Monroe County Emergency Medical Services Report

Draft
February 18, 2013
Comprehensive Emergency Medical Services Study
Monroe County EMS

Monroe County, NY
FITCH & ASSOCIATES, LLC

2901 Williamsburg Terrace #G § Platte City § Missouri § 64079
816.431.2600 § www.fitchassoc.com
CONSULTANT REPORT
Monroe County EMS – Monroe County, NY
Comprehensive Emergency Medical Services Study
Table of Contents
EXECUTIVE SUMMARY __________________________________________________________________________ 1
PROJECT DESCRIPTION ___________________________________________________________________________ 1

FINDINGS ____________________________________________________________________________________ 1
Governance of EMS in Monroe County Is Very Weak ______________________________________________ 1
EMS in Monroe County Does Not Operate As a System ____________________________________________ 1
The Closest Ambulance Is Often Prohibited From Responding _______________________________________ 2
Emergency Medical Care Is Not Consistent ______________________________________________________ 2
Slow Response Times Occur Throughout the System ______________________________________________ 2
Reliable Data Is Lacking _____________________________________________________________________ 2
Medical Directors Do Not Track Basic Clinical Performance _________________________________________ 3
Appropriate Interface with Hospital Emergency Departments Is Lacking ______________________________ 3
Monroe County Is More Urban than People Think ________________________________________________ 3
Fewer Ambulances Can Achieve Performance Metrics _____________________________________________ 3
RECOMMENDED OPTIONS FOR CHANGE _______________________________________________________________ 4
Option Zero: Retain the Existing Emergency Medical System _______________________________________ 4
Option One: Staged Steps Toward Higher Performance ____________________________________________ 4
Option Two: Implement The “M-xR” Model Using Existing Agencies__________________________________ 6
Option Three: Implement The “M-xR” Model Using a Contract Agency _______________________________ 7
METHODOLOGY _______________________________________________________________________________ 8
AREA OVERVIEW_______________________________________________________________________________ 9
DEMOGRAPHICS INTRODUCTION ____________________________________________________________________ 9

EMS DEMOGRAPHIC ENVIRONMENT ________________________________________________________________ 11
Historical Population Changes _______________________________________________________________ 14
Predicted Population Changes _______________________________________________________________ 16
DEMAND FOR EMERGENCY MEDICAL SERVICES _________________________________________________________ 17
MONROE COUNTY SYSTEM _____________________________________________________________________ 19
SYSTEM DESCRIPTION ___________________________________________________________________________ 19

CURRENT EMS GOVERNANCE STRUCTURE _____________________________________________________________ 21
Monroe-Livingston Regional EMS (MLREMS) ___________________________________________________ 21
EMS Program Agency ______________________________________________________________________ 22
Regional Emergency Medical Advisory Committee (REMAC) _______________________________________ 22
Technical Advisory Groups __________________________________________________________________ 22
County EMS Office ________________________________________________________________________ 22
County Medical Director ___________________________________________________________________ 23
EMS AGENCIES _______________________________________________________________________________ 24
Monroe County, NY © Fitch & Associates, LLC

Comprehensive Emergency Medical Services Study Page i February 18, 2013
FIRE FIRST RESPONDERS _________________________________________________________________________ 29
SYSTEM DATA ________________________________________________________________________________ 34
Data Deficiencies _________________________________________________________________________ 34
CALL VOLUMES _______________________________________________________________________________ 35
BUILT-IN INEFFICIENCIES _________________________________________________________________________ 37
CALL PROCESSING ATTRIBUTES AND STANDARDS_________________________________________________________ 39
DISPATCH AND EMS AGENCY RESPONSE TIME PERFORMANCE ______________________________________________ 41
Dispatch Time ____________________________________________________________________________ 41
Agency Processing Time ____________________________________________________________________ 42
Chute Time ______________________________________________________________________________ 44
En Route Time____________________________________________________________________________ 45
Total Response Time ______________________________________________________________________ 45
MUTUAL AID AND NEW YORK CERTIFICATES OF NEED _____________________________________________________ 52
CURRENT COUNTY MUTUAL AID PLAN _______________________________________________________________ 53
Innovative Nursing Home Mutual Aid Plan _____________________________________________________ 53
CALL COVERAGE ISSUES _________________________________________________________________________ 54
CLINICAL VISION/MEDICAL DIRECTION____________________________________________________________ 55
QUALITY MANAGEMENT _________________________________________________________________________ 55

MEDICAL DIRECTION ISSUES AND OPPORTUNITIES________________________________________________________ 56
Multiple Layers/Little Authority ______________________________________________________________ 56
Clinical Performance Is Not Measured ________________________________________________________ 56
Patient Care Reports Not Provided to Emergency Department _____________________________________ 57
Clinical Data Deficits_______________________________________________________________________ 57
Role of Full-Time County Medical Director Limited _______________________________________________ 57
HOSPITAL SURGE CAPACITY _______________________________________________________________________ 58
PATIENT DESTINATION REVIEW ____________________________________________________________________ 59
ALTERNATIVE DESTINATION OPPORTUNITIES ___________________________________________________________ 59
FUTURE INVOLVEMENT WITH RHIO _________________________________________________________________ 61
SYSTEM FINANCES ____________________________________________________________________________ 62
DUPLICATED FUNCTIONS AND COSTS ________________________________________________________________ 62
BENCHMARKING THE MONROE SYSTEM __________________________________________________________ 64
SYSTEM BENCHMARKING ________________________________________________________________________ 64

CLINICAL BENCHMARKING ________________________________________________________________________ 67
911/MEDICAL COMMUNICATIONS __________________________________________________________________ 68
Best Practice Benchmarks for Communications _________________________________________________ 68
Key Accomplishments and the Current Situation in Monroe County _________________________________ 69
Automatic Vehicle Location (AVL) and Global Positioning Systems (GPS) _____________________________ 70
CAD to Mobile Data Terminals_______________________________________________________________ 71
Electronic Patient Care Records (ePCR) ________________________________________________________ 72
911 Emergency Call Processes and Standards___________________________________________________ 72
Dispatch Personnel ________________________________________________________________________ 76
SPECIFIC AREAS FOR IMPROVEMENT _____________________________________________________________ 77

Comprehensive Emergency Medical Services Study Page ii February 18, 2013
SOLUTIONS TO ALLOW FOR AGENCY BACKFILL __________________________________________________________ 77
IMPROVING EMS SUPPORT TO LAW ENFORCEMENT, FIRE AND SPECIAL OPERATIONS ________________________________ 77
BUILDING AN INCIDENT COMMAND STRUCTURE _________________________________________________________ 78
THE OPTIMIZED MODEL SYSTEM _________________________________________________________________ 80
GEOGRAPHIC AREA (M-XR) ______________________________________________________________________ 80

Operating Environment ____________________________________________________________________ 81
Historic Demand for Service _________________________________________________________________ 81
Defining Incident Zones ____________________________________________________________________ 83
Locating Ambulance Stations________________________________________________________________ 85
Sizing the Fleet ___________________________________________________________________________ 89
IMPLEMENTATION OF M-XR AS OPTION TWO __________________________________________________________ 91
Estimate of Costs _________________________________________________________________________ 91
Comparison to the Existing System ___________________________________________________________ 92
Estimates of Revenues _____________________________________________________________________ 93
FINANCIAL OUTCOME OF M-XR MODEL ______________________________________________________________ 95
“IMPLEMENTATION” OF M-XR AS OPTION THREE________________________________________________________ 95
FIGURE 1. MAP OF MONROE COUNTY __________________________________________________________________ 10

FIGURE 2. PROJECTED CHANGE OF TOTAL POPULATION IN MONROE COUNTY TO 2040 ________________________________ 16
FIGURE 3. PROJECTED CHANGES OF 65+ YEAR OLD POPULATION IN MONROE COUNTY TO 2040 __________________________ 17
FIGURE 4. EMS TRANSPORTS BY AGE GROUP JUL 2000 – JUN 2001 PINELLAS COUNTY, FL _____________________________ 18
FIGURE 5. CALL VOLUMES BY AGENCY CY2011 ___________________________________________________________ 35
FIGURE 6. CALL VOLUME SUMMARIZED CY2011 __________________________________________________________ 36
FIGURE 7. CALLS BY DAY OF WEEK CY2011 _____________________________________________________________ 37
FIGURE 8. CALLS BY TIME OF DAY CY2011 ______________________________________________________________ 38
FIGURE 9. SCHEMATIC REPRESENTATION OF THE FLOW OF A TYPICAL 911 CALL ______________________________________ 40
FIGURE 10. FLOW OF AN EMS CALL IN MONROE COUNTY ____________________________________________________ 42
FIGURE 11 PERCENTAGE OF URBAN, RURAL AND REMOTE INCIDENT ZONES COMPRISING EACH AGENCY’S DISTRICT _____________ 49
FIGURE 12. TYPICAL CAD DESIGN ____________________________________________________________________ 70
FIGURE 13. MATCHING DEMAND AND SUPPLY IN SOPHISTICATED MODELS _________________________________________ 71
FIGURE 14. CRITICAL COMMUNICATIONS FUNCTIONS OF AN EMS COMMUNICATIONS CENTER ___________________________ 73
FIGURE 15. TYPICAL EMS DISPATCH ACTIVITIES AND TASKS ___________________________________________________ 74
FIGURE 16. CALLS BY DAY OF WEEK CY2011 ____________________________________________________________ 82
FIGURE 17. CALLS BY HOUR OF DAY CY2011 ____________________________________________________________ 82
FIGURE 18. INCIDENT ZONES IN MONROE COUNTY BASED ON CALL DENSITIES ______________________________________ 84
FIGURE 19. PERCENTAGE OF URBAN, RURAL AND REMOTE INCIDENT ZONES COMPRISING EACH AGENCY’S DISTRICT_____________ 85
FIGURE 20. CALL AND DRIVE ZONES FOR “M-XR” MONROE COUNTY EXCLUDING ROCHESTER ____________________________ 86
FIGURE 21. AMBULANCE STATIONS FOR M-XR MODEL ______________________________________________________ 87
TABLE 1. SELECTED CENSUS PARAMETERS FOR MONROE COUNTY ________________________________________________ 9

TABLE 2. POPULATION AND POPULATION DENSITIES BY MUNICIPALITIES FOR MONROE COUNTY __________________________ 11
TABLE 3. MONROE COUNTY HOSPITALS _________________________________________________________________ 12
TABLE 4. MONROE COUNTY AMBULANCE SERVICES_________________________________________________________ 12
TABLE 5. NON-TRANSPORTING FIRST RESPONSE SERVICES ____________________________________________________ 13
TABLE 6. MONROE COUNTY TOTAL POPULATION AND POPULATION CHANGE 2000 TO 2010 ____________________________ 15

Comprehensive Emergency Medical Services Study Page iii February 18, 2013
TABLE 7. ROCHESTER – RURAL/METRO RESPONSE TIME REQUIREMENTS __________________________________________ 20
TABLE 8. URBAN/SUBURBAN AREA RESPONSE TIME PERFORMANCE MEASURES – COUNTY EXROCHESTER ____________________ 20
TABLE 9. RURAL AREA RESPONSE TIME PERFORMANCE MEASURES – COUNTY EXROCHESTER ____________________________ 21
TABLE 10. EMS AGENCIES’ SELF-ASSESSMENT - SURVEY RESPONSES _____________________________________________ 25
TABLE 11. EMS VOLUNTEER/PAID PERSONNEL, CARE LEVEL, VEHICLES – SURVEY RESPONSES____________________________ 26
TABLE 12. SPECIAL CAPABILITIES – SURVEY RESPONSES ______________________________________________________ 27
TABLE 13. EMS AGENCIES’ LOCAL SUPPORT, TRANSPORTS, BILLING – SURVEY RESPONSES ______________________________ 28
TABLE 14. EMS AGENCIES’ MAJOR ISSUES – SURVEY RESPONSES _______________________________________________ 29
ST
TABLE 15. FIRE 1 RESPONDER SURVEY - DEMOGRAPHICS ____________________________________________________ 30
TABLE 16. FIRE 1ST RESPONSE AGENCIES’ PERSONNEL AND CARE LEVEL – SURVEY RESPONSES ___________________________ 31
TABLE 17. FIRE 1ST RESPONDER SURVEY – SPECIAL CAPABILITIES & MAJOR ISSUES ___________________________________ 32
TABLE 18. NFPA 1221 DISPATCH STANDARDS ___________________________________________________________ 39
TABLE 19. NENA CALL TAKING OPERATIONAL STANDARDS ___________________________________________________ 39
TABLE 20. NFPA STANDARD FOR CHUTE TIME ____________________________________________________________ 39
TABLE 21. INITIAL STEPS OF 911 CALL HANDLING AND PERFORMANCE STANDARDS ___________________________________ 40
TABLE 22. DISPATCH TIMES FOR LIFE THREATENING CALLS BY AGENCY CY2011 _____________________________________ 43
TABLE 23. CALL PROCESSING TIME BY AGENCY ____________________________________________________________ 44
TABLE 24. ADVISORY MLREMS RESPONSE TIMES FOR URBAN/SUBURBAN AREAS ___________________________________ 46
TABLE 25. ADVISORY MLREMS RESPONSE TIMES FOR RURAL AREAS ____________________________________________ 46
TABLE 26. CONTRIBUTIONS TO TOTAL RESPONSE TIME ______________________________________________________ 47
TABLE 27 COMPOSITE TARGET RESPONSE TIME BY AGENCY ___________________________________________________ 50
TABLE 28 COMPARISON OF TOTAL RESPONSE TIMES WITH COMPOSITE TARGET RESPONSE TIMES BY DISTRICT _________________ 51
TABLE 29. MONROE COUNTY SYSTEM-WIDE BENCHMARK ASSESSMENT ___________________________________________ 64
TABLE 30. BEST PRACTICE SIDE-BY-SIDE COMPARISON ______________________________________________________ 75
TABLE 31. AMBULANCE LOCATION FOR THE M-XR MODEL EXCLUDING ROCHESTER ___________________________________ 87
TABLE 32. UNITS REQUIRED BY HOUR OF DAY ____________________________________________________________ 90
TABLE 33. ESTIMATED ANNUAL COST OF A FULLY PAID OPTIMIZED M-XR MODEL ____________________________________ 92
TABLE 34. ESTIMATED UNIT HOURS ALLOCATED TO THE EXISTING SYSTEM _________________________________________ 93
TABLE 35. COMPARISON M-XR MODEL COST AND EXISTING “VIRTUAL COST” OF CURRENT SYSTEM _______________________ 93
TABLE 36. GROSS REVENUE PER EMERGENCY TRANSPORT ____________________________________________________ 94
TABLE 37. ESTIMATE OF ANNUAL NET REVENUE FOR THE OPTIMIZED M-XR MODEL SYSTEM ____________________________ 95
Attachment A: EMS & Fire Survey List

Attachment B: January 11, 2013 New York State Department of Health Letter

Comprehensive Emergency Medical Services Study Page iv February 18, 2013
EXECUTIVE SUMMARY
PROJECT DESCRIPTION
In May 2012, Monroe County, New York engaged Fitch & Associates (“Fitch” or “Consultant”) to conduct
a comprehensive review of emergency medical services (EMS) provided countywide. Fitch was asked to
assess the capabilities of all agencies/components needed to deliver care and to evaluate their
contributions as part of a system. The County’s overarching objective is to improve care provided to
patients, to assess and preserve resources and to determine and document any inconsistencies in
service level that could be reasonably rectified, given the challenges of Monroe County’s mixed urban
and rural environment.
The existing EMS delivery model is composed of a diverse mixture of dedicated personnel and
organizations, rich with impressive histories of community service. Many have roots extending back to
volunteer groups of citizens reaching out to help other citizens. Those organizations grew into today’s
multitude of agencies, which are comprised of career and volunteer EMS providers offering varying
levels of service delivery and business sophistication.
The Consultant interviewed system participants and stakeholders, gathered and analyzed data and
developed deployment plans, along with three options for the future of Monroe County EMS. Below is a
summary of the Consultant’s findings.
FINDINGS
Governance of EMS in Monroe County Is Very Weak
There is a complex network of governing bodies where EMS physicians, agency leaders, and others
collaborate to write policy hampered by the absence of reliable and verifiable data describing the
performance of the Monroe County 911 Emergency Communications Department (911 Dispatch Center)
or the performance of the individual ambulance agencies. Implementation of these policies is another
matter. Mechanisms to monitor compliance, by-and-large, are not available to Monroe County. In
addition, the County EMS Office has no statutory authority over much of the activities of local EMS
agencies.
EMS in Monroe County Does Not Operate As a System

Monroe County’s EMS is a collection of more than 50 ambulance and first response agencies whose
uncoordinated activities do not always work in the best interest of patients. This collection of agencies is
not optimized to deliver consistent service across the County. Most importantly, the “system” does not
meet nationally accepted standards of response times for the delivery of emergency medical services to
patients.

Comprehensive Emergency Medical Services Study Page 1 February 18, 2013
The Closest Ambulance Is Often Prohibited From Responding
Too often, the closest appropriate ambulance cannot be dispatched to a request for service because of
an arbitrary line on a map that designates a particular address as another agency’s territory. These
territories are entrenched as part of New York State’s requirement that ambulance agencies operate
under a “certificate of need.” What was originally intended as a tool to manage growth and contain cost
instead has become a barrier to timely delivery of emergency medical care.
Emergency Medical Care Is Not Consistent

Emergency medical care is not delivered to patients at a consistent level across the County. Clinical care
available on emergency response vehicles varies from basic emergency medical technicians to advanced
life support paramedics, depending on location and ambulance agency.
Slow Response Times Occur Throughout the System

Dispatch time is the interval from when a call rings-in to County 911 to when a request for service is
transferred to an ambulance agency. The dispatch time of the Monroe County 911 Dispatch Center is
2:02 (min:sec). This is 17 seconds longer than the nationally accepted standard of 1:45. Staff at the
Dispatch Center do their best to compensate for inadequate technology.
Total response time is the interval from when a call rings-in to County 911 to when a unit is on-site at
the patient. Monroe Ambulance Service does not report response times back to the County 911
Dispatch Center. Rural-Metro Ambulance Service has its own contract objectives and reports and is held
accountable to those times. Chili, Point Pleasant, and Rush respond faster than their target response
times based on nationally accepted standards. Irondequoit, Hamlin, and Spencerport are slower than
these targets by less than 60 seconds. All of the other agencies are slower than these targets by multiple
minutes.
Agency processing time is the interval from when a County 911 request for service rings-in to the local
agency to when the local agency acknowledges its acceptance of the request back to County and notifies
its unit of the request. Agency processing time is a major contributor to slow total response times of
many ambulance agencies.
Reliable Data Is Lacking

Prior to the forensic extraction of data from the Northrop Grumman CAD conducted for this report, the
data describing the performance of the Monroe County 911 Emergency Communications Department
(911 Dispatch Center) or the performance of the individual ambulance agencies was inaccessible.
Historical data reflecting the geographic and temporal demands for service across Monroe County is of
irreplaceable value to policy makers because it predicts future emergency incidents by location and
time of day. The analyses in this report provide a snapshot of activities for 2010 and 2011. Going
forward, there will be, again, a lack of accessible data.

All of the local ambulance agencies collect data on their operations. In the opinion of Fitch & Associates,
this pool of data has four deficiencies that dilute its value: 1.) it is self reported and as such has not
been verified by independent third parties; 2.) it is often manually entered and as such is subject to
transcription errors; 3.) it is collected in response to local criteria that are not consistent agency-to-
agency; 4.) it is scattered across 29 agencies and is not available in a unified repository.
Medical Directors Do Not Track Basic Clinical Performance

There is no aggregation of patient care records from all ambulance agencies, so there is no way to
benchmark the quality of clinical services to patients countywide. Basic clinical performance benchmarks
such as cardiac arrest survival rates or evidence-based EMS performance measures, as described by the
Metropolitan EMS Medical Directors Consortium, cannot be produced by medical directors at most of
the ambulance agencies.
Appropriate Interface with Hospital Emergency Departments Is Lacking

Monroe County ambulance agencies do not provide a copy of the patient care report to the emergency
department (ED) physicians and staff when delivering a patient. During interviews, emergency
department physicians and staff noted that the lack of documentation provided by ambulance crews is
an important and significant issue.
Monroe County Is More Urban than People Think

From the perspective of land planning and utilization, most cities in the County perceive themselves as
“Rural,” as judged from the content of their websites. From the perspective of emergency medical
services, the call density (calls/square km/month) experienced in most of Monroe County falls into what
is termed the “Urban” category. To the surprise of almost everyone, including Fitch, the geographic area
experiencing “Urban” call densities extends out into the County, well beyond the limits of the City of
Rochester.
Fewer Ambulances Can Achieve Performance Metrics

The analyses conducted to construct an Optimized Model for the area of Monroe County excluding
Rochester (M-xR) indicate that the geography and call densities in the County do not intrinsically
prevent achieving nationally accepted emergency response times of 8:59/14:59/29:59 minutes in
urban/rural/remote incident zones respectively. Achieving these performance metrics during hours of
peak daily demand requires a maximum fleet of only 29 active ambulances, albeit, deployed
dynamically. Fitch opines the proposed fleet is modest compared to the fleet currently available among
existing ambulance agencies in the County.

RECOMMENDED OPTIONS FOR CHANGE
Option Zero: Retain the Existing Emergency Medical System
Because the existing “system” is largely supported by the local communities, the minimum option is to
do as little as possible. Except in the City of Rochester, which operates under a performance-based
contract, community support for local EMS agencies is not based on concrete and independently
verifiable data. Prior to the analyses presented in this report, no concrete performance data was
available for any of the individual ambulance agencies. Until the communities become aware that the
existing “system” does not perform to nationally accepted standards, there is little incentive to abandon
the status quo.
Option One: Staged Steps Toward Higher Performance

The County EMS Office should have authority to define EMS policies on a Countywide and consistent
basis. Empower the County EMS Office with local legislation to promote performance of all components
of the system against specific metrics. The County EMS Office should have authority for response and
incident management in certain circumstances. The County EMS Coordinator should be designated as
the operational and administrative executive officer for all EMS matters arising within the County. The
County EMS Medical Director should be designated as the lead clinical authority for all EMS matters
arising within the County. As part of these legislative actions, the County should obtain a countywide
certificate of need.
The County EMS Office should establish a consistent standard level of care (at a minimum Certified First
Responder (CFR) with defibrillation) to be provided by all fire service first response organizations. The
County EMS Office should authorize an Emergency Medical Technician (EMT) level of care, provided that
the fire service organization moves to that level as an agency such that all calls from that point forward
include at least one EMT with the first response contingent. The costs of these additional responsibilities
of the first responders should remain the burden of the local communities, as they are today.
As a matter of imminent public safety, the County EMS Office should establish a medically-mediated
response matrix that authorizes the use of “hot” response only to EMS calls involving substantial risk to
life (ECHO and DELTA), as defined by the Medical Priority Dispatch System (MPDS). All calls classified at
the MPDS levels ALPHA and BRAVO should use only “cold” response, if first response is dispatched at all.
Pending replacement of the antiquated Northrop Grumman Computer-Aided Dispatch (CAD) system,
implement an add-on that provides real time and reliable reports of the on-line/off-line status of
ambulance vehicles and crews (units) among the various ambulance agencies in the County. County
Dispatch may be able to work around some of the deleterious effects of hard boundaries when timely
reports of on-line/off-line status are available. Realistically, this implementation will need to have some
incentive to reward the district ambulance agencies for entering accurate reports of their on-line/off-
line status.

Replace the Northrop Grumman CAD system, and bring the Monroe County 911 Dispatch Center up to
modern capabilities of capturing and reporting the data describing operations.
Each agency’s district should be divided into incident zones based solely on call densities and not on
population densities. These incident zones should be designated as “Urban”, “Rural”, and “Remote”
using the criteria presented in the Optimized M-xR Model System. Target response times in each type of
incident zone should be established by the County EMS Office, preferably conforming to nationally
accepted standards.
After operating the new CAD system for six months, and quarterly thereafter, the performance of
Monroe County Dispatch and of each ambulance agency should be verified independently and
documented by the Monroe County EMS Office. Each agency should receive three separate scores — for
response time in its “Urban,” “Rural,” and “Remote” Incident Zones. Providing three scores per agency is
necessary to fairly assess performance between agencies operating in districts with different mixes of
Incident Zones.
Empower the County EMS Office with local legislation to promote compliance of all EMS agencies with
these target response times. Such an approach emphasizes the importance of the timely delivery of
emergency services to the patient, leaves the implementation to the discretion of each ambulance
agency and its local community, and recognizes that there can be as many ways to achieve the target
response times as there are local ambulance agencies.
Regularly publish and publicize the various operational and clinical performance metrics with the goal of
making the district’s ambulance agencies, as well as the general public, aware of the relative
performance of all agencies. Use these performance statistics as leverage to lobby state government to
remove the statues that entrench hard boundaries.
The impact of slow response times in Monroe County on patient outcomes needs to be measured,
especially in the case of life threatening calls. Regularly publish, in cooperation with the medical
directors of the existing ambulance services, clinical performance metrics per Utstein Style for cardiac
arrest reporting guidelines and the Eagle’s Cardiac Risk Assessment benchmark standards.
Empower the County EMS Office with local legislation to promote compliance of all EMS agencies with a
policy that a complete patient care report be provided to the Emergency Department (ED) prior to
departure, unless there is an extraordinary situation (disaster declaration, etc.). Look into the liability
issues surrounding the current practice of providing only abbreviated drop sheets to seek further
leverage to encourage compliance. Seek to establish community awareness of the importance of patient
care records.
Empower the County EMS Office with local legislation to mandate a centralized, uniform system of
electronic patient care records (ePCRs). Alternately, the County should require all agencies to participate
in the Regional Health Information Organization (RHIO) data repository for purposes of analysis and

review. The RHIO EMS depository should be expanded to include an enlarged data set, including the
National EMS Information System (NEMSIS) 3.x software.
Work with RHIO and others to develop and implement bidirectional data exchange that uploads ePCR
data directly in to the physician electronic medical record (eMR), and provides ED/hospital discharge
outcomes data directly back to the ePCR data base.
Install an Automated Vehicle Location/Global Position System (AVL/GPS) on all ambulances. Again,
County Dispatch may be able to work around some of the deleterious effects of hard boundaries when
the physical locations of ambulances are available to County dispatchers in real time.
Develop a strategic approach to community paramedicine, as an alternative to ambulance

transportation and emergency department treatment for those who call 911 with sub-acute and chronic
health conditions.
Further develop an incident command capability, such as the National Incident Management System
(NIMS)/Incident Command System (ICS), responsible for major incident planning and management.
More immediately, the County EMS Medical Director should be authorized to take operational control
of EMS actions at emergency scenes.
Option Two: Implement The “M-xR” Model Using Existing Agencies

Consider Monroe County, excluding the City of Rochester, (M-xR), as a single service district and
implement the optimized “M-xR” Model, as presented in this report. Obtain a countywide certificate of
need (CON) and obtain the authority to set station locations and dispatch ambulances. Installation of a
modern CAD system, AVL/GPS, ePCR, as specified in Option One, will need to have occurred.
Retain the existing ambulance service agencies. Have the existing ambulance service agencies contribute
ambulances and crews (units) to County 911 on a per shift basis. Coordinate on-line/off-line status by
time of day across all agencies to match active resources with demand, and thereby relieve operational
pressure on all agencies. This will be especially helpful to the smaller agencies. Implement dynamic
deployment of units. Site the units at the optimum locations identified in this report’s analyses of
historical call densities. Have County 911 dispatch units from these locations.
Centralize billing at the County level and have the County disburse reimbursement payments to the
ambulance agencies. Cost normalization based on out-of-jurisdiction call activity needs to be provided.
Centralize purchasing at the County level.

Option Three: Implement The “M-xR” Model Using a Contract Agency
As in Option Two, obtain a Certificate of Need that encompasses all of Monroe County, excluding the
City of Rochester (M-xR). Prepare detailed specifications and performance standards defined by zone
and for the overall system, and put emergency services in Monroe County, excluding the City of
Rochester, out to a competitive procurement process.
An intuitive expectation for the success of this approach is supported by two facts. First, such an
approach is already successful with the current contractor, Rural/Metro, operating within the City of
Rochester. Second is the realization that much of Monroe County experiences an “Urban” density of
calls, implying that the experience within Rochester likely applies to Monroe County.
A quantitative expectation for the success of this approach is provided by models of costs and revenues
that show a “revenue neutral” outcome for Monroe County. These models are grounded in this report’s
analyses of historic call densities.
Many of the existing ambulance vehicles may be acquired by, or partner with, the new service agency.
Many of the existing volunteer positions could convert to paid positions. Costs to the County are
expected to be very small. Costs to the municipalities are expected to be very small. The new contractor
may be required to reimburse the County for certain services.

METHODOLOGY
The Consultant team used a multi-pronged approach for this project that included on-site interviews
with a broad spectrum of service agencies, fire departments, medical directors, hospital administrators,
county and state officials. Relevant state and local laws were reviewed with a specific focus on current
Certificate of Need regulations. A survey of local agencies provided answers to the specific questions.
EMS service agencies and fire departments were sent two separate survey tools. There were 20 survey
responses from 31 EMS providers and 22 survey responses from the 38 fire departments that received
the survey.
The Consultant reviewed a two-year data extraction from the 911 County CAD system and the same two
years from Monroe Ambulance Service CAD. The County is operating with an old version of a Northrop
Grumman CAD written in Cobol. Data can be extracted only as a comma delimited flat file. The extracted
data file had many problems, including multiple duplicate entries, significant outliers and corrupted data
fields.
Ten percent (40,000 of the more than 400,000 calls) were discarded because the data was suspected to
be erroneous. Data that exceeded the following limits were assumed to be “data errors” rather than
actual events and were excluded from the Consultants’ analyses:
1. Dispatch Time greater than 10 minutes
2. Chute Time greater than 1 hour
3. Response Time greater than 1 hour
The Consultant further used the Monroe Ambulance data set in order to normalize the 911 Dispatch
Center data. Monroe Ambulance call volume set was considered as the accurate call volume. The 911
Dispatch Center data set was corrected to those values, thus eliminating duplicate calls in the data set.
Using the corrected/amended data set, the consultants plotted call density across the County and
developed a series of deployment models. The modeling efforts formed the basis of findings and options
presented in the report.
Financial data provided to the Consultant was scant, at best. Conclusions based on information available
in Fitch proprietary databases and on experience with like systems, were made.

AREA OVERVIEW
DEMOGRAPHICS INTRODUCTION
Monroe County is in the northern tier of western New York State, northeast of Buffalo and northwest of
Syracuse. The northern county line is also the state line and the border of the United States, marked by
Lake Ontario. According to the United States Census Bureau the County has a total area of 1,366 square
miles, of which 659 square miles is land and 706 square miles (51.72%) is water. Within the County are
19 towns, 10 villages and the City of Rochester. The City of Rochester sits approximately in the
geographic center of the County and is the third largest city in the state. Selected census parameters for
Monroe County are presented in the Table below.
Table 1. Selected Census Parameters for Monroe County

Parameter Name Parameter Value
Population, 2011 estimate 745,625
Population, 2010 744,344
Population Change, April 1, 2010 to July 1, 2011 +0.2%
Persons under 5 years, percent, 2011 5.8%
Monroe County is the center of the seven-county Rochester region, accounting for 64% of the region’s
population, yet the Monroe County's population has grown by just 1% since 2000. Monroe had around
744,300 residents in 2010, with about 28% of those residents living in the City of Rochester and 72%
living in the County, ex-Rochester. The population of the County, excluding Rochester, is 2.6 times larger
than that of the City of Rochester.
Monroe is the most racially and ethnically diverse county in the area, and home to most of the region's
cultural and tourist attractions. Its economy and population counts are largely stagnant. More
significantly, the City of Rochester lost about 4% of its population between 2000 and 2010, compared to
a 2% increase in the state and a 10% increase nationwide in the past 10 years.

The figure below is a map of Monroe County showing towns, villages and the City of Rochester.
Figure 1. Map of Monroe County
Monroe County's population has been aging. The number of adults 40 to 59 years old increased by 7%
from 2000 to 2010, making it the largest segment of the population and consistent with regional, state
and national trends. During that same period the number of 60 to 84-year old residents increased by
18%. The largest proportional increase was in the number of senior residents 85 and older, which grew
28%. Although this group represented only 2% of the total county population, the increase in both older
groups highlights the growing need for sufficient elder care and support services. The table below is a
snapshot from County planning documents depicting basic demographics for the County, Rochester and
the Towns and Villages in Monroe County.

Table 2. Population and Population Densities by Municipalities for Monroe County 1
The highest population densities are in the City of Rochester and East Rochester. Brighton, Greece, and
Irondequoit represent a second tier of population densities. Clarkson, Hamlin, Mendon, Rush, and
Wheatland represent the sparsest population densities.
EMS DEMOGRAPHIC ENVIRONMENT

Monroe County had a smaller proportion of people under 65 without health insurance than the State or
the nation. In 2009, 9% of Monroe residents lacked health insurance, compared to 11% in the
surrounding counties, 13% in the state and 17% in the nation. Within the region, Monroe had the
second highest enrollment rate in the Medicaid program of health insurance for the poor and disabled
1 Monroe County Total Population and Population Change 2000-2010. Thomas Goodwin, Planning Manager, Monroe County.
http://www2.monroecounty.gov/planning-planning.php

at 18% (below Orleans). Monroe had the highest number of physicians per 10,000 residents at 37 in
2009, slightly above the state level of 34.
Monroe saw a decline (-13%) in its overall mortality rate and much larger reductions in mortality from
certain diseases. From 2000 to 2008, Monroe residents had declines in mortality from heart disease
(-22%), cancer (-4%), respiratory disease (-10%), and stroke (-33%). 2
According to the New York State Department of Health, Monroe County has seven main hospitals as
reflected in the table below. Significantly, five of these are within the City of Rochester with only two of
them in more peripheral locations. 3
Table 3. Monroe County Hospitals

Hospital Name City/County Location
Highland Hospital of Rochester (an affiliate of University of Rochester) City
Rochester General Hospital City
Monroe Community Hospital (no Emergency Department; County owned & City
operated long term care facility)
Unity Hospital St. Mary’s Campus (no emergency department; will admit City
911 psych patients)
University of Rochester Strong Memorial Hospital (Level One Trauma City
Center)
Lakeside Memorial Hospital In County (out of City limits)
Unity Hospital Park Ridge Campus In County (out of City limits)
As of September 2012, the New York State Department of Health listed 29 ambulance services as being
licensed in Monroe County. In conversations with the County EMS Office, five of the agencies are no
longer providing transport services and two are to be added to the list resulting in a total of 26
ambulance (transporting) agencies in Monroe County. The amended list is in the table below.
Table 4. Monroe County Ambulance Services

Agency Name Level of Care
Beacon Transportation, Inc. d.b.a. Rural/Metro Medical Services Basic Life Support
Brighton Volunteer Ambulance, Inc. Paramedic
Brockport Volunteer Ambulance Paramedic
Caledonia Ambulance Paramedic
Chili Fire Department, Inc. Basic Life Support
Churchville Volunteer Fire Department, Inc. Basic Life Support
East Rochester Volunteer Ambulance Corps, Inc. Basic Life Support
Gates Volunteer Ambulance Service, Inc. Paramedic
Greece Volunteer Ambulance Service Paramedic
Hamlin Volunteer Ambulance Corps, Inc. Basic life Support
2
ACT Rochester, “Community Indicators for the Greater Rochester Area”. ACT Rochester is a partnership of Rochester Area
Community Foundation and United Way of Greater Rochester. http://www.actrochester.org/OurCommunity/Monroe/.
3
New York State, Department of Health, Bureau of EMS, EMS Agency and Hospital Information By County.
http://www.health.ny.gov/professionals/ems/counties/monroe.htm. Information supplement by County EMS Office.

Henrietta Volunteer Ambulance Service, Inc. Paramedic
Hilton Fire Department, Inc. Basic Life Support
Honeoye Falls Ambulance Paramedic
Irondequoit Volunteer Ambulance, Inc. Paramedic
Monroe Medi-Trans, Inc. d.b.a. Monroe Ambulance Paramedic
National Ambulance & Oxygen Svc, Inc. d.b.a. Rural/Metro Medical Paramedic
Services
Penfield Vol. Emergency Ambulance Service, Inc. Basic Life Support
Perinton Volunteer Ambulance Corps, Inc. Basic Life Support
Pittsford Volunteer Ambulance Service, Inc. Basic Life Support
Rochester Institute of Technology Ambulance Basic Life Support
Rush Fire Department, Inc. Basic Life Support
Scottsville Volunteer Fire Department, Inc. Basic Life Support
Sea Breeze Volunteer Fire Association Basic Life Support
Spencerport Volunteer Ambulance Service, Inc. Paramedic
Union Hill FD Basic Life Support
West Webster Volunteer Firemen’s Association d.b.a., West Webster Basic Life Support
Fire District
Of these ambulance services, Rural/Metro Medical Services and Monroe Ambulance are the largest
providers. Significantly, both are private for-profit agencies operating with paid staff. At the other end of
the spectrum are agencies such as Hamlin and Rush. These are located in small municipalities with low
population densities, and operate on a not-for-profit basis using volunteer staffing.
Twenty-eight fire first responder agencies support Monroe County’s EMS system. They vary in size and
capability from the large metropolitan City of Rochester Fire Department to smaller all-volunteer
departments outside the City. A number of Monroe County fire agencies have transport capability and
are included in the transport agencies listed above. The table below provides a list of fire first response
fire agencies that do not have transport capability.
Table 5. Non-Transporting First Response Services

Barnard Fire District Paramedic
Brighton Fire District Basic Life Support
Bushnell's Basin Fire Association, Inc. Basic Life Support
Clifton Fire Department Basic Life Support
East Rochester Fire Department Basic Life Support
Egypt Fire Department Basic Life Support
Fairport Fire Department Basic Life Support
Gates Fire District Basic Life Support
Greater Rochester Intl. Airport Fire Dept. Basic Life Support
Henrietta Fire District Basic Life Support
Honeoye Falls Fire Department Basic Life Support
Lakeshore Fire Department Basic Life Support
Laurelton Fire District Basic Life Support

Mendon Fire District Basic Life Support
Morton Volunteer Fire Company, Inc. Basic Life Support
Mumford Fire Department Basic Life Support
North Greece Fire Department Basic Life Support
Penfield Fire Company Basic Life Support
Pittsford Fire District Basic Life Support
Point Pleasant Fire Department Basic Life Support
Ridge Road Fire District Basic Life Support
Ridge-Culver Fire Department Basic Life Support
Rochester Fire Department Basic Life Support
Spencerport Volunteer Fire Department Basic Life Support
St. Paul Blvd. Fire Department Basic Life Support
Walker Fire Department Basic Life Support
Webster Volunteer Fire Department Basic Life Support
West Brighton Fire Department, Inc. Basic Life Support
Historical Population Changes

Data from the United States Censuses of 2000 and 2010 was compiled by the Monroe County Planning
Manager and is compared in the table below.

Table 6. Monroe County Total Population and Population Change 2000 to 2010 4
Between 2000 and 2010, the population of Monroe County increased by 1.2%. Over the same time span,
the population of the City of Rochester decreased by 4.2%. Population growth in the County, ex-
Rochester, was greater than the loss of population experienced by the City of Rochester. The hotbeds of
population growth in the County are the towns of Henrietta, Pittsford, and Webster.
4
Table prepared by Monroe County Department of Planning and Development. Source: US Census Bureau, 2010 Census
Redistricting Data (PL 94-171), released March 24, 2011.

Predicted Population Changes
Cornell University’s Program on Applied Demographics5 makes projections of future changes of
population in Monroe County over the next 27 years. The figure below reflects the projected changes to
2040.
Figure 2. Projected Change of Total Population in Monroe County to 20405
The most striking aspect of this projection is that the total population of Monroe County will be
numerically stagnant over the near future.
PAD also analyzed the internal dynamics of this projected population. While the total population may be
stagnant, the distribution of ages within this population is changing dramatically. For purposes of the
delivery of healthcare and emergency medical services, the most significant cohort of ages is the
segment 65 years and older. Changes in the number of people in this age bracket are presented in the
figure below.
5
Cornell Program on Applied Demographics. http://pad.human.cornell,edu/counties/projections.cfm

Figure 3. Projected Changes of 65+ Year Old Population in Monroe County to 2040
Significantly, the population in the 65+ age group will increase 24% between 2010 and 2020. Between
2010 and 2030 it will increase by 35%.
DEMAND FOR EMERGENCY MEDICAL SERVICES

Intuitively, there exists the sense that as the number of older people increases, there will be an increase
in the number of age-related emergency events. Notwithstanding a stagnant total population in Monroe
County, the increased number of people in the 65+ age group will predictably drive demand for
emergency medical services. Of course, the critical question is, by how much? Four studies provide
insight into the impact of such population trends.
First, the Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill,
North Carolina, conducted a retrospective study of 2,743,221 EMS transports to emergency department
across North Carolina in 2007. A major finding of this study was that individuals 65 years of age or older
accounted for 38.3% of all EMS transports to North Carolina emergency departments. 6
6
TF Platt-Mills, B Leacock, JG Cabañas, FS Shofer, SA McLean, Prehospital Emergency Care, 2010 Jul-Sep; 14(3): 329-333. doi:
10.3109/10903127.2010.481759.“Emergency medical services use by the elderly: analysis of a statewide database.”
www.ncbi.nlm.nih.gov/pubmed/20507220.

A second study supported by Florida’s Pinellas County Mental Health and Substance Abuse Task Force
with cooperation of the Pinellas County Data Collaborative, evaluated the impact of seasonal migration
of “snowbirds” into Pinellas County on EMS transports for 1999 - 2001. The result of this migration is to
increase the number of EMS transports during the winter months as depicted in the figure below. 7
Figure 4. EMS Transports by Age Group Jul 2000 – Jun 2001 Pinellas County, FL
What is more relevant to predictions for Monroe County, are the statistics reported for the summer
months in Pinellas County. Per the 2000 United States Census, Pinellas County had 22% of its domiciled
population in the 65+ age group. During the summer months, at least 50% of all EMS transports involved
the 65+ age group. One fifth of the domiciled population accounted for one half of the EMS transports.
Similar observations regarding age and EMS transports were made in smaller and earlier studies in
Forsyth County, North Carolina in 1995 and in Dallas, Texas in 1990. 8
The consequences of these observations for Monroe County are clear. Even through total population
will be stagnant, the demand for EMS transports will grow by about 10% between 2010 and 2020
because of the aging population. A growth rate of 1% per year in transports appears modest and should
not apply extraordinary additional pressure to the County’s emergency medical services, assuming that
the growth is distributed uniformly across the County. However, assuming a uniformly distributed
growth of the population in the 65+ age bracket is optimistic. The existing demographic data for
Henrietta, Pittsford, and Webster already show a very asymmetric growth of population in the County
and these areas will be impacted more significantly.
7
D Haynes, “The Impact of Snowbirds to Pinellas County Emergency Medical Services”, Oct., 2003.
psrdc.fmhi.usf.edu/Pinellas/TheImpactofSnowbirdstoPinellasCountyEMS.pdf
8
JL Wofford, WP Morgan, MD Heuser, E Schwartz, R Velez, MB Mittelmark, Am J Emerg Med, 1995 May, 13(3): 297 - 300.
“Emergency medical transport of the elderly: a population-based study” and CE McConnel, RW Wilson, Soc Sci Med, 1998 Apr,
46(8): 1027 - 1031.“The demand for prehospital emergency services in an aging society”.

MONROE COUNTY SYSTEM
SYSTEM DESCRIPTION
The Monroe County EMS system is made up of a diverse collection of system participants. Fire and
ambulance agencies vary from those with all-volunteer personnel to those with fully paid staffing and
management; some agencies receive taxing district funds or local tax support; some, but not all, bill for
patient transport services; most are not-for-profit organizations and at least two are major for-profit
corporations.
The 911 public safety access point (PSAP), also known as the Emergency Communications Department
(ECD) is an agency of the City of Rochester that provides service throughout Monroe County. The County
and the City have a renewable 10-year contract under which the County provides all radio, telephone
and computer equipment while the City provides and maintains the building in which the PSAP is
located. ECD, or the County 911 Dispatch Center, as it is referred to in this report, provides dispatching
services for all fire departments and EMS agencies in the County. The two for-profit EMS agencies,
Monroe Ambulance and Rural/Metro Corporation, maintain sophisticated dispatch systems and
dispatch their own units after an emergency call is transferred to them from the County 911 Dispatch
Center.
Monroe Ambulance is a family-owned, for-profit corporation that has operated in Monroe County since
1975. The company holds a countywide Certificate of Need and competes with Rural/Metro in the non-
emergency patient transport market within the City of Rochester and the greater County. The company
provides backup services under mutual aid agreements with a number of the suburban EMS agencies
and is available to back-up Rural/Metro as needed.
Monroe Ambulance operates a sophisticated dispatch system and can receive 911 calls directly from the
911 Dispatch Center. The company is active in the community and has grown exponentially over its 30+
years of operations.
The City of Rochester currently contracts with Rural/Metro Corporation to provide paramedic treatment
and transport. Rural/Metro, a private-for-profit transport agency owned by a private equity firm, has
held the contract with the City since the mid-90s. Rural/Metro transports both emergency patients
(under exclusive contract) and non-emergency patients (non-exclusive rights) with paramedic advanced
life support (ALS)-staffed and equipped ambulances, as appropriate. Rural/Metro operates under a
performance-based contract with the City to respond to emergency 911 calls.
The current contract was the result of a competitive procurement process. The contract took effect on
April 1, 2012. The City receives emergency response services at no cost to taxpayers (no subsidy) and, as
part of the contract the company is obligated to reimburse the City for fire department first response

and other services. This contract is for a four-year term with provisions for renewals for a possible
contract length of eight years.
Services provided under contract include: advanced and basic life support services, critical care
transport, specialized care for bariatric patients and non-emergency ambulance service to hospital
systems and healthcare facilities throughout the area.
Both Monroe Ambulance and Rural/Metro deploy ambulances in a dynamic manner, and staff
ambulances to meet call demand based on historical call data. Both agencies hold countywide
certificates of need in Monroe County.
The contract between Rural/Metro and the City of Rochester spells out the following response time
performance requirements within four City-designated zones as follows:
Table 7. Rochester – Rural/Metro Response Time Requirements

Call Prioritization Response Time Requirement Clock Begins
Priorities 1 & 2 Within 8 minutes 59 seconds at 90% Receipt of call at R/M Dispatch
Priority 3 Within 12 minutes 59 seconds at 90% Receipt of call at R/M Dispatch
Priority 4 Within 17 minutes 59 seconds at 90% Receipt of call at R/M Dispatch
Response time is measured upon transfer of a call from the County 911 Dispatch Center and receipt of
the call at Rural/Metro Dispatch Center. The majority of the City of Rochester is an “Urban” designated
area, based on the density of calls. The City’s performance requirements for Rural/Metro are within
accepted standards for emergency medical responses.
On November 29, 2010, Dr. Jeremy Cushman, the County/Regional Medical Director issued Advisory 10-
18 outlining Regional Performance Measures for Urban/Suburban and Rural areas that are summarized
in Tables 8 and 9. Dr. Cushman notes in the advisory memorandum that the performance measures are
endorsed by the Monroe-Livingston EMS Council, the Monroe-Livingston REMAC, the Livingston County
Board of Health, and the Monroe County EMS Advisory Board.
Table 8. Urban/Suburban Area Response Time Performance Measures – County exRochester

Responding Agency Call Prioritization Response Time Requirement Clock Begins
st
BLS or ALS 1 Responders All emergency events Within 5 minutes 0 seconds at From time of unit
(Delta or Echo) 90% reliability notification (dispatch)
ALS Transport Ambulance Priorities 1 & 2 Within 10 minutes 0 seconds at From time of unit
90% reliability notification (dispatch)
ALS Transport Ambulance Priority 3 Within 15 minutes 0 seconds at From time of unit
BLS Transport Ambulance Priority 4 Within 25 minutes 0 seconds at From time of unit

Table 9. Rural Area Response Time Performance Measures – County exRochester
st
The Advisory memo indicates that the Urban/Suburban and Rural designations are based on population
density. Later sections of this report discuss in depth the errors incurred by using population density as
the basis for performance designation. Briefly, 72% of the population lives outside the City of Rochester,
yet at least 48% of calls occur within the City. Using population density could result in areas being
designated as Rural, which based on call density (need), should be deemed Urban/Suburban.
CURRENT EMS GOVERNANCE STRUCTURE

Monroe County Emergency Medical Services agencies are subject to a number of governing influences.
Regulation of EMS in New York State (NYS) is primarily a state function. The Bureau of Emergency
Medical Services is located within the NYS Department of Health (DOH), Office of Health Systems
Management. The Bureau is responsible for the general oversight of the EMS system statewide. The
EMS Bureau is responsible for implementing state statutes relevant to EMS, and for developing and
promulgating regulations (administrative code) as authorized by statute. Laws and regulations governing
EMS in New York can be referenced at the EMS Bureau's comprehensive web site
www.health.ny.gov/regulations.
Despite the fact that Monroe County has no statutory authority over much of the activities of EMS
agencies (first responder and ambulance services alike), there is a network of governing bodies where
EMS physicians, agency leaders, and others collaborate in an effort to make policy and resolve
differences. Monroe County, through its EMS Coordinator and Medical Director, actively participates in,
and in many cases provides active leadership to, the activities of each group.
Monroe-Livingston Regional EMS (MLREMS)

The Monroe-Livingston Regional EMS (MLREMS) is one of the 18 regional councils in New York State that
were created to oversee EMS for the NYS DOH. Each region consists of a council that is responsible to
report to the NYS DOH Bureau of EMS, coordinate EMS programs within its region, and make
determinations of public need for additional EMS services in the region.

EMS Program Agency
MLREMS also utilizes a program agency that is responsible for facilitating quality improvement (QI) of
EMS care within its region, supporting the Regional Emergency Medicine Advisory Committee (REMAC),
providing prehospital education programs and other activities to support and facilitate regional EMS
systems. In this region, the program agency is the Division of Prehospital Medicine at the University of
Rochester Medical Center - Strong Hospital.
Regional Emergency Medical Advisory Committee (REMAC)

The Council is supported by the REMAC. The REMAC develops policies, procedures and triage, treatment
and transportation protocols to reflect the needs of the region; however, all policies, procedures, and
protocols are consistent with the standards of the SEMAC (State Emergency Medical Advisory
Committee). The REMAC also approves physicians to provide on-line medical control, coordinate the
regional medical control systems and participate in quality improvement activities.
Technical Advisory Groups

Ad hoc groups, known as technical advisory groups, or TAGs, are formed to address specific issues when
group work, input, and consensus are needed. There is currently a TAG working on the perplexing
"closest unit dispatch" issue.
County EMS Office

The County EMS Office is staffed by a single professional staff member, the County EMS Coordinator,
and clerical support. The County also provides a contracted EMS physician, whose primary responsibility
involves in-field response to serious emergencies, along with providing clinical advice and guidance to
the EMS office and agencies.
The EMS Office has been active, aggressive and enthusiastic about improving the County EMS system
and the role of EMS agencies in improving the health and safety of the community. Examples of current
EMS Office functions include:
§ Providing technical and administrative support to local emergency medical services agencies
§ Investigating and develops recommendations dealing with problems impacting the EMS system
§ Administering training programs and services for EMS agencies
§ Providing on-site medical control and quality assurance through the Monroe County EMS
Physician Response Vehicle
§ Administering EMS Mutual Aid plan
§ Serving as information resource to governmental and local agencies (including hospitals and
ambulance services) regarding EMS
§ Providing support to Monroe/Livingston REMAC, EMS Council and EMS Advisory Board
§ Administering County supported Critical Incident Stress Management Program
§ Responding to major incidents including Hazardous Materials
§ Staffing the EMS desk at the County Emergency Operations Center (EOC)

This impressive list of involvements belies the fact that in a county of with just under three-quarters of a
million people and with a complex EMS system composed of over 50 agencies, the County EMS Office is
woefully understaffed. Basic EMS office functions, such as measuring and reporting EMS system
performance, investigating citizen concerns and complaints, assuring prompt response and responder
safety, can only be addressed as exceptions and not in a proactive or systematic manner. Functions that
could be effectively managed as shared services (as evidenced by the County’s strong history with
shared fire and law enforcement services), such as specialized medical rescue efforts and medical
support to law enforcement and fire special operations units, cannot be addressed due to lack of both
human resources and funding.
County Medical Director

The EMS Office contracts for the Monroe County EMS Medical Director, who provides medical direction
and oversight for fire agencies, law enforcement, 911 Dispatch Center, transporting and non-
transporting EMS agencies. However, it is not mandatory - any one of these agencies may choose to
execute their own contract with a REMAC-approved physician.
Prior to the EMS office putting this contract in place, many fire and EMS agencies did not have a medical
director as required by NYS regulations. Since this contract has been put in place, all regulations are met,
such as real time field auditing by the physician, support for special operations etc. The EMS portion of
federal grants has funded equipment and supplies for the Medical Director.
The County Medical Director’s field responsibilities are noted below:

§ Facilitate patient care by responders
§ Expand scope of practice of responders
§ Assist with patient destination decisions
§ Provide direct patient care when needed
§ Assure the health and safety of responders
§ Serve as on-scene subject matter expert
§ Provide real-time quality assurance oversight
The Medical Director’s overarching objective is to establish medical policy for prehospital care and
operations of Emergency medical Services in the County. He provides medical direction and oversight
for a number of system participants and programs including but not limited to:
§ The County’s Public Access Defibrillation Program for all Automated External Defibrillators
(AEDs) owned/maintained by the County
§ Medical review of patient outcomes and statistical data a necessary to protocol application and
modification
§ Advice to the Monroe County Public Health Department on all matters relating to emergency
medical providers and issues as they may arise in relation to their impact on public health

§ Liaison relationship with the medical community (for example, hospitals, emergency
departments and out-of-hospital providers).
The Medical Director helps all special teams to meet or exceed Federal Emergency Management Agency
(FEMA) medical Equipment/Service Capability targets at specialized levels. Special teams include the
Monroe County Hazardous Materials Team, Sherriff’s Department Tactical Team and specific regional
initiatives such as the Urban Search and Rescue and Regional Incident Management Team. Routine
dispatches of the Medical Director are to mass casualty incidents, when there are three or more
ambulances on a scene, GRIA Alert 1, 2 or 3, Hazmat calls, working fires and special operations incidents.
As detailed in the Medical Director’s job description, he is to set and ensure compliance with patient
care standards including communications standards and dispatch and medical protocols, and oversee
the coordination of activities such as mutual aid, training, disaster planning and management, hazardous
materials response including weapons of mass destruction and terrorism.
EMS AGENCIES
The level of care provided by ambulance service agencies operating in Monroe County breaks down as
follows:
§ 11 ambulance agencies provide paramedic or advanced life support (ALS) care,
§ 15 provide basic life support (BLS)
One of the fire first response agencies provides ALS care.
In order to gain a better understanding of the ambulance service agencies, the Consultant sent a survey
to the 29 agencies listed by DOH, augmented by additional agencies per the EMS Coordinator and those
that may provide mutual aid response into Monroe County. In total, the survey was sent to 42 agencies
and administrative personnel. Only responses from the agencies were considered. Of the total, 20
agencies responded and substantially completed the questions.
The survey included 29 questions about demographics, fleet size, calls, responses and transport volume,
volunteer and paid personnel, personnel certifications, subsidies received, organizational structure,
transport billing, special response capabilities and identification of major issues.
A list of the agencies that received the survey, along with notations of those that completed it and those
that did not is provided in Attachment A.

The following tables provide the survey responses by agency with questions grouped into topic areas.
Table 10. EMS Agencies’ Self-Assessment - Survey Responses

Municipal Cannot afford Needing Non-profit
At acceptable BLS transport
support, but paid staff & mutual aid to having trouble
levels re organization
Agency pressured to volunteer handle calls is covering calls
personnel & w/o reliable
be more self- availability is more than a and/or
finances ALS backup
sustaining decreasing rare one surviving
Brighton X
Chili X
Churchville X
E. Rochester X
9
Greece X
Henrietta X
Hilton X
Honeoye X
Monroe X
NE Quad ALS X
Penfield X
Perinton X
Rural/Metro X
Rush X
Scottsville X
SE Quad MCCU X
Spencerport X
U of R MERT X
W Webster X
Xerox X
Total 13 1 2 1 1 2
Agencies were asked to self-assess in six specific areas. It is notable that of the 20 that answered, 13
answered that they are at acceptable level with regard to personnel and finances. There is no clear
pattern in the other areas of the self-assessment.
The following table provides detailed information on volunteer versus paid staff, medical certifications
of paid and volunteer personnel and the number of licensed ambulances and quick response vehicles
(QRVs) available.
9
This is the self-assessment information provided by Greece in the survey; however, Greece is a paramedic-level agency.

Table 11. EMS Volunteer/Paid Personnel, Care Level, Vehicles – Survey Responses
Agency EMS Chief Medical Paid Volunteer Paid Volunteer Licensed Licensed
Personnel Officer Capability EMTs EMTs Para- Paramedics Ambulances QRVs
medics
Brighton Combination Paid ALS 14 27 23 0 5 2
Chili Combination Volunteer BLS 15 41 0 0 3 0
Churchville Volunteer Volunteer BLS 0 14 0 0 1 0
E. Rochester Volunteer Volunteer BLS 0 14 0 0 2 0
Greece Combination Paid RSI 50 25 25 1 5 1
Henrietta Combination Paid RSI 23 9 23 0 6 4
Hilton Volunteer Volunteer BLS 0 49 0 0 2 0
Honeoye Combination Volunteer ALS 32 28 9 1 4 2
Monroe Paid Paid RSI 97 0 65 0 26 4
NE Quad Paid Paid RSI 15 0 20 0 0 4
ALS
Penfield Combination Paid BLS 10 45 0 0 3 0
Perinton Combination Paid BLS 60 10 0 0 4 1
Rural/Metro Paid Paid RSI 187 0 119 0 37 5
Rush Volunteer Volunteer BLS 0 15 0 0 1 2
Scottsville Volunteer Volunteer BLS 0 6 0 0 2 1
SE Quad Paid Paid RSI 16 0 34 0 0 6
MCCU
Spencerport Combination Paid RSI 30 10 12 0 2 1
U of R MERT Volunteer Volunteer BLS 0 30 0 0 0 1
W Webster Combination Volunteer BLS 8 34 0 0 2 1
Xerox Paid Paid ALS 18 0 3 0 1 1
Totals 9 Combo 3 ALS 575 357 333 2 106 36
6 Volunteer 9 Volunteer 10 BLS
5 Paid 11 Paid 7 RSI
A surprising six agencies report that all field personnel, including the Chief Officer, are volunteers. Five
of the agencies report all paid EMS personnel and a paid Chief Officer position. The remaining nine
agencies are some combination of paid and volunteer personnel. “Combination” for EMS personnel
means that both paid and volunteer personnel staff ambulances. It is typical for combination agencies to
staff with paid personnel during weekday work hours and to augment with volunteer staffing in
evenings and weekends.
It is important to note that the number of EMTs and paramedics is likely to be duplicative. Many paid
personnel work and volunteer with more than one agency. Nevertheless, according to the 20 survey
respondents, there are 575 paid EMTs and 333 paid paramedics. The 20 agencies report a total of 106-
licensed ambulance vehicles and 36 licensed Quick Response Vehicles.

Based on the survey responses, there are three ALS agencies in the survey and seven that are certified
to perform rapid sequence induction (RSI), an ALS/paramedic level procedure. Per the County EMS
Office, Greece and Spencerport have RSI capability, but did not answer that survey question.
Table 12. Special Capabilities – Survey Responses

EMS Teams on Bicycles
EMS Support to SWAT
EMS Support to Bomb

Ems Support to USAR
EMS Teams on Snow
EMS Teams on ATVs
Swiftwater Rescue
Bariatric Patient
Rapid Sequence
EMS Support to
Agency
Rope Rescue
Dive Rescue
Intubation
Ice Rescue
HAZMAT
Machine
Squad
Brighton
Chili
Churchville Yes Yes Yes
E. Rochester
Greece
Henrietta Yes
Hilton Yes Yes
Honeoye
Monroe Yes Yes Yes Yes Yes Yes Yes Yes Yes
NE Quad ALS Yes
Penfield Yes Yes
Perinton
Rural/Metro Yes Yes Yes Yes Yes Yes Yes Yes
Rush Yes Yes Yes Yes
Scottsville Yes
SE Quad MCCU Yes
Spencerport
U of R MERT
W Webster Yes Yes Yes Yes Yes Yes
Xerox Yes Yes
Total 3 6 1 1 3 3 2 0 4 5 4 2 6
Special capabilities are scattered. Only Rural/Metro and Monroe Ambulance approach the majority of
the 13 capabilities in the survey. The table below provides information about local financial support,
patients transport numbers and other administrative information.

Table 13. EMS Agencies’ Local Support, Transports, Billing – Survey Responses
Patients
Local Jurisdiction Bill for
Agency Transported If yes, how is billing done?
Tax Support Service?
CY2011
Brighton Yes 3,515 Yes Contracted billing company
Chili Yes 1,560 Yes Contracted billing company
Churchville Yes 250 No N/A
E. Rochester Yes 331 Yes Contracted billing company
Greece No 3,500 Yes Contracted billing company
Henrietta Yes 3,980 Yes Contracted billing company
Hilton No 453 No N/A
Honeoye Yes 707 Yes Contracted billing company
Monroe No 15,543 Yes In-house personnel
NE Quad ALS No 2,000 Yes Contracted billing company
Penfield Yes 1,943 Yes Contracted billing company
Perinton Yes 2,549 Yes Contracted billing company
Rural/Metro No 57,641 Yes In-house personnel
Rush Yes 150 No N/A
Scottsville Yes 221 Yes Contracted billing company
SE Quad MCCU No 3,461 Yes Contracted billing company
Spencerport No 1,068 Yes Contracted billing company
U of R MERT No 250 No N/A
W Webster Yes 1,210 No N/A
Xerox No 99 No N/A
Summary 9 No; 11 Yes 100,431 6 No; 14 Yes 2 In House; 12 Contracted
Eleven of the 20 agencies that responded to the survey report receiving a tax subsidy from their local
jurisdiction. Nine report no tax support. In retrospect, an additional question could have been included
asking whether or not there is indirect or in-kind support to the agency. Frequently, local communities
provide building space at no cost or below market rates as well as access to discounted fuel and other
commodities. Some communities prefer to maintain ownership of ambulances or other major assets.
The 20 agencies that responded to the survey report having transported 100,431 patients in CY2011. Of
the 20 agencies, six do not bill for their transport services. Of the 14 that bill for service, 12 contract out
this function.

Table 14. EMS Agencies’ Major Issues – Survey Responses
CON, structure,
service training
Future training
Increased pre-
training issues
cannot afford
management
Mutual aid &
performance
County EMS
Threatened
Inadequate
closest unit
Need more
volunteers
collections
measures
paid staff
Need but
response
Bad debt
takeover
financial
Monroe
Current
process
and/or
issues
costs
Agency
Brighton X
Chili X X X
Churchville X
E. Rochester X X X X
Greece X X X
Henrietta X X X
Hilton X X X X X
Honeoye X X X X
Monroe X X
NE Quad ALS X
Penfield X X
Perinton X X X X
Rural/Metro X
Rush X
Scottsville X X X X X X X X
SE Quad
X X
MCCU
Spencerport X X X X
U of R MERT X X
W Webster X X
Xerox
Total 11 3 3 8 6 7 3 5 3 4 0
Eleven of the 20 survey respondents noted that they need more volunteers. This was the most
significant, but not unexpected, issue reported by the agencies. The next most listed major issue was the
cost of pre-training for field personnel. Costs of training to become certified are likely to be a barrier to
volunteering.
FIRE FIRST RESPONDERS

Medical first response (non-transporting) is provided primarily by the 38 fire departments/districts that
serve the County. These fire departments range from the 500+ person career-staffed Rochester Fire
Department to several small volunteer departments.

Surveys were sent to 38 fire agencies identified by the EMS Office and 22 agencies completed the
survey. The largest fire agencies, the City of Rochester Fire Department, did not complete the survey.
The tables below provide a summary of the responses.
Table 15. Fire 1st Responder Survey - Demographics

st
Agency Sq. Miles Population Medical 1 Service Type
Response Calls
CY2011
Barnard FD 4 25,000 2,214 Fire Service (municipal or district)
Brighton FD 16 36,609 864 Fire Service (municipal or district)
Brockport FD 63 19,000 350 Fire Service (municipal or district)
Bushnell's Basin 5 10,000 30 Private non-profit
Chili FD 40 28,625 474 Private non-profit
Churchville FD 30 5,300 169 Private non-profit
Clifton FD 36 3,000 112 Fire Service (municipal or district)
Egypt FD 11 15,000 60 Fire Service (municipal or district)
Fairport FD 20 18,000 105 Fire Service (municipal or district)
Gates FD 20 32,000 1,553 Fire Service (municipal or district)
Rochester Airport 2 n/a 248 Fire Service (municipal or district)
Hamlin FD 46 6,000 325 Fire Service (municipal or district)
Henrietta FD 44 46,000 1,267 Fire Service (municipal or district)
Hilton FD 22 9,800 150 Fire Service (municipal or district)
Lake Shore FD 7 10,000 600 Fire Service (municipal or district)
Mendon FD 21 4,372 142 Fire Service (municipal or district)
North Greece FD 24 45,000 2,000 Fire Service (municipal or district)
Penfield FD 3 32,000 168 Fire Service (municipal or district)
Pittsford FD 7 25,000 79 Fire Service (municipal or district)
Ridge Road FD 16 34,667 4,474 Fire Service (municipal or district)
Spencerport FD 38 19,620 126 Fire Service (municipal or district)
Union Hill FD 25 20,000 1,580 Fire Service (municipal or district)
All but three fire agencies are municipal or district-based organizations. Call volumes range from a low of
30 in CY2011 to a high of 4,474.

Table 16. Fire 1st Response Agencies’ Personnel and Care Level – Survey Responses
Highest # # #
EMS Chief # Paid
Agency Medical Volunteer Paid Volunteer
Personnel Officer EMTs
Capability EMTs Medics Medics
Barnard FD Combo Vol. RSI 9 15 12 0
Brighton FD Combo Vol. BLS 28 24 0 0
Brockport FD Vol. Vol. BLS 0 N/A 0 0
Bushnell's Basin No answer Vol. BLS 0 12 0 0
Chili FD Vol. Vol. BLS 0 46 0 4
Churchville FD Vol. Vol. BLS 0 17 0 0
Clifton FD Vol. Vol. BLS 0 6 0 0
Egypt FD Vol. Vol. BLS 0 10 0 1
Fairport FD Vol. Vol. BLS 0 22 0 1
Gates FD Combo Paid BLS 26 20 0 0
Rochester Airport Paid Paid BLS 22 0 0 0
Hamlin FD Vol. Vol. BLS 0 15 0 0
Henrietta FD Combo Paid BLS 36 13 0 0
Hilton FD Vol. Vol. BLS 0 100 0 0
Lake Shore FD Combo Vol. BLS 20 10 0 0
Mendon FD Vol. Vol. BLS 0 14 0 1
N. Greece FD Combo Vol. BLS 60 12 0 0
Penfield FD Vol. Vol. DEFIB 0 14 0 0
Pittsford FD Vol. Vol. DEFIB 0 15 0 1
Ridge Road FD Paid Paid BLS 60 0 0 0
Spencerport FD Vol. Vol. BLS 0 37 0 0
Union Hill FD Combo Vol. BLS 25 15 0 0
Combo=7 Vol=18 BLS=19 286 378 12 8
Vol=12 Paid=4 DEFIB=2
Paid=2 RSI=1
No
Answer=1
The chief operating officers for a surprising number of fire agencies are volunteers. Again, the number
EMTs and paramedics in the system may be duplicated, as individual providers tend to work and
volunteer for more than one agency.

Table 17. Fire 1st Responder Survey – Special Capabilities & Major Issues
Agency Special Capabilities Major Issues
Barnard FD Swift-water rescue, Ice rescue, Insufficient volunteers, Need paid staff but can't afford, Other
Water rescue including boat organizations threatening takeover
operations
Brighton FD Ice rescue Pre-service training costs (EMT school), Recent increases,
Current training issues
Brockport FD Swift-water rescue, Ice rescue, Insufficient volunteers, Pre-service training costs (EMT school),
Rope rescue Recent increases, Current training issues
Bushnell's Basin Swift-water rescue, Ice rescue, Insufficient volunteers, Current training issues, Future training
All-terrain vehicles issues
Chili FD Aircraft rescue Pre-service training costs (EMT school), Recent increases,
Current training issues
Churchville FD Ice rescue, All-terrain vehicles No answer
Clifton FD Ice rescue, Heavy rescue Pre-service training costs (EMT school), Recent increases,
capabilities Current training issues, Future training issues
Egypt FD No answer Pre-service training costs (EMT school), Recent increases,
Compliance with performance measures
Fairport FD Ice rescue, Rope rescue Insufficient volunteers, Pre-service training costs (EMT school),
Recent increases, Current training issues, Compliance with
performance measures
Gates FD Rope rescue Pre-service training costs (EMT school), Recent increases,
Future training issues
Rochester Airport Swift-water rescue, Ice rescue Insufficient volunteers, Pre-service training costs (EMT school),
Recent increases, Current training issues, Future training issues
Hamlin FD Rope rescue, Rapid Sequence Pre-service training costs (EMT school), Recent increases
Intubation (RSI)
Henrietta FD No answer No answer
Hilton FD Swift-water rescue, Ice rescue, Insufficient volunteers, Need paid staff but can't afford,
Rope rescue Mutual aid and closest-unit response issues
Lake Shore FD Ice rescue, All-terrain vehicles, Insufficient volunteers, Pre-service training costs (EMT school),
water rescue Recent increases, Mutual aid and closest-unit response issues
Mendon FD EMS Bike Team, Swift-water Pre-service training costs (EMT school), Recent increases,
rescue, Ice rescue, Rope rescue Current training issues, Future training issues
N. Greece FD Swift-water rescue, Ice rescue, Insufficient volunteers, Future training issues
Rope rescue
Penfield FD Swift-water rescue, Ice rescue , Insufficient volunteers, Pre-service training costs (EMT school),
Rope rescue, confined space Recent increases, Future training issues
Pittsford FD Ice rescue, Rope rescue , Confined Current training issues, Future training issues
Space Rescue
Ridge Road FD Swift-water rescue, Ice rescue , Insufficient volunteers
Rope rescue
Spencerport FD Ice rescue, All-terrain vehicles Insufficient volunteers, Pre-service training costs (EMT school),
Recent increases, Current training issues, Future training
issues, Compliance with performance measures
Union Hill FD Ice rescue Insufficient volunteers, Pre-service training costs (EMT school),
Recent increases, Current training issues, Compliance with
performance measures
Special operations capabilities appear to be diverse among the fire agencies. Most of the agencies
report a concern about insufficient numbers of volunteers and current training issues and costs.

The County Fire Bureau, which is analogous to the County EMS office, provides firefighter training, fire
investigation services, juvenile fire setter intervention programs, hazardous material responses and
provides field coordination to the County, Town and Village fire departments. In addition, the Fire
Bureau is the conduit to the New York State Office of Fire Prevention and Control for fire reporting,
firefighter training databases and initiatives offered by New York State.
The County Fire Coordinator administers the Monroe County Mutual Aid Fire Plan. This plan, in
existence since 1941, is the basis for mutual aid fire resources and responses for both in and out of
Monroe County for major fires, disasters and hazardous material-related incidents. Monroe’s 12
volunteer deputy fire coordinators assist the Fire Coordinator with field responses and administration of
the Mutual Aid Fire Plan. The Mutual Aid Plan is robust and is highly functional. Importantly, the plan is
unhindered by the type of impacts that the New York State Certificate of Need process has on the
County’s ambulance services.
The Fire Bureau leads a specialized unit of firefighters from all Monroe County fire agencies. These
firefighters comprise the Monroe County Hazardous Materials Response Team. The Hazmat Team has
been in existence since 1984 and continues to respond to hazardous material incidents today. The
Hazmat Team is led by the Assistant Fire Coordinator and a volunteer deputy Hazmat coordinator. This is
a model that, in consultant interviews, was held out as a successful one and a model that could be
emulated by the County to meet the special operations needs in the EMS arena.
In consultant interviews, the fire community identified their top three issues regarding EMS in Monroe
County as follows:
1. The EMS community relies heavily on the fire service for “lifting assistance.” There is a widely
held perception that the EMS agencies do not require their members to meet any standard of
physical fitness, rendering many unable to participate in the lifting and moving of patients.
Spokesmen indicated their belief that the EMS community needs to step up and make sure that
they are able to “carry the load” that is required.
2. Fire services render aid as medical first responders. They believe that they wait too long for
ambulances to arrive, particularly in communities that rely on volunteers to staff ambulances.
This contention is supported by the data derived during the course of this review.
3. Fire services respond to EMS events using an inconsistent matrix regarding use lights and sirens
that must be “remembered” and applied by dispatchers on a district-by-district basis. The fire
service needs to standardize its responses to EMS events.
Despite well-meaning volunteers and agencies, the response of the Monroe County fire service first
responder organizations to requests for medical assistance is erratic, inconsistent, and in some cases
detrimental to the health and safety of the community. Some fire service organizations do not respond
to EMS calls at all. The level of medical care provided varies widely, sometimes involving a single
Certified First Responder and on other occasions involving the response of several emergency medical
technicians (EMTs) and one service provides firefighter paramedics. Some fire service organizations

respond "hot" (using lights and sirens) to EMS calls of any priority, which provides no demonstrable
medical benefit to the patient or the scene, while placing the public at greater risk due to the greatly
increased possibility of a piece of heavy fire apparatus experiencing a collision en route to a call. The fire
services in Monroe County, like the ambulance services, operate under the authority of a wide variety of
medical directors, who provide varying degrees of oversight and accountability.
SYSTEM DATA
This section of the report provides analysis of the data available to the consultants for calendar years
(CY) 2010 and 2011. The overall objective of the analysis is to report on current performance and to
project what system performance in Monroe County could be achieved if an optimized system was
adopted.
The Northrop Grumman Computer Aided Dispatch (CAD) System used by the Monroe County Emergency
Communications Department (911 Dispatch Center) is antiquated and at the end of its service life. The
major deficiency of this system is that it cannot automatically generate retrospective reports detailing
the performance of the system as a whole or the performance of any individual ambulance service
within the system. Prior to the analysis presented in this report, agencies at both the county and local
levels had little concrete data available for comparison and/or to drive their policy decisions regarding
emergency medical services.
Data Deficiencies
The data analyzed in this report was culled from Monroe County 911 Northrop Grumman CAD system.
The consultants obtained raw dispatch records for the CY2010 and CY2011. The Northrop Grumman
CAD’s raw data was output in a partially corrupted format. Fitch applied proprietary algorithms to the
raw records to remove the corrupted records. The Consultant team believes that the corrupted records
occurred randomly and that the removal of the corrupted records from the data set does not introduce
any systematic bias into the remaining records.
The Consultant identified an anomaly in the record creation algorithm used in the Northrop Grumman
CAD software that resulted in duplicate entries for a single call whenever the call was transferred to a
first ambulance service and then bounced to a second ambulance service. The reported number of calls
handled by the system was thereby inflated. The Consultant was able to estimate the duplication
inflation by comparing calls transferred to Monroe Ambulance with the number of calls logged by the
Monroe Ambulance CAD. The Monroe Ambulance CAD is an up-to-date reliable system. The Consultant
chose to compare to Monroe Ambulance’s data instead of Rural/Metro’s data in order to establish a
correction factor because Monroe Ambulance’s call locations are more consistent with those
experienced by all other agencies in the county. The correction factor was applied to the Northrop
Grumman raw data records to best represent the true volume of calls for the county as a whole.

Many of the ambulance agencies receive additional calls directly through 10 digit phone lines. These
calls are not reported back to the 911 Dispatch Center, resulting in an underreporting of calls for each
agency and the overall system as a whole. Notwithstanding the issues discussed, the conclusions and
recommendations of this report are based on the Consultant’s best efforts to adjust and confirm data
points within the limitations of the available data. Call volumes throughout the report, unless noted as
self-reported, are the results of such adjustments. While this methodology results in an approximation
of the true call volumes, the conclusions and recommendations of this report do not change materially if
the details of these approximations are changed.
CALL VOLUMES
There is a wide variation in the call volumes of the various EMS agencies in Monroe County. The figure
below indicates the call volumes for 34 agencies for which calls were dispatched from the Monroe
County 911 Dispatch Center during CY2011. Call volumes are amended as described above. Call volumes
for Rural/Metro and Monroe Ambulance are included in text in Figure 5 to avoid a significant scale issue.
The purpose of Figure 5 is to provide a visual sense of the relative number of calls handled by the
various agencies. As explained in the preceding section, “Data Deficiencies,” the absolute number of
calls per agency is under reported.
Figure 5. Call Volumes by Agency CY2011

Together, Rural/Metro (48%) and Monroe Ambulance (8%) respond to 56% of all CY2011 emergency
calls in the County. Collectively, the next five agencies with the largest call volume respond to 21% of all
calls. The remaining 27 agencies respond to 23% of all calls. The distribution of calls is depicted as a pie
chart in the figure below.
Figure 6. Call Volume Summarized CY2011 10
As noted above, Rural/Metro and Monroe Ambulance respond to 56% of all calls in Monroe County. This
leaves some 30 individual ambulance services attempting to achieve response time performance and
financial sustainability based on potential revenue from the remaining calls. Based on the
adjusted/corrected call volumes, at least 17 Monroe County ambulance agencies respond to fewer than
1,000 calls per year. Calls do not always result in a transport, which further undermines financial
sustainability.
The low call volume makes it difficult for these ambulance services to afford to staff ambulances 24
hours a day, 365 days a year without receiving some form of tax subsidies and/or a heavy reliance on
unpaid volunteers. The use of unpaid volunteers, while cost effective, often comes with the hidden cost
of longer response times to patients. The response time of an ambulance service that relies upon
volunteers is often lengthened while the local dispatcher rousts and assembles a crew for a response.
10
SE Quadrant is an ALS fly-car service (non-transporting) and covers ALS level calls with East Rochester, Penfield, Periton and
Pittsford. SE Quadrant responses appears in the CAD data, which likely results in duplications that could not be sorted out.

The existing Monroe County system operates under New York State law that calls for hard boundaries
surrounding each ambulance district thereby giving the home ambulance service the right of first refusal
on a call. For smaller ambulance agencies that bill for transport services, this policy is especially
important in that every single call is a significant increment to their potential total revenue.
The hard boundaries lead to a system that is not patient centric in that it incurs response times to the
patient that are longer than could otherwise be achieved by assigning the closest ambulance, regardless
of district. The policy of hard boundaries limits the system’s ability to do the right thing for the patient.
BUILT-IN INEFFICIENCIES
The Monroe County EMS system is inherently inefficient because the smaller ambulance services act
independently and do not coordinate the number of active units and their levels of staffing in response
to predictable changes in demand.
Performance-based EMS systems look at how call demand changes by day of week and time of day.
Analysis of data over several time periods allows the “system” to staff ambulances to meet the peak
demand and then reduce ambulances when and where calls are not prevalent. The figure below
indicates the day of the week changes for calls in Monroe County for CY2011.
Figure 7. Calls By Day of Week CY2011

The data for CY2011 indicates that demand is fairly consistent Monday through Friday, with a range of
456 calls to 466 calls, a difference of only 10 calls per day. The volume of calls on Sundays is about 10%
less than the peak number of Fridays. Day of the week data for CY2010 is consistent with the CY2011
data.
The figure below reflects calls in Monroe County by time of day.
Figure 8. Calls By Time of Day CY2011
The figure above clearly depicts the dramatic difference in call volume with a sharp minimum number of
calls at 0500 to 0600 hours (8.3 calls/hour) and a broad maximum number of calls occurring at 1100 to
1800 hours (24.6 to 24.7 calls/hour). There is three times the number of calls during this peak period
than at the minimum. Clearly, operating a uniform number of active staffed ambulances throughout the
day, despite the changes in demand, is inefficient.
The most costly factor in providing ambulance services is the crew. Agencies operating in larger and
denser service areas such as the City of Rochester are able to be more efficient as they adjust the
number of staffed units (unit hours) in response to the predictable changes in demand based as noted in
the Figures above. The smaller ambulance agencies scattered across Monroe County do not have this
opportunity. When an agency operates only one or two ambulances, adjustments to the number of
active units becomes an all-or-nothing proposition. When each of the smaller ambulance services acts
strictly independently as they do in the Monroe County system, there is no opportunity to fine-tune the
number of active units among the smaller services by coordinating who goes off-line.

CALL PROCESSING ATTRIBUTES AND STANDARDS
Two organizations, the National Fire Protection Association (NFPA) and the National Emergency Number
Association (NENA), publish standards for processing emergency calls. The NFPA standards on
dispatching (NFPA 1221) specify the flow of an emergency call and the time allotted for each step in the
process. For clarification, the PSAP or Public Safety Access Point, is the call answering point(s)
designated in a community to receive 911 calls. A summary of NFPA standards regarding the dispatch
process and its performance is provided in the table below.
Table 18. NFPA 1221 Dispatch Standards

NFPA 1221 Section # Standard
Section 6.4.2 95% of calls to be answered within 15 seconds; 99% within 40 seconds.
Section 6.4.3 95% of emergency dispatching shall be completed within 60 seconds.
Section 6.4.5 95% of calls transferred from the PSAP (911 intake) shall be within 30 seconds (10
seconds for ring answer and 20 seconds for identification of primary resource
required).
Standards published by the National Emergency Number Association (NENA) are consistent with NFPA
1221 with additional embellishments as noted in the table below.
Table 19. NENA Call Taking Operational Standards

NENA 56-005 Standards
Master Glossary 90% of all PSAP calls to be answered within 10 seconds during the busy hour; 95% of all calls
00-001 should be answered within 20 seconds.
911 call taker limited to very few questions prior to transferring the call to the agency that
Page 8 of 12 will dispatch the call. This is done in order to reduce the delay of the responding agency
which will ultimately deal with the crisis.
All 911 lines at a PSAP shall begin with “911.” The correct statement is “Nine-One-One,”
Section 3.3 never “Nine Eleven.” Additional information or questions may be added, as in: “911, what is
the emergency?”, or “911 what is the address of the emergency?”
Chute Time is the time interval from when the district ambulance service receives notification from the
Monroe County 911 Dispatch Center to when the ambulance with its crew is rolling en route to the site
of the emergency. The table below indicates the NFPA standards for Chute Time performance.
Table 20. NFPA Standard for Chute Time

Section Standard
NFPA 1710 After “tone-out,” response units shall be rolling within 90 seconds 90% of the time.
The table below is a simplified depiction of the first six of the multiple steps in the flow of a 911 call.
Step 5 in the table is very significant. The dispatcher at the 911 Call Center has authority to assign a unit

to meet the request for service. As discussed below, this authority is not available to the County
Dispatcher in the Monroe system.
Table 21. Initial Steps of 911 Call Handling and Performance Standards
Step Action
1 An individual observes an emergency event and determines the need for emergency intervention.
2 The individual initiates a call to 911.
3 A call taker at the 911 Dispatch Center answers the incoming call, identifies whether it should be
medical, police or fire that handles the call, and transfers the call to a dispatcher.
NFPA 1221 6.4.5 Performance Standard: Less than 30 seconds for 95% of calls
4 The dispatcher answers the transfer and uses experience and/or scripted dialogs based on best practices
to identify the category and acuity of the call.
5 The dispatcher identifies an available response unit and “tones out” that unit.
6 The unit “turns-out” and begins rolling to the site of the emergency.
NFPA 1710 Performance Standard: Less than 90 seconds for 90% of calls
The complete flow of a 911 call in a typical high performance system is schematically depicted in the
figure below.
Figure 9. Schematic Representation of the Flow of a Typical 911 Call
This schematic is presented to show the relationships between the named intervals of time in a typical
911 call. This schematic is incomplete with respect to procedures existing in the Monroe County System.
Two additional tasks are introduced between T2 and T3 because the County dispatcher does not have

authority to assign a unit to meet the request for service. These additional tasks are shown in the figure
below, and discussed in the Section titled “Dispatch Time,” below.
In many smaller 911 systems, the call taker and the dispatcher may be the same individual. The clinical
data regarding emergency medical response is clear: for calls where time is of the essence, faster
response times correlate to better clinical outcomes. The standards published by NFPA and NENA reflect
this reality and emphasize the need for rapid dispatch to medical emergencies but allow as much time
as possible for responding units to travel to a patient’s side. Dispatch centers that execute Step 3, Step
4, and Step 5 in less than 105 seconds or one minute, and forty-five (1:45) seconds for 95% of calls are
considered “high performance.”
In any large system things invariably go wrong. The County’s 911 Northrop Grumman CAD does not
individually log the time intervals of Step 3, Step 4, and Step 5 described in the table above. The inability
of the Northrop Grumman CAD System to provide concrete data for each of the three steps impedes
attempts to diagnose issues and implement improvements. Too often, the diagnosis of an incident gone
wrong degenerates into conflicting anecdotal recollections that are ultimately irresolvable.
DISPATCH AND EMS AGENCY RESPONSE TIME PERFORMANCE

Performance in EMS systems is measured by the ability of the system to achieve a given response time
to provide appropriate aid to a sick or injured patient (and from the financial perspective to do so for a
reasonable cost). In Monroe County, there are four time intervals that directly affect a patient:
§ County Dispatch Interval: The time it takes the Dispatch Center to answer the call, to determine
the type and location of the emergency, to assess the acuity of the emergency, and to make a
request for service to a local ambulance agency
§ Processing Interval: The time it takes the local agency dispatcher to decide to accept or decline
the request for service, to acknowledge this decision back to County Dispatch and to notify an
agency unit (ambulance with its crew).
§ “Chute” Interval: The time it takes the unit to begin rolling
§ En Route Interval: The time it takes the unit to drive from its base to the scene of the emergency
How long the patient has to wait before receiving help is the aggregate of these four time intervals.
Dispatch Time
The table below looks at the dispatch interval component of 911 call handling, as described above, for
30 agencies for which data was available. It depicts the time for the County 911 Dispatch Center to
answer the call, to determine the type and location of the emergency, to assess the acuity of the
emergency, and to dispatch an ambulance.
In the Monroe County system, there are two significantly different dispatch processes that occur. In
both processes, County Dispatch answers the call and then determines its type, location, and acuity. For

calls in the Rural/Metro service district, the transfer from County Dispatch to Rural/Metro is done
electronically with the push of a button. Rural/Metro automatically and immediately acknowledges
acceptance of the call. County Dispatch did its job, and the clock stops ticking for County Dispatch. The
flow of an EMS call going to Rural/Metro approximates the flow of events depicted in Figure 9 above.
Agency Processing Time

For calls in the service districts of agencies other than Rural/Metro, County Dispatch again answers the
call and then determines its type, location, and acuity. The transfer from County Dispatch to the local
agency is done manually by radio. The local agency has to pick up the radio call, gets to decide whether
to accept or decline the request for service, and has to acknowledge that decision back to County
Dispatch. County Dispatch did its job, the local agency introduced delays, and the clock keeps ticking at
County Dispatch. County Dispatch gets “dinged” for delays introduced by the local agencies. This
situation is an artifact of inadequate data logging by the Northrop Grumman CAD system.
The figure below depicts the flow of an EMS call in Monroe County. As noted above, the difference
between dispatches to Rural/Metro and all other agencies is that for Rural/Metro the transfer to the
agency dispatcher and acknowledgement of the accept/decline decision are effectively instantaneous.
Figure 10. Flow of an EMS Call in Monroe County
The table below presents the dispatch times ( 0:00 -> T3 in Figure 10 above) as logged by the Northrop
Grumman CAD for the County 911 Dispatch Center for life threatening calls at 90% reliability.

Table 22. Dispatch Times for Life Threatening Calls by Agency CY2011
Dispatch Time Dispatch Time
Agency th Agency th
at 90 % at 90 %
Brighton 03:33 NE Quad ALS 02:40
Brockport 04:57 Penfield 02:34
Caledonia 04:14 Perington 02:54
Chili 02:37 Pittsford 02:48
Churchville 06:27 Pt Pleasant 03:42
E. Rochester 04:19 RIT Amb 03:35
Gates 02:57 Rural/Metro 02:02
Greece 02:02 Rush 06:32
Hamlin 06:42 Scottsville 07:31
Henrietta 03:10 SE Quad MCCU 05:22
Hilton 05:56 Sea Breeze 02:47
Honeoye 03:08 Spencerport 02:36
Irondequoit 03:30 Union Hill 03:24
Macedon 06:22 Victor 06:34
Monroe 03:01 W Webster 03:27
The data, as logged, indicates that Monroe County 911 Dispatch Center’s dispatch performance is in all
cases slower than the 1:45 NFPA Standard. Call handling times range from 2:02 for calls to the
Rural/Metro district to 7:31 for calls to the Scottsville district.
In the opinion of Fitch & Associates, the dispatch time reported for calls going to the Rural/Metro
district is the best available indicator of how well County Dispatch is currently performing. The 2:02
dispatch time is a metric based on handling 80,000 calls, or 48% of all EMS calls processed by the County
Dispatch Center. For the remainder of this report, the 2:02 dispatch time will be used as the
“benchmark” representing the intrinsic performance of the County 911 Dispatch Center.
Furthermore, it is the opinion of Fitch & Associates that variations in dispatch times for calls going to
other agencies reflect events occurring locally at that agency and not variations at County Dispatch.
Dispatch times beyond 2:02 are delays that can be attributed to the local agency locating and assigning
an available crew and ambulance before acknowledging acceptance of the request for service back to
County Dispatch. Call processing times for those agencies can be refined by subtracting the 911 Dispatch
Center benchmark time (2:02) from the entries in the table above in order to reflect the time needed by
agencies to locate an available ambulance (labeled Agency Processing Time in the table below).

Table 23. Call Processing Time by Agency
Dispatch Agency Agency
Dispatch Time
Agency Time Processing Agency th Processing
th at 90 %
at 90 % Time Time
Brighton 03:33 1:31 NE Quad 02:40 0:38
Brockport 04:57 2:55 Penfield 02:34 0:32
Caledonia 04:14 2:12 Perinton 02:54 0:52
Chili 02:37 0:35 Pittsford 02:48 0:46
Churchville 06:27 4:25 Pt Pleasant 03:42 1:40
E. Rochester 04:19 2:17 RIT Amb 03:35 1:33
Gates 02:57 0:55 Rural/Metr 02:02 Benchmark
Greece n/a n/a Rush 06:32 4:30
Hamlin 06:42 4:00 Scottsville 07:31 5:29
Henrietta 03:10 1:08 SE Quad 05:22 3:20
Hilton 05:56 3:54 Sea Breeze 02:47 0:45
Honeoye Falls 03:08 1:06 Spencerpor 02:36 0:34
Irondequoit 03:30 2:28 Union Hill 03:24 1:22
Macedon 06:22 4:20 Victor 06:34 4:32
Monroe Amb 03:01 0:59 W Webster 03:27 1:25
The table above indicates wide variations in the time for agencies to locate staffed, available
ambulances on 90% of calls to their service area. The agency processing time for Rural/Metro is
assumed to be instantaneous. The agency processing times for Chili, NE Quad, Penfield, and Spencerport
are reasonable, given the delays inherent in system that uses radio calls to communicate and
acknowledge a request for service between County Dispatch and the local agency.
Monroe County has no policy governing the time interval between the request for service ringing-in
from County Dispatch to the local agency, and the local agency acknowledging its accept/decline
decision back to County Dispatch. In the opinion of Fitch & Associates, it is unreasonable for any agency
to take three, four and five minutes to make the accept/decline decision and acknowledge it back to
County Dispatch. Given the existence of modern communications and wireless data links, the local
dispatcher should be held accountable for knowing the status of all the agency’s units at all times and be
able to answer the accept/decline question without delay. The accept/decline decision should be
reached in a matter of seconds and not multiple minutes.
Chute Time
In the Monroe County system, chute time is the interval from when the dispatcher at the local
ambulance agency notifies an ambulance and its crew of a request for service to when the unit is rolling
en route to the site of the emergency. Fitch decided not to attempt an analysis of chute time because
the demarcation between agency response time and chute time is especially blurry.

Consider the decision tree facing the local agency dispatcher when a request for service rings-in from
County Dispatch. The local dispatcher must acknowledge to County Dispatch the agency’s decision to
accept/decline the request for service.
Is there an ambulance with its crew set to go?
YES – accept request
NO – check further
Is here an ambulance without crew available?
YES – check further
NO – decline request
Can a crew be assembled in a reasonable interval?
MAYBE – Attempt to roust a crew and get to firm YES/NO.
YES – Accept request
NO – Decline Request
What is a “reasonable” interval and at what point in the “MAYBE” process does the local dispatcher
commit back to County Dispatch. There are as many answers to these questions as there are agencies.
Some unknowable portion of the chute time is certainly embedded in the agency processing time.
Knowing this portion would not change the conclusions of this report.
En Route Time
En route time is the time interval from when an ambulance begins rolling from its base to when it arrives
at the site of the emergency. En route times are, of course, impacted by time of day and day of week
(rush hour on a week day versus the same time on a weekend), by the road networks, geographic
impediments and severe weather events that confront ambulances. More importantly, the en route
time interval reflects whether the ambulance was based in the right location compared to historical call
demand. En route times can only be improved by choosing the optimum locations to station ambulances
waiting on standby; driving faster does not change en route time significantly. An agency can attempt to
understand and improve performance only by looking at historical data, noting significant events (such
as a major storm or roadway blockages due to construction) and looking at station locations.
Total Response Time

The patient’s clock starts from when the call for emergency services is initiated and runs until help
arrives. The patient does not care about what steps are taken to get help to their side. The question
then becomes “How fast is fast enough?” The answer to this question is a matter of opinion.
The Monroe-Livingston Regional EMS Council (MLREMS), with the endorsement of the Monroe-
Livingston REMAC, the Livingston County Board of Health and the Monroe County EMS Advisory Board
adopted the following regional Performance Measures in the MLREMS November 29, 2010 Advisory 10-
18: Regional Performance Measures. The table below addresses Advisory Memo response time
performance for Urban/Suburban designated areas and the next table addresses Advisory Memo
response time performance for Rural designated areas.

Table 24. Advisory MLREMS Response Times for Urban/Suburban Areas
st
90% re notification (dispatch)
90% notification (dispatch)
90% notification (dispatch)
Table 25. Advisory MLREMS Response Times for Rural Areas

st
The performance measures above reflect the consensus of most EMS systems in the US and Canada. 11
However, the Advisory memo notes that the Urban/Suburban and Rural designations are based on
population density as opposed to call density. Best practice is to use call density as the indicator for
application of an Urban or Rural performance measures to a particular district.
The County Medical Director reports that Urban/Suburban and Rural response zones have not yet been
defined. The system is operating without agency specific guidelines for response times to patients. The
consultants recommend that if and when the system undertakes to monitor response time
performance, that it be measured against incident zones as determined by the call density formulas
presented in this report.
Underscoring the importance of the Urban or Rural designation is the unexpected and surprising finding
of this report that the majority of Monroe County qualifies as “Urban” when applying the standard
definition based on call densities of two calls per square kilometer per month. The Consultant learned
through the interviews that many, if not most, of the Monroe County system participants believe that
much of the greater County is “Rural” for application of response time standards. Apparently, local
perceptions lag actual demographics.
11
Dr. Joseph Fitch, JEMS, June 25 2007, “Response Times: Myths, Measurement and Management.”
http://www.jems.com/article/communications-dispatch/response-times-myths44-measure

The table below indicates the total response time – from initial call receipt by County 911 Dispatch
Center until the ambulance arrives on the scene of an emergency call. The table indicates those time
increments that are under the control of the County 911 Dispatch Center and those under the control of
individual agencies. The agency processing time is the interval from when the request for service rings-in
to the local agency, the agency decides whether to accept or decline the request, acknowledges this
decision, and notifies a unit. The overall total response time is of great importance to patients and may
impact clinical outcomes.
Table 26. Contributions to Total Response Time

Under Control of
Under Control of
Individual EMS
County 911 Dispatch
Agencies
Total Response Time (911 Call
Dispatch Time Agency Chute and Drive Time After
Agency Ring-In to Unit On-Site at
at 90% Processing Time Dispatch by Local Agency*
90%)*
Brighton 2:02 1:31 14:21 17:54
Brockport 2:02 2:55 15:51 20:48
Caledonia 2:02 2:12 Not available Not available
4:21
Chili 2:02 0:35 06:58
Churchville 2:02 4:25 10:42 17:09
E. Rochester 2:02 2:17 8:26 12:45
Gates 2:02 0:55 11:37 14:34
Greece 2:02 n/a Not available Not available
Hamlin 2:02 4:00 6:42 13:24
Henrietta 2:02 1:08 12:22 15:32
Hilton 2:02 3:54 9:08 15:04
Honeoye
2:02 1:06 14:51 17:59
Falls
Irondequoit 2:02 2:28 6:36 10:06
Macedon 2:02 4:20 27:10 33:32
Monroe Amb 2:02 0:59 Not available Not available
NE Quad ALS 2:02 0:38 14:53 17:33
Penfield 2:02 0:32 10:50 12:24
Perinton 2:02 0:52 11:28 14:22
Pittsford 2:02 0:46 9:19 12:07
Pt Pleasant 2:02 1:40 4:53 07:35
RIT Amb 2:02 1:33 5:83 09:58
Rural/Metro 2:02 Benchmark 7:21 09:23
Rush 2:02 4:30 7:14 13:46
Scottsville 2:02 5:29 9:55 16:26
SE Quad
2:02 3:20 9:40 15:02
MCCU
Sea Breeze 2:02 0:45 3:17 06:34
Spencerport 2:02 0:34 8:33 11:09
Union Hill 2:02 1:22 12:51 16:15
Victor 2:02 4:32 13:20 19:54
W Webster 2:02 1:25 8:42 12:09
*Determined by subtracting 911 Dispatch Center time and agency call processing time from total response time.

It is important to note that the data above may conflict with what is reported by individual agencies.
Table 26 contains historical data extracted from the Northrop Grumman CAD system. The existence of
any such discrepancies emphasizes the need for a modern CAD system with sophisticated reporting
capabilities to provide verifiable data going forward.
Several ambulance agencies do not report back to County Dispatch when their units begin rolling en
route. Monroe Ambulance does not report back to County Dispatch when their units arrive on-site.
Consequently, the entries in the table above are incomplete.
Ambulance agencies in Monroe County are not required meet the standards for response times
proposed by the County Medical Director. While the MLREMS advisory prescribes standards are
somewhat in line with best practices, the exclusion of the dispatch time from total response time
significantly misrepresents what a patient actually experiences. Rural/Metro is a special case because it
operates under a contract that specifies metrics of performance
To further interpret the data presented in the table above it is necessary to introduce the concept of
composite response times applicable to each agency’s district. We emphasize that the use of a
composite response time is a stopgap intended for this report only. Fitch & Associates recommends
that after the new CAD is installed, each agency should receive three separate scores based on its
response in the urban, rural, and remote incident zones comprising its district. Incident zones are to be
defined based on call densities as described in “Defining Incident Zones” as discussed in the Optimized
M-xR Model System.
Reporting three response times per district is not possible at this time because the detailed data is not
yet available. What is available at this time is the percentage composition of urban, rural, and remote
incident zones comprising each agency’s district as presented in the figure below. The figure below is in
this position for convenience of the reader. It is based on the analysis of data described in “Defining
Incident Zones” below and displayed in that section.

Figure 11 Percentage of Urban, Rural and Remote Incident Zones Comprising Each Agency’s District
Fitch then derived a composite target response time for each agency based on the distribution of calls
occurring in the urban, rural, and remote incident zones present in each agency’s district.
The first step was to apportion urban:rural:remote calls per incident zone in the ratio of 64:8:1; to assign
a target response time to each call based on the type of zone it occurs in; to sum the target response
times over the district; to sum the number of calls over the district; and to divide the summed response
times by the summed number of calls to obtain a “composite” target response time per call.
The percentage of urban, rural, and remote incident zones and composite target response times for
each agency’s district are presented in the table below.

Table 27 Composite Target Response Time by Agency
% % % Composite Target
EMS Service Area
Urban Rural Remote Response Time
Barnard 100.0 0.0 0.0 08:59
Bergen 0.0 0.0 100.0 29:59
Brighton 95.0 5.0 0.0 09:01
Brockport 10.5 34.9 54.6 11:47
Caledonia 0.0 23.4 76.6 19:20
Chili 42.9 25.5 31.6 09:37
Churchville 9.4 49.0 41.7 12:06
East Rochester 100.0 0.0 0.0 08:59
Gates 95.1 4.9 0.0 09:01
Greece 44.4 41.4 14.1 09:42
Greece Ridge 82.9 11.4 5.7 09:06
Hamlin 8.0 52.7 39.3 12:25
Henrietta 68.6 22.1 9.3 09:15
Hilton 21.1 64.5 14.5 10:48
Honeoye Falls 6.4 53.6 40.0 12:53
Irondequoit 84.2 15.8 0.0 09:07
Penfield 48.9 42.1 9.1 09:37
Perington 74.1 21.0 4.9 09:13
Pittsford 72.1 23.0 4.9 09:14
Point Pleasant 88.9 11.1 0.0 09:05
Rush 2.4 49.4 48.2 14:41
Scottsville 17.4 37.0 45.7 10:52
Sea Breeze 100.0 0.0 0.0 08:59
Spencerport 24.3 61.7 14.0 10:34
St Paul 92.9 7.1 0.0 09:02
Union Hall 54.2 40.7 5.1 09:31
Victor Farmington 1.7 5.2 93.1 18:00
West Webster 91.5 6.4 2.1 09:03
The composite target response time is a single parameter that represents a response time for the
district as a whole and accounts for response times on calls in the urban, rural, and remote incident
zones (the subzones) comprising the agency’s district. The target response times in the subzones used in
this calculation are: 8:59 urban subzones, 14:59 rural subzones, and 29:59 remote subzones.
A comparison of actual response times for the ambulance agencies and the composite target response
times expected from the composition of urban, rural, and remote incident zone that comprise their
districts is presented in the table below.

Table 28 Comparison of Total Response Times with Composite Target Response Times by District
Total Response Time
(911 Call Ring-In to Composite Target Over / Under
Agency
Unit On-Site Response Times Target Response
at 90%)* Time
Brighton 17:54 9:01 8:53
Brockport 20:48 11:47 9:01
Caledonia not available not available not available
Chili 06:58 9:37 UNDER TARGET
Churchville 17:09 12:06 5:03
E. Rochester 12:45 8:59 3:46
Gates 14:34 9:01 5:33
Greece not available 9:42 not available
Hamlin 13:24 12:25 0:59
Henrietta 15:32 9:15 6:17
Hilton 15:04 10:48 4:16
Honeoye Falls 17:59 12:53 5:06
Irondequoit 10:06 9:07 0:59
Macedon 33:32 not available not available
Monroe Amb not available not available not available
NE Quad ALS 17:33 not available not available
Penfield 12:24 9:37 2:47
Perinton 14:22 9:13 5:09
Pittsford 12:07 9:14 2:53
Pt Pleasant 07:35 9:05 UNDER TARGET
RIT Amb 09:58 not available not available
Rural/Metro 09:23 8:59 0:24
Rush 13:46 14:41 UNDER TARGET
Scottsville 16:26 10:52 5:34
SE Quad MCCU 15:02 not available not available
Sea Breeze 06:34 not available not available
Spencerport 11:09 10:34 0:35
Union Hill 16:15 9:31 6:44
Victor Farmington 19:54 18:00 1:54
W Webster 12:09 9:03 3:06
Chili, Point Pleasant, and Rush are the three bright spots in this table. Chili, Rush and Point Pleasant
respond quicker than the composite target.12 Rural/Metro responds faster than the requirements of its
contract. Rural/Metro responds 24 seconds slower than the 8:59 expected of a district comprised of
100% urban subzones. However, 17 seconds of this delay is due to County Dispatch taking 2:02 instead
of 1:45 to get the request for service to Rural/Metro.
12
Point Pleasant no longer operates an ambulance.

Spencerport is an example of another dynamic in the system. Spencerport responds 35 seconds slower
than the 10:34 of its composite target response time. However, 17 seconds of this delay is due to County
Dispatch. An additional 34 seconds of delay is due to the Spencerport’s agency processing time. If
County Dispatch had a modern CAD and performed to a 1:45 standard, Spencerport would come close
to making its target response time. If Spencerport had an automated communications link to County
Dispatch ala Rural/Metro, Spencerport would be under its target.
Monroe County is designed as are many systems are in New York State, to follow the concept of
ambulance districts. The ambulance districts are artificial boundaries that are designed to set a specific
responsibility for ambulance service to a specific zone. These districts are totally autonomous and, as
such, are responsible for care, coverage and billing for ambulance service. What was built to protect the
citizens and give them autonomy of service has had an unexpected deleterious effect on the level and
consistency of service provided.
There are an excess number of ambulances and crews in Monroe County, especially among the smaller
ambulance services. Despite the excess capacity, but because the agencies operate with hard
boundaries, many of the EMS agencies in Monroe County under perform as judged by a comparison of
total response time against nationally accepted standards. A factor that further contributes to the long
total response times Monroe County is the existence of long agency processing times. The Consultant
speculates that the long agency processing times represent the time required by the local dispatcher to
assemble a complete crew for an ambulance. It is Consultant’s experience in other EMS systems that
this is a common experience for agencies that staff with a predominance of volunteers.
MUTUAL AID AND NEW YORK CERTIFICATES OF NEED

New York State’s Public Health Law, Article 30, governs the certification of ambulance services in the
state. Pursuant to the terms thereof, no ambulance service may commence operations without a valid
operating certificate (see Public Health Law § 3005[1]), also known as a “Certificate of Need” (CON). In
addition, an amendment to Public Health Law § 3008 in 1997 permits municipalities to begin operating
ambulance services for a two-year period without first obtaining a certificate of public need. Thus, in
accordance with Public Health Law § 3008(7)(a), a municipal ambulance service that has satisfied all
other pertinent requirements—i.e., municipal authorization to establish an ambulance service and
demonstrated compliance with respondent Department of Health's standards governing training,
staffing and equipment, is deemed to have satisfied any and all requirements for determination of
public need for the establishment of additional emergency medical services, pursuant to [Public Health
Law article 30] for a period of two years.
Currently, the two private for-profit agencies (Rural/Metro and Monroe Ambulance) hold countywide
certificates of need (CONs). Each of the remaining ambulance services holds a CON for its primary
response territory. Under current interpretations and applications of Article 30, it is not possible, without
change in either the law, the status of the CON holders, or via some other approach, to send the closest
appropriate ambulance to a request for service.

Under existing law, a “mutual aid” ambulance from one of the countywide CON holders could drive past
five available ambulances en route to an emergency call in a community whose home resources are
depleted. While agencies strive to provide the most appropriate response from the closest ambulance,
Medicaid accuses them of fraudulent billing and “operating illegally” when they do so.
There are additional issues at play. The current City of Rochester contract provides for exclusivity for
Rural/Metro within the city limits. The City may or may not be open to modifying those provisions to
accommodate for response by closest units (regardless of agency) at the edges of the City. At the same
time, if the suburban and rural agencies had AVL they would be afraid of getting caught in the
“downtown vortex” that is often created around hospitals – where ambulances depart the hospital and
become in-service, and then are “caught” by the AVL system and assigned to additional center-city calls.
CURRENT COUNTY MUTUAL AID PLAN

The existing County Mutual Aid Plan appears sound. However, “mutual aid” is a concept that is evoked
when an agency faces an extraordinary or unanticipated demand for service – when all of its resources
become depleted. This does not address the need for routine coverage, move-ups, or closest forces
agreements. In fact, NYS Department of Health EMS Policy 95-04 provides that “ . . . for EMS mutual aid,
the provisions of Article 30 with regard to primary operating territory must prevail, all other
circumstances being the same - e.g. response time, location, staffing, etc.” 13
Innovative Nursing Home Mutual Aid Plan

The County has developed, and all nursing facilities in the County are signatories to, an innovative
countywide nursing home evacuation and mutual aid plan. Functionally, the plan makes evacuation of a
nursing home the responsibility of that nursing home, using contract arrangements, rather than (as
occurs in most communities) simply shifting the responsibility to the 911/EMS system.
The plan has been tested over the years. Twice a year the County stands up the Emergency Operation
Center for federal and state observed drills related to the Ginna Nuclear Power Plan. What often results
is that will be shelter in place or an evacuation of one of the facilities and the Plan is exercised to see
what resources are available real-time to complete transportation. Typically emergency ambulances will
transport where gaps are identified. Should multiple nursing homes be taken off line in a critical event,
there would be an even greater need to utilize 911 dedicated ambulances to fulfill the mission. In the
short term, this situation would likely negatively impact the EMS system until spare ambulances and
staff could be called in for response.
13
http://www.health.ny.gov/professionals/ems/policy/mut_aid.htm).

CALL COVERAGE ISSUES
Many of those interviewed noted that operational decisions about ambulance placement, mutual aid,
and response are not made in a patient-centric manner. Commentary included information about
“predatory posting” practices, absent or slow response to certain types of calls, inappropriate response
to calls requiring advanced life support services (sending BLS ambulances and designating a hospital as
the nearest available ALS resource instead of sending a paramedic response unit), and triaging response
in favor of a contracted (thus guaranteed payment) instead of responding to 911 calls. In the current
regulatory environment there is little that the County can do about such allegations. It has no
enforcement authority, no contractual authority, no verifiable data sources, and no support from the
current CON regulations—all of which exacerbate rather than help alleviate the problem.

CLINICAL VISION/MEDICAL DIRECTION
QUALITY MANAGEMENT
With the exception of a few smaller ambulance services, most emergency ambulance calls in Monroe
County receive a paramedic-level response, either via an advanced life support ambulance, or through
the response of a paramedic single responder vehicle (“fly car”).
The impact of Monroe County ambulance services is generally not measured, nor are performance and
outcomes data made available to the public. The internationally recognized Utstein Template measures
cardiac arrest save rates. None of the EMS physicians interviewed were able to document the cardiac
arrest save rate for patients using this template. Additionally, they were not able to report on the
performance of the aggregate of Monroe County EMS agencies against the most common EMS clinical
performance benchmarks – the “Eagles Benchmarks” developed by the Metropolitan EMS Medical
Directors Consortium of the United States. 14
The lack of clinical performance information can be attributed to three factors:

1. There is no single repository for clinical data. Each EMS agency independently operates its own
patient care reporting system, and all data is segregated. No one examines clinical data on a
countywide basis.
2. There is no one individual at the County EMS Office dedicated to the EMS quality improvement
function. A typical EMS system of a size similar to the aggregate of Monroe County’s ambulance
services would have one to four full-time individuals, either senior paramedics or registered
nurses, devoted to the quality improvement function.
3. Medical Directors at individual ambulance services in the system are generally unwilling to push
hard for either data or for staff resources to examine data, because they fear that if they “rock
the boat” too much, they may simply be replaced. This situation is the result of each ambulance
service contracting independently with whatever physician they chose. Medical director
contracts reflect responsibilities (and payment) as defined by each agency.
Monroe County has no single, countywide electronic patient care reporting (ePCR) system. Each
ambulance service independently contracts for an ePCR system, which serves as the repository for all of
that service’s clinical and operational data. A few smaller agencies still utilize paper records. Agencies
perform their own internal quality reviews, to whatever degree they deem appropriate. Quality
performance data is not integrated. In interviews with medical directors, not one was able to answer the
extent to which generally accepted clinical performance measures are met either for the County as a
whole or for individual EMS agencies.
14 Evidence-based performance measures for emergency medical services systems: a model for expanded EMS benchmarking.
Myers, Slovis CM, Eckstein M, Goodloe JM, Isaacs SM, Loflin JR, Mechem CC, Richmond NJ, Pepe PE; U.S. Metropolitan
Municipalities' EMS Medical Directors. Prehosp Emerg Care. 2008 Apr-Jun;12(2):141-51.

Clinical and performance data is needed to assess the impact of the system on patients. Improvements
can only be made if data such as that outlined below is available in a timely and reliable manner. Best
practice EMS systems provide the following data that is regularly reviewed and reported to the
community:
§ Response times to emergency calls for each provider, aggregated countywide, and often broken
down in to “equity zones” in larger systems
§ Cardiac arrest survival per the industry standard “Utstein template”
§ Time from 911 call to “balloon inflation” at the cardiac percutaneous coronary intervention (PCI
or “cardiac cath lab”) laboratory
§ Scene intervals for patients meeting the American College of Surgeons criteria for transport to a
trauma center
§ Airway management success rates
§ Critical vehicle and equipment failures
§ Response vehicle crash rates per 100,000 miles
§ Rapid Sequence Induction (RSI) utilization
§ Stroke center – time from onset to therapy
§ Appropriate use of aero-medical services
MEDICAL DIRECTION ISSUES AND OPPORTUNITIES

Monroe County is a regional center of health services delivery, and as such is blessed with a wealth of
resources. A medical school with a focus on emergency medicine (including an EMS fellowship program
and a structural Division of Prehospital Medicine) sets the stage for an EMS system that could be a
model of excellence. However, against this backdrop, effective medical oversight with the ability to
enforce compliance is almost non-existent.
Multiple Layers/Little Authority

The current structure, with each individual agency contracting for or hiring its own medical director,
makes these medical directors reluctant to assert themselves. For example, the medical directors are
unable to access sufficient data to measure clinical performance. Quality improvement (QI) seems to be
relegated to case-based problem investigation, with little look at system-level or agency-level trends.
The multiple layers, most without much actual authority (except the authority to suspend or de-certify
medics), do not result in timely educational or administrative mitigation of clinical issues.
The County EMS Office should assume responsibility for medical direction of all EMS agencies in the
County, and should be empowered with local legislation to promote the functioning of the system to
specific metrics of performance.
Clinical Performance Is Not Measured

Currently, Monroe County does not collect commonly accepted clinical EMS metrics, including
resuscitation outcomes per Utstein, or any of the current evidence-based benchmarks described by the

Metropolitan EMS Medical Directors Consortium. In the absence of concrete data, no evaluation of EMS
metrics in Monroe County is possible.
Empowered with local legislation, the County EMS Office should mandate a centralized, uniform
electronic Patient Care Reporting system, or at the minimum, should require all agencies to participate
in the Regional Health Information Organization (RHIO) data repository. Data in the repository is to be
verified and analyzed. The RHIO EMS depository could be enhanced to include an expanded data set,
including the National EMS Information System (NEMSIS) 3.x software when it becomes available, and
“special studies” capabilities. In addition, the County, in cooperation with the medical directors, should
regularly report typical operational performance metrics and clinical performance metrics per Utstein
and the Eagles’ benchmark standards.
Patient Care Reports Not Provided to Emergency Department

Hospital emergency departments (as expressed by the physician directors of emergency medicine) are
uniformly very concerned that they do not receive written patient care reports at the time of patient
transfer in the emergency room. This is perceived as being a substantial clinical impediment and a
significant liability issue.
Empowered with local legislation, the County EMS Office should require all EMS agencies to provide a
complete patient care report (not an abbreviated “drop sheet”) on all patients prior to departure from
the emergency department, unless there is an extraordinary situation (disaster declaration, etc.) The
County should work with RHIO and others to develop and implement bidirectional data exchange that
uploads ePCR data directly in to the physician electronic medical record, and provide emergency
department/hospital discharge outcomes data directly back to the ePCR data base.
Clinical Data Deficits

The County’s CAD system is badly outdated and there are multiple disconnected and disparate
electronic patient care reporting (ePCR) systems. As a result there is a dearth of data and even less
information for examining any aspect (operational, clinical, administrative, financial, or customer
service) of the EMS system.
Given the expertise of the Rochester Health Information Organization (RHIO) and Monroe County’s
strong academic health care community, it is practical and possible to build an integrated EMS
information system that links CAD data, ePCR data, and hospital outcomes data, without great difficulty.
Role of Full-Time County Medical Director Limited

The County is fortunate to have a full-time contracted EMS physician, as Medical Director, available as a
field responder. However, the defined role of this position is limited, and it does not appear that this
resource is being used to its highest and best potential.

Inasmuch as the EMS physician is often the only career EMS person at the scene that is not part of a
two-person ambulance crew, he should be authorized to take operational control of EMS actions at
emergency scenes.
HOSPITAL SURGE CAPACITY

The concept of “surge capacity” is a confusing discussion, as there are no generally accepted or standard
meanings associated with the terminology. Discussions during on-site interviews addressed one of three
different concerns by hospital physicians and staff.
The first concern was with hospital capacity. Each of the major hospitals in greater Rochester reports
operating at or in excess of 100 percent of its capacity nearly every day. This typically refers to the ability
of the hospital to handle an increased patient load using its regular, daily compliment of equipment,
staff, and policies in relation to licensed or staffed bed counts.
The second concern addresses surge capacity as contemplated by the New York State Department of
Health. This evaluation is in relation to each hospital’s “surge plan,” in which special equipment, staff,
and policies are activated in response to an “event.” Each hospital has identified surge areas outside of
their emergency department to begin treatment for less injured or less salvageable victims, designated
specific activities that will be cancelled or delayed to allow use of their space and/or staff to support
surge, and devised means to evaluate the quick discharge or transfer of inpatients to make room for
incoming victims.
Rarely would these activities take place due to a “busy day” unless activity exceeded certain thresholds.
There are reported instances of a couple of hospitals instituting “surge procedures” due to
overcrowding without a specific event as a trigger. Although the smaller rural hospitals are less likely to
be operating at or over capacity on a regular basis, their resources are equally limited to be able to surge
enough to take up the slack of the region.
The Department of Health has reported that all hospitals, generally speaking, are proportional in their
ability to surge and respond. The concern here is that the tipping point for activation of surge plans is
much lower when hospitals are operating at higher volumes and with leaner staff. During “surge
period,” many busy and important services (such as same day surgery and other outpatient processes)
would be altered to meet the needs of the event and provide the required surge capacity. 15 This is not
sustainable in the long term.
The third “surge capacity” discussion dealt not with hospital beds, but with emergency department
capacity and ambulance offload delays. This issue was clearly the concern of EMS leaders, EMS medical
15
The State Health Department reports that the U.S. Department of Health and Human Services has recommended that a
region have an “event” surge capacity of 500 beds above daily operating count per million persons. They reported to the
interview team that each evaluation of the region’s ability to meet this standard had found it possible to do so.

directors, and hospital emergency medicine chiefs when asked about surge capacity. In short, the metro
area emergency departments are frequently beyond capacity, and in the not-too-recent past ambulance
off-load delays were a great concern to the EMS community. An aggressive and inclusive approach to
this issue, coordinated by many interested parties and supported by leadership at each hospital, has
greatly reduced this problem over the last year. In the event hospital wait times become unreasonable,
the Monroe County Director of Public Health and the chief executive officers of the hospitals become
engaged.
All three of the surge issues have come to bear recently due to the current active influenza season. The
New York State Department of Health issued a letter in January 2013 regarding the marked increase in
influenza patients presenting to hospital emergency departments. The letter, provided as Attachment B,
discusses hospital overcrowding and specifically addresses the delays to ambulance services in
transferring patients to hospital staff. “Ambulances and accompanying EMS personnel are not to be
detained in the emergency department and should be placed promptly back into services . . . ambulance
patients must be transferred promptly to emergency department staff.”
PATIENT DESTINATION REVIEW

Hospital capabilities are well known in the Monroe County EMS community, and destination selection
appears appropriate. Patients suffering severe multi-system trauma are transported to a Level I
accredited trauma center. Patients suffering S-T segment elevation myocardial infarction (STEMI) are
transported to percutaneous intervention (PCI) capable hospitals only (hospitals having interventional
cardiac catheterization capabilities).
ALTERNATIVE DESTINATION OPPORTUNITIES

As is true with most metropolitan areas, the community must provide service to a significant number of
individuals whose needs for medical care are less acute and may not actually require the services of an
emergency ambulance, or treatment at a hospital emergency department. However, because of a
variety of state and federal requirements, only EMS and hospital emergency departments must care for
those individuals.
This results in not only an unnecessarily increased demand for services (often uncompensated), but also
results in those medical services being provided in the most expensive manner possible: transportation
in an emergency ambulance when a less-costly mode would be sufficient, and treatment in the hospital
emergency room when a lower acuity and less costly venue would be more appropriate. The costs are
borne not only by those directly involved, but also by the community as a whole.
Against this backdrop, EMS systems with strong clinical leadership began several years ago to explore an
expansion of evaluation and decision-making capabilities of local EMS systems. Instead of simply
responding and transporting all callers, more appropriate transportation modes and destinations could

be utilized. These programs, known collectively as “community paramedicine” programs, now dot the
nation.
Monroe County examined this issue several years ago, and a “Priority Four Diversion Project” was
undertaken. This project was concluded after some small design defects were noted to interfere with
the desired outcomes 16, but the concept remains viable. There remains great interest in the EMS,
emergency medicine, and community health arenas in further exploring options to utilize EMS
paramedics as part of this effort. Both the Finger Lakes Health Systems Agency (Senior Planner Arthur
Streeter, M.H.A.) and the Monroe County Public Health Director (Andrew S. Doniger M.D., M.P.H.) have
history with the earlier project and believe that it should be pursued. That sentiment was shared by all
of the hospital emergency department directors, and much of the EMS community.
The Finger Lakes Health System Agency (FLHSA) is a community-independent health planning
organization, serving the City of Rochester and the Finger Lakes region. FLHSA has been awarded a
multi-year grant in excess of $26 million by the Centers for Medicare and Medicaid Services “Health
Care Innovations” grant program, for a community-wide, outcomes-based payment model for primary
care that will serve Medicare and Medicaid beneficiaries in six counties in the Rochester, New York area.
The project creates a collaborative of agencies, payers, employers, government, patients, social
coalitions, and community service organizations to integrate community services with primary care and
leverage social and health care resources.
Primary care physicians will receive technical, process, and adaptive support, and will be connected with
a team of care managers, care coordinators, and community health workers. This approach will
strengthen primary care and reduce avoidable hospitalizations, readmissions, and emergency room use.
Over a three-year period, the Finger Lakes Health Systems Agency will train 726 health workers and hire
76 health care agencies in positions as care managers, community health workers, community-based
care coordinators, and practice improvement advisors. 17
It is important that the County and all EMS agencies develop a strategic approach to community
paramedicine, as an alternative to ambulance transportation and emergency department treatment for
those who call 911 with sub-acute and chronic health conditions. The County can collaborate closely
with the FLHSA to assure that EMS fulfills its potential to reduce unnecessary hospitalizations, hospital
re-admissions, and unnecessary emergency department use.
16
The Monroe County effort involved the ambulance paramedic in the alternate destination decision, as well as the
transportation to alternate destinations (which often required more time than a simple hospital transport.) Other programs,
such as those in Fort Worth, Texas and Wake County, North Carolina, utilize another resource – the community paramedic or
advanced practice paramedic – to make this decision, thereby taking the decision-making away from the ambulance paramedic.
This keeps the clinical decision separate from the individual, whose workload is impacted, allowing for better decision-making.
Other programs perform alternate destination transportation using vehicles that are less expensive than a paramedic
ambulance, such as a taxi or paratransit van, when the patient’s condition is less acute.
17
http://innovations.cms.gov/Files/x/HCIA-Project-Profiles.pdf

FUTURE INVOLVEMENT WITH RHIO
Regional Heath Information Organizations (RHIOs) are non-governmental, not-for-profit organizations
that enable interoperable health information exchange in New York. The RHIOs build interfaces with
healthcare organizations in their community to either collect or register clinical information at a patient
level and help exchange their data with other agencies in the community. The Rochester RHIO includes
40 health care organizations in the 13 county Greater Rochester area.
The Rochester RHIO Executive Director, Ted Kremer, provided the consultants with his vision of the
future for the Rochester RHIO as it pertains to EMS agencies and the individual provider. His thoughts
are summarized below.
As we move forward in making critical patient information available at the point of care, integrating EMS into
regional and national health information exchange (HIE) strategies needs to be an area of focus. Even though
the adoption of digital records by EMS agencies has not seen the same national focus and funding that
hospitals and physician practices have seen, they represent a key part of the health care delivery system.
Including EMS agencies into a larger health information exchange strategy necessitates that we establish
interoperability with the software technology companies serving this market.
There is a core set of interoperable functionality that should emerge from the integration of pre-hospital care
system as they connect with local, regional or state health information exchanges.
§ EMS agencies should be able to send to an HIE not only completed ePCRs but should also be able to
send biometric reading from ancillary devices (ECG, pulse oximetry, BP readings, etc.).
§ EMS data should be available to a patient’s treating providers through an HEI. This includes calls that
resulted in patient transport as well as treat and release calls that did not result in patient transport.
§ A physician should be able to subscribe to, or be notified of, emergency events involving their patients.
Such notification should either be sent directly to the physician’s electronic medical record through an
HIE or utilize the Office of National Coordinator’s “Direct”’ messaging protocol.
§ EMS agency personnel should be able to query and retrieve a patient’s Continuity of Care summary
document from an HIE in high priority calls. Such a document should contain patient demographics,
medications, allergies, problem list and advanced directives such as Do Not Resuscitate (DNR) or
Medical Orders for Life-Sustaining Treatment (MOLST).
§ This Continuity of Care document should be both readable and the ePCR system should allow for
populating appropriate fields in the agency’s ePCR.
§ In evaluating care trends and moving towards quality outcomes, analytical services looking at care
measures should include EMS-based services and link them to subsequent hospital utilization or other
outpatient care trends to better understand the complete picture of both patient and the complete
picture of patient care.
Mr. Kremer’s comments underscore that urgent need for Monroe County to move towards an up-to-
date and fully functional, integrated Computer Aided Dispatch system and unified ePCR system.

SYSTEM FINANCES
In a typical system review, the consultants are provided with relatively extensive financial data from
ambulance agencies, cities and/or counties. For this project, no financial data was forthcoming, other
than the very scant information gathered from 20 ambulance agencies that responded to the survey
tool.
Fitch was able to ascertain that two major ambulance agencies have provided emergency and non-
emergency medical response and transport for over a decade and without tax or other subsidy. Both
organizations maintain up-to-date, sophisticated CAD systems and deploy in an efficient and dynamic
manner.
The City of Rochester has successfully conducted several procurements for the provision of emergency
medical services. The Rochester market has proven sufficient to attract competition resulting in no
subsidy, performance-based contracts. The greater Monroe County area provides sufficient transport
revenue streams to sustain both organizations.
The remaining ambulance agencies are supported by a combination of transport fees, local tax and
other subsidies, monetary donation and volunteer staffing donations. The consultants were not
provided with detailed financial documents from the ambulance agencies in Monroe County. However,
based on our experience in like-sized communities, it would be unusual for ambulance agencies that
operate in relatively small districts to be totally supported by patient transport revenue. The area
outside the City limits of Rochester, in aggregate, could potentially support one or several coordinated
ambulance agencies. This concept will be explored in the options section of this report.
DUPLICATED FUNCTIONS AND COSTS

Monroe County’s multiple agency-operating structure results in a significant duplication of services,
equipment, administrative, and overhead costs (direct and indirect, tangible and intangible). While the
consultants were not privy to the financial accounting systems of the various agencies, and a detailed
cost-audit was beyond the scope of this project, there are a number of areas in which costs appear
excessive:
§ In the aggregate, the system appears to have far more ambulance vehicles than are needed to
serve the EMS needs of the community. Rural/Metro serves the City of Rochester with
approximately 36 ambulances and provides more than 57,000 emergency patient transports
annually. There are approximately 87 ambulances operating in the area outside of the City of
Rochester. Based on review by the Consultant, it appears that if the area outside the City of
Rochester deployed as a unified system, it could be served by significantly fewer ambulances. 18
18
The ambulance count was provided by the County EMS Office.

§ Each agency requires general management, financial accounting services, billing services, and
many other administrative services. Although the Consultant was unable to quantify these
factors, it appears feasible that savings could be gained by pooling functions and contracting for
like services.
§ Electronic Patient Care Report systems and transport billing services all are conducted
separately. These services, if bundled and competitively bid, likely could result in significantly
reduced costs.
§ Each agency conducts its own vehicle procurement. An agency buying one or two ambulances
has little to no negotiating power. Conversely, vendors are encouraged to “sharpen their
pencils” when bidding for the sale of an annual aggregate of 15-20 ambulances that might
require replacement countywide. In that same vein, major medical equipment (such as cardiac
monitor-defibrillators) can yield substantial savings if purchases and maintenance contracts are
made in larger numbers.

BENCHMARKING THE MONROE SYSTEM
SYSTEM BENCHMARKING
Benchmarking is the opportunity to compare oneself against others. This notion was incorporated into
best practice EMS more than a decade ago. This model has allowed EMS organizations to continuously
improve by setting goals that are achievable, sharing best practices to achieve those goals and to
innovate to improve on what is being done.
The tables below look at benchmark/best practices in the following areas.

§ Communications
§ Medical Fire Response
§ Medical Transportation
§ Medical Accountability
§ Customer/Community Accountability
§ Prevention/Community Education
§ Ensuring Optimal System Value
§ Organizational Structure and Leadership
The table provides comment about the Monroe County EMS systems on a total of 50 specific items.
Table 29. Monroe County System-wide Benchmark Assessment

Communications Benchmarks Comments
Public access through a single number, preferably
4
enhanced 911
Coordinated PSAPs exist for the system 4
4
Certified personnel provide pre-arrival instructions and
Personnel are EMD certified; as is practical,
priority dispatching (EMD) and this function is fully
911 Dispatch Center should consider hiring
medically supervised
medics with field experience for new hires
Data collection which allows for key service elements to
No
be analyzed
Technology supports interface between 911,
No
dispatching & administrative processes
Radio linkages between dispatch, field units & medical
facilities provide adequate coverage and facilitate 4
communications

Medical First Response Benchmarks Comments
Partial
First response agencies may choose but are
First responders are part of a coordinated response
not required to use the County Medical
system and medically supervised by a single system
Director; some do and many do not;
medical director
CON does not impact medical first
responders.
Defined response time standards exist for first
No
responders
First response agencies report/meet fractile response
No
times
AED capabilities on all first line apparatus 4Most have AED capability.
4However, record keeping and
Smooth transition of care is achieved
documentation are not well integrated.
Medical Transportation Benchmarks Comments

Partial
Yes for City of Rochester; there are consensus
standards for outside the City, but not
Defined response time standards exist monitored, not enforceable, do not meet
generally accepted definition as clock starts
when wheels roll as opposed to when call is
received.
Partial
Rural/Metro reports and meets Response
times per contract (data source is the R/M
Agency reports/meets fractile response times
CAD; no regular reporting of response times
for other agencies from a central data source
– all self-reporting.
Units meet staffing and equipment requirements 4
No
Resources are efficiently and effectively deployed Closest ambulance is not sent to calls; hard
boundaries do not service patients well.
There is a smooth integration of first response, air,
4
ground and hospital services
Develop/maintain coordinated disaster plans 4
Medical Accountability Benchmarks Comments

No
Single point of physician medical direction for entire Countywide medical director has little
system authority over individual agencies; each
agency hires its own medical director.
Partial
Written agreement (job description) for medical Yes for County Medical Director; no standard
direction exists job description for other agency medical
directors.
4Most medical directors are board certified
emergency physicians; County medical
Specialized medical director training/certification
director is board certified and fellowship
trained in EMS and has an MS in EMS.

Medical Accountability Benchmarks Comments
Partial
As much as possible with system and with
Physician is effective in establishing local care standards
data research impairments; much medical
that reflect current national standards of practice
direction policy is made by regional
committees.
4
Proactive, interactive and retroactive medical direction
As much as possible with system and with
is facilitated by the activities of the medical director
data research impairments.
No
PCR/QI data transparency for MD review Data is self-selected by providers; reviewed
by individual agency medical directors.
Clinical Education/Development Effectiveness. Not within scope of review
Clinical Education Efficiency Not within scope of review
Customer/Community Accountability Benchmarks Comments

Partial
Legislative authority to provide service and written
Yes in City of Rochester
service agreements are in place
No in outside City of Rochester
Units and crews have a professional appearance. 4Crews appear to provide quality level care.
Formal mechanisms exist to address patient and
Not within scope of review
community concerns.
No
Other than Rural/Metro which operates
Independent measurement and reporting of system
under a performance based contract, there is
performance are utilized.
no system reporting; all is self-reported and
not published in a uniform manner.
Internal customer issues are routinely addressed Not within scope of review
Prevention/Community Educations Benchmarks Comments

System personnel provide positive role models Not within scope of review
Programs are targeted to “at risk” populations Not within scope of review
Formal and effective programs with defined goals exist. Not within scope of review
Targeted objectives are measured and met. Not within scope of review
Ensuring Optimal System Value Benchmarks Comments

No
Clinical outcomes not reported; response
Clinical outcomes are enhanced by the system time “targets” are outdated with respect to
call density categorization; clock starts at
wheels rolling which disregarding chute time.
Ambulance response utilization and transport utilization
(UHU) is measured and hours are deployed in a manner No
to achieve efficiency and effectiveness
Partial
City of Rochester pays no subsidy and
Ambulance cost per unit hour & transport document
receives franchise fee.
good value
In exRochester area, agencies utilize
volunteers which lowers cost per UH
Partial
Service agreements represent good value
Rochester has a good value agreement;

Ensuring Optimal System Value Benchmarks Comments
Not within scope to review agreements of
other agencies
Non-emergency ambulance effective & efficient Not within scope of review
Non-Ambulance but medically necessary (MAV) services
are effective and efficient
System facilitates appropriate medical access 4Medical access appears to function well.
Financial systems accurately reflect system revenues Not within scope of review
and both direct and indirect costs. Scant financial information was provided.
Revenues are collected professionally and in
compliance with regulations.
Tax subsidies exist; not within scope to
Tax subsidies when required are minimized
review subsidies of individual agencies; no tax
subsidy in City of Rochester.
Organizational Structure/Leadership Benchmarks Comments

Partial
A lead agency is identified and coordinates system County EMS Office (with limited authority and
activities. sparse staffing) coordinates MLREMS and
REMAC.
Organizational structure and relationships are well
Partial
defined.
Human resources are developed and otherwise valued. Not within scope of review
No
Business planning and measurement processes are
Management efforts are fragmented in multiple
defined and utilized.
agencies.
No
Operational and clinical data informs/guides the
Data is not forthcoming from traditional sources
decision process.
(911).
No
A structured and effective performance based quality
Data is not forthcoming from traditional sources
improvement (QI) system exists.
(911).
Of the 50 benchmarks, 14 are outside the scope of this review. Of the remaining 36 benchmarks, the
Monroe County system affirmatively meets 13, receives a definite “No” on 13 benchmarks and has
partial recognition for 10 benchmarks. Clearly, there is room for improvement.
CLINICAL BENCHMARKING
Best practice EMS systems review clinical data frequently and down to the level of the individual agency
and the individual provider. There was no evidence that Monroe County EMS agencies conduct
appropriate, ongoing clinical benchmarking and/or quality improvement that is shared with the County
EMS Coordinator or the County Medical Director. Rural/Metro is required by contract to monitor
quality/clinical metrics and share these with the City’s Medical Director.

Some of the areas of clinical benchmarks that other best practice systems regularly measure and report
are listed in the Quality Management section of this report. Additional items are as follows:
§ Measure Return of Spontaneous Circulation
§ Measure Defibrillator to Patient Side
§ Measure 911 call to Percutaneous Intervention in ST Elevation Myocardial Infarcts (STEMI)
patients
§ Measure Pulmonary Edema/Congestive Heart failure receiving non-invasive positive pressure
ventilations
§ Measure percentage of American College of Surgeons defined criteria for trauma patients
transported to trauma center
§ Measure American College of Surgeons trauma cycle time from 911 to trauma center arrival
§ Measure American College of Surgeons trauma patients with 10 minute or less scene times
§ Inspect defined sample of medical records for protocol compliance
§ Participation in research
§ Physician Medical Director 3 or more NAEMSP recommended qualifications
911/MEDICAL COMMUNICATIONS
Best Practice Benchmarks for Communications
EMS dispatch centers are considered the coordination centers for EMS systems; they take calls with
complex call taking algorithms, categorize and prioritize calls, and then assign the appropriate resource.
Best practice EMS dispatch centers are designed to accommodate Public Emergency Reporting Services
(PERS) and phase II network-to-network interface of wireless agencies. These mandatory connections
facilitate wire-line, cellular, voice over internet protocol, automatic crash notification, patient alerting
system devices and other public 911 access to the Emergency Medical Services System. Voice, video,
telemetry, and other data communications conduits are utilized as necessary to best enhance real-time
information management for patient care.
Quality in dispatch centers is established through continuous quality improvement that, at the front
end, is medically directed. These medically directed systems use protocol based emergency call taking.
The most commonly used protocol based call taking system is Emergency Medical Dispatch (EMD).
Nationally recognized performance standards exist for each part of the call taking process (see prior
section titled Call Processing Attributes and Standards). These standards provide a yardstick against
which the performance of the communications center can be measured. Technology should support the
caller and direct the call from the primary Public Safety Answer Point (PSAP) to the appropriate
secondary PSAP for the geographic location of the call.
The collection of comprehensive data on performance and the routine reporting of this data are key
elements of quality in a dispatch center. Routine reports on performance become the foundation for
performance measurements that are the accountability standards by which the service will be
considered as adequate, excellent or failing in its delivery of service. Technology should support the

interface between 911 and the medical dispatch functions and administrative processes. Radio/cellular
linkages between dispatch, field units and medical facilities need to provide coverage and facilitate both
voice and data communications. Interoperability between allied public safety agencies needs to be
present at all levels. 19
Key Accomplishments and the Current Situation in Monroe County

Monroe County has one principle dispatch center that handles all the 911 calls in the County. The
dispatch center is a “hold system,” which means that the call taker will hold the call and proceed to
determine the location, acuity, and priority of the call using scripted questions appropriate to medical,
fire, or police. The Monroe County 911 Dispatch Center uses medical priority dispatch protocols,
considered “best practices” in the medical field. 20 The next step in the call taking process is “dispatch.”
The details of the dispatch step are determined by the location of the call—in the Monroe Ambulance
Service district, in the Rural/Metro ambulance service district, or elsewhere.
Calls located in the Monroe Ambulance district or Rural/Metro district are sent electronically to
dispatchers at either Monroe or Rural/Metro. These dispatchers are then responsible for allocating the
calls to an ambulance waiting on station.
In the case of call locations other than in the Monroe Ambulance, Rural/Metro, and a few other districts,
the Monroe County 911 Dispatch Center is responsible for ambulance dispatch. They initiate a call to the
indicated ambulance service district, and the ambulance agency responds with a verbal
acknowledgement. In the event of “no response,” some agencies have a prescribed five-minute wait
time before the Dispatch Center tries to get a response from one of the neighboring ambulance districts.
The Dispatch Center will not wait if the ambulance district has no ambulance logged on or if the logged-
on ambulance is on a call. This does not mean that they are selecting the closest ambulance, as it is
often not the case. The dispatch center is blind to vehicle movements and cannot select the closest,
most appropriate vehicle to the call. Logons into the system are done through a County-created web
page. The system has many operational advantages, yet it is totally passive, maintains no records and
provides no data.
In this section we describe and contrast the differences between the Monroe County 911 Dispatch
Center and best practice. A specific focus is put on dispatch technologies, processes in the dispatch
center, medical priority dispatch and quality improvement, and electronic patient care records (ePCR).
The principle communication center is equipped with an antiquated Northrop Grumman CAD system
that does not integrate rostering, automatic vehicle location (AVL), global positioning system (GPS), and
other important components. Even more alarming than the incomplete data that the Northrop
19
The County should make the new trunked radio system available to both Monroe Ambulance and Rural/Metro. The County
will need to determine user fees to be reimbursed and each agency will be responsible for portables/mobiles, etc.
20
The Monroe County 911 Center (Emergency Communications Department of the City of Rochester) has been accredited in
past years, but is not listed on the National Academies of Emergency Dispatch website as a currently accredited center of
excellence.

Grumman CAD system collects, is its inability to output this data into any form of meaningful and timely
performance reports.
Ambulance agencies receive no meaningful feedback to measure problems or to implement

improvements. The consultants understand that the County has been working on a new CAD system.
The consultants feel that any new CAD system must integrate all of the components that follow and as
represented in the figure below.
Figure 12. Typical CAD Design
Automatic Vehicle Location (AVL) and Global Positioning Systems (GPS)

The key technology for EMS optimization is the addition of automatic vehicle location/ global positioning
systems (AVL/GPS). Well-designed emergency systems do not use fixed stations; rather, they
continuously move resources based on where the most likely location of the next call is predicted to be
and assign the closest unit to the call. The key to making this work is to know (in real time) where the
ambulance resources are located. Monroe County 911 Dispatch Center does not have the ability to see
where the resources are and is unable to reallocate resources in order to maximize coverage. 21
21
Both Monroe Ambulance and Rural/Metro have offered their AVL view to County Dispatch Center. To date, County Dispatch
has declined the offer.

Thus Monroe County 911 Dispatch Center is effectively blind and must rely on the self-reporting of the
field personnel to establish vehicle location. Compounding this inadequacy is the fact that the 911
Dispatch Center does not have the right to assign an ambulance to any location. It must request the
permission of the ambulance service districts. It will post the resource based not on need or probability
of risk but on pre-established and rigid mutual aid parameters.
The figure below is an example of a demand and coverage map. Hot spots of call demand are color-
coded and coverage is determined by showing the drive zone capability from specific posts or stations.
Figure 13. Matching Demand and Supply in Sophisticated Models
CAD to Mobile Data Terminals

Another key component of a high-performance system is accurate data in real time. In order to enhance
the capture of data and to share better information between the field operations (ambulances) and the
dispatch center, sophisticated systems use data connectivity between CAD and Mobile Data Terminals
for information sharing. In such systems, the ambulances are equipped with ruggedized laptop
computers, which interact with the CAD and pass relevant call information back and forth without the
need for the voice channel on the radio. Voice communications should be used as back up to the data
transfers.
Currently, Monroe County does not have data connectivity into the field and instead, it relies on voice
communications for all vehicle information exchange, be it activity tracking (call assign, depart for call,
arrive on scene, etc.) or pertinent patient information exchange. This means that all time stamps and

information are manually updated or keyed in by dispatch center personnel. This adds to inaccuracy and
uses more dispatcher time than is optimal. Rural/Metro and Monroe Ambulance services have
ruggedized laptops in the field running multiple applications that assist in patient information exchange,
time stamps, and supervisory views that allow for better field management.
Electronic Patient Care Records (ePCR)

Electronic Patient Care Records are the industry standard for emergency medical systems. The care
delivered in the field needs to be both prospectively and retrospectively managed. This is particularly
true when advanced care is delivered in the field that can result in negative patient outcomes. Advanced
intervention is a positive act for the patient when it is done well. Likewise, it can have very negative
outcomes when it is performed poorly or performed inappropriately. These medically delegated acts
require strong supervision and a continuous quality improvement that allows medical oversight to
continually monitor and correct behavior in the field. An ePCR system has a number of benefits for
patient care:
1. ePCRs have mandatory fields that must be completed allowing for excellent data quality and
mining capabilities. These “call closure rules” as they are commonly referred to, allow system
administrators to capture the required data elements to properly manage the system.
2. ePCRs will flag certain calls for mandatory review and alert medical control to review this call
specifically. This ensures that the highest risk calls are reviewed for quality. This is both in the
patient’s and the County’s best interest in order to reduce liability.
Electronic PCRs transfer data several ways and to several recipients. They first supply an electronic or
paper record to the receiving hospital through Wi-Fi or Bluetooth technology. They supply system
information to administrators either in real time over cell tower connections or through Wi-Fi/
Bluetooth/docking station back at the base. This data is parsed and sent to the relevant recipient, be it
medical control, billing, or operations.
Alarmingly, many ambulance services in Monroe County leave no record of patient contact at the
receiving hospital. This is a serious lapse in patient care and may have liability consequences to the
ambulance service agency and the receiving hospital.
911 Emergency Call Processes and Standards

The flow of a 911 call is described in the section titled Call Processing Attributes and Standards as are
the National Fire Protection Association standards specifying the “best practices” time intervals for the
various steps in the dispatch process.
Understanding the medical dispatch center’s role is the key to interpreting how the processes are core
to the success of an EMS system. The dispatch center must be able to provide sophisticated real-time
deployment and re-deployment of resources. It must engage callers in medical interrogation and
intervention. It is the primary source for information necessary to manage the system for the benefit of
patients. The figure below depicts the critical communication functions of a 911 call center.

Figure 14. Critical Communications Functions of an EMS Communications Center
As can be seen in the figure above, there are distinct and critical functions in the dispatch operation. In
best practice systems at least five of these functions (i.e., deployment, medical call reception,
categorization, prioritization, and resource assignment) are governed by EMS dispatch. In some systems,
the control of hospital destination is also governed by EMS dispatch.
While the Monroe County 911 Dispatch Center has a coordination role, it does not play its role as a
dispatch center holistically. It does not have full control of the locations of ambulance resources and
cannot reassign them to uncovered areas. The Monroe County 911 Dispatch Center has limited control
on destination management. This often results in overwhelming specific hospitals and underutilizing
others. Each of the functions in the figure above roles has activities and tasks associated with them as
illustrated in the figure below.

Figure 15. Typical EMS Dispatch Activities and Tasks

When processes are not well designed and activities are not well integrated, more resources have to be
deployed in the field, resulting in increased expenses. In the Monroe County 911 Dispatch Center there
is a failure to deploy to optimize available coverage, a lack of data transfer between field operations and
dispatch, and longer than required call handling times.
In the Monroe County 911 Dispatch Center, call handling takes longer than specified by the nationally
accepted best practices. There is a lack of real-time data transfer between field operations and dispatch.
There is an inability to deploy available units to optimize coverage due to limitations imposed by existing
state policies. The table below provides a side-by-side comparison of industry best practices with
Monroe County 911 Dispatch Center practices.
Table 30. Best Practice Side-By-Side Comparison

Best Practice Monroe County 911 Dispatch
YES AND NO
1. Call taking done by specialized personnel Some Paramedics with field experience handle call taking
to ensure optimal patient contact; all are EMD trained.
YES
Use Medical Priority Dispatch System (MPDS), a standard
2. Protocol based call taking
of care protocol for medical emergency triage and pre-
arrival instructions to patients/callers
YES
3. Quality assurance program with calls reviewed
This is a requirement of being an accredited center of
for call taking accuracy
excellence
YES
4. External oversight
Independent medical director for dispatch
NO
Lack accountability, no performance requirements by
5. Time measurements and reporting
oversight body, no apparent reporting and no
consequences for poor performance
NO
6. Computer aided dispatch (CAD) with mapping Weak geospatial capabilities; not up to date in version of
CAD system
7. AVL/GPS, automatic vehicle location, global NO
positioning system Very little and not integrated in CAD
NO
8. Mobile data terminals communicate with CAD
None
9. Radio/Radio interoperability YES
10. Drag and drop dispatching, ensures proper NO
time stamps Not possible in existing Northrop Grumman CAD
YES
11. Prescribed continuous training for call takers
24 hours of bi-annual continuing education is required
YES AND NO
Fully trained paramedics can be promoted both internally
12. Personnel mobility
and externally, those that are not field trained do not
have mobility
13. Field and Dispatch SOP, standard operating YES AND NO
procedures, up to date For internal SOP but not integrated with field operations
The Monroe County 911 Dispatch Center fully performs only five of 13 best practices, partially performs
three and fails to perform five practices. Implementing an up-to-date, fully integrated CAD system is the
first step in addressing poor performance system-wide.

The processing of a 911 call is the key component of effective dispatching as well as cost efficiency. Each
dispatch task is complex and requires different talents and training. As discussed above, structures and
technologies that recognize both the differences and similarities in different dispatching tasks are able
to maximize efficiencies. Those that do not tend to run slower and cost more.
Dispatch Personnel
Fitch & Associates was asked for its opinion of the resources required for dispatch center operations.
Fitch reviewed the report prepared by the Monroe County 911 Dispatch Center on staffing requirements
and agrees with the methodology applied. However, making decisions on staffing appears premature.
The existing Northrop Grumman CAD system is antiquated and does not optimize the dispatch process.
As such, personnel are compensating for inadequate technology. The appropriate time to review staffing
is after the existing Northrop Grumman CAD system is replaced.

SPECIFIC AREAS FOR IMPROVEMENT
Fitch & Associates was asked to address several specific issue areas — solutions to allow for agency
backfill, improving EMS support to law enforcement, fire and special operations, and building an
incident command system. Those areas are addressed below.
SOLUTIONS TO ALLOW FOR AGENCY BACKFILL

Throughout the Consultant’s site visit, virtually everyone interviewed expressed agreement with the
notion that a patient-centered EMS system would always send the closest available— and patient-
appropriate— ambulance to every call for service. The current CON environment makes that practice
difficult and this is a source of constant consternation.
In the long term, a change to the state EMS regulatory structure could resolve this issue. New York State
has a long history of home rule, village-centric municipal governance, that was once quite functional but
which does not align well with modern concepts of regionalized health care and EMS delivery. 22
In the meantime, one viable option involves the County itself obtaining a CON for ambulance service
throughout the County. Utilizing the provisions of Public Health Law § 3008, the County could obtain a
countywide CON. Utilizing the authority of its CON, the County could provide centralized coordination
and management services, and could enter in to service area agreements with each of the existing
ambulance services to serve particular subareas within the County. Those agreements could include
provisions governing “closest unit dispatch” and address other operational improvements. This new
organization could also facilitate the development of countywide EMS special operations capabilities,
which are sorely needed as noted elsewhere in this report.
IMPROVING EMS SUPPORT TO LAW ENFORCEMENT, FIRE AND

SPECIAL OPERATIONS
An emergency medical services system typically engages in two categories of operations – ambulance
operations, entailing responding to requests for service and providing ambulance transportation, and
special EMS operations, which entail providing out-of-hospital medical services in a variety of
challenging environments that may or may not lead to eventual transportation by ambulance. Examples
of special EMS operations include the following:
§ Providing organic emergency medical support to law enforcement and fire service special
operations units (tactical/SWAT teams, explosive ordinance disposal/bomb squads, water
safety/rescue units, hazardous materials teams, urban search and rescue teams, etc.)
22
See, “Emergency Medical Services At the Crossroads”, Institute of Medicine, National Academies, June 2006, recommending
the delivery of EMS on a regional basis.

§ Developing, maintaining, and operating special response packages consisting of trained
leadership elements, special EMS vehicles (logistics vehicles and ambulance busses), and
communications resources, such as “Ambulance Strike Teams” and “EMS Task Forces,” such as
those that might be required to evacuate a hospital or large nursing home, or to relieve a
community beset by natural or man-made disaster.
§ Developing and operating trained incident management teams, and other specialized units (bike
teams, all-terrain vehicles,) that provide medical support to large public events or mass
gatherings
Within Monroe County, EMS providers have varying degrees of training and experience supporting
public safety special operations teams. Everything from scene awareness to treatment of patients would
benefit from specialty-trained medics. There are some EMS providers trained in support of law
enforcement SWAT teams, but there are too few to provide consistent 24 hours/7 day- a-week
coverage. Other providers are trained in Advance Hazmat Life Support, but not in other special
operations areas.
A current program that was spearheaded by Monroe County EMS involves a formal assessment of
special operations capabilities and development of training modules. The University of Rochester is
completing the assessment and development phases of the program. The goal of the program is to
cross-train a group of providers in all special operations areas. The result would be that, for example, a
provider who responds to a bomb squad incident that turns into a hazmat incident is prepared and
trained to support in both areas (as well as others).
The program is funded to include reviewing County Response Plans, developing modifications to take
advantage of EMS Special Operations, integrating the program into the Plans and accomplish training
through CY2012 and CY2013.
BUILDING AN INCIDENT COMMAND STRUCTURE

Monroe County has a long history of county leadership, inter-governmental cooperation, and successful
shared specialized service, in both the law enforcement and the fire service communities. In the absence
of a robust County EMS system, specialized services have not evolved to the extent that might be
expected in a major metropolitan area. While individual ambulance services may have developed a
limited capacity in a particular area, those capabilities are limited and not embraced by the entire EMS
community.
At the same time, the ambulance services have evolved sufficient leadership to support their daily
functions. The leadership effort focuses primarily on staffing transport ambulances, recruiting and
maintaining ambulance personnel, and the myriad details that are involved in operating an ambulance
service on a day-to-day basis. Probably because most of the day-to-day ambulance activity involves one-
patient, one-contact, one-transport, and because of the small size of the organizations involved, there
has not developed a focus in incident command — National Incident Management System

(NIMS)/Incident Command System (ICS) — capability within the EMS community. There is no EMS “field
supervision” outside of the City of Rochester. Accordingly, many of those interviewed agreed that one
weakness of the current system is the lack of expertise in larger incident management.
Into the patchwork of ambulance services that serve the County, the County EMS office has evolved a
small group of volunteer deputy County EMS coordinators also known as “battalion coordinators,”
whose functions are primarily advisory, both to the County and to the ambulance services. Operational
coordination, where it occurs, is provided by the deputy County EMS coordinators, operating under the
general supervision of the County EMS Coordinator. In a major incident, these coordinators will be slow
to respond (as they are at-home volunteers with day jobs), and have no authority to direct, but merely
serve as advisors and resources to local ambulance service and the municipality having jurisdiction. This
was evidenced by the lukewarm performance of the EMS system generally at the Greater Rochester
International Airport drill (see 2008 and 2011 airport drill reports for evidence of lack of progress).
During the course of this study, the Consultant had an opportunity to observe a full-scale exercise
involving a simulated aircraft crash at the Rochester International Airport. Although the planning of the
exercise did not meet current guidelines for the planning and evaluation of exercises, 23 the exercise
provided an opportunity to test the infield response and incident management capabilities of the local
EMS community. The airport’s emergency operations center was impressive, stood up quickly, and
provided excellent support throughout the event.
Although incident command was appropriately provided by the airport’s crash-fire-rescue officers, the
EMS component of the event was not well-organized at the field level. A significant illustration of
suboptimal resource utilization was the fact that the County’s EMS physician, present in his field
response role and properly outfitted for assignment, was never assigned a function, remaining in a
staging location throughout the event. There was no evidence of any personnel accountability for EMS
personnel on site.
The evolution of Monroe County’s patchwork of independent ambulance services to a fully functional
EMS system will require the building of an empowered infrastructure responsible for major incident
planning and management, special team and project coordination, quality management, operational
analysis and reporting, and support to the office of the medical director as that function evolves.
23
The Homeland Security Exercise and Evaluation Program (HSEEP) constitutes a national standard for all exercises. Through
exercises, the National Exercise Program supports organizations to achieve objective assessments of their capabilities so that
Strengths and areas for improvement are identified, corrected, and shared as appropriate prior to a real incident. See
https://hseep.dhs.gov/pages/1001_HSEEP7.aspx.

THE OPTIMIZED MODEL SYSTEM
All patients want the fastest, most appropriate ambulance to arrive when they are in need of help. An
optimal system must be designed with the patient in mind. Most patients are also citizens/residents,
and, as such, they want the best service for the lowest cost. If money were not a concern, then the
simple answer would be to continuously add resources to the system until response times were fully
satisfied and patients were receiving the best care. This is simply not possible. A more sophisticated
approach must be taken.
When dealing with emergency medical services, it is essential to understand the concept of the
“probability of a call” or the “probability of a demand for service,” herein referred to as “risk.” The
metric for risk is (calls/square km/month). The mistake that many policymakers make is to believe that
risk is attached to census-derived population densities, where communities deemed “rural” by a
planning or census definition carry low risk for emergency medical services.
In emergency medical services, census-derived population density has proven to be only a relative
predictor of demand for services. This is primarily due to the fact that many regions in the County are
“bedroom communities.” The population of the “bedroom community” affects other areas that have the
working populations. Simply put, not everyone has their emergency event at home. This effect is
exemplified by the numbers for the City of Rochester: per the United States Census, only 28% of the
domiciled population of Monroe County lives in Rochester. Yet as presented in this report, 48% of all
EMS calls in Monroe County originates within the City of Rochester.
To proceed, four questions must be answered:

§ What is the geographical area under consideration?
§ What is the operating environment?
§ How are demands for service distributed, by location and by time of day, across this
geographical area?
§ Where ambulances should be stationed to meet these demands for service?
GEOGRAPHIC AREA (M-XR)

Fitch & Associates chose Monroe County, excluding the City of Rochester (M-xR) as the most germane
geographical area for consideration. The City of Rochester was excluded because it already has an
emergency medical service that is held accountable by contract to meet specific metrics of performance.
Since Rural/Metro is working well and contributes to public coffers, any proposal to change it becomes
very weak. Excluding other segments of the County was not considered. The number of possible
combinations of which districts are included or excluded becomes significantly large as to preclude
construction of models.

Operating Environment
This model assumes that Monroe County obtains a countywide Certificate of Need and has the authority
to dynamically post ambulances at locations, as driven by changing demands for service, and to dispatch
these ambulances as needed. This model assumes that a modern CAD system has been installed at the
County Dispatch Center and that AVL/GPS hardware has been installed in all ambulances.
The Consultant used a “clean canvas” approach. None of the existing infrastructure was considered.
Further analysis would be required to ascertain which of the existing buildings might be used as stations
in this model.
To be defensible, any model for delivery of emergency medical services to Monroe County must be
designed to perform to what has been institutionalized as best practices by most high- performance
systems in the United States and Canada. The arrival of a transport capable ambulance should occur
within a clinically appropriate time frame 24. For the M-xR Model, this parameter has been set to the
following metrics:
§ Less than nine minutes (8:59) on life-threatening emergencies (Echo and Delta type calls) in
areas of Urban call densities,
§ Less than fifteen minutes (14:59) in areas of Rural call densities,
§ Less than thirty minutes (29:59) in areas of Remote call densities.
Note that performance metrics are applied to urban, rural and remote areas that are designated based
on call densities and are not based on population densities.
Response time should be measured in a consistent fractile manner (nine times out of ten, or 90%
reliability) as opposed to average (five times out of ten, or 50% reliability). Response times for non-life
threatening assignments and inter-facility transports should be set by the County EMS Office with
capabilities to monitor and publically report compliance to standards.
Historic Demand for Service

Answering the question of how demands for service will be distributed across Monroe County requires a
prediction of future behavior. From the perspective of EMS risk, historic demand is a good predictor of
where future demand will be because the geographic and temporal mobility of the population is already
reflected in the historic demand. Hence, historic data is of immense and irreplaceable value to planners
and policy makers because it obviates the need to otherwise know the details of the geographic and
temporal mobility of the population.
The Consultant obtained raw dispatch records from the County’s Northrop Grumman Computer Aided
Dispatch (CAD) System for CY2010 and CY2011. Using proprietary algorithms, Fitch removed duplicate
24
Dr. Joseph Fitch, JEMS, June 25 2007, “Response times: Myths, Measurement & Management.”
http://www.jems.com/article/communications-dispatch/response-times-myths44-measure

and corrupted records from the dump of raw records to obtain a “best representation” of the true
volume of calls for the County as a whole. Prior to the data analyses conducted for this report, no
evaluation of the distribution of risk (call density) across Monroe County had ever been made.
Temporal volume of activity is calculated by dividing the call volume by a standard notion of time
(month, week, weekday, hour etc.). For this analysis, the call volume was divided by days and hours to
get an average demand per day of week and an average demand per hour of day. How the demand for
service changes with day of week is presented in the figure below. How demand for service changes by
hour of day is presented in the figure below. (These figures are viewable at larger scale in Monroe
County System description earlier in this report.
Figure 16. Calls By Day of Week CY2011
Figure 17. Calls By Hour of Day CY2011

Changes in the need for ambulances and crews by day of week and by time of day follow these changes
in temporal demand. The changes in demand that occur hour-by-hour are significant and are explicitly
accounted for in this model.
There is some fluctuation in demand from Sunday to Saturday, but it is less than ten percent. For
purposes of the model in this report, these day-by-day fluctuations in demand are small enough to be
disregarded. If an implementation analysis is required, these day-by-day fluctuations need to be
considered more closely in order to match resources to demand.
Defining Incident Zones

Manually placing calls on a map becomes overwhelming very quickly because the geography becomes
overrun with calls. In addition, manual placement gives no sense of the temporal distribution of calls. In
order to create maps of call demand that are intelligible and interpretable, the Ontario Municipal
Benchmarking Initiative, OMBI, derived an algorithm to automate the establishment of Urban, Rural,
and Remote call behavior. Fitch & Associates used proprietary software that refines the OMBI
methodology for the analyses in this report.
There are three steps to determine urban and rural incident zones:
1. Use the predetermined political boundaries of Monroe County excluding the City of Rochester
as the mapping area.
2. Import the historic data for demands for service onto this map.
3. Create a grid of one-kilometer (1km) squares that covers the area to be evaluated. For all
squares in the 1km grid, the analysis counts the number of incident locations that fall within
each square. For each 1km square, the analysis also determines the number of incidents that fall
within the eight adjacent 1km squares in the grid. This methodology removes the artifact or
potential that a singular address, such as a nursing home, can affect a square to such a degree
that it becomes Urban (high density demand) without truly exhibiting high-density demand over
the whole square.
The outcome of this process results in the map of incident zones presented in the figure below:
§ RED: Urban Incident Zones—two calls per square kilometer per month with at least half the
adjacent square kilometers having the same number of calls per month.
§ GREEN: Rural Incident Zones —at least one call per square kilometer every four months with at
least half the adjacent square kilometers having the same number of calls per month.
§ WHITE: Remote Incident Zones —less than one call per square kilometer every four months.

Figure 18. Incident Zones in Monroe County Based on Call Densities 25
Three characteristics are noteworthy regarding the figure above of incident zones, based on call
densities for Monroe County:
1. High demands for service (Urban risk) extend significantly out into the County beyond
the geographic limits of the City of Rochester.
2. Medium demands for service (Rural risk) occur in only a moderate number of the zones in
Monroe County and represent a smaller portion of total calls.
3. Low demands for service (Remote risk) occur in very few of the zones in Monroe County and
represent a very small portion of the total calls.
The figure below lists the EMS agencies dispatched during the period of the data dump and indicates the
percentage of incident zones based on call density that quality as “Urban”, “Rural” or “Remote”
according to the RED, GREEN and WHITE legend above.
25
Areas labeled City Contract 1, 2 and 3 are not relevant to this analysis and should be disregarded.

Figure 19. Percentage of Urban, Rural and Remote Incident Zones Comprising Each Agency’s District 26
Very few of the agency districts are comprised of a single type of incident zone. Almost all of the districts
are comprised of a mix of incident zones with urban incident zones predominating. Only three agency
districts have less than 15% urban zones. The preponderance of urban incident zones is much greater
than perceived by system participants.
The impact of urban incident zones on the functioning of the system is greater still. An urban incident
zone generates at least eight times the number of calls as a rural incident zone. In almost every district,
the total call activity for the district is dominated by the activity occurring in the urban incident zones.
Locating Ambulance Stations

An ambulance station is the map location where an ambulance passively waits to respond to the next
demand for service. In constructing the M-xR Model, demand coverage was achieved by placing an
ambulance at a station in the highest density of calls. Fitch & Associates used proprietary algorithms to
derive a drive zones around the location of this ambulance station. Drive zones were either 7:00 or
13:00 minutes as required by the density of calls surrounding the site of the station. Drive zones are set
at less than 8:59 and 14:59 standards because County dispatch time, agency processing time and chute
time have already elapsed on the call. Then another ambulance was placed at a station in the next
highest demand area outside of the original area and drawing a drive zone around that station. This
26
Areas labeled City Contract 1, 2 and 3 are not relevant to this analysis and should be disregarded.

exercise was repeated until all the demands for service in Monroe County was covered at the prescribed
response times for coverage of Urban and Rural call densities. The locations of these ambulance stations
and their drive zones are mapped in the following figures.
Figure 20. Call and Drive Zones for “M-xR” Monroe County Excluding Rochester

Figure 21. Ambulance Stations for M-xR Model
Detailed descriptions of the locations of these ambulance stations are listed in the table below.
Table 31. Ambulance Location for the M-xR Model Excluding Rochester
Post Urban or Total Percent
Rank Location Post Capture Drive Time
Number Rural Capture Capture
1 1443 near Towpath Motel/Monroe U 36043 36043 16.45% 7
near Fairport Village Justice Court/14 W
2 1588 U 25754 61797 28.21% 7
Church St, Fairport, NY 14450
3 994 near House of Hsu/House of Hsu U 25098 86895 39.67% 7
near Di Bella's Old Fashioned/Di Bella's
4 1655 U 22874 109769 50.11% 7
Old Fashioned
5 1187 near Bazil/Monroe U 19143 128912 58.85% 7
near Nick's Imports and Meat
6 1459 U 15631 144543 65.98% 7
Market/1354 SR-386, Rochester, NY 14624
near Guida's/North Ave, Webster, NY
7 924 U 11088 155631 71.05% 7
14580
near Richardson's Canal House Inn/516
8 1795 U 7503 163134 74.47% 7
SR-96, Pittsford, NY 14534
near Parma Town Justice Court/1071 SR-
9 647 U 6182 169316 77.29% 7
18, Hilton, NY 14468
near Gordon Steak and Crab
10 785 U 5745 175061 79.92% 7
House/Monroe
near Portico Bed and Breakfast/8399 SR-
11 862 U 5156 180217 82.27% 7
104, Brockport, NY 14420

Post Urban or Total Percent
Rank Location Post Capture Drive Time
Number Rural Capture Capture
near Domenico's Ristorante/775 CR-92,
12 1804 U 4812 185029 84.47% 7
Pittsford, NY 14534
13 1157 near Chef King/Monroe U 4531 189560 86.53% 7
14 2169 near Rush Town Justice Court/Monroe U 3568 193128 88.16% 7
15 1231 near Penfield Town Justice Court/Monroe U 3520 196648 89.77% 7
near Mill Art Center and Gallery/46
16 2414 U 2247 198895 90.80% 7
Boughton Hill Rd, Honeoye Falls, NY 14472
17 1770 No address available R 2914 201809 92.13% 13
near Forest Hill Restaurant/Lake Ontario
18 488 R 2403 204212 93.22% 13
State Pkwy, Rochester, NY 14612
19 401 near Hamlin Inn/Monroe R 2172 206384 94.22% 13
20 730 near Fioravantis on the Lake/Lake Ontario R 2091 208475 95.17% 13
near Wegmans/1709 SR-33A, Rochester,
21 1403 U 1773 210248 95.98% 7
NY 14624
22 1633 near Bosch Security Systems/Wayne R 1610 211858 96.71% 13
23 778 near Castaways/Lake Ontario U 1334 213192 97.32% 7
24 901 near Friendly Motel/Monroe R 1047 214239 97.80% 13
near Springdale Farms/3654 Brockport
25 1112 R 907 215146 98.22% 13
Spencerport Rd, Spencerport, NY 14559
26 2053 near Crabby and Dan's Grill/Monroe R 873 216019 98.61% 13
27 2070 near Oatka Steak and Seafood/Monroe R 478 216497 98.83% 13
28 1468 near Riga Court/Monroe R 384 216881 99.01% 13
near Bazil/1534 Creek St, Rochester, NY
29 1185 U 357 217238 99.17% 7
14625
30 2133 near Genesee Country Inn B & B/Monroe R 322 217560 99.32% 13
There are more stations identified than there are ambulances required. Due to dynamic deployment,
ambulances will not be on standby at all stations at all times of day. Eighteen of thirty ambulance
stations are at locations serving areas of Urban call densities. Twelve of thirty ambulance stations are at
locations serving areas of Rural call densities.
There are two key observations regarding the location of ambulance stations in this model:
§ With only 16 ambulances on standby at these stations, 90% of Urban demands for service and
90% of Rural demands for service are covered in the prescribed time.
§ Additional ambulances on standby at additional stations do little to improve performance and
reduce response times.
With 16 ambulances on standby, 90 percent of demand coverage can be achieved in the allocated time
interval. With 20 ambulances on standby, coverage increases to only 95%. Adding ambulances causes
the system to saturate and enter a regime of rapidly increasing costs.
The fact that it was possible to find optimum locations for ambulance stations in the M-xR Model shows
that the geography and call densities of Monroe County do not intrinsically prevent achievement of the
8:59 and 14:59 response times required to meet nationally accepted standards.

Sizing the Fleet
The total number of ambulances and crews (units) required in a system is the sum of those units
passively waiting on station to answer the next request for service (coverage) and those actively
responding to prior requests for service. A driving principle in planning emergency medical services is
that a unit actively responding to a request for service is not yet available to respond to the next request
for service.
The equations for sizing a fleet can be expressed as:

Total units = units for coverage + units on active response, and
Total (unit hours) = hours of coverage + hours on active response to calls.
Figure 10 located in the Agency Processing Time section, presents the flow of an EMS call in Monroe
County. The interval of time indicated as T3 -> T8 is referred to Time-On-Task. This interval reflects the
time a unit spends responding to and returning from a request for service. During this interval the unit is
not available for coverage.
Fitch concluded that the data for Time-On-Task available from the County’s Northrop Grumman CAD
was unreliable. The next best source for relevant data is Monroe Ambulance Service because they have
a reliable CAD, have a Countywide CON and responds to more than 13,000 of all calls in the County. In
2011, Monroe Ambulance Service reported its Time-On-Task as 68 minutes.
For purposes of constructing this model, Fitch decided to use a Time-On-Task of exactly 60 minutes in
order to ease comprehension of the model by the reader. The difference between 60 and 68 minutes is
only 13%, and is well within the margin of uncertainty of a model constructed at this level detail.
With this principle in mind, the Consultant performed an analysis to determine the number of
ambulances and crews needed in the M-xR Model. The historic demand data show variations in demand
for service that are insignificant by day of week. However, variations in demand for service are
substantial by hour of day.
The changes in demand that occur hour-by-hour are significant to the M-xR Model and are explicitly
accounted for in the table below which tabulates call volume per hour, the number of ambulances
passively waiting on station to answer a call for service (coverage), and the number of ambulances
actively responding to a request for service.

Table 32. Units Required By Hour of Day
Units
Units on
Responding to
Time of Day Standby at Total Units
Requests for
Station
Service
00 7.5 16 24
01 6.9 16 23
02 6.2 16 22
03 5.3 16 21
04 4.6 16 21
05 4.3 16 20
06 5.2 16 21
07 7.6 16 24
08 9.2 16 25
09 11.4 16 27
10 12.2 16 28
11 12.9 16 29
12 12.8 16 29
13 12.8 16 29
14 12.8 16 29
15 12.8 16 29
16 12.8 16 29
17 12.7 16 29
18 12.5 16 28
19 12.0 16 28
20 11.7 16 28
21 11.0 16 27
22 10.3 16 26
23 8.9 16 25
Unit Hours per
236.3 384.0 620.3
Day
Unit Hours per
86,250 140,160.0 226,409.5.1
Year
The total number of active units required by the M-xR Model varies from a low of 20 at 5:00 a.m. to high
of 29 at noon. A “unit hour” refers to an ambulance and its crew being in service for one hour. The
Optimized M-xR Model requires 620.3 unit hours per day, or 226,410 unit hours per year. A requirement
of 620 unit-hours per day represents a temporal adjustment of -11% off of the maximum number of unit
hours, calculated as if the maximum number of units had to be in service all day long (29 units x 24 hour
= 696 unit hours/day).

In the opinion of Fitch & Associates, the 29 units required in the M-xR Model is quite modest compared
to the 87 ambulances currently serving in the same area. Yet, the response times actually experienced in
the County are substantially slower than the response times built into the M-xR Model. Two
explanations for the slow response times actually experienced in Monroe County come to mind:
§ Active ambulances, with their crews, are not stationed at optimum locations so that the drive
zones are too large.
§ The number of active ambulances (ambulances manned by crews set-to-go) is
less than the 29 required to do the job.
There is insufficient data available to Fitch & Associates at this time to distinguish the proportionate
contribution of each possibility or to merely distinguish between these possibilities.
IMPLEMENTATION OF M-XR AS OPTION TWO

This option centers on considering Monroe County, excluding the City of Rochester, (M-xR) as a single
service district and implementing the aforementioned optimized M-xR Model as follows:
§ Utilize the provisions of Public Health Law § 3008, obtain a countywide Certificate of Need
(CON) and obtain the authority to set station locations and dispatch ambulances. Installation of
a modern CAD system, AVL/GPS, and ePCR, as specified in Option One, will need to have
occurred.
§ Retain the existing ambulance service agencies. Have the existing ambulance service agencies
contribute ambulances and crews (units) to County 911 on a per shift basis. Coordinate
online/offline status by time of day across all agencies to match active resource with demand,
and thereby relieve operational pressure on all agencies. This will be especially helpful to the
smaller agencies.
§ Implement dynamic deployment, as indicated by the time-of-day changes in demand identified
in this model. Site units at the optimum stations were identified in this model. Have County 911
dispatch units from these stations. Conduct operations against nationally accepted standards of
performance. Enforce performance standards among the existing agencies by “idling” non-
performers.
Further aid may be afforded the individual ambulance agencies by centralizing billing at the County level
and having the County disburse reimbursement payments to the ambulance agencies. Cost
normalization based on out-of-jurisdiction call activity needs to be provided. Centralized purchasing at
the County level may also be an aid.
Estimate of Costs
The analysis in this section is intended to provide an estimated operating cost of the Optimized M-xR
Model System. The “back-of-the envelope” approach to our estimate is based Fitch’s experience with
other systems and repeated finding that the largest single component of operating costs is that of an

active ambulance with its crew (unit). Knowing the number of annual unit hours required by the system,
and knowing the hourly cost of a unit, permits calculation of an annual operating cost.
Fitch & Associates did not have access to financial data for the 28 ambulance agencies across Monroe
County. It was not possible to obtain a blended average based on actual hourly costs for a unit-hour as
currently experienced by ambulance agencies in Monroe County. Fitch & Associates was compelled to
rely upon two limited sources of information to estimate a county-wide cost per unit-hour.
The first was a report published in 2011 by Scottsville, NY EMS Chief Mathew Jarrett titled, “Town of
Wheatland and Village of Scottsville, Financial Analysis and EMS Delivery Options.” In this report, the
personnel cost of a fully staffed ALS ambulance (one advanced care paramedic and one basic care
paramedic) was reported as $65 per hour. Based on Fitch’s experience with other systems, a unit hour,
fully burdened with administration, benefits, and depreciation, will come in at 50% over labor cost
alone. In this case, the fully burdened cost per unit hour becomes $97.50/hr.
The second resource, informal conversations between Fitch & Associates and several of the ambulance
agencies using paid staff, yielded multiple estimates of the fully burdened cost per unit-hour that
centered around $100.
The confluence of these two sources of information convinced Fitch & Associates to use $100 as the
fully burdened cost per unit hour. That said, some agencies, specifically those that use a large portion of
volunteer paramedics, probably experience a much lower cost per unit hour.
The table below presents the estimated annual cost of the Optimized M-xR Model performing to
nationally accepted standards of response times in areas of both Urban and Rural call densities. The
number of unit hours drops down from the table above titled Units Required by Hour of Day above. The
cost per unit hour is as discussed above.
Table 33. Estimated Annual Cost of a Fully Paid Optimized M-xR Model
System Model Unit Hours/Year Cost/Unit Hour Cost/Year
M-xR Model 226,410 $100/ unit-hour $22,641,000
Comparison to the Existing System

Today, a number of the ambulance agencies in Monroe County use only volunteers or use a combination
of volunteers and paid staff. 27 Substantial savings of direct and indirect costs accrue to their
communities. The current reality is that such volunteerism is slowly disappearing in the United States.
Eventually, under this social pressure, more and more emergency medical services will use paid staff.
This change in paradigm is already playing out in Monroe County where the majority of emergency
patients are handled by agencies with paid staffs.
27
Based on survey responses from 20 of the Monroe County ambulance agencies, five used volunteers for field and chief
operating officer positions, nine were a combination of paid and volunteer and only five utilized all paid personnel.

In the existing system, many of the ambulance agencies function with volunteers, receive local subsidies,
and receive local support “in-kind.” A direct comparison between the estimated operating costs of the
Optimized M-xR Model and the cost of the existing system becomes impossible. An alternate approach
is to compare the estimated cost of the Optimized M-xR Model with the estimated “virtual cost” of the
existing system. This latter approach asks, how much would the existing system cost if its activities were
conducted using only paid staff? To this end Fitch & Associates needed a measure of the number of
active ambulances in the existing system.
The antiquated Northrop Grumman CAD system is not capable of generating reports listing how many
ambulances were online by month, by day, or by time-of-day. To fill this gap in data, Fitch & Associates
went back to the raw data dump from the CAD, selected a single day at random, and manually tallied
ambulances online for that day. The result was a maximum of 85 units per hour. 28 To give the existing
system the benefit of the doubt, we applied a -22% temporal adjustment, double the temporal
adjustment seen in the Optimized M-xR Model resulting in the unit hours per year presented in the
table below.
Table 34. Estimated Unit Hours Allocated to the Existing System

Maximum -22% Temporally Unit Hours Unit Hours
Units/Hour Temporal Adjusted per Day per Year
Adjustment Units/Hour
85 -18.7 66.3 1,591 580,788
The table below compares the estimated operating cost of the Optimized M-xR Model with the
estimated “virtual cost” of the existing system in Monroe County.
Table 35. Comparison M-xR Model Cost and Existing “Virtual Cost” of Current System
System Unit Hours/Year Cost/Unit Hour Cost/Year
Optimized M-xR Model System 226,410 $100/unit-hour $22,642,200
Existing System (Monroe County, 580,788 $100/ unit-hour $58,078,800
excluding Rochester)
The extraordinary result is that the “virtual cost” of the existing operations in Monroe County is 2.6
times greater than estimated cost of the Optimized M-xR Model.
Estimates of Revenues
For ambulance services, transports are the primary source of revenue; other lesser sources include
subsidies, donations and in-kind or indirect support. Transports are divided into inter-facility transports
28
The consultants validated this number with the County EMS Office that indicated there are 87 ambulances servicing the area
excluding the City of Rochester.

and emergency transports associated with 911 calls. Inter-facility transports are not explicitly tallied into
this estimate of revenues because no data for Monroe County was available to Fitch & Associates.
Past experience with inter-facility transports leads to our expectation that they are a positive stream of
revenue to the Optimized M-xR Model. The principal reason for this expectation is that the transporting
ambulance agency has the ability to validate the facility’s ability to pay prior to proceeding with the
transport.
In contrast, emergency transports exhibit a significant spread between gross billings and net revenues,
as can be reasonably collected by the billing agent. In large cities where the collection rate is low, it is
common to collect net revenues of approximately 40% of gross billings. In suburban and affluent
communities, it is more common to receive a higher ratio, often as high as 60%. These collection rates
were validated by ambulance agencies in Monroe County as realistic estimates of what they are
collecting today.
In order to estimate the gross revenue per emergency transport, as billed, Fitch & Associates used data
from a Coalition of Advanced Emergency Medical Systems (CAEMS) report published in 2009, as
tabulated in the table below. The gross revenues for each agency were inflated from 2009 to 2012 as
indicated, which results in an average of $956.41 per transport as noted in the table below.
Table 36. Gross Revenue per Emergency Transport

Gross Revenue 2009 Gross Revenue
Ambulance Agency
(blended ALS & BLS + miles) Inflated to 2012
Davenport $624.96 $668.38
Fort Wayne 1,114.62 1,192.07
Fort Worth 1,259.97 1,347.52
Kansas city 878.30 939.33
Little Rock 584.97 625.62
Mecklenburg 880.28 941.44
Pinellas 652.09 697.40
Reno 986.94 1,055.51
Richmond 504.97 540.06
Tulsa 1,174.97 1,256.61
Oklahoma 1,174.97 $1,256.61
Average $894.28 $956.41
Fitch & Associates next went back to the raw data dump from the Northrop Grumman CAD and
determined that there were 76,806 emergency transports in Monroe County, excluding Rochester, in
the time frame of the model.
A revenue stream was estimated based on this number of transports and the gross billing per transport
as tabulated in the table below. To be conservative, the collection rate was assumed to be only 40%.

Table 37. Estimate of Annual Net Revenue for the Optimized M-xR Model System
Emergency Gross Billings Collection Rate Net Revenue/Year
Transports/Year per Transport
76,809 $956.41 40% $29,384,470
Operation of Monroe County, excluding the City of Rochester, under the Optimized M-xR Model System
is conservatively estimated to generate $29 million per year in revenues (assumes all transports are
billed).
FINANCIAL OUTCOME OF M-XR MODEL

The estimated annual cost of the Optimized M-xR Model is $23 million per year. The estimated annual
revenue from the Optimized M-xR Model is $29 million per year. Fitch & Associates believes that the
Optimized M-xR Model System qualifies as revenue neutral or better to Monroe County. Such a system
would be sustainable without subsidies.
“IMPLEMENTATION” OF M-XR AS OPTION THREE

The Optimized M-xR Model does not get implemented as such. As in Option Two, obtain a Certificate of
Need that encompasses all of Monroe County, excluding the City of Rochester (M-xR).
The lesson to be learned from the process of constructing the M-xR Model is that emergency services in
Monroe County, excluding the City of Rochester, can be managed in such a way as to meet nationally
accepted standards of performance AND be revenue neutral. With this result as background, prepare
detailed specifications and performance standards defined by zone and for the overall system and put
emergency services in Monroe County, excluding the City of Rochester, out to competitive procurement.
Fitch & Associates expects that the contracting agency will use a dynamic deployment model that has
the characteristics of the Optimized M-xR Model System described herein.
Many of the existing ambulance vehicles may be acquired by, or could partner with, the new service
agency. Many of the existing volunteer positions could convert to paid positions. Costs to the County are
expected to be very small. Costs to the municipalities are expected to be very small. The new contractor
may be required to reimburse the County for certain services and thereby become a source of revenues.

ATTACHMENT A
EMS & Fire Agency

Survey List

ATTACHMENT A: EMS & Fire Agency Survey List
The following EMS agencies identified by the EMS Coordinator as providing ambulance transport
were sent a survey tool in late October 2013. The list indicates which agencies responded in a
complete manner to the survey and those that did not.
EMS Agencies That Responded EMS Agencies That Did Not Respond
Brighton Volunteer Ambulance Brockport Ambulance
Chili Volunteer Ambulance Gates Volunteer Ambulance Service
Churchville Volunteer Fire Dept. Ambulance Genessee Valley EMS
East Rochester Volunteer Ambulance Corps Hamlin Volunteer Ambulance
Greece Volunteer Ambulance Service Inc. Irondequoit Volunteer Ambulance
Henrietta Volunteer Ambulance Pittsford Volunteer Ambulance
Hilton Fire Point Pleasant Fire
Honeoye Falls-Mendon Volunteer Ambulance RIT Ambulance
Monroe Ambulance Sea Breeze Volunteer Fire
North East Quadrant ALS Inc. St. Paul Boulevard Fire
Penfield Volunteer Emergency Ambulance Union Hill Fire
Perinton Volunteer Ambulance, Inc.
Rural/Metro Medical Services
Rush F.D. Volunteer Ambulance
Scottsville Rescue Squad
Southeast Quadrant MCCU
Spencerport Volunteer Ambulance Service, Inc.
U of Rochester Medical Emergency Response Team
West Webster Fire
Xerox Ambulance

ATTACHMENT A: EMS & Fire Agency Survey List
Fire first response (non-transporting) agencies were identified by the EMS Coordinator and sent
a survey tool in late 2012. The table below indicates those that responded in a complete manner
and those that did not.
Fire Agencies That Responded Fire Agencies That Did Not Respond
Barnard Fire District Bergen FD
Brighton FD East Rochester FD
Brockport FD Fishers FD
Bushnell's Basin Fire Association, Inc. Honeoye Falls FD
Chili FD Kodak FD
Churchville FD Laurelton Fire District
Clifton FD Morton Volunteer Fire Company
Egypt FD Mumford FD
Fairport FD Ridge-Culver FD
Gates Fire District Rochester FD
Greater Rochester Airport Fire Rochester Protectives
Hamlin FD Rush FD
Henrietta FD Scottsville FD
Hilton FD Walker FD
Lake Shore FD Webster Volunteer FD
Mendon FD West Brighton FD
North Greece FD
Penfield Fire Company
Pittsford Fire District
Ridge Road Fire District
Spencerport FD
Union Hill FD

ATTACHMENT B
January 11, 2013 New York State

Department of Health Letter
January 11, 2013
Dear Hospital Chief Executive Officer:
As you are aware, New York State has seen a marked increase in influenza patients
presenting to hospital emergency departments. Ongoing conditions of hospital overcrowding
have served to further strain the ability of hospitals to manage the current patient influx.
Overcrowding in hospitals and emergency departments (EDs) can directly impact a hospital’s
ability not only to meet community needs, but also to respond to peak periods of critical need.
With the increased attention and commitment to emergency preparedness, we must refocus our
efforts on the continuing issue of hospital overcrowding.
Despite these surge and overcrowding conditions, EDs must remain open to ambulances
and must maintain the capacity to accept new emergent patients in order to ensure that the
capabilities of our health care system as a whole can, when called upon, respond, unless
otherwise authorized to go on diversion. As you are well aware, overcrowding affects ongoing
service delivery, and can have a negative impact on the quality of patient care. The enclosed
guidelines have been developed to advise hospitals of expectations and responsibilities in regard
to maintaining the capacity to respond to, and manage, emergency health care needs throughout
the year.
During this period of overcrowded emergency departments and increased admissions

during the respiratory infection season, the Department will activate HERDS to determine
emergency department activity and bed availability in hospitals.
Please review the enclosed documents and ensure that your institution has in place
appropriate policies and procedures to implement these responsibilities. Your immediate and
continuing attention to this critical matter is of utmost importance. Thank you for your
anticipated cooperation.
Sincerely,
Nirav R. Shah, M.D., M.P.H.

Commissioner of Health
Attachments
GUIDANCE DOCUMENT FOR HOSPITALS
Overcrowding / Emergency Preparedness
Hospital Obligations & Responsibilities
Hospitals must meet the needs of the communities they serve on an ongoing basis. It is the
responsibility of the hospital’s Governing Body and Senior Management personnel to
review the following guidelines to help relieve overcrowding, and to implement, as
appropriate. Additionally provided is CMS guidance that describes options hospitals may
use to facilitate relief of ED surge that fall under existing EMTALA requirements (no
waiver required).
• Emergency preparedness and readiness is not an episodic response, but is an ongoing

commitment to maintaining a hospital’s capacity and capabilities to respond to
emergencies. Emergency Departments need to remain open and fully operational to
ensure that each hospital is able to maintain the capacity to respond, not only to episodic
events, but to long term or seasonal periods of overcrowding. Hospitals should activate
their internal disaster plan, to focus on early discharges, transfers of patients to other
healthcare facilities, bringing in additional appropriately trained staff to care for the
additional inpatients, etc.
• Hospitals should use all available inpatient beds in managing admissions from the
emergency department. Maintaining admitted patients within the emergency department
is not acceptable. Hospital administration must be proactive in identifying and utilizing
inpatient beds for admissions from the emergency department. All hospital beds and
inpatient areas should be identified and considered in determining bed assignments.
During peak periods of overcrowding as a temporary emergency measure, hospitals
should activate their facility surge plans and make use of planned, non-traditional surge
spaces as necessary to alleviate hospital overcrowding, e.g., placing beds in solariums
and hallways near nursing stations.
• Hospitals are required to have in place effective monitoring protocols to track and
identify length of stay patterns and deviations, both for inpatients and for patients in the
emergency department. Priority attention should be given to initiating inpatient and
emergency department discharge planning activities to ensure the prompt and safe
discharge of patients. Efforts to coordinate with community resources, nursing homes,
and other patient support services should be in place and functioning at all times.
• Ambulances and accompanying EMS personnel are not to be detained in the emergency
department and should be placed promptly back into service. To ensure that patient care
needs are met by hospital staff, ambulance patients must be transferred promptly to
emergency department staff.
• Hospitals should evaluate staffing levels on a hospital-wide basis. Cross training and
coordination among programs and services is necessary to ensure adequate staffing levels
during peak periods of need.
• Hospitals must assume responsibility for the quality and appropriateness of all patient
care services. Regardless of the location within the facility, staffing, services, privacy,
infection control and confidentiality protections must be consistently in place.
• Hospitals must make available to ED staff the ancillary services which permit the prompt
disposition of patient care needs. The 24-hour availability of transport services is
necessary to meet patient needs and to allow for the timely transfer of admitted patients.
• Elective admissions/surgical cases projected as requiring short term (or longer) use of
inpatient beds should be postponed, until inpatient beds have been assigned to the
emergency department patients waiting for beds.
• Neighboring health care institutions should be surveyed as to their capacity for accepting
transfers from the hospital.
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Service
7500 Security Boulevard, Mail Stop S2-12-25
Baltimore, Maryland 21244-1850
Center for Medicaid and State Operations/Survey and Certification Group

Ref: S&C-09-52
DATE: August 14, 2009
TO: State Survey Agency Directors
FROM: Director
Survey and Certification Group
SUBJECT: Emergency Medical Treatment and Labor Act (EMTALA) Requirements and
Options for Hospitals in a Disaster
Memorandum Summary
• Planning for Surge in Emergency Department Services: A brief summary of EMTALA

requirements and options for hospitals experiencing an extraordinary surge in demand for ED
services has been developed to assist hospitals and their communities in planning for a
potential surge in ED volume this fall related to H1N1 influenza.
• Waiver Description: Rules governing EMTALA waivers are also described.
• Availability and Distribution of Summary Sheet: State Survey Agencies (SAs) are
requested to distribute this summary sheet widely to hospital and emergency response
planning officials.
In anticipation of a possible significant increase in demand for emergency services due to H1N1
influenza resurgence this fall several Federal agencies, State health departments, and hospitals
have expressed significant concerns about compliance with EMTALA requirements during an
outbreak. Many stakeholders perceive that EMTALA imposes significant restrictions on
hospitals’ ability to provide adequate care when EDs experience extraordinary surges in demand.
The attached fact sheet clarifies options that are permissible under EMTALA and should
reassure the provider community and public health officials that there is existing flexibility under
EMTALA. Among other things, the fact sheet notes that an EMTALA-mandated medical
screening examination (MSE) does not need to be an extensive work-up in every case, and that
the MSE may take place outside the ED, at other sites on the hospital’s campus.
The fact sheet also summarizes the provisions governing EMTALA waivers. Surveyors and
managers responsible for EMTALA enforcement are expected to be aware of the flexibilities
hospitals are currently afforded under EMTALA and to assess incoming EMTALA complaints
accordingly in determining whether an on-site investigation is required. They are also expected
to keep these flexibilities in mind when assessing hospital compliance with EMTALA during a
survey.
Page 2 – State Survey Agency Directors
To help dispel misconceptions among the provider community concerning EMTALA

requirements, SAs are requested to distribute the attached fact sheet widely to the provider
community in their State, as well as to State and local public health officials responsible for
emergency preparedness.
Questions about this document should be addressed to CDR Frances Jensen, M.D., at
frances.jensen@cms.hhs.gov.
Training: The information contained in this letter should be shared with all survey and
certification staff, their managers, and the State/RO training coordinators immediately
/s/
Thomas E. Hamilton
cc: Survey and Certification Regional Office Management
Attachment
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Service
7500 Security Boulevard, Mail Stop S2‐12‐25
Baltimore, Maryland 21244‐1850
FACT SHEET
Emergency Medical Treatment and Labor Act (EMTALA) &

Surges in Demand for Emergency Department (ED) Services During a Pandemic
I. What is EMTALA?
• EMTALA is a Federal law that requires all Medicare-participating hospitals with dedicated
EDs to perform the following for all individuals who come to their EDs, regardless of their
ability to pay:
- An appropriate medical screening exam (MSE) to determine if the individual has an
Emergency Medical Condition (EMC). If there is no EMC, the hospital’s EMTALA
obligations end.
- If there is an EMC, the hospital must:
+ Treat and stabilize the EMC within its capability (including inpatient admission when
necessary); OR
+ Transfer the individual to a hospital that has the capability and capacity to stabilize the
EMC.
• Hospitals with specialized capabilities (with or without an ED) may not refuse an appropriate
transfer under EMTALA if they have the capacity to treat the transferred individual.
• EMTALA ensures access to hospital emergency services; it need not be a barrier to providing
care in a disaster.
II. Options for Managing Extraordinary ED Surges Under Existing EMTALA

Requirements (No Waiver Required)
A. Hospitals may set up alternative screening sites on campus
• The MSE does not have to take place in the ED. A hospital may set up alternative sites
on its campus to perform MSEs.
- Individuals may be redirected to these sites after being logged in. The redirection
and logging can even take place outside the entrance to the ED.
- The person doing the directing should be qualified (e.g., an RN) to recognize
individuals who are obviously in need of immediate treatment in the ED.
• The content of the MSE varies according to the individual’s presenting signs and symptoms.
It can be as simple or as complex, as needed, to determine if an EMC exists.
• MSEs must be conducted by qualified personnel, which may include physicians, nurse
practitioners, physician’s assistants, or RNs trained to perform MSEs and acting within
the scope of their State Practice Act.
• The hospital must provide stabilizing treatment (or appropriate transfer) to individuals
found to have an EMC, including moving them as needed from the alternative site to
another on-campus department.
B. Hospitals may set up screening at off-campus, hospital-controlled sites.
• Hospitals and community officials may encourage the public to go to these sites instead
of the hospital for screening for influenza-like illness (ILI). However, a hospital may not
tell individuals who have already come to its ED to go to the off-site location for the
MSE.
• Unless the off-campus site is already a dedicated ED (DED) of the hospital, as defined
under EMTALA regulations, EMTALA requirements do not apply.
• The hospital should not hold the site out to the public as a place that provides care for
EMCs in general on an urgent, unscheduled basis. They can hold it out as an ILI
screening center.
• The off-campus site should be staffed with medical personnel trained to evaluate
individuals with ILIs.
• If an individual needs additional medical attention on an emergent basis, the hospital is
required, under the Medicare Conditions of Participation, to arrange referral/transfer.
Prior coordination with local emergency medical services (EMS) is advised to develop
transport arrangements.
C. Communities may set up screening clinics at sites not under the control of a hospital
• There is no EMTALA obligation at these sites.

• Hospitals and community officials may encourage the public to go to these sites instead
of the hospital for screening for ILI. However, a hospital may not tell individuals who
have already come to its ED to go to the off-site location for the MSE.
• Communities are encouraged to staff the sites with medical personnel trained to evaluate
individuals with ILIs.
• In preparation for a pandemic, the community, its local hospitals and EMS are
encouraged to plan for referral and transport of individuals needing additional medical
attention on an emergent basis.
III. EMTALA Waivers
• An EMTALA waiver allows hospitals to:

- Direct or relocate individuals who come to the ED to an alternative off-campus site, in
accordance with a State emergency or pandemic preparedness plan, for the MSE.
- Effect transfers normally prohibited under EMTALA of individuals with unstable EMCs,
so long as the transfer is necessitated by the circumstances of the declared emergency.
• By law, the EMTALA MSE and stabilization requirements can be waived for a hospital only if:
- The President has declared an emergency or disaster under the Stafford Act or the
National Emergencies Act ; and
- The Secretary of HHS has declared a Public Health Emergency; and
- The Secretary invokes her/his waiver authority (which may be retroactive), including
notifying Congress at least 48 hours in advance; and
- The waiver includes waiver of EMTALA requirements and the hospital is covered by the
waiver.
• CMS will provide notice of an EMTALA waiver to covered hospitals through its Regional
Offices and/or State Survey Agencies.
• Duration of an EMTALA waiver:
- In the case of a public health emergency involving pandemic infectious disease, until the
termination of the declaration of the public health emergency; otherwise
- In all other cases, 72 hours after the hospital has activated its disaster plan
- In no case does an EMTALA waiver start before the waiver’s effective date, which is
usually the effective date of the public health emergency declaration.
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Monroe County Emergency Medical Services Report

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Monroe County Emergency Medical Services Report

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Draft

February 18, 2013

Comprehensive Emergency Medical Services Study

Monroe County EMS

FITCH & ASSOCIATES, LLC

EXECUTIVE SUMMARY __________________________________________________________________________ 1

PROJECT DESCRIPTION ___________________________________________________________________________ 1

DEMOGRAPHICS INTRODUCTION ____________________________________________________________________ 9

MONROE COUNTY SYSTEM _____________________________________________________________________ 19

SYSTEM DESCRIPTION ___________________________________________________________________________ 19

Monroe County, NY © Fitch & Associates, LLC

CLINICAL VISION/MEDICAL DIRECTION____________________________________________________________ 55

QUALITY MANAGEMENT _________________________________________________________________________ 55

SYSTEM FINANCES ____________________________________________________________________________ 62

DUPLICATED FUNCTIONS AND COSTS ________________________________________________________________ 62

BENCHMARKING THE MONROE SYSTEM __________________________________________________________ 64

SYSTEM BENCHMARKING ________________________________________________________________________ 64

SPECIFIC AREAS FOR IMPROVEMENT _____________________________________________________________ 77

Monroe County, NY © Fitch & Associates, LLC

THE OPTIMIZED MODEL SYSTEM _________________________________________________________________ 80

GEOGRAPHIC AREA (M-XR) ______________________________________________________________________ 80

FIGURE 1. MAP OF MONROE COUNTY __________________________________________________________________ 10

TABLE 1. SELECTED CENSUS PARAMETERS FOR MONROE COUNTY ________________________________________________ 9

Monroe County, NY © Fitch & Associates, LLC

Attachment A: EMS & Fire Survey List

Monroe County, NY © Fitch & Associates, LLC

EMS in Monroe County Does Not Operate As a System

Monroe County, NY © Fitch & Associates, LLC

Emergency Medical Care Is Not Consistent

Slow Response Times Occur Throughout the System

Reliable Data Is Lacking

Monroe County, NY © Fitch & Associates, LLC

Medical Directors Do Not Track Basic Clinical Performance

Appropriate Interface with Hospital Emergency Departments Is Lacking

Monroe County Is More Urban than People Think

Fewer Ambulances Can Achieve Performance Metrics

Monroe County, NY © Fitch & Associates, LLC

Option One: Staged Steps Toward Higher Performance

Monroe County, NY © Fitch & Associates, LLC

Monroe County, NY © Fitch & Associates, LLC

Develop a strategic approach to community paramedicine, as an alternative to ambulance

Option Two: Implement The “M-xR” Model Using Existing Agencies

Monroe County, NY © Fitch & Associates, LLC

Monroe County, NY © Fitch & Associates, LLC

Monroe County, NY © Fitch & Associates, LLC

Table 1. Selected Census Parameters for Monroe County

Monroe County, NY © Fitch & Associates, LLC

Figure 1. Map of Monroe County

Monroe County, NY © Fitch & Associates, LLC

EMS DEMOGRAPHIC ENVIRONMENT

Monroe County, NY © Fitch & Associates, LLC

Table 3. Monroe County Hospitals

Table 4. Monroe County Ambulance Services

Monroe County, NY © Fitch & Associates, LLC

Table 5. Non-Transporting First Response Services

Monroe County, NY © Fitch & Associates, LLC

Historical Population Changes

Monroe County, NY © Fitch & Associates, LLC

Monroe County, NY © Fitch & Associates, LLC

Figure 2. Projected Change of Total Population in Monroe County to 20405

Monroe County, NY © Fitch & Associates, LLC

DEMAND FOR EMERGENCY MEDICAL SERVICES

Monroe County, NY © Fitch & Associates, LLC

Monroe County, NY © Fitch & Associates, LLC

Monroe County, NY © Fitch & Associates, LLC

Table 7. Rochester – Rural/Metro Response Time Requirements

Table 8. Urban/Suburban Area Response Time Performance Measures – County exRochester