Health Policy Journal Club, Health Policy, Advocacy

Health Policy Journal Club: Putting Out Fires

There appear to be proven benefits of dual dispatch of Fire and EMS in urban areas

As fire services become more entrenched in EMS systems, cities are employing dual dispatch of Fire and EMS for medical runs. Dual dispatch is a method where both emergency medical services and medically-trained firefighters are dispatched in a medical response. This has become increasingly common for out-of-hospital cardiac arrest (OHCA) cases; however, until 2019 there has been a lack of peer-reviewed evidence to support increased survivability. New research provides evidence to better inform EMS policy in the effectiveness of dual dispatch to OHCAs.

This study analyzed 6,961 cases where dual dispatch was activated to respond to OHCAs in Houston, Texas, between May 2008 and April 2013. The authors sought to determine if the dispatch of Fire with EMS impacted the return of spontaneous circulation (ROSC) in OHCA cases while controlling and accounting for the arrival of an EMS unit to the scene.

In this study, fire apparatuses arrived before EMS ambulances 46.7% of the time with a median value of 1.5 minutes prior to arrival of an EMS crew. When controlling for the arrival time of EMS, the chance of ROSC achieved by fire responders was not modified by the arrival of EMS. However, when the fire services did not respond, the chance of achieving ROSC fell by 20.1% regardless of the heart rhythm. Further, patients with ventricular fibrillation and bystander CPR saw an even sharper 47.7% decrease in successful ROSC when fire services were not dispatched.

For Houston, Texas, the study demonstrates dual dispatch with fire services increased the probability of achieving ROSC in OHCAs independent of the arrival of an EMS unit. While this study provides strong evidence for the benefit of dual dispatch for OHCAs, perhaps it is yet premature to consider this the gold standard of EMS dispatch systems. We should carefully consider the consequences, such as an increased budgetary burden on the locality in costs of personnel, training, equipment, and fuel. Further, do these results suggest significant impacts on reduction of 30-day mortality? Finally, we should also consider the training disparities between Houston's medically-trained firefighters compared to firefighters in rural/volunteer services.

The study demonstrates proven benefits of dual dispatch in a metropolitan area. We should cautiously advocate for dual dispatch as the standard for OHCAs. However, study into the training, expenses, and disparities that exist between rural/volunteer services should be explored.

Abstract: Raun L, Pederson J, Campos L, Ensor K, Persse D. Effectiveness of the Dual Dispatch to Cardiac Arrest Policy in Houston, TexasJ Public Health Manag Pract. 2019;25(5):E13-E21.

BACKGROUND: Houston policy is to dual dispatch medically trained firefighters, in addition to emergency medical services (EMS) units to out-of-hospital cardiac arrest (OHCA) cases. While believed to improve public health outcomes, no research exists supporting the policy that when firefighters respond before a better-equipped EMS unit, they increase the probability of survival.

OBJECTIVE: To inform EMS policy decisions regarding the effectiveness of dual dispatch by determining the impact of medically trained firefighter dispatch on return of spontaneous circulation (ROSC), a measure of survivability, in OHCA 911 calls while controlling for the subsequent arrival of an EMS unit.

DESIGN: This retrospective study uses logistic regression to determine the association between ROSC and response time for fire apparatus first responders controlling for arrival of the EMS unit.

SETTING: Out-of-hospital cardiac arrest cases in Houston between May 2008 and April 2013 when dual dispatch was used

PARTICIPANTS: A total of 6,961 OHCA cases with the complete data needed for the analysis

MAIN OUTCOMES MEASURED: Logistic regression of the dependence of OHCA survival using the indicator ROSC, as related to the fire first responder response times controlling for subsequent arrival of the EMS

RESULTS: Fire apparatus arrived first in 46.7% of cases, a median value of 1.5 minutes before an EMS unit. Controlling for subsequent arrival time of EMS has no effect on ROSC achieved by the fire first responder. If the firefighters had not responded, the resulting 1.5-minute increase in response time equates to a decrease in probability of attaining ROSC of 20.1% for cases regardless of presenting heart rhythm and a 47.7% decrease for ventricular fibrillation cases in which bystander cardiopulmonary resuscitation was initiated.

CONCLUSIONS: The firefighter first responder not only improved response time but also greatly increased survivability independent of the arrival time of the better-equipped EMS unit, validating the public health benefit of the dual dispatch policy in Houston.

PMID: 31348172

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.