Putting out Fires

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

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

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

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

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

This Health Policy Journal Club review is a collaboration between Policy Prescriptions® and the Emergency Medicine Residents’ Association. It is written by Aaron R. Kuzel, DO, MBA. He is an emergency medicine resident at the University of Louisville School of Medicine.

Abstract

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

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

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

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

PARTICIPANTS: A total of 6961 OHCA cases with the complete data needed for the analysis.

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

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

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

PMID: 30211769 

Raun, L, et al. J Public Health Manag Pract. 2018 Sep 11. (online first)