Crew exhaustion, better service to Exeter among reasons for altering agreement with Ambulance Provider Association of Tulare County
TULARE COUNTY – As local health officials have pleaded with the public to follow health orders and guidelines, it’s no secret now that hospitals are being overrun with COVID patients, all the while bringing doctors, nurses and healthcare workers to a tipping point. Another arm of healthcare, ambulance crews, is also experiencing exhausting conditions amidst the prolonged pandemic in Tulare County.
Exeter District Ambulance (EDA) is considering modifying their agreement with the Ambulance Provider Association of Tulare County (APATC)—the rare coalition of ambulance companies operating as a single association with the common goal of providing better patient care—to bring some relief to their overworked crews. Peter Sodhy, district manager at EDA, said his crews are being worn out by the current process.
“Our concern is that we want to make sure that our crews have the ability to get some level of rest,” Sodhy said. “Rest time for the crews so that they make fewer mistakes and are less likely to have accidents.”
Beginning as Memorial Hospital District in 1977, Exeter District Ambulance rose from what was left of Exeter Memorial Hospital and the district when the hospital closed in 1995. EDA started with one ambulance, and at its peak built a high of a fleet of four.
In 2008, Tulare County Board of Supervisors gave the scattered ambulance providers of the county a choice: The county would move to a single provider system—a common solution across the state and country—or providers can continue to operate, but in a way that operates like a single provider while being allowed to retain individual existence and entity.
As of March 2009, the APATC was born, a collection of nine ambulance providers—now down to six: American Ambulance of Visalia, Lifestar Ambulance, Imperial Ambulance, Exeter District Ambulance, and volunteers Camp Nelson Ambulance Associates of Springville and CA Hot Springs Ambulance—from across the county all operating under one dispatch system with a shared goal: better patient care.
Paul Main, president of American Ambulance of Visalia, and president of the APATC, said the posting plan—an agreement between American, Imperial, EDA and Lifestar on how they would back each other up and move units around based on call volume rather than geography—has been through some 30 different iterations since its inception.
“I think some of the folks call it the living document of Tulare County,” Main said, “because we see things that maybe need to be adjusted or whatnot and we work together to try to change that.”
Main said changes to the posting plan have been made regularly once a quarter or once every six months, and that the coalition of providers will continue to do so as systems and demographics change within the county.
Interestingly enough, EDA is not the only ambulance provider who has taken issue with the way the posting plan functions. American Ambulance of Visalia, the largest provider in the county, modified their posting plan agreement with APATC in 2019, to which Main attributed crew fatigue and vehicle maintenance issues.
Under American’s modified agreement, Main said every individual unit of their fleet is available for three post moves per shift, or a 90 minute time frame during post moves, whichever comes first.
“For us, if we’ve got 10 or 11 paramedic units on that day, that’s a significant amount of time,” Main said. “So that allowed, I think, a lot of flexibility for the dispatchers and the system, while at the same time we didn’t have a single crew that would be stuck in a particular location for hours on end and not have access to their food or their quarters and particular comforts that we try to give them while they’re on duty.”
Meanwhile, over at EDA, which shares the Woodlake, Three Rivers, Badger and Lemon Cove areas with American, Sodhy said their crews—generally three vehicles—are moving anywhere from eight to 12 times a day.
“There’s a level of exhaustion that sets in,” Sodhy said. “There were a couple of really bad nights that actually made this a bigger issue for us, where our crews never got more than one continuous hour sitting still in a 48 hour period. That’s bad, when your crews can’t even sleep.”
Sodhy, who described American’s role as “for all intents and purposes no longer part of the overall posting plan,” said EDA has no intent of pulling out of the posting plan, but is looking for a more careful and rational approach that doesn’t leave their crews feeling like they’re being abused. EDA is a public agency, a distinction from the other ambulance providers of Tulare County. With a board governed by the Brown Act, Sodhy said not having shareholders places a different set of requirements to operate than the other providers.
EDA is also the only Tulare County ambulance provider not centered on a hospital, which has some implications in regards to the posting plan and how it has shaken out.
“If you’re centered on a hospital, one of the things that you get as a benefit is that you do a lot of the inter-facility transfers for that hospital,” Sodhy said. “So they transfer people from Sierra View in Porterville, to Kaweah Delta, let’s say for a higher level of service, or sometimes they transfer them out to CRMC for specialty service or to UCLA—they get those, and they make what we refer to as guaranteed money.”
When an ambulance provider has transfers lined up, they take ambulances in service and assign them to those transfers, effectively making them no longer available to Tulare County. From Sodhy’s point of view with EDA as the small fish, that becomes a problem when those units are gone from an hour to sometimes eight hours, and EDA units end up having to go cover areas where units are missing on transfers.
Dave Byl, operations manager at American Ambulance, says delays aren’t just about transfers out of the hospital, but also the myriad of issues that have arisen from a serious capacity problem in California hospitals due to the surge in COVID-19 patients.
“These issues include everything from a lack of nurse staffing to a lack of beds available for admission, to lack of physical space for patients within the hospital,” Byl said. “This causes a significant issue with patient throughout, which has a direct effect on us and other EMS providers trying to get these patients into the [hospital].”
Sodhy said that Exeter is getting the short end of the stick from these conditions.
“Exeter, in terms of metro areas, is the last place to be covered as units come back available,” Sodhy said. “The preference is covering Porterville and Tulare and Lindsay before Exeter gets covered. We feel like our area is getting shortchanged.”
As the company with the city’s name on the side of their trucks, Sodhy said EDA is disappointed that they’re not in Exeter enough providing coverage, and that one of the motivations to modify their posting plan agreement is finding a way to service their own community more than they currently are.
Dale Dotson, EMS coordinator with Central California Emergency Medical Services Agency (CCEMSA)—the organization that monitors the ambulance providers’ contract compliance with Tulare County—said the common thread that keeps the band of providers together is performance standards.
“The result of poor performance in one [provider] or all of the county would be that the county would consider putting out a request for a proposal for a single ambulance provider to cover the whole county,” Dotson said. “That’s something they obviously don’t want to see happen, because that would mean several of them would be going out of business, maybe all of them.”
Dotson described this as a strong reason to succeed, and a unique strength of the Tulare County system for ambulance providers to have a vested interest in their success. So how have the numbers looked since American made changes to their posting plan agreement? Dotson said they have not seen any measurable difference. Main said it’s hard to tell due to so much “wall time,” time crews spend bogged down at hospitals, sometimes waiting in the hallway for a patient to be admitted.
“Again, this is where COVID comes into play, is that it’s hard to measure,” Main said, “CCESMA has removed compliance currently, because we’re in a pandemic mode.”
American Ambulance’s changes to the posting plan went into effect February 2020, shortly before the world was turned upside down by the coronavirus pandemic. Main said delays causing paramedic ambulances to be stuck at hospitals for hours on end are affecting everyone, not just American, and he is confident the APATC will continue to work towards providing better patient care without endangering both crew or lives in the county.
“That’s what we’re good at,” Main said. “Our goal is to come out with an agreement, and that’s how we resolve things. I think we’ve done very well as a provider group, we’ve really been working together since 2008.”
Sodhy said EDA is in the time-consuming process of collecting data to bring to the board of EDA to make an informed plan to bring to the table for APATC. While nothing is concrete, Sodhy said a suggestion similar to American’s updated plan came across his desk, where after a set number of post moves are made, a judgment call would be made before making any additional post moves.
“If there is a need to go cover another outside area, the request doesn’t go directly to the ambulance to move, the request has to go to our supervisor,” Sodhy said, “or me, in this case, and I would have to make the determination of whether we can move that unit.”
The EDA board meets generally two Mondays a month, and it’s meetings and agendas are available to the public.