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Operation Overload


      Just 17 short years ago, Henderson, NV, was a pleasant little burg of around 65,000, nestled just southeast of Las Vegas. Then the explosion happened. From 1990–98, Henderson was the fastest-growing city in America, outpacing even Sin City's rapid expansion. By 2000, its population had tripled. By 2010, it's expected to hit 322,000-an eye-popping growth of almost 500% in 20 years.

      Now try to imagine the challenges this might pose for public safety.

      "The biggest challenge, I think, is looking into the crystal ball and seeing how much growth is happening and where," says the city's fire chief, Jim Cavalieri. "We have to make sure our city administration and electorate understand that we need to provide public safety for these areas."

      There are many aspects to that, but for the Henderson Fire Department, which provides the city's EMS, they can largely be grouped into issues of a) personnel and b) infrastructure.

Ambulance Diversions
      Second things first: Infrastructure includes things like fire stations, apparatus and equipment, and, increasingly, the information technologies agencies of the 21st century need.

      It's especially relevant to the issue of growth as it affects the area's hospitals. The whole Vegas metro area has suffered critical problems with ED overloads and resulting ambulance diversions and offload delays.

      "Hospitals have struggled to keep up with demand not just in Henderson, but throughout our whole Valley," says HFD EMS chief Randy Howell. "They've built unprecedented numbers of hospitals to try to keep up, and they still haven't been able to. We've been caught in the middle, not being able to offload our patients."

      The problem got so bad that in 2005, the state legislature mandated that patients transported to EDs be off their EMS gurneys within 30 minutes. Concurrently, hospitals were instructed to start collecting data and examining ways to improve things like throughput and other root causes of ED delays.

      For HFD, the new law helped-"We've specifically seen a decrease in wait times over an hour," Howell says-but the problem's not fully solved yet. Methods established for clocking EMS wait times weren't always followed, and the entire process wasn't well regulated. Providers hope to address that during the current legislative session.

      "We're going to push to make sure everyone stays engaged in the process," Howell says. "I think what happened was, we got the system in place and assumed it was working correctly, and we didn't check it as closely as we should have throughout the process. It turned out there was a lot of bad information."

      The department's not just waiting for the legislature to act, though. It's taken additional steps to keep operating efficiently.

      EMSystem is a popular tool for communicating the real-time status of hospital EDs to help EMS make better-informed transport decisions. It's based on color codes: Black, for instance, means a crew could be waiting for more than an hour. Green, conversely, means they'll likely be cleared in 15 minutes. But those colors rely on a human element: Hospitals report their own status-which means the information is only as good as the person entering it.

      "There's no standard definition of what black means-it's based upon the charge nurse's opinion," says Howell. "It's an estimation, and that can vary from nurse to nurse and hospital to hospital. So the struggle we had was getting our guys to believe that if they say they're black, they're really black."

      At the same time, departments in the Valley were working with FirstWatch, whose system monitors live community health data and resources to help detect trends that might signal problems. Officials hit upon the idea of combining the two systems into an integrated whole that realized the benefits of each.

      This happened late in 2006. Once it was done, hospital status updates were automated based on data from the EMS side, thus becoming more reliable. The hospitals, however, weren't happy.

      "They didn't like that the colors changed automatically, without their approval, so they disabled the color system," says Howell. "But it still tells us how many units are en route, how many units have arrived, the average wait time and the longest wait time. So now, if our guys see there are four units either at or en route to a particular hospital, that can tell them how busy they are or may become."

Meeting the Challenge
     Elsewhere on the information-technology front, the department is working with Roam IT to implement electronic patient-care reports (a final version was to be tested in April). It also has a STEMI program whereby field 12-leads are sent ahead to local hospitals, allowing expedited treatment for those with ST-elevation myocardial infarctions.

      On the broader question of infrastructure, public/private partnerships with master-plan developers are helping build out stations at no cost to the city.

      "When a developer chooses to develop," explains Cavalieri, "we enter into agreements that require them to build the fire stations and provide equipment. The majority of our fire stations and apparatus are paid for through this process, and the city provides the staffing."

      Staffing is a constant struggle. The HFD reaches out in numerous ways, including an annual police/fire Safety Day and sponsoring an Explorer post. It's also added a new "Careers" area to its website (, and last year, with EMS EXPO in Vegas, the HFD exhibited for the first time. These various efforts led to an increase in applications, but as is often the case with such endeavors, half of those never actually showed up to test.

      As Henderson keeps growing, such challenges are likely to continue. It will remain up to department leaders and their colleagues in local government to find ways to keep providing all those citizens with quality prehospital medical services.

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