ST. GEORGE – Closing arguments brought four days of hearings between Dixie Ambulance and Gold Cross Ambulance to an end Thursday. Attorneys for Dixie Ambulance said Gold Cross’s argument only proved the dispatch system in Washington County is flawed, while Gold Cross’s legal team reiterated its belief the ambulance service is in violation of state law and should have its license revoked.
A broken system?
Alan Sullivan, an attorney for Gold Cross, said he was in attendance at the public comment hearing Monday and heard repeatedly the phrase, “If it ain’t broke, don’t fix it.” However, he added the public didn’t have the whole picture. “We’ve had the privilege of actually knowing the facts … Dixie Ambulance is broken,” he said.
Sullivan also said Dixie Ambulance is stuck in the past in some ways because it doesn’t utilize the latest in EMS technologies and its employees don’t record patient data like Gold Cross does.
Tony Randall, president of Dixie Ambulance, said EMTs and paramedics take patient information on pen and paper. Sullivan said the handwritten data is put into a computer system many hours after a transport or even at the end of a 12-hour shift when an employee is tired and may not remember everything.
“EMS is a data driven environment,” said Jerry Overton, chair of the International Academy of Emergency Dispatch, testifying for Gold Cross. “The reliability of a pad and paper is not reliable,” he said.
Overton said that, in his opinion, Dixie Ambulance is not adequately communicating critical patient data to hospital personnel once a delivery is made. In contrast, he said Gold Cross does a superior job of relating patient information due to its use of computers and a highly integrated dispatch system.
Mike Moffitt, president of Gold Cross, said the EMS is able to provide accurate and timely records on transported patients thanks to agreements between the ambulance service and hospitals in the Salt Lake City area. “We share data all the time,” he said.
Overton said there would be no way to effectively analyze data surrounding EMS-related items if he didn’t have the proper data-points to start with. In Dixie Ambulance’s case, the data-points would be a series of protocols concerning patient care, response times, how to work with other emergency agencies, and so forth. Without written protocols to provide a standard of service, Overton said, there is no way to measure an ambulance service’s performance and note any shortfalls or improvements.
Overton noted one particular set of protocols absent is a standard of care agreement between Dixie Ambulance and the City of St. George. The agreement is basically a list of standards and protocols created by the city for the ambulance service to follow.
St. George currently lacks a standard of care agreement. St. George Fire Chief Robert Stoker said the city council was approached with the idea of creating such a contract in the past, but did not wish to pursue it at the time.
Following the hearing, Marc Mortensen, assistant to the City of St. George city manager, said the city is currently looking into the creation of a standard of care contract.
Dispatch discrepancies and crippled communication
“Dispatch is the first component” of patient care, Overton said.
Much of the data collected by Gold Cross concerning response times comes from records provided by the St. George Dispatch Center. The computer-aid dispatch software used by the center is called Spillman software.
“We’re very familiar with (the software),” Moffitt said. “Our history with it, in this case alone, (shows) it is accurate.”
Moffitt said the Spillman software is used by dispatch centers across the nation, including the center Gold Cross maintains in Salt Lake City. “You can’t disparage the dispatch program,” he said.
Tom Kuhlmann, Hurricane City fire chief and chief of the Hurricane Valley Fire District, doesn’t agree with Moffitt’s assessment of the software.
Kuhlmann gave an example of inputting the same information into the Spillman software three separate times. Each time, it produced different data.
“I have not found the data to be reliable,” Kuhlmann said.
Clifford Dunn, one of Dixie Ambulance’s attorneys, quoted testimony from City of St. George city manager Gary Esplin, who said, “We’ve had problems in our dispatch center.”
Dunn said perceived problems with response times may actually originate from the St. George Dispatch Center. According to testimony, he said, the dispatchers may be struggling and working as hard as they can, but can’t produce all of the data needed for a comprehensive study on response times, such as the one created by Darren Judd, CAD system deployment coordinator for Gold Cross.
According to Judd’s data, Dixie Ambulance had dismal response times to highly critical medical calls between 2009 and 2011. If the data used for the study is as flawed as Kuhlmann testified it is, Gold Cross has proved nothing, Dunn said.
“Those numbers are a record of actual performance,” Sullivan said. He also cited a Utah Department of Health study on Dixie Ambulance’s response, which, according to the department’s data, timed the EMS at an average 13-minute response time for critical calls. The recognized industry standard for these kinds of calls is 8 minutes 59 seconds.
“Dixie Ambulance has failed by a significant degree” in its response times, Sullivan said.
Integrated dispatch system
Overton said it is the responsibility of the ambulance service to be proactive in “fixing” potential problems involving dispatch, interaction with related agencies, and approaching the city about standard of care protocols.
In Washington County, due to the lack of an integrated, system approach to better coordinate EMS and other emergency responders, Overton said, “the whole dispatch process … endangers the public.”
He said this is due to multiple vehicles – ambulances, fire trucks, and police units – all responding to the same call, which creates traffic hazards, particularly if lights and sirens are blazing. Overton also said he believes Dixie Ambulance is in violation of state code by not having two paramedics on the same vehicle.
“EMS should be proactive in implementing a system approach,” he said.
If Gold Cross receives the EMS licenses for St. George, the CAD system used by Gold Cross in Salt Lake City could be brought to the St. George Dispatch Center.
“Utah is the only state that thinks it takes two paramedics to equal one brain,” Kuhlmann said. The Hurricane City Fire Department also employs a single paramedic per vehicle at times, though it does its best to get two paramedics on scene to satisfy state code.
“There are stakeholders in this community that have a stake in the dispatch system,” Dunn said. Aside from St. George, the center covers all of Washington County with the exception of Hildale.
If the real problem is communication, he said, then Gold Cross should give a presentation on how to improve dispatch performance to the county, rather than try to have Dixie Ambulance’s licenses revoked.
Nick Turner, attorney representing the Hurricane Valley Fire District, asked Max Miller, the presiding hearing officer, to consider the precedent the current case could set. He said it could open the door for litigation against EMS providers elsewhere by competitors who want their licenses.
Turner also asked consideration of the “drastic impact” revoking Dixie Ambulance’s license could have on the communities outside of St. George.
Sullivan said the question presented at the hearing was a simple one – which ambulance service is better for St. George? He said Gold Cross is the superior choice, because it has more resources than Dixie Ambulance; will be more accountable, thanks to adherence to written protocols; employs advanced medical technologies on its ambulances; is financially sound; and will provide an integrated system approach for the area.
“Wouldn’t that be novel for this community?” he said.
He also touched on Dixie Ambulance’s company finances. “The numbers take Dixie Ambulance underwater.”
He said Gold Cross’s equity for 2011 was over $1 million. Dixie Ambulance had a negative equity of minus $5,000, while RAM Properties, the holding company side of the company, has $500,000 in liabilities over assets, according to the balance sheets.
“There can be no question of Gold Cross’s solvency.” Sullivan said. He also said the alleged misuse of funds connected to the recent audit of Dixie Ambulance goes against “the competence of Dixie Ambulance’s management.”
“Past is prologue,” he said. “Consider each company’s history.”
Based on the claims of financial instability and state code violations, Sullivan said Dixie Ambulance could not provide quality patient care, and asked Miller to recommend BEMS revoke its license in favor of Gold Cross.
Dunn said the burden of proof against Dixie Ambulance is with Gold Cross. He said all Gold Cross had really accomplished was proving some people don’t like Dixie Ambulance, and that there a is communication problem in the county.
“There is no evidence Dixie Ambulance is substandard,” Dunn said. He recalled response time data compiled by Randall, and said, “Response times are excellent, over 90 percent.”
As to Dixie Ambulance’s solvency, he cited the testimony of David Hall, an accountant who had examined the company’s finances. Hall said he saw a $200,000 profit 2011. “They have financial viability to move forward,” he said.
As to patient care, Dunn pointed to the testimony of Dr. Michael Tremea, an emergency medical doctor at Dixie Regional Medical Center and medical director for Dixie Ambulance, who said he and other emergency room physicians were pleased with Dixie Ambulance. In contrast, Tremea was not impressed with Gold Cross, which currently operates a unit that provides inter-facility transport at the hospital. “They don’t know what they’re doing,” he said.
Dunn also poked at Overton’s testimony for Gold Cross.
“BEMS has defined a scene in a way for Dixie Ambulance to conduct its business the way they are,” Dunn said. If Overton had his way, he said, not only would Dixie Ambulance lose its licenses, but so would the Hurricane City Fire Department and Davis County Sheriff’s Office, both of which operate in a similar manner.
“The burden of proof is upon the applicant,” Dunn said.
The final recommendation to the state will not be made at that time. Miller said the decision could take a week, a month, or longer to finalize. Once he made his recommendation, it would be sent to Paul Patrick, BEMS director.
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