Emergency Services Authority Q&A

The Summit County Emergency Services Authority group consists of Copper Mountain Fire District, Lake Dillon Fire District, Red, White & Blue Fire District and Summit County Ambulance Service. These four organizations have been working together over the past several years to identify cost-savings and opportunities for financial stability in our communitywide ambulance system, while maintaining or improving the level of patient care.

Many questions have arisen about the group’s work and the ambulance system itself.
Photo of an ambulance in front of a ski area.

What is the goal of the countywide EMS system?

As agreed upon by the four partners, the goal is to develop a system that maintains or improves the level of quality of the countywide emergency medical services (EMS) system, while taking advantage of the resources throughout the community to improve its efficiency and create financial stability and cost savings over time for all agencies involved.

Who operates the ambulance system in Summit County?

In Colorado, licenses to operate ambulance services are granted and held by county governments.

Summit County has operated the Summit County Ambulance Service (SCAS) since the 1970s. Today, the County operates eight ambulance units, which provide 911 response and interfacility patient transports throughout all of Summit County.

In 2014, Red, White and Blue Fire District and Summit County entered into an agreement that allowed Red, White and Blue to transport patients under the auspices of the SCAS license. RWB provides 24/7/365 coverage primarily within its district boundaries; in-county and out-of-county interfacility transport; coverage elsewhere in the county, based on the system status plan; and additional surge capacity.

In 2015, Lake Dillon Fire and Copper Mountain Fire each entered into agreements with Summit County to co-staff Summit County Ambulance Service units under the auspices of the SCAS license. These units are based at Keystone and Copper Mountain, respectively. These two fire districts also provide additional surge units to the system when needed.

Why did the four agencies come together to create a multijurisdictional system?

Prior to 2005, Summit County Ambulance Service’s revenues from patient fees reliably covered the service’s expenses. But after the 2005 opening of St. Anthony Summit Medical Center, a significantly greater breadth and depth of medical services became available locally, and out-of-county patient transports dropped off, thereby reducing revenue to the ambulance service.

The subsequent economic recession, increases in operating costs, limited reimbursement rates from Medicaid and Medicare patients and increasing numbers of uninsured patients further depressed Summit County Ambulance Service’s revenues. Between 2011 and 2013, SCAS deficits averaged more than $460,000 per year.

Ambulance services across the nation, including in our neighboring communities in Colorado, face similar pressures. Meanwhile, fire districts are also experiencing significant changes. Firefighting agencies have spent decades developing and enforcing modern building codes, which have been extremely successful in reducing the incidence of structure fires. Fire-resistant building materials, fire-suppression systems, smoke detectors, lower smoking rates and increased levels of public education and awareness have all resulted in safer communities with fewer fires. This has freed up fire agencies’ resources to spend more time attending to other types of emergencies, such as medical emergencies.

Together, these trends make a compelling case for EMS and fire agencies to develop new, collaborative relationships through which to provide high-quality emergency services in a way that makes the most efficient use of taxpayer resources. This is exactly what we’re working to achieve in Summit County.

What is the current trend in the volume of medical calls for service in our community?

The total number of medical calls for service (CFS) in Summit County has been relatively consistent over the last four years, as shown in the graph below. While the number of CFS varies from year to year, the average over the last four years is 4,682 medical CFS.

2015 was the first year that all three fire districts participated in the countywide EMS system. Since this integration, the number of medical calls for service originating in the Lake Dillon Fire District increased slightly, from 2,204 CFS in 2015 to 2,312 CFS in 2016. The medical CFS in the Copper Mountain Fire District also increased slightly, from 314 to 335, over those two years.

During the same period, the number of medical calls for service in the Red, White and Blue Fire District decreased very slightly, from 1,252 medical CFS in 2015 to 1,246 in 2016. The Red, White and Blue medic unit (Medic 6) responds to most of the calls for service in its district, but Summit County Ambulance Service medic units handle a significant number of calls there, too. In 2015, of the 1,252 total medical calls in the RWB area, a SCAS unit responded to 426 of those calls. In 2016, a SCAS unit responded to 324 of the medical calls that occurred in the RWB district. This illustrates the benefit of a collaborative, multijurisdictional system: Surges in call volume can be accommodated through deployment of other units in the system, rather than any one agency having to procure additional equipment and maintain extra staffing to be able to handle all calls within its boundaries at any given time.
Bar chart showing medical calls for service from 2013-2016. There were 4,644 calls for service in 20

Do we have enough ambulances and crews in Summit County to accommodate current levels of activity and growth? How busy are our ambulances, relative to industry standards?

There are two ways to evaluate the activity level of fire and medical response units: the number of calls for service (CFS) and the unit-hour-utilization (UHU) rate. CFS is simply a count of the number of calls that a unit responds to over one year. Below are guidelines developed by TriData, a public safety services consulting company headquartered in Washington, D.C., that outline CFS levels, categorized from “Very Low” to “Very High” levels of activity.

  • Very Low: Fewer than 500 responses per year
  • Low: 500-999 responses per year
  • Moderate: 1,000-1,999 responses per year
  • High: 2,000-2,999 responses per year
  • Very High: 3,000-3,999 responses per year 
  • Extremely High: More than 4,000 responses per year
Our local ambulance system operates five 24/7/365 medic units (along with one part-time unit and some seasonal surge units). Of these five full-time units, two units had “Moderate” levels of activity in 2016, and three units had “Low” activity in 2016, per the CFS metric.

UHU rates are based on the total time that a unit spends responding to calls (from initial dispatch through call termination) divided by the amount of time the unit is in operation. In other words, UHU measures the percentage of a unit’s time in service that is spent running calls. It’s important to note that UHU doesn’t account for other activities personnel must perform, such as training, maintenance and other preparedness-related functions. However, UHU is considered an important workload indicator. Expressed as a percentage, it describes the amount of time a unit is not available for response, as it is already committed to an incident.

The annual UHU rates for all of the 24/7/365 medic units serving Summit County are listed in the table below; the numbers of calls for service for these units are also included. The legend lists the utilization categories for activity levels commonly accepted in the fire and emergency medical services industry.
When evaluating annual activity levels using the UHU measure, most of the medic units operating in Summit County are in the “Low Utilization” range, and some are in the “Below Average Utilization” range.
Legend of UHU ranges, according to industry standards. Values ranging from 15 to 25 percent are cons
Table displaying annual UHU values for all 24-7-365 medic units in Summit County, years 2013-2016. V
The winter season is the busiest time of year for emergency services because of the substantial number of visitors to Summit County. Even during this time, the seasonal UHU rates for our 24-hour ambulance units remain “Below Average” or less, according to industry standards.
Table displaying winter peak season UHU values for all 24-7-365 medic units in Summit County, years
As noted above, there are important non-emergency activities that are not included in the UHU measure. In recognition of this, fire and ambulance services have established an upper limit for utilization rates that allows for completion of these non-emergency activities, in addition to emergency response. The upper range for utilization rates that has been commonly accepted for this purpose is 0.30, or 30%. This limit on utilization rates has been used in several studies and publications, including the following:

  • District of Columbia Task Force on Emergency Medical Services (2007). Report and Recommendations. “EMS calls per unit hour range from 0.17 to 0.70 for the systems surveyed. Calls per unit hour rations reflect the activity of the system and generally should be in the range of 0.30 to 0.40 for public agencies.”
  • Castle Rock Fire and Rescue Department (2011). Community Risk Analysis and Standards of Cover. “However, fire-service-based EMS units are expected to perform other duties outside of caring for and transporting patients, and typically are in the not‐for‐profit business. Therefore, understanding that there are other duties as assigned, the UHU of 0.30 should be considered to be the limit for these units.”
  • Illinois Fire Chiefs Association Consulting Service (2015). Consolidation Study for the Darien Woodridge and Lisle Woodridge Fire Districts. “In most dynamic deployment systems such as the System Status Management program used by private ambulance companies, UHU rates as high as 0.40 can be achieved. This, however, can lead to paramedic burnout. This is considered to be the point at which a unit is fully committed. For static or fixed deployment systems such as the traditional fire station, the maximum UHU is closer to 0.25 − 0.30, depending on factors such as geography or the transportation network and other workload that must be accomplished.
  • ICMA (2015). The New EMS Imperative: Demonstrating Value. “EMS agencies responding solely to 911 calls typically target a lower unit hour utilization (between 0.30 and 0.50 UHU) than nonemergency ambulance transport providers—in order to ensure that a sufficient number of units remain available to respond to emergency calls. Agencies whose providers work longer shifts, such as 24 hours, also often aim for lower UHUs due to concerns over fatigue and safety.”
  • Fitch & Associates (December 2016). Addendum, Workload On Rescue Units, Summit County, Colorado. “Workload on emergency service units, including Rescues, is often couched in term of “Unit Hour Utilizations,” UHU. This parameter is expressed as the decimal ratio of hours spent actively executing the functions of the unit, time-on-task, divided by hours on shift. The upper target for UHU is not fixed, but depends on the length of the shift. It is feasible to run crews on shorter shifts, 8-hour to 12-hour shifts, at UHUs as high as 0.7. UHUs in this range are commonly seen in high performance, private, and profitable EMS systems. Crews on 24-hour shifts should be restricted to UHUs of 0.3. The 30% utilization is not an arbitrary metric, but is supported by realistic studies.”

Even in the busiest months of the year, none of the medic units operating in Summit County nears the upper limit of a 30% utilization rate for 24-hour units or the 70% utilization rate for 12-hour units. For example, for RWB’s Medic 6 to reach the 30% utilization rate, it would have to respond to almost 350 additional calls over the four-month peak period, for a total of more than 900 CFS, which would represent an increase of approximately 60% over its current CFS for that period. That is not likely to happen in the next 10 years.

What is an out-of-county transport? Who performs them?

When patients require a higher level of care than is available at any of our local medical facilities, our EMS personnel must transport them to facilities outside Summit County, usually in the Denver area. These out-of-county transports (OCTs) are much more time consuming and often more stressful than in-county transports, particularly during winter storms. In calendar year 2016, the average OCT duration was 4 hours and 20 minutes.

It’s important that OCTs are spread equitably among all ambulance crews in the system, to guard against crew fatigue and to ensure patient safety. Equitable distribution of OCT duties among all crews also gives all personnel the opportunity to exercise their critical-care skills, as they must care for patients with serious conditions for longer durations. The overall capacity, flexibility and efficiency of the system would be reduced if some medic units were to have limitations on the functions they agree to perform.

Why doesn’t the County contract a third-party ambulance service to handle out-of-county transports?

Summit County has explored the possibility of contracting a third-party ambulance provider to handle out-of-county transports (OCTs). We have held discussions with AMR Denver, Flight For Life Colorado, Pridemark Paramedic Services and Rural/Metro. All these organizations expressed that if they were to act in this role, their operations would be much more limited than what we have now: When OCT services were needed, the Denver-based organization would dispatch a medic unit from the Denver area to conduct a transport from Summit County to a Front Range facility. Some indicated they might station one unit locally to be available for OCTs. However, it is not uncommon for two OCTs to be needed simultaneously in Summit County.

This third-party model would result in substantially longer wait times for patients than under our current system, particularly during winter weather events and periods of I-70 traffic congestion. While we haven’t found that third-party providers could offer an equivalent (or even acceptable) level of service for OCTs, we are exploring whether such a provider could offer surge support during extremely busy periods.

Financial factors are also important to consider in any discussion of OCTs in the Summit County system. OCTs generate fee-based revenues that are much more reliable than patient fees collected from 911 calls. OCT revenues are fed back into the system to help to offset financial deficits we incur from 911 coverage operations. If local Summit County agencies were to stop providing OCTs, the financial health of our ambulance system would be significantly weaker.

What is an Insurance Services Office (ISO) Fire Suppression Rating Schedule (FSRS) rating? How is it determined?

The Fire Suppression Rating Schedule (FSRS) lists the criteria ISO uses to review a community’s fire prevention and fire suppression capabilities. The schedule measures the elements of a community’s fire protection system and develops a numerical grade. ISO ratings are a factor in the determination of property insurance rates for homes and businesses.

The FSRS considers three main areas of a community’s fire suppression system: emergency communications, fire department (including operational considerations) and water supply. It also includes a community risk reduction section that recognizes fire prevention, public fire safety education and fire investigation.

Learn more about how FSRS determines an ISO rating.

Can out-of-county transports impact an ISO rating?

The only way in which out-of-county transports (OCTs) might impact an ISO rating is under the manual’s section on Existing Company Personnel. This section awards points based on a calculation of annual average staffing levels. It states, “Personnel staffing ambulances or other units serving the general public shall be credited if they participate in fire-fighting operations, the number depending upon the extent to which they are available and are used for response to first alarms of fire. … When fire fighters respond to medical calls, deduct one fire fighter for every 2,000 such calls per year.”

A 2016 study of our local system by industry analyst Fitch & Associates indicated that units on OCTs would not result in a lack of availability to respond to fires or other hazards. Therefore, it is extremely unlikely that OCTs would result in any negative impact on the ISO rating for local fire districts.

Summit County, Lake Dillon Fire and Copper Mountain Fire have inquired directly with ISO to determine whether OCTs could impact Red, White and Blue’s ISO rating. The response to Summit County was, “ISO does not evaluate or give credit for EMS/Paramedic units. We only evaluate the fire department and their capabilities. The transportation of patients will not affect the ISO rating if the fire department is still responding to all structure fires with the required amount of personnel/apparatus.” Both Lake Dillon Fire and Copper Mountain Fire have confirmed that ISO provided a similar response that OCT’s would not have a negative impact on the Red, White and Blue ISO rating.

What was the conclusion of the independent analysis by Fitch & Associates regarding the risk of out of county transports?

Summit County worked closely with all three fire departments and the ambulance service to develop a scope of services for a consulting company to analyze the possible impact of out-of-county transports (OCTs) by the fire departments on other critical priority incidents. We also worked jointly to select the consulting company that would conduct the study.

After the initial study was complete, the fire departments requested that the study be repeated with a broader scope, using a number of additional critical incident types. The findings of both the initial study and the follow-up study showed that OCTs by the fire departments would have no negative impact on their ability to respond to critical fire incidents or other medical incidents in the county.

The following documents present the findings and recommendations of both studies:
The findings of the initial study by Fitch & Associates showed there is a greater than 99.9% probability that out-of-county transports have no impact on response times to critical priority emergency medical incidents in Summit County.

In addition, the study found that there is a greater than 99.9% probability that out-of-county transports have no impact on response times to critical priority fire incidents in Summit County.
The report’s conclusion stated, “Based on the outcome of the analyses, the consultants conclude that the Summit County 911 system has a sufficiency and availability of units to readily accommodate the conduct of out-of-county transports without compromising in-county operations on critical priority fire, all hazards or critical priority emergency medical responses.”

The findings of the follow-up study by Fitch & Associates showed there is a 98.8% probability that one simultaneous out-of-county transport has no impact on response intervals to critical emergency medical incidents in Summit County. In addition, there is a greater than 99.9% probability that two or more simultaneous out-of-county transports have no impact.

The follow-up study also found that there is a 96.6% probability that one or more simultaneous out-of-county transports have no impact on response intervals to critical fire incidents in Summit County.

The follow-up study concluded, “The conduct of out-of-county transports undoubtedly imposes a burden on emergency service resources in Summit County. Nevertheless, with ambulances and personnel frequently traveling back and forth to Denver, there remains a sufficiency of resources within Summit County to execute normal emergency service operations and experience no increases to response intervals. This is the case for both critical emergency medical and critical fire related incidents.”