies have the opportunity to participate.

Integration of Health Services

Integration between the EMS agencies and Montrose Memorial Hospital is good, especially along the U.S. 50/550 corridor. Montrose Fire Protection District is a regular participant in the quality improvement/quality assurance activities of Montrose Memorial Hospital and the feeling amongst stakeholders is they have a very positive relationship. Additionally services from Delta, Olathe, Montrose and Ouray County enjoy a great working relationship with liberal use of mutual and automatic aid as necessary. The new partnership with St. Mary’s Hospital to place a CareFlight helicopter at Montrose Memorial Hospital should further enhance integration and timely system access. Ground interfacility transfers out of Montrose Memorial Hospital are usually handled by TransCare Ambulance, a local private provider, leaving Montrose Fire available for 9-1-1 emergency requests. This arrangement is covered by an agreement between Montrose Fire and TransCare, and all parties report this relationship is working well.

http://www.laurensproject.org/

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Stakeholders expressed concern with the challenges of system integration amongst the services in Montrose County’s west end. These small communities all share similar challenges. Not surprisingly, the travel times exceeding two hours to reach a hospital along with the varying weather conditions make more intentional steps toward integration necessary. These communities share the additional challenges of a depressed economy and volunteer personnel shortages. Transports to a hospital or attending a meeting in Montrose can tie up an ambulance crew from four to more than eight hours.

Each community’s EMS is a part of their local fire protection district. Like all Colorado Title 32 Special Districts, property tax revenue is a function of assessed valuation, which has been on the decline in recent years. Assessed valuation on the west end of the county has been hit particularly hard with the decline in mining. While the cash positions of each district vary, stripping away differences in personalities or approach and we find the challenges between the districts to be almost identical.

It is imperative for survival that west end services commit to daily cooperation and long term strategic planning. They have a unique interdependence upon each other as the only agencies able to provide effective EMS for the area. Given the vast distances served, shortages of qualified providers and the prolonged time on task for each ambulance transport, the team feels no single agency can fully support its mission alone.

Recommendations

Promote opportunities for greater integration of health services in Montrose County. County EMS regulations should be designed to encourage effective and coordinated delivery of services. The county should consider stakeholder input when composing regulations. Looking at formal and informal groups that promote communication and cooperation, Montrose County has momentum with the Western Regional EMS Leadership Council as well as opportunity with the Western RETAC. Many county governments have facilitated regular stakeholder communication and cooperation through formation of an EMS Council established by resolution. Properly formed, this body will foster collaboration and encourage system improvements through setting achievable goals.

Develop ALS capabilities on the west end. Many have expressed concern with the availability of ALS throughout the west end. Proposed solutions should enhance the remarkable work volunteers and part-time staff provide to their communities. Often small communities with transport capabilities at the BLS level will form a cooperative to staff a single resource paid ALS provider in a quick response vehicle. The existing system is left intact and the ALS provider will respond from a central location and intercept or meet up with the BLS ambulance. From that point there are several options available to the team as they determine the best course of action pursuant to protocol and SOP. Often a clinic, such as the Basin Clinic in Naturita, serves as a base for the ALS provider. Through a combination of local and regional tax support, transport revenue and possibly grants, it is possible to create this type of service model.

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Evaluation

As previously mentioned, Montrose County through the agencies and medical directors does a good job at quality assurance and quality improvement. Along with enhancing quality management processes per the recently passed legislation mentioned in Medical Direction and Clinical Care sections, evaluating system performance measures is the next step in enhancing EMS care. Looking at Montrose County as a whole is a difficult task since there are vast differences in population density, call volume and road access across the county. Performance standards are a challenge in the rural communities; however, steps can be taken to evaluate the response effectiveness. Montrose Fire Protection District is considered more of an urban department and operates accordingly. The district has policies in place to evaluate performance standards. The policies are set up according to the American Heart Association recommendations and NFPA 1710 Standard. Since Montrose Fire responds ALS personnel to every 9-1-1 request, the performance goal is set at an eight minute response time (dispatch to arrival) 85 percent of the time. The dispatch to en route time goal is one minute. Per the 2014 statistics, Montrose Fire does an acceptable job at meeting these internal performance goals. Establishing performance standards for the volunteer agencies is a challenge for numerous reasons. During the onsite interviews, Olathe Fire Protection District stated that they were able to establish a five minute response time for the time interval from dispatch to en route. It was discussed however, that this does influence the pool of volunteers they can attract. The west end agencies stated this was a challenge due to the simple fact that their volunteers live various distances from the main station. In reviewing the 2014 response data, it appears that the agencies do an acceptable job arriving to 9-1-1 requests in an appropriate time.

Evaluating the effectiveness of the EMS system goes beyond the clinical care provided and also looks at the data and outcomes of the care. Finding appropriate ways to evaluate response time data, clinical care and positive outcomes is crucial to demonstrate the value EMS has to the community it serves. All the agencies within the county do an excellent job serving their respective communities and should be commended on the dedication they have for the service. Establishing reasonable response goals for the various response areas should be considered and evaluated on an annual basis to demonstrate the effectiveness of the services they provide to the community.

Performance standards vary throughout the nation based upon each individual communities need. The standard throughout the nation is based upon these performance standards5:

1. Respond to 90 percent of urban calls in less than 9 minutes

2. Respond to 90 percent of rural calls within 15 minutes

3. Respond to 90 percent of wilderness calls within 30 minutes

The American Heart Association and NFPA 1710 standard set lower response time goals for urban environments at four minutes for BLS first response and eight minutes for ALS response. The above response times are a general guideline based upon national industry standards and should be evaluated and adjusted based upon existing county response data and reasonable expectations provided by Montrose EMS agency management. Safety considerations should be made for inclement weather periods and crews should not justify

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increasing speed or taking risks to meet a response time. It is also important to note that the overall response time should be evaluated based upon the responding units dispatch time to the onscene time. This shows a true picture of how long it is taking crews to arrive on scene once dispatched. Montrose Fire sets their performance standard based upon the 85 percentile, which is an acceptable range since their service area includes urban, rural and frontier (wilderness) response zones, which can significantly skew response times.

El Paso County, another jurisdiction in Colorado with similar geographic challenges, originally established the following response time performance standards for the contracted ambulance provider:

1. Respond to calls in the urban zone in 8 minutes and zero seconds or less 90 percent of the time with a maximum response time of 12 minutes and zero seconds on any call. The urban zone included the more densely populated areas in Colorado Springs.

2. Respond to calls in the suburban zone in 12 minutes and zero seconds or less 90 percent of the time with a maximum response time of 18 minutes and zero seconds on any call. The suburban zone included predominately residential areas around Colorado Springs.

3. Respond to calls in the rural zone in 20 minutes and zero seconds or less 90 percent of the time with a maximum response time of 30 minutes and zero seconds on any call. The rural zone included the less densely populated areas surrounding Colorado Springs including communities like Falcon and Monument.

4. Respond to calls in the first tier of the frontier zone in 25 minutes and zero seconds or less 90 percent of the time with a maximum response time of 35 minutes and zero seconds on any call. This zone included areas farther east of Colorado Springs including small towns like Peyton.

5. Respond to calls in the second tier of the frontier zone in 35 minutes and zero seconds or less 90 percent of the time with a maximum response time of 45 minutes and zero seconds on any call. This zone included open prairies and sparsely populated areas in the far eastern and southern reaches of El Paso County including very small communities like Calhan and Ellicott.

6. Respond to calls in the third tier of the frontier zone in 45 minutes and zero seconds or less 90 percent of the time with a maximum response time of 55 minutes and zero seconds on any call. This zone included open prairies and sparsely populated areas in the far eastern and southern reaches of El Paso County including very small communities like Rush and Edison.

7. Respond to calls in the wilderness zone in 45 minutes and zero seconds or less 90 percent of the time. This zone included the mountainous areas west of Colorado Springs accessible by primitive roads.

Compliance was only measured if there were 100 emergency calls or more in a response zone to account for random statistical variation. Specific emergency calls could be excluded from the calculation if the response was delayed due to inclement weather or other adverse circumstances beyond the control of the ambulance service provider. Calls could also be excluded if the location was

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so distant that it was impossible to meet the performance standard even from the closest ambulance post. El Paso County went through months of stakeholder meetings and extensive deliberations to develop realistic response time standards for the vast expanses outside the urban area. Their experience clearly demonstrates the magnitude of the challenges involved in the creation of meaningful standards to benchmark the level of service throughout the county.

It is common for EMS providers to state that seconds matter in life or death. In reality, high acuity calls occur infrequently;

however, decreasing response times may have positive outcomes for certain time sensitive syndromes such as trauma, cardiac events or strokes. The key for these patients is quick access to appropriate treatment at a hospital. For cardiac arrest patients, studies have shown that at the national nine minute response time goal, there is a 10 percent survival rate.5 As the minutes progress after nine minutes, survival is possible but the likelihood decreases for every minute that CPR is not performed.5 Studies are showing that there is an equal chance of survival regardless if BLS or ALS providers arrive onscene first.5 The key is that CPR is being performed effectively and an AED is available as soon as possible. Montrose Communications Center is the biggest ally in being able to instruct 9-1-1 callers how to perform CPR before EMS arrival. This service provided by the communication center enhances the overall system performance, increases the potential for positive outcomes and diminishes the effect of some challenges faced by EMS providers in rural communities.

Recommendations

Evaluate the response time performance for the various Montrose County EMS agencies. Evaluate response data to include but not limited to dispatch to en route time, en route to arrival time, dispatch to arrival time and GIS plotting of call locations. Pay attention to any trends in areas where calls are increasing year after year, especially in areas where development is likely to increase population.

Evaluate the need to set performance standards. Performance standards should be developed based upon reasonable expectations geographically throughout the county to ensure citizens and visitors receive reasonably quick access to EMS care. Standards should be set up based upon a specific percentile to mitigate the effect of challenges inherent to emergency responses in a rural and frontier area. If performance standards are to be applied, the response zones and time standards should be evaluated on an annual basis to ensure the criteria is reasonable, attainable and EMS care is being delivered with increased positive outcomes. The EMS advisory council should be responsible for proposing the performance goals and advising the elected officials.

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Summary

According to the survey results, the various Montrose County stakeholders scored the EMS system above average for overall EMS and trauma effectiveness. From the comments provided as well as the discussions in the stakeholder interviews, Montrose County EMS spans two different extremes. Montrose Fire Protection District has embraced its role in EMS and the agency’s response model shows accordingly. The ambulance out of the main station is staffed with three EMS providers and the paired engine is staffed with two. This allows flexibility and efficiency in the deployment model where the ambulance can respond and handle most medical emergencies while keeping the fire apparatus available for its intended purpose. When a fire does occur, the third EMS provider can cross-staff over to the engine to create a three-person engine crew. This staffing model is the example of the paradigm shift from a traditional fire department to an innovative EMS, fire and rescue agency.

The various volunteer agencies within the county do a good job with the resources at their disposal. Interagency conflicts that exist seem to prevent a cohesive working relationship needed for support within a rural/frontier area. Agencies should seek to break down the silos of communication and work to establish common goals to ensure the best services for the residents are provided. Progress seems to be made by bringing a full time ALS provider into the west end of the county. The capability for the paid ALS provider to be mobile in a quick response vehicle enhances the ability to respond to an emergency request for service from anywhere in the area at any time of day or night. The challenge with having only one ALS provider for the community is the concern of burnout or the need to take sick or vacation time. In addition, if there is only one ALS provider and that person is needed for a transport, the community will be without ALS coverage for several hours. Seeking ways to partner with other agencies nearby to provide backup ALS coverage due to long transport times, sick or vacation requests should be considered and worked out through mutual aid agreements or an “adopt an agency program.” Due to the distances on the west end, utilizing a mobile ALS provider in a quick response vehicle could fill a gap and limit unnecessary air medical scene flight requests. The mobile ALS provider would have to be dispatched automatically to any 9-1-1 call in the area and either respond directly to the scene or rendezvous with the ambulance to save time. The responding ambulance if on scene first should have the ability to cancel the ALS provider if the BLS crew is able to handle the call appropriately.

The Montrose County EMS system overall functions well thanks to the cornerstone of all the agencies and the individual dedicated EMS providers, both paid and volunteer. The continuous effort on the medical directors’ part to be actively involved with the agencies is demonstrated by the quality care that is being provided throughout the county. As the EMS system grows and innovates through the current stakeholder leadership, coordination and cooperation between the agencies will be the key to a lasting effective EMS system in Montrose County. Establishing an EMS Council to advise the Board of County Commissioners is highly encouraged in order to improve cooperation among the EMS agencies and elected officials.

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Summary of Recommendations

County Recommendations

Short-term (1 to 2 years)

Enact a resolution to form a council to advise the Board of County Commissioners on emergency medical and trauma services. This would promote continuity of communications, team building and cooperation among the agencies. The council should have representation from every agency in the county that participates in the emergency medical services system, including the communications center, first response agencies, ground and air ambulance providers, fire and rescue services, health care facilities, law enforcement and the coroner. This council can also serve as a forum to enhance coordination and address issues within the system among the agencies involved. Once formed, the council should diligently serve as advisors to the Board of County Commissioners and keep the commissioners apprised of the status of the EMS system in the county, reporting the successes as well as working together to address the challenges.

Revisit the EMS Resolution and deliberately consider stakeholder concerns. The EMS Resolution should be reviewed at least biannually and the EMS Council should take the lead in making recommendations for changes to ensure an effective, coordinated system remains in place to keep pace with changes imposed by new laws governing health care delivery and public safety as well as variations in the demand for services within the county.

Develop a county mass casualty incident plan dividing the county into regions based on capability rather than individual jurisdictional boundaries. Define what constitutes a mass casualty incident in each of those regions and develop an automatic aid response for incidents that meet the established threshold.

Medium-term (3 to 5 years)

Consider improving funding of rural agencies. This could be accomplished by reallocation of local funding or dedicated mill levies, but focusing on grants for underserved, rural healthcare may prove beneficial. In addition, agencies should look to Western RETAC for help with additional funding opportunities provided by the state and federal grant programs for fire departments and EMS agencies.

Develop a comprehensive Training and Exercise Plan (TEP) for the entire county for the next three to five years. This would allow the emergency manager to request state assistance to provide training within the county. It would also increase the efficiency of exercise planning by designing exercises to meet the needs of multiple agencies.

Conduct mass casualty incident exercises in all areas of the county on a rotating basis to

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ensure all agencies have the opportunity to participate.

Hospital/Clinic Recommendations


Make use of the Western RETAC for grant writing assistance. The Basin Clinic is in need of new radiology equipment and other updates for the facility. Work with the grant writer from Western RETAC to seek out and apply for various grant opportunities from the Colorado Rural Health Center, Caring for Colorado and federal or state programs for funding assistance.


Implement a recorded phone line to capture communications between field providers and hospital medical direction. This information is highly valuable for quality improvement activities and risk management for agencies and medical directors.

Investigate providing online access through agency ePCR systems for receiving facility trauma coordinator. This could serve to improve the continuum of care as well as enhance trauma data collection and system data analysis.

Montrose County Agency Recommendations

Short- term (1 to 2 years)

Develop job descriptions for each position to include the EMS director, full-time paramedics, part-time paramedics, intermediates and the professional volunteer EMS provider for the agencies that do not currently have job descriptions in place.

Continue to use the CREATE grant as well as the EMS Provider grant systems. The CREATE grant process is an excellent opportunity to assist in the financial ability to provide and promote training of the staff. The EMS Provider grant can also provide assistance for staffing in the short-term by helping to offset the initial cost of hiring someone as well as provide backfill when sending staff to training programs. The backfill option could make sending someone to paramedic school more affordable since it reduces the cost for coverage during their absence.

Seek out resources and tools to aid in recruitment and retention. In recruitment and retention of staff there are tools, education and training available from numerous resources including the National Fire Academy, American Ambulance Association (AAA) and Volunteer Fireman’s

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Insurance Services (VFIS). These organizations have developed a number of programs to provide leadership training, organizational training and professional development. The National Fire Academy has specific courses applicable to EMS in addition to their courses designed for both fire and EMS. The American Ambulance Association provides a number of tools for free to its members as well as making them available to non-members for a fee. VFIS is well known to fire and emergency services agencies for its insurance products and has developed a number of courses from safety training through human resources training and information. The various Montrose County agencies may be able to access information and training from VFIS through the area fire departments in a cooperative manner. Below are some website links for more information.

• http://www.usfa.fema.gov/training/nfa/

• www.the-aaa.org/

• www.vfis.com

Adopt consistent quality management programs across all agencies that include the components required to invoke the confidentiality protections enacted by the Colorado legislature in 2014.

Increase collaboration among EMS leaders and political leaders. Develop some form of an advisory council to advise the Board of County Commissioners and bring all of the agencies to the table on a regular basis. This council should have a direct line of communication to advise the Board of County Commissioners on emergency medical services issues. The idea of all of the agencies serving Montrose County coming together would benefit the EMS system and also bring forth information, knowledge and understanding with the Board of County Commissioners. It is apparent the Board of County Commissioners has an interest in the EMS system and would like to bring a positive message toward the continued success of EMS for the future. The meetings would help to identify constraints and could facilitate a stronger team approach in developing answers, sharing results and creating a more unified EMS system. This would also promote continuity of communications, team building and cooperation among the agencies.

Review agency quality management programs to ensure they reflect the most current research and best practices, and thoroughly assess system and individual performance.

Update agency quality management programs to incorporate all components required to invoke the confidentiality protections enacted by the Colorado legislature in 2014.

Engage all the stakeholder agencies and work to resolve the current issues including increased operating costs. Efforts should be made to keep current agency users from seeking services elsewhere.

Form a standalone communications center overseen by a communications board composed of representatives of the user agencies. Since the user agencies fund the center they should have a voice in the budget of the center and other issues that could substantially increase their

http://www.usfa.fema.gov/training/nfa/

http://www.the-aaa.org/

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costs. As active participants in the process user agencies will have a better understanding of the constraints affecting the operation and finances for the communications center.

Provide electronic documentation training to rural agencies struggling with provider reporting compliance. Investigate initiatives within these agencies to promote provider acceptance of this important practice.


Increase collaboration among agencies. Look to develop a roving paramedic program among the ALS agencies to cover service area gaps that exist. This can be done through an “adopt an agency” program where the larger departments help the smaller agencies. This approach could also be adapted to assist with quality management, peer review and training programs. Another way to increase collaboration is through regional trainings with rotating locations so that the agencies can learn from each other while decreasing the need to always have to travel to a distant location.

Work to identify key performance indicators for agency activities both operationally and in clinical care, and use them as a driver for the quality improvement program and provider education efforts. Devise processes to ensure that data input by field providers is valid and being entered correctly. This should be performed with the understanding that that data can change clinical practice and improve patient outcomes. It should be noted that efforts along these lines will likely require some additional specialized training for staff charged with this responsibility. This training can often be accomplished by informational visits with larger agencies who have dedicated staff performing this function.

Investigate providing online access through agency ePCR systems for agency medical directors to review patient care reports remotely and securely. This will help ease chart review workload for the medical director covering the more rural agencies.

Investigate cooperative information technology support services amongst the rural agencies.

Long-term (5 years)

Evaluate the response time performance for the various Montrose County EMS agencies. Evaluate response data to include but not limited to dispatch to en route time, en route to arrival time, dispatch to arrival time and GIS plotting of call locations. Pay attention to any trends in areas where calls are increasing year after year, especially in areas where development is likely to increase population.

Evaluate the need to set performance standards. Performance standards should be

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developed based upon reasonable expectations geographically throughout the county to ensure citizens and visitors receive reasonably quick access to EMS care. Standards should be set up based upon a specific percentile to mitigate the effect of challenges inherent to emergency responses in a rural and frontier area. If performance standards are to be applied, the response zones and time standards should be evaluated on an annual basis to ensure the criteria is reasonable, attainable and EMS care is being delivered with increased positive outcomes. The EMS advisory council should be responsible for proposing the performance goals and advising the elected officials.

EMS and Trauma System-Wide Recommendations

Short- term (1 to 2 years)

Continue to seek grant funding and other revenue streams to support all EMS agencies throughout Montrose County. Using the Western RETAC for grant writing assistance and researching various EMS and fire related grants can help fill in financial gaps to purchase needed equipment or fund staffing positions.

Look at improving EMS communications to expedite alerts and activations for critical syndromes as described in the communications section.

Implement a STEMI alert protocol at Montrose Memorial Hospital. Completion of a STEMI alert protocol will serve to increase the reliability of emergent cardiac care and may see positive outcomes in cardiac patient recovery.

Increase the collaboration of Nucla-Naturita Fire Protection District and Paradox Fire Protection District. This would be a high yield move that would likely help improve health care quality and access. Collaborative trainings, improving mutual aid and facilitating professional interactions could assist in breaking down the silos that exist in this isolated valley.

Ensure automatic number identification and automatic location information are correct in the database. Establish a comprehensive procedure to verify that addresses in the database correspond to the actual physical location of the telephone and have all of the correct response agencies assigned. Establish procedures to identify duplicate addresses, or addresses with similarities that could be mistaken, and dispatch responders to all locations unless the actual physical location can be determined. Consider review of the street address system county wide and change street names or address ranges to eliminate duplicates.


Develop a Stroke alert protocol at Montrose Memorial Hospital. Consider following American

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Heart Association/American Stroke Association Guidelines for Early Management of Adults with Ischemic Stroke or ACLS. Seek referral neurologist input. Having a stroke alert protocol may increase the recovery outcomes of stroke patients.

Evaluate the potential for EMS to send ECG transmissions and Montrose Memorial Hospital’s ability to receive those transmissions. There is good evidence that pre-arrival to the hospital identification of STEMI via telemetry can reduce mortality and morbidity in systems that have cardiac catheterization facilities available. Collaboration between EMS agencies and the hospital should take place in order to lessen the financial costs associated with this technology. Seeking various grants through the Colorado Rural Health Center, Caring for Colorado, Centers for Medicare and Medicaid system improvement grant, and the Colorado Department of Public Health and Environment may also decrease the financial burden. Seeking a CMS system improvement grant may be a viable option in that the grant could be set up for a hospital cardiology program establishing a STEMI program with EMS capabilities to transmit ECG from the field in order to decrease mortality in cardiac patients.

Increase the number of car seat technicians in the area. Concern was expressed that the program devolved to more of a “free car seat” program; however, a comprehensive inspection and installation program does not need to include a free car seat component. Programs can obtain coupons from local businesses that incentivize parents to purchase a new seat. Given the remoteness of the west end of Montrose County, a suggestion is to support one or more paid EMS providers and a resident Montrose County Sheriff Deputy to obtain Child Passenger Safety Technician certification. Successful programs have also partnered with local car dealerships to increase access to car seat inspections.

Launch a community-wide awareness and carbon monoxide detector program through the various fire and EMS agencies in Montrose County. This type of program is not only highly effective, but it offers the opportunity for agencies to work together with the goal of having every household in Montrose County protected with a carbon monoxide detector. Private foundations such as The Lauren Project offer grants and assistance to agencies. (http://www.laurensproject.org/)

Long-term (5 years)

Promote opportunities for greater integration of health services in Montrose County. County EMS regulations should be designed to encourage effective and coordinated delivery of services. The county should consider stakeholder input when composing regulations. Looking at formal and informal groups that promote communication and cooperation, Montrose County has momentum with the Western Regional EMS Leadership Council as well as opportunity with the Western RETAC. Many county governments have facilitated regular stakeholder communication and cooperation through formation of an EMS Council established by resolution. Properly formed, this body will foster collaboration and encourage

http://www.laurensproject.org/

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system improvements through setting achievable goals.

Develop ALS capabilities on the west end. Many have expressed concern with the availability of ALS throughout the west end. Proposed solutions should enhance the remarkable work volunteers and part-time staff provide to their communities. Often small communities with transport capabilities at the BLS level will form a cooperative to staff a single resource paid ALS provider in a quick response vehicle. The existing system is left intact and the ALS provider will respond from a central location and intercept or meet up with the BLS ambulance. From that point there are several options available to the team as they determine the best course of action pursuant to protocol and SOP. Often a clinic, such as the Basin Clinic in Naturita, serves as a base for the ALS provider. Through a combination of local and regional tax support, transport revenue and possibly grants, it is possible to create this type of service model.

Education Recommendations


Promote current teleconference opportunities using WebEx or similar technology to facilitate medical director interactions with outlying agencies. Travel can be difficult for volunteers to access training and EMS meeting opportunities. Using video and teleconferencing capabilities allows outlying agencies the ability to interact over streaming video and gain real time feedback. This allows the volunteers the ability to receive high quality training from their medical director and neighboring agencies without having to drive outside their area.

Engage rural EMS service managers and medical directors collectively and individually in best practices evaluation of EMS education models for their agencies and the rural regions. This should include polling pre-hospital providers as to what the roadblocks are to initial training, continuing education and certification advancement.

Evaluate how grant funds are applied to the rural training problem. Western RETAC, along with agency medical directors and managers, should review gaps in funding and seek to provide ways to obtain grants for training opportunities. Consider developing and seeking funds for alternative educational strategies or partnerships outside of the more traditional conference scholarships and standard classes. Work to create innovative solutions and approach foundations and other grant providers to fund a more comprehensive rural EMS education model.

Work to improve coordination of training offerings in rural areas. Increase communication between rural agencies in order to maximize cost efficiencies and to avoid duplication of efforts (e.g. an initial EMT class offered in the rural areas should always be widely advertised and made available to multiple agencies and communities). Whenever possible, work to develop joint training sessions.

P a g e | 43


Continue to promote the idea of an “adopt an agency” program for educational support of rural providers. Travelling guest presenters have generally been well received by rural providers, and they offer exposure to current clinical practices and consistency of training message. Opportunities exist for the larger coordination of this program through the regional medical director group and the Western RETAC.

Work in general to improve access and availability of initial and continuing education to rural volunteer providers. Volunteer agency educational delivery is best when held locally and when it meets volunteer personnel availability (e.g. evenings, weekends, considerations for childcare and seasonal agricultural activities, etc.). Rural agency leadership, particularly in fire-based EMS agencies, must place a premium on the educational support of their medical providers. Departments should fully fund the educational activities of their providers and strive to provide, at a minimum, enough access to training to maintain provider medical certification. Providers should not be expected to pay out of pocket for any significant portion of training activities.

Employ online educational offerings as an example of innovative delivery models. High quality online continuing education offerings can be contracted through several national providers and can fill gaps in needed continuing education. This should not be considered the sole or primary method of training delivery but it can serve as a cost-effective supplement to a larger educational scheme.

Enhance integration of emergency dispatch center personnel with greater EMS community education. Participating in some shared training initiatives may enhance cooperation between field providers and dispatchers and may help patient outcomes by improving benchmarked clinical care issues. An example of this could be implementation and ongoing evaluation of a new STEMI alert program.


Consider implementing regional trainings. This would assist the rural agencies with their training. This is also likely to increase the collaboration of the region. Electronic aids such as WebEx could be utilized.

Increase the use of distance learning methods and the hybrid (part online and part live instruction) course model. This delivery model can reduce student travel time but retain valuable direct instructor contact opportunities for students. Some additional competency may need to be developed in the instructor pool to use this delivery method effectively.

Ensure that specialized training is provided for agency managers/supervisors, both urban and rural, that enhances their leadership skill-set and avoids a “Peter Principle” system of promotion. The Montrose County EMS system should embrace the idea of growing new

P a g e | 44


leaders within their ranks.

Consider creating a regional training coordinator position. The existing efforts of Western RETAC, the Western Regional EMS Leadership Council and others toward providing and improving educational opportunities in the region has been very good but may benefit from a focused-role approach. This role could provide an overall coordination of efforts and could act as an advocate for the more rural agencies.

Look to Montrose Memorial Hospital and St. Mary’s CareFlight to play an increased role in county EMS education efforts. The hospital is the cornerstone of emergency medical care in the community and the opportunity exists to play a lead role in the EMS system. The hospital should work to provide leadership and become a focus for clinical practice example for prehospital providers. An example of this could be the implementation and educational support of a new STEMI or stroke alert system. Efforts should be coordinated with the Western Regional EMS Leadership Council and could extend into many clinical practice areas such as maintenance of ALS skills for rural providers through access to clinical experiences in the emergency department or operating room.

Long-term (5 years)

Work to tie quality improvement issues and benchmarking of clinical care fundamentals in developing educational priorities. Planning of educational offerings, both system-wide and within individual agencies, should go beyond the standard fare of courses geared toward maintenance of certification and the occasional “hot topic” class. Topics of focus in the educational realm should be identified through the quality improvement process. The key to engaging in this level of coordination is to acknowledge the connection of quality improvement data analysis and the identification of educational needs. Development of a regional quality improvement initiative through the Western Regional EMS Leadership Council would be an excellent format for its growth and implementation. Additionally, some form of outreach to smaller, more rural agencies could be integrated with regionally coordinated educational activities.

Investigate acquiring a mobile, high-fidelity training lab for the region. In the absence of frequent patient contact experiences provider clinical competency wanes. There is now good science in support of the use of human simulators for developing and maintaining provider skills in the absence of numerous patient contacts. This mobile lab could be used as a regional resource to extend critical patient care practice to the more rural, lower call volume providers. Efforts to this end should be led by Western RETAC and done in consultation with training centers serving the region.

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County

# of

Runs

% of

Runs

Delta 2 0.08%

Gunnison 3 0.12%

Montrose 2515 99.37%

Ouray 11 0.43%

Unk 0 0.00%

Total 2531 100%

City

# of

Runs

% of

Runs

Cimarron 10 0.40%

Colona 2 0.08%

Delta 2 0.08%

Montrose 2494 98.54%

Olathe 9 0.36%

Ouray 8 0.32%

Ridgway 6 0.24%

Unknown 0 0.00%

Total 2531 100%

Minutes

# of

Runs

% of

Runs

0 - 1 1803 71.24%

2 - 3 631 24.93%

4 - 5 70 2.77%

> 5 26 1.03%

Unk 1 0.04%

Total 2531 100%

Enroute (Unit Notified

Dispatched- Responding)

Minutes

# of

Runs

% of

Runs

0 - 5 1925 76.06%

5 - 10 494 19.52%

11 - 15 65 2.57%

> 15 46 1.82%

Unknown 1 0.04%

Total 2531 100%

Response Time (Enroute-

Arrive Scene)

Enroute 0:01:16

To Scene 0:04:23

At Scene 0:11:48

To Destination 0:07:03

Back in

Service 0:02:23

Total 0:26:53

Average Run Times

Minutes

# of

Runs

% of

Runs

0 - 5 752 29.71%

6 - 10 718 28.37%

11 - 15 162 6.40%

> 15 92 3.63%

Unk 807 31.88%

Total 2531 100%

Transport Time

(Depart Scene-Arrive

Hospital)

Appendix A EMS Statistics These statistics are based upon what was reported to the state for NEMSIS reporting Montrose Fire EMS Statistics 2014

Request for Service Townships/Counties

Request for Service Time Frames

Run Times

Time Period Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total Percent

0000 - 0300 35 25 16 27 28 28 38 197 7.78%

0300 - 0600 13 24 23 23 22 17 25 147 5.81%

0600 - 0900 26 44 42 37 44 40 36 269 10.63%

0900 - 1200 42 45 62 69 64 63 57 402 15.88%

1200 - 1500 40 51 58 103 62 60 56 430 16.99%

1500 - 1800 51 61 71 47 61 75 61 427 16.87%

1800 - 2100 44 53 50 56 46 67 67 383 15.13%

2100 - 2400 34 36 48 44 40 26 48 276 10.90%

Unknown 0 0 0 0 0 0 0 0 0.00%

Total 285 339 370 406 367 376 388 2531 100%

P a g e | 46


Transport Mode from

Scene

# of

Times

% of

Times

Upgraded to Lights and

Sirens 1 0.04%

Lights and Sirens 116 4.58%

No Lights or Sirens 1627 64.28%

Not Applicable 787 31.09%

Unknown 0 0.00%

Total 2531 100%

Response Mode to

Scene

# of

Times

% of

Times

Downgraded to No

Lights or Sirens 2 0.08%

Upgraded to Lights and

Sirens 4 0.16%

Lights and Sirens 1179 46.58%

No Lights and Sirens 1346 53.18%

Unknown 0 0.00%

Total 2531 100%

Response Disposition

# of

Times

% of

Times

Dead at Scene 19 0.75%

No Patient Found 82 3.24%

Patient Refused Care 56 2.21%

Treated and Released 189 7.47%

Treated, Transferred Care 20 0.79%

Treated, Transported by EMS 1735 68.55%

Treated, Transported by Private Vehic le 430 16.99%

Unknown 0 0.00%

Total 2531 100%

Destination

# of

Runs

% of

Runs

Not Applicable 705 11.90%

Delta County Memorial

Hospital 3 0.05%

Facility Not Listed 4 0.07%

Montrose Memorial Hospital 1721 29.05%

Private Residence 4 0.07%

San Juan Living Center 7 0.12%

St. Mary's Hospital 1 0.02%

Valley Manor Care Center 4 0.07%

No Destination 3475 58.66%

Total 5924 100%

Age # of Runs % of Runs

Less Than 1 14 0.55%

1 - 4 44 1.74%

4 - 9 26 1.03%

10 - 14 29 1.15%

15 - 19 77 3.04%

20 - 24 75 2.96%

25 - 34 211 8.34%

35 - 44 192 7.59%

45 - 54 233 9.21%

55 - 64 339 13.39%

65 - 74 341 13.47%

75 - 84 429 16.95%

85+ 418 16.52%

Unknown 103 4.07%

Total 2531 100%

Average Patient Age: 60

Response and Transport Mode Destination and Disposition Patient Age Range

P a g e | 47


City

# of

Runs

% of

Runs

NATURITA 32 60.38%

NUCLA 18 33.96%

Redvale 1 1.89%

Unknown 2 3.77%

Total 53 100%

County

# of

Runs

% of

Runs

MONTROSE 51 96.23%

Unknown 2 3.77%

Total 53 100%


0000 - 0300 0 1 1 0 0 0 0 2 3.77%

0300 - 0600 1 0 1 0 0 0 0 2 3.77%

0600 - 0900 0 0 0 0 1 1 2 4 7.55%

0900 - 1200 1 2 3 4 3 3 2 18 33.96%

1200 - 1500 0 0 2 1 1 0 0 4 7.55%

1500 - 1800 1 0 0 0 1 2 1 5 9.43%

1800 - 2100 2 1 2 0 1 4 1 11 20.75%

2100 - 2400 0 2 0 1 0 1 1 5 9.43%

Unknown 0 1 0 0 0 0 1 2 3.77%

Total 5 7 9 6 7 11 8 53 100%

Minutes

# of

Runs

% of

Runs

0 - 5 26 49.06%

6 - 10 23 43.40%

11 - 15 2 3.77%

> 15 0 0.00%

Unk 2 3.77%

Total 53 100%

Response Time (Arrive

Scene - Enroute)

Minutes

# of

Runs

% of

Runs

0 - 5 7 13.21%

6 - 10 8 15.09%

11 - 15 0 0.00%

> 15 31 58.49%

Unknown 7 13.21%

Total 53 100%

Transport Time (Depart

Scene- Arrive Hospital)

Enroute 0:17:51

To Scene 0:05:18

At Scene 0:43:48

To Destination 1:26:18

Back in Service 2:19:12

Total 4:52:27

Average Run Times

Nucla-Naturita EMS Statistics 2015 (Data submission began 2015)



Run Times

Minutes

# of

Runs

% of

Runs

0 - 1 3 5.66%

2 - 3 1 1.89%

4 - 5 1 1.89%

> 5 46 86.79%

Unknown 2 3.77%

Total 53 100%

Enroute ( Unit Notified

Dispatched)

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Miles# of

Runs% of

Runs

0 - 5 33 62.26%

6 - 10 4 7.55%

11 - 15 2 3.77%

16 - 20 0 0.00%

> 20 1 1.89%

Unk 13 24.53%

Total 53 100%

To Scene

Miles# of

Runs% of

Runs

0 - 5 20 37.74%

6 - 10 1 1.89%

11 - 15 1 1.89%

16 - 20 0 0.00%

> 20 29 54.72%

Unk 2 3.77%

Total 53 100%

To Destination

To Scene 4

To Destination 63

Total 67

Average Run Mileage # of

Times

% of

Times

9 16.98%

1 1.89%

41 77.36%

2 3.77%

53 100%

No Lights and Sirens

Unknown

Total

Response Mode to

Scene

Lights and Sirens

Lights, no siren

# of

Times

% of

Times

1 1.89%

1 1.89%

35 66.04%

1 1.89%

15 28.30%

53 100%

Not Applicable

Unknown

Total

Lights and Sirens

Lights Only - No Sirens

No Lights or Sirens

Transport Mode from

Scene

# of Runs

% of Runs

1 1.89%

6 11.32%

2 3.77%

11 20.75%

1 1.89%

16 30.19%

16 30.19%

53 100%

ST MARYS HOSPITALNo Destination

Total

COMMUNITY HOSPITAL

MONTROSE MEMORIAL HOSPITAL

Not Applicable

Destination

ADOLESCENT AND FAMILY INSTITUTE OF COLORADO

BASIN CLINIC INC


# of

Times

% of

Times


No Treatment Required 2 3.77%

Patient Refused Care 2 3.77%

Transported, Treatment by Other

Agency 2 3.77%

Treated and Refused Transport 4 7.55%

Treated, Transferred Care 1 1.89%


Treated, Transported by EMS (ALS) 27 50.94%

Treated, Transported by EMS (BLS) 9 16.98%

Unknown 2 3.77%

Total 53 100%

Age

# of

Runs

% of

Runs

Less Than 1 0 0.00%

1 - 4 0 0.00%

5 - 9 2 3.77%

10 - 14 2 3.77%

15 - 19 2 3.77%

20 - 24 1 1.89%

25 - 34 4 7.55%

35 - 44 6 11.32%

45 - 54 5 9.43%

55 - 64 5 9.43%

65 - 74 8 15.09%

75 - 84 9 16.98%

85+ 3 5.66%

Unknown 6 11.32%

Total 53 100%


Run Mileage Response and Transport Mode

Destination and Disposition

Patient Age Range

P a g e | 49


County

# of

Runs

% of

Runs

Delta 17 9.60%

Montrose 159 89.83%

Unknown 1 0.56%

Total 177 100%

Minutes

# of

Runs

% of

Runs

0 - 1 16 9.04%

2 - 3 12 6.78%

4 - 5 74 41.81%

> 5 74 41.81%

Unk 1 0.56%

Total 177 100%


Dispatched-

Responding)

Minutes

# of

Runs

% of

Runs

0 - 5 106 59.89%

6 - 10 37 20.90%

11 - 15 10 5.65%

> 15 2 1.13%

Unk 22 12.43%

Total 177 100%


Arrive Scene)

Minutes

# of

Runs

% of

Runs

0 - 5 1 0.56%

6 - 10 2 1.13%

11 - 15 11 6.21%

> 15 110 62.15%

Unk 53 29.94%

Total 177 100%


Scene-Arrive Hospital)Enroute 0:05:26

To Scene 0:04:33

At Scene 0:25:09

To

Destination 0:19:26

Back in

Service 1:13:43

Total 2:08:17

Average Run Times

Olathe Fire EMS Statistics 2014



Run Times

City

# of

Runs

% of

Runs

Delta 5 2.82%

Montrose 4 2.26%

Olathe 154 87.01%

Unknown 14 7.91%

Total 177 100%


0000 - 0300 3 1 2 3 1 4 1 15 8.47%

0300 - 0600 0 2 0 2 1 1 1 7 3.95%

0600 - 0900 3 0 4 2 0 3 1 13 7.34%

0900 - 1200 6 4 5 6 7 3 8 39 22.03%

1200 - 1500 4 4 4 3 4 2 5 26 14.69%

1500 - 1800 3 4 5 1 4 3 6 26 14.69%

1800 - 2100 1 8 6 8 2 9 2 36 20.34%

2100 - 2400 3 2 0 0 3 2 4 14 7.91%

Unk 0 0 0 1 0 0 0 1 0.56%

Total 23 25 26 26 22 27 28 177 100%

P a g e | 50


Miles

# of

Runs

% of

Runs

0 - 5 173 97.74%

6 - 10 1 0.56%

11 - 15 1 0.56%

16 - 20 0 0.00%

> 20 0 0.00%

Unk 2 1.13%

Total 177 100%

To Scene

Miles

# of

Runs

% of

Runs

0 - 5 55 31.07%

6 - 10 13 7.34%

11 - 15 92 51.98%

16 - 20 3 1.69%

> 20 0 0.00%

Unk 14 7.91%

Total 177 100%

To DestinationTransport

Mode from

Scene

# of

Times

% of

Times

Downgraded

to No Lights

or Sirens 1 0.56%

Upgraded to

Lights and

Sirens 1 0.56%

Lights and

Sirens 10 5.65%

No Lights or

Sirens 111 62.71%

Not Recorded 52 29.38%

Unk 2 1.13%

Total 177 100%

Response Mode

to Scene

# of

Times

% of

TimesDowngraded to

No Lights or

Sirens 10 5.65%

Upgraded to

Lights and

Sirens 1 0.56%

Lights and

Sirens 133 75.14%

No Lights and

Sirens 32 18.08%

Unk 1 0.56%

Total 177 100%

Destination

# of

Runs

% of

Runs

Delta County

Memorial Hospital 54 13.47%

MONTROSE

MEMORIAL

HOSPITAL 70 17.46%

No Destination 277 69.08%

Total 401 100%


# of

Times

% of

Times

Cancelled 11 6.21%


No Patient Found 10 5.65%

No Treatment Required 25 14.12%

Treated and Released 1 0.56%


Treated, Transported by Private Vehic le 2 1.13%

Unknown 1 0.56%

Total 177 100%

Run Mileage Response and Transport Mode

Destination and Disposition

P a g e | 51


Dispatch Reason

# of

Times

% of

Times

Abdominal Pain 10 5.65%

Allergies 1 0.56%

Animal Bite 1 0.56% (

Recent Trauma) 2 1.13%

Breathing Problem 17 9.60%

Chest Pain 6 3.39%

CO Poisoning/Hazmat 2 1.13%

Diabetic Problem 1 0.56%

Fall Victim 29 16.38%

Headache 1 0.56%

Hemorrhage/Laceration 2 1.13%

Industrial Acc ident/Inaccessible

Inc ident/Other Entrapments

(Non-Vehic le) 1 0.56%

Ingestion/Poisoning 3 1.69%

Not Known 20 11.30%

Not Recorded 4 2.26%

Psychiatric Problems 4 2.26%

Seizure/Convulsions 5 2.82%

Sick Person 20 11.30%

Stab/Gunshot Wound 1 0.56%

Stroke/CVA 7 3.95%

Traffic /Transportation Acc ident 16 9.04%

Traumatic Injury 8 4.52%

Unconsc ious/Fainting 9 5.08%

Unknown Problem/Man Down 6 3.39%

Unknown 1 0.56%

Total 177 100%

Age

# of

Runs

% of

Runs

Less Than 1 2 1.13%

1 - 4 0 0.00%

5 - 9 1 0.56%

10 - 14 4 2.26%

15 - 19 8 4.52%

20 - 24 8 4.52%

25 - 34 11 6.21%

35 - 44 15 8.47%

45 - 54 8 4.52%

55 - 64 23 12.99%

65 - 74 13 7.34%

75 - 84 26 14.69%

85+ 24 13.56%

Unk 34 19.21%

Total 177 100%


Dispatch Info Patient Age Range

P a g e | 52


County # of Runs % of Runs

Montrose 5 83.33%

Unk 1 16.67%

Total 6 100%

City # of Runs % of Runs

Naturita 2 33.33%

Paradox 3 50.00%

Unk 1 16.67%

Total 6 100%

Minutes

# of

Runs

% of

Runs

0 - 1 1 16.67%

2 - 3 0 0.00%

4 - 5 0 0.00%

> 5 4 66.67%

Unknown 1 16.67%

Total 6 100%


Dispatched- Responding)

Minutes

# of

Runs

% of

Runs

0 - 5 2 33.33%

6 - 10 0 0.00%

11 - 15 0 0.00%

> 15 3 50.00%

Unk 1 16.67%

Total 6 100%


Arrive Scene)

Minutes

# of

Runs

% of

Runs

0 - 5 0 0.00%

6 - 10 0 0.00%

11 - 15 0 0.00%

> 15 5 83.33%

Unk 1 16.67%

Total 6 100%


Scene - Arrive Hospital)

Enroute 0:15:36

To Scene 0:19:12

At Scene 0:25:00To

Destination 1:38:36

Back in

Service 3:08:45

Total 5:47:09

Average Run Times

Paradox Valley EMS Statistics 2014



Run Times


0000 - 0300 0 0 0 0 0 0 0 0 0.00%

0300 - 0600 0 0 0 0 0 0 0 0 0.00%

0600 - 0900 0 0 0 0 0 1 0 1 16.67%

0900 - 1200 0 0 0 0 0 0 0 0 0.00%

1200 - 1500 0 0 0 0 0 0 0 0 0.00%

1500 - 1800 0 0 1 2 1 0 0 4 66.67%

1800 - 2100 0 0 0 0 0 0 0 0 0.00%

2100 - 2400 0 0 0 0 0 0 0 0 0.00%

Unk 0 0 1 0 0 0 0 1 16.67%

Total 0 0 2 2 1 1 0 6 100%

P a g e | 53


Miles

# of

Runs

% of

Runs

0 - 5 2 33.33%

6 - 10 0 0.00%

11 - 15 0 0.00%

16 - 20 0 0.00%

> 20 2 33.33%

Unk 2 33.33%

Total 6 100%

To Scene

Miles

# of

Runs

% of

Runs

0 - 5 0 0.00%

6 - 10 0 0.00%

11 - 15 0 0.00%

16 - 20 0 0.00%

> 20 4 66.67%

Unk 2 33.33%

Total 6 100%

To Destination

To Scene 14

To Destination 49

Total 63

Average Run Mileage

# of

Times

% of

Times

1 16.67%

1 16.67%

3 50.00%

1 16.67%

6 100%

Response Mode to

Scene

Lights and Sirens

Lights, no siren

No Lights and Sirens

Unk

Total

# of

Times

% of

Times

2 33.33%

2 33.33%

2 33.33%

6 100%

Unk

Total

Transport Mode from

Scene

Lights Only - No Sirens

No Lights or Sirens

# of

Runs

% of

Runs

1 12.50%

1 12.50%

2 25.00%

4 50.00%

8 100%

No Destination

Total

Destination

BASIN CLINIC INC

Out of State Hospital

ST MARYS HOSPITAL AND

MEDICAL CENTER

Dispatch Reason

# of

Times

% of

TimesBack Pain (Non-

Traumatic/Non-

Recent Trauma) 1 16.67%

Nausea/Vomiting 1 16.67%

Seizure/Convulsions 3 50.00%

Unknown 1 16.67%

Total 6 100%

Age

# of

Runs

% of

Runs

Less Than 1 0 0.00%

1 - 4 0 0.00%

5 - 9 0 0.00%

10 - 14 0 0.00%

15 - 19 0 0.00%

20 - 24 0 0.00%

25 - 34 1 16.67%

35 - 44 0 0.00%

45 - 54 2 33.33%

55 - 64 1 16.67%

65 - 74 1 16.67%

75 - 84 0 0.00%

85+ 0 0.00%

Unk 1 16.67%

Total 6 100%


Run Mileage Patient Age Range

Response and Transport Mode

Destination and Disposition Dispatch Info

P a g e | 54


Appendix B List of Stakeholders Interviewed

Basin Clinic

County Commissioners

County Emergency Manager

CareFlight (St. Mary’s CareFlight)

Delta County Ambulance District

Delta County Memorial Hospital

Delta Montrose Technical College

Montrose Fire Protection District

Montrose Memorial Hospital

Montrose Regional Communications Center

Olathe Fire Protection District

Paradox Fire Protection District and Ambulance Association

Norwood Fire Protection District

Nucla-Naturita Fire Protection District and Ambulance

Regional Medical Directors

TransCare Ambulance Service

Tristate CareFlight

P a g e | 55


Appendix C: Survey Results

Answer Options 1 2 3 4 5 6 7 8 9 10Rating

AverageResponse

CountRating 1 0 1 1 3 6 12 10 6 4 7.20 44

444

In your opinion, how effective is the overall local EMS and hospital system in meeting the needs of the community (1 means does not meet community needs at all and 10 means meets all community needs completely)?

answered questionskipped question

Answer Options 1 2 3 4 5Don't Know

Rating Average

Response Count

The County EMS Resolution is up to date 4 2 2 6 5 21 3.32 40

Fire/EMS agencies are in compliance with

all applicable regulations2 0 9 11 6 12 3.68 40

The hospital is in compliance with all

applicable regulations1 1 1 5 3 28 3.73 39

The EMS system is accountable to the public

for its performance3 5 2 13 12 5 3.74 40

The hospital is accountable to the public for

its performance7 3 4 10 8 8 3.28 40

408skipped question

Legislation and Regulation Please rate the following on a scale of 1 - 5. 5 = Strongly Agree 1 = Strongly Disagree

answered question

P a g e | 56



Rating Average

Response Count

The EMS system in Montrose County is adequately

funded3 8 15 3 0 11 2.62 40

The trauma system in Montrose County is adequately

funded2 7 10 4 0 17 2.70 40

The local EMS system is sustainable over the long term 3 6 10 7 3 11 3.03 40

The hospital is sustainable over the long term 2 4 7 3 4 20 3.15 40

The EMS system is funded equitably across Montrose

County10 4 6 0 0 20 1.80 40

The hospital is funded equitably across Montrose

County4 1 7 2 0 26 2.50 40

Ambulance rates are reasonable 0 1 10 5 4 20 3.60 40

The public is willing to support EMS funding needs 1 6 9 6 2 16 3.08 40

408skipped question

System Finance Please rate the following on a scale of 1 - 5. 5 = Strongly Agree 1 = Strongly Disagree

answered question

1 2 3 4 5Don't Know

Rating Average

Response Count

4 13 11 4 2 6 2.62 40

2 8 13 11 1 5 3.03 40

0 4 2 17 11 4 4.03 38

2 10 11 6 3 7 2.94 39

6 14 8 5 1 6 2.44 40

4 11 5 5 3 11 2.71 39

408skipped question

Answer Options

EMS providers have a high turnover rate

Adequate numbers of EMS response units are

available

answered question

Human Resources Please rate the following on a scale of 1 - 5. 5 = Strongly Agree 1 = Strongly Disagree

People want to work or volunteer for EMS positions

Our community has adequate numbers of EMS

providers

Resiliency training is provided to EMS providers

EMS providers are held in high regard by the

community

P a g e | 57


1 2 3 4 5Don't Know

Rating Average

Response Count

0 7 6 10 9 7 3.66 39

1 5 5 11 9 8 3.71 39

0 8 6 7 4 14 3.28 39

1 3 5 7 9 14 3.80 39

2 1 2 7 4 23 3.63 39

399skipped question

Medical Direction Please rate the following on a scale of 1 - 5. 5 = Strongly Agree 1 = Strongly Disagree

The medical director is consulted on EMS system

issues

The medical director actively participates in the

system

answered question

The medical director actively participates in EMS

activities in the community

Answer Options

The medical director is consulted on hospital issues

The medical director regularly monitors clinical

performance

1 2 3 4 5Don't Know

Rating Average

Response Count

1 1 10 13 8 7 3.79 40

9 12 3 3 2 10 2.21 39

11 15 2 3 1 7 2.00 39

0 5 4 17 10 4 3.89 40

1 4 4 14 12 5 3.91 40

0 4 5 12 10 9 3.90 40

0 4 9 14 12 1 3.87 40

1 1 7 10 5 15 3.71 39

0 2 9 16 12 1 3.97 40

1 1 5 9 8 15 3.92 39

408

The quality of EMS is consistent across Montrose

County

Hospital care providers are well trained

Answer Options

The EMS protocols are up-to-date

Hospital care providers are experienced

The level of clinical care is consistent across Montrose

County

EMS care providers are well trained

skipped question

Clinical Care Please rate the following on a scale of 1 - 5. 5 = Strongly Agree 1 = Strongly Disagree

The EMS system has good clinical protocols

EMS care providers are experienced

Capability to provide critical care interfacility

transport is available locally

EMS protocols are coordinated between EMS agencies

including mutual aid agencies

answered question

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1 2 3 4 5Don't Know

Rating Average

Response Count

2 9 5 11 2 10 3.07 39

1 3 3 3 1 28 3.00 39

0 4 5 9 17 5 4.11 40

1 3 2 7 7 19 3.80 39

408

Education Please rate the following on a scale of 1 - 5. 5 = Strongly Agree 1 = Strongly Disagree

The hospital provides continuing medical education

for their employees or volunteers

Leadership training is available for EMS

administrators, managers and supervisors

skipped question

Fire/EMS agencies provide continuing medical

education for their employees or volunteers

Answer Options

answered question

Leadership training is available for hospital

administrators, managers and supervisors

1 2 3 4 5Don't Know

Rating Average

Response Count

0 3 5 11 18 3 4.19 40

0 2 2 12 10 14 4.15 40

0 6 10 9 8 7 3.58 40

1 5 4 7 8 14 3.64 39

2 12 8 2 4 11 2.79 39

4 7 13 6 3 7 2.91 40

408skipped question

Answer Options

There is good access to EMS in all areas of Montrose

County

Emergency medical instructions are provided to callers

when dialing 9-1-1

answered question

Public Access Please rate the following on a scale of 1 - 5. 5 = Strongly Agree 1 = Strongly Disagree

The public can access 911 in all areas of Montrose

County

The public can easily access EMS services

There are enough response units to provide a prompt

response to every call

Interfacility ambulance transport is readily available

when needed

1 2 3 4 5Don't Know

Rating Average

Response Count

2 9 9 9 2 7 3.00 38

4 12 9 3 1 9 2.48 38

2 7 9 5 1 14 2.83 38

3810skipped question

Regular efforts are made to inform the public about

EMS and trauma care

Public education Please rate the following on a scale of 1 - 5. 5 = Strongly Agree 1 = Strongly Disagree

answered question

The public understands and supports the local EMS and

trauma care system

Regular efforts are made to inform policy makers

about EMS and trauma care

Answer Options

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1 2 3 4 5Don't Know

Rating Average

Response Count

3 6 4 2 1 23 2.50 39

4 6 5 4 1 19 2.60 39

5 8 5 3 1 17 2.41 39

399skipped question

Prevention programs are developed based on local

needs

Prevention Please rate the following on a scale of 1 - 5. 5 = Strongly Agree 1 = Strongly Disagree

answered question

An analysis of local injury and illness data is

performed regularly

Prevention programs are regularly offered to the

community

Answer Options

1 2 3 4 5Don't Know

Rating Average

Response Count

4 15 7 9 1 3 2.67 39

2 6 6 13 2 10 3.24 39

1 7 9 10 7 5 3.44 39

0 4 5 15 12 4 3.97 40

1 5 5 15 8 6 3.71 40

408skipped question

Communications Please rate the following on a scale of 1 - 5. 5 = Strongly Agree 1 = Strongly Disagree

Fire and EMS have the ability to communicate over

radio frequencies

Local cell phone coverage is adequate

answered question

Public safety agencies have an effective radio system

Answer Options

Adjoining areas for mutual aid have the ability to

communicate with local EMS and fire agencies over

the radio

EMS and trauma care organizations have good access

to broadband internet service

1 2 3 4 5Don't Know

Rating Average

Response Count

2 1 7 10 11 9 3.87 40

3 1 3 8 6 18 3.62 39

7 7 2 7 0 17 2.39 40

4 4 5 11 0 15 2.96 39

408

Information Systems Please rate the following on a scale of 1 - 5. 5 = Strongly Agree 1 = Strongly Disagree

Information technology needs are being met within

the EMS and trauma care system

EMS/Fire services collect and upload electronic

patient care data to the state system

skipped question

The EMS/Fire and hospital electronic health records

are integrated

Answer Options

answered question

System performance data is regularly collected and

analyzed

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1 2 3 4 5Don't Know

Rating Average

Response Count

4 6 9 9 5 7 3.15 40

2 8 7 11 5 7 3.27 40

3 8 9 9 5 6 3.15 40

0 4 4 14 8 10 3.87 40

0 5 4 11 5 15 3.64 40

408skipped question

Mass Casualty Please rate the following on a scale of 1 - 5. 5 = Strongly Agree 1 = Strongly Disagree

EMS/Fire agencies and facilities have written mass

casualty response plans

MCI exercises are performed at least once a year

answered question

EMS/Fire and trauma agencies participate in annual

MCI exercises

Answer Options

EMS/Fire and trauma care leaders are aware of local

and state emergency management efforts and

Montrose County EMS and fire departments perform

MCI exercises annually


Rating Average

Response Count

The hospital and EMS agencies work well

together1 2 9 16 11 2 3.87 41

EMS is well connected to the overall healthcare

system2 2 10 16 8 3 3.68 41

EMS and fire agencies work well together 1 1 2 13 19 4 4.33 40

All participants in the EMS and trauma care

system understand their role2 2 8 20 6 3 3.68 41

417

System Integration Please rate the following on a scale of 1 - 5. 5 = Strongly Agree 1 = Strongly Disagree

skipped questionanswered question

1 2 3 4 5Don't Know

Rating Average

Response Count

0 2 11 10 4 12 3.59 39

1 2 7 10 2 17 3.45 39

4 4 8 6 2 15 2.92 39

408skipped question

Quality improvement findings are integrated into the

EMS and hospital care system

Evaluation Please rate the following on a scale of 1 - 5. 5 = Strongly Agree 1 = Strongly Disagree

answered question

Montrose County EMS/Fire agencies have a defined

and ongoing quality improvement program

Quality improvement activities are coordinated and

communicated between services

Answer Options

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Appendix D Montrose County Service Map

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Appendix E

Consultative Visit Team Biographical Information

Herb Brady, NR-Paramedic Herb Brady is currently the fire chief for the Windsor Severance Fire Rescue. The district is a combination fire district of 110 square miles that answers over 2,000 calls per year. His role included guiding the district through significant growth in call volume in the midst of an economic downturn. His team opened two new stations, cut administrative costs and brought EMS in-house through an innovative partnership with University of Colorado Health and neighboring fire districts. Presently WSFR is working toward international accreditation and creating innovative volunteer support services. His EMS career began in 1982 as a firefighter/EMT in Atascocita, Texas. He later took a position as a Captain with the City of Galveston EMS and Jamaica Beach Fire Department. In 1987 he returned to Colorado working as a paramedic for Denver General Hospital, later taking positions with Weld County Ambulance, Air Life of Greeley and Aims Community College. In 1996 he became a vice president for Regional EMS Authority (REMSA) in Reno, NV. In this time he started a for-profit subsidiary for the not-for-profit Authority with the mission being the provider of comprehensive EMS within the northern Nevada/California region. Regional Ambulance Services, Inc. (RASI) managed an ALS ground service that responded to 35,000 calls annually. On behalf of REMSA, RASI operated Care Flight – a HEMS air operation that grew from one to three aircraft and a regional 911 EMS communications center for both ground and air. Herb also worked to create SEMSA, a not-for-profit company designed to provide EMS in rural California communities including Lassen County/Susanville California. Herb was appointed by Nevada Governor Guinn to chair the Nevada EMS Committee and has served in many roles in injury/illness prevention and community outreach. He returned to Colorado working as a supervisor for Morgan County Ambulance and EMS director for Poudre Valley Hospital where he implemented many changes in deployment and clinical care.

Roger Coit, Paramedic Roger Coit is a faculty member at Colorado Mountain College in Leadville where he teaches as an Assistant Professor of EMS and Outdoor Studies. He has been an EMT since 1993, a paramedic since 1997, and he completed critical care paramedic training in 2003. He has been an EMS educator for 20 years, training responders for both wilderness and traditional EMS roles. In addition to his role as an EMS educator he is an AIARE avalanche safety course leader and an ACA swift water rescue instructor. Roger has served variously as an EMS service director, deputy director, supervisor and quality improvement and training officer in Chaffee, Lake and Summit counties. He completed the American Ambulance Association’s Ambulance Service Manager Certificate program in Kansas City, Mo. in 2004 and was awarded the Summit County Rotary ‘Hero’ award for his development of the Summit County AED Project that same year. He has a BS in animal biology from Colorado State University (1986). Roger carries a significant background in state and regional emergency medical services activities. He has served on the SEMTAC Medical Direction Committee, as a member of the Central Mountains RETAC, as Chairman of Lake County Emergency Services Board, as the Assistant Planner for the Northwest Colorado Regional Counter-Bioterrorism program, and as a private EMS system consultant. Roger lives

From left to right: Ray Jennings, Roger Coit, Tom Soos, Matt Concialdi, Phyllis Uribe, Herb Brady, Matt Skwiot

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in Salida, Colo. with his wife and two sons and is an avid skier and river runner, having worked as a professional ski patroller and river guide for many years.

Ray Jennings Jr., NR-Paramedic Ray Jennings is the chief of EMS and emergency management for Grand County Government since 2003. He has 30 years of experience in EMS as well as previous experience in the fire service, law enforcement and emergency management. Ray began his career as a volunteer firefighter and was given the opportunity to attend EMT training. Finding a new frontier to explore, he used his EMT training in the U.S. Army where he developed an EMT training program in conjunction with the local Vo-Tech to train sergeants as EMTs to help wounded and ill soldiers. Ray received an Army Commendation Medal for lifesaving and an Army Achievement Medal for system design. After completing his tour of duty, Ray returned to Texas and obtained his paramedic certification from Tarrant County Junior College. This opened the door for him to pursue his career in EMS. During his tenure, Ray has worked for hospital-based EMS, private EMS and public EMS and fire agencies. He has previously held positions as a fire marshal, a fire lieutenant, reserve sheriff’s deputy, paramedic field trainer and an instructor/trainer for initial training and continuing education programs. Ray’s primary toolbox includes system design and overhaul to grow failing EMS systems. As a manager, Ray has led public and private organizations made up of paid professionals and volunteer professionals. He has completed various training and educational programs as well as taught many programs during his career. Ray is a past member of the State Emergency Medical and Trauma Services Advisory Council and served on a number of committees. He also has been a speaker for the Northwest Leadership Conference. Ray was awarded the EMS Administrator of the Year for Colorado and has been the chief of two ambulance services that have won the Colorado Ambulance Service of the Year and Texas Ambulance Service of the Year. He is a member of multiple EMS societies. Ray holds current certifications from the National Registry of EMTs as a paramedic, Texas Department of Health as a paramedic and Colorado EMTS Branch as a paramedic.

Tom Soos, Paramedic Tom Soos has served as the emergency management coordinator for Moffat County since 2008. In this role, he is responsible for advising the Board of County Commissioners on matters related to EMS, emergency management and public health issues (animal and human) in the county. Through a collaborative stakeholder process, he ensures that emergency plans are updated as needed and that MCI exercises are conducted annually. Tom completed his Master Exercise Practitioner (MEP) certification from FEMA in 2014. Tom was the director of EMS for The Memorial Hospital in Craig, Colo., from 2002-2008, where he was responsible for the day-to-day operations and management for the hospital-based EMS service. During his time at the facility, he was instrumental in upgrading the service to providing ALS level of care on all calls. He also worked to develop a high profile EMS presence at public events, to ensure public awareness of the importance of an EMS presence at public events in the county. Tom was an EMS program instructor at Colorado Northwest Community College from 2004 to 2011 where he taught basic EMT classes, IV certification and refresher classes. Prior to moving to Colo., he worked at Rutgers, The State University of New Jersey, in the Department of Fire and Emergency Services for 19 years. In 1982 he completed his Paramedic training. In 1992 he completed the National Fire Academy’s Executive Fire Officer Program (EFO). While there he managed a combined paid and volunteer department. He established an in-house billing system that achieved a

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68 percent collection rate. He routinely commanded EMS operations at sporting events which drew over 40,000 spectators, and provided oversight of EMS coverage for high profile events such as presidential visits and World Cup events. Tom began his career in EMS and the fire service in Franklin Township, N.J. on volunteer departments as well as volunteering for the American Red Cross.

Matt Skwiot, M.D. Dr. Skwiot is currently a practicing Emergency Medicine Physician at Grand River Hospital in Rifle, Colo. where he is the chief of the Department of Emergency Medicine. He is the medical director for Colorado River Fire Rescue in Rifle, New Castle and Silt. In addition he is the medical director for Garfield County Search and Rescue. Dr. Skwiot is currently working on completing his Master’s Degree in Health Care Administration at Saint Joseph’s College of Maine. Dr. Skwiot began his medical career as an EMT-B for the Western State College Mountain Rescue Team. He attended medical school at St. Matthew’s University School of Medicine. During this time in Belize, C.A. where, with other medical students, he developed an Emergency Response Team in a third-world environment. He completed his clinical rotations in Chicago where he spent significant time working in urban underserved hospitals focusing on emergency medicine. He completed the Mountain Area Health Education Center Rural Family Medicine Residency in Hendersonville, NC with a focus on Rural Emergency/Acute Care. He went on to complete the Premier Healthcare Emergency Medicine Fellowship in Dayton, Ohio and Saint Rita’s Hospital in Lima, Ohio He is Board Certified in Family Medicine.

Phyllis Uribe, MS, BSN, RN Phyllis Uribe is a Colorado native and has been a registered nurse for over forty years. Her clinical background includes neurosurgical nursing, emergency department, and critical care as both a caregiver and a manager. She supervised the trauma program at Swedish Medical Center from 1982 through 2014, and was responsible for the transition process from a Level II to a Level I Trauma Center verified by the American College of Surgeons and designated by Colorado Department of Public Health and Environment. Phyllis has experience in quality improvement on the clinical and the system level, and served as both a site reviewer for trauma centers for the department and as an appointed member of the CDPHE Designation Review Committee. She has participated in gap analysis and process analysis projects for both trauma systems and individual trauma programs. Phyllis is currently Affiliate Faculty in the nursing program at Regis University, a national ATLS Educator, teaches and directs TNCC courses for EdCor, and works for MedPartners HIM in a variety of consulting and interim program manager roles.

The Department Representatives

Matt Concialdi, BA, NR-Paramedic Matt Concialdi is the EMS system development coordinator at the Colorado Department of Public Health and Environment, Emergency Medical and Trauma Services Branch. In addition, Matt staffs the State Emergency Medical and Trauma Services Advisory Council’s Safety Committee and is the co-chair on the Safety and Security Committee for the department. Matt served as the project manager, writer and editor for this consultative visit. He is a NREMT-Paramedic who started his EMS career in 2001 working in the EMS system of Orange County, Calif. Matt holds degrees in Emergency Management, Fire Technology Medical Services Officer and Paramedic and is finalizing a Master’s Degree in Emergency Services Administration. In 2011, he moved to Colorado and began working in the City of Aurora EMS system. He has spent most of his career as a field training officer training both EMTs and

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Paramedics as well as worked as a dispatcher in an emergency and non-emergency ambulance communication center. Matt has additional experience in EMS education as a primary instructor and clinical skills specialist. He is a certified train the trainer in Incident Response to Terrorist Bombing, FitResponder and First Response Resiliency. In 2012 Matt became a member of CO-2 Disaster Medical Assistance Team, a federal response team through the Health and Human Services Division of the Department of Homeland Security. In 2013 he received the Excellence in Patient Care (EPIC) coin award through HealthOne and was a recipient of the Phoenix Lifesaving Award from the City of Aurora Fire Department. He also owns his own CPR/First Aid and emergency preparedness business serving the Denver Metro area.

Eric Schmidt, RN, BSN, MBA, EMT-I Eric is a Colorado native and began his career in emergency services 30 years ago as a volunteer firefighter in Copper Mountain. He has provided EMS consulting services and technical assistance to local governments in Colorado through his firm, EMS Services, since 1992. He is currently the funding section manager at the Colorado Department of Public Health and Environment, Emergency Medical and Trauma Services Branch. Prior to that he contracted with the Northwest RETAC to serve as coordinator and provided ambulance inspection services for ten counties. Eric’s consulting services are supported by a broad array of experiences in emergency medical and trauma services. He was a trauma nurse for Penrose Hospital, a Level II trauma center in Colorado Springs. Before that, Eric served as the EMS Officer for El Paso County where his duties included contract administration of a high performance ambulance agreement for the El Paso County Emergency Services Agency, administration of the county’s ambulance licensing program and EMS system coordination. He has also served as the manager for a hospital district that operated an ambulance service and built a community clinic and emergency center during his tenure, directed the EMS training program for Colorado Northwestern Community College, administered federal pass-through grants as a program manager for the Colorado Department of Transportation, collected prehospital data for system analysis as an information system specialist at the Colorado Department of Public Health and Environment, and held paid and volunteer positions as an EMT at several rural EMS agencies. He earned Bachelor of Science degrees in Nursing, Business Administration and Mechanical Engineering from the University of Colorado, and a Master of Business Administration from the University of Oregon. Eric currently holds a Colorado Registered Nurse license, Colorado EMT-Intermediate certification and a technician level Amateur Radio license from the Federal Communications Commission.

References: 1US Census Bureau. State & County Quick Facts. Montrose County, CO. Found at http://quickfacts.census.gov/qfd/states/08/08085.html 2City of Montrose. Things to Do. Found at http://www.visitmontrose.com/27/Things-To-Do 3Montrose County. Learn About Montrose County. Found at http://www.co.montrose.co.us/622/Learn-About-Montrose-County 4US Census Bureau. State & County Quick Facts. Ouray County, CO. Found at http://quickfacts.census.gov/qfd/states/08/08091.html 5Mclay, Laura. (2010) Emergency Medical Service Systems that Improve Patient Survivability. Department of Statistical Sciences and Operations Research. Commonwealth University. Richmand, VA.

All photos taken and provided courtesy of Matt Concialdi or used by permission.

http://quickfacts.census.gov/qfd/states/08/08091.html

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