Safety And Licensing Committee Approves 3 Year Ambulance Service Agreement With Gold Cross

The Safety and Licensing Committee met 07/12/2023. Most of the meeting was taken up by review and discussion of the Fire Department service agreement for Gold Cross ambulance. Fire Chief Jeremy Hansen reviewed the agreement, and then the committee voted unanimously to recommend it for approval.

I’ve prepared a complete transcription of the discussion for your downloading pleasure.

Chief Hansen told the committee that Gold Cross had been providing ambulance service for the City of Appleton for over 35 years, but this would be the first agreement between the city and Gold Cross. Nock Romenesko, a representative for Gold Cross, said that a lot of what Gold Cross has done has been on handshake agreements with previous administrations. The goal of this document was to memorialize their agreement and to create expectations for both the city and Gold Cross.

Chief Hansen gave a brief history of the fire department and the medical services it has provided over the years.

• 1894 – the Appleton Fire Department was founded.
• 1954 – the fire department purchased its first ambulance.
• 1966 – the fire department adopted CPR.
• 1974 – the fire department started providing paramedic level service to the community
• 1986 – a public referendum ended the fire department’s ambulance service after Mayor Dorothy Johnson argued that was necessary due to cuts in shared revenue.
• 1998 – the fire department resumed responding to medical emergencies at the level of “first responder”, the lowest pre-hospital care level.
• 2011 – the fire department developed a tactical EMS program with the police department. Paramedics from the fire department utilized their skills to promote or provide assistance to injured officers and civilians.
• 2019 – the Appleton, Grand Chute, and Kaukauna fire departments agreed to respond to all active threats and actives of violence within Outagamie County and parts of Calumet and Winnebago counties.
• 2021 – the fire department upgraded its level of service from “first responder”, the lowest pre-hospital level, to “EMT Basic”, which is in the middle.
• 2024 – the fire department plans to move to a “paramedic” level of service in mid-2024.

In 2019, the fire department began tracking Gold Cross ambulance response times. [My inference is that they were satisfied with the ambulance services response times, and therefore…] In 2021, Chief Hansen and Mayor Woodford started working on some shared expectations which they discussed with the leadership of Gold Cross. Eventually, in September of 2022, the city and Gold Cross came to a tentative agreement on five shared goals, and City Attorney Christopher Behrens drafted a shared service and operating agreement based on those shared goals.

Chief Hansen did not go through the agreement word for word, but he did highlight several areas.

• This agreement is for a 3-year term.
• The agreement is exclusive, and Gold Cross will be the city’s primary provider of ambulance services – neither the fire department nor the city will be allowed to obtain an ambulance and start offering transport services or partner with another ambulance service. An exception is for services provided by mutual-aid agreements, automatic-aid agreements, Mutual-Aid Box Alarm System (MABAS) resources, or requests due to special circumstances.
• The city will owe no compensation to Gold Cross for providing transport services.
• Gold Cross will provide both basic and advanced life support ambulances in the city. Advanced Life Support ambulances will be staff with at least one paramedic. Chief Hansen mentioned that this did cause him some concern because similarly sized cities across Wisconsin had two paramedics for ALS calls; however, they will soon have a paramedic on every firetruck which will make that lower staffing level on Gold Cross more acceptable to him.
• Gold Cross employees will need to display their medical license level. This is to help the fire department know when they can transfer patient care and to whom they can transfer patient care.
• The fire department will continue to provide non-transport EMTs on all emergency apparatus. Chief Hansen noted that almost every single person in the fire department is either an EMT Basic or a paramedic.
• The agreement establishes a hierarchy of care for various types of emergency calls.
• Gold Cross will replace all consumable supplies and equipment used on medical incidents at no charge to the fire department.
• Gold Cross will provide training on a quarterly basis on topics that are approved by both Gold Cross and the city.
• The agreement establishes goals for emergency response times with a goal of 8 minutes 59 seconds for Gold Cross and 4 minutes and 59 seconds for the fire department.
• Gold Cross will notify the fire department if their response time will exceed 15 minutes.
• Gold Cross will have the necessary equipment to transmit and receive on the fire department’s main fire channel.
• Gold Cross will assist the fire department in developing an EMS operations plan.
• Gold Cross and the fire department will each provide each other with copies of documents submitted to the state.
• Gold Cross will capture and record performance measurement data and will meet regularly with the fire department to discuss ways they can collaborate and improve.
• Either party can terminate the contract with a 12-month notice.

Mr. Romenesko was confidence Gold Cross would be able to meet the expectations outlined in the agreement and believed the agreement would help improve their response times and also the quality of the collaboration between Gold Cross and the city members on scene.

A number of questions from the committee revolved around staffing levels on the ambulances specifically and responding to scenes in general. The fire department is working toward getting paramedics on ever fire truck and by July of 2024 expected to have 25-30 paramedics in the department which would be enough to put one on every truck.

Mr. Romenesko said that maintaining staffing levels was a challenge nationwide right now, particularly in regards to maintaining paramedic levels. They were doing everything they could to get paramedics on every single call and would continue to do so. At a minimum, there would be one paramedic and one EMT responding to a call. They also did have several ambulances that are staffed by two paramedics, rather than a paramedic and an EMT.

Additionally, another resource they had was a paramedic in a rapid response vehicle that responded separately from the ambulance. The paramedic in the rapid response vehicle did not have the requirements to transport and restock at the hospital, so they could quickly turn around and get on multiple calls throughout the day to provide that second set of paramedic hands.

Gold Cross was also working on building a training center so that they could train paramedics in-house, but currently they were only training at the EMT level.

Alderperson Katie Van Zeeland (District 5) asked if Gold Cross had any controls for rest or time off. Mr. Romenesko said that they did. They have been reducing the housed-worked requirements for their staff members. They moved away from 24-hour shifts to 12-hour shifts, and over the last year made the full-time requirement 24 hours a week. Right now, most of their staff had either a 24-hour week or a 36-hour week. That reduced provider fatigue: however, the problem was that by reducing the number of hours per employee they then needed more people to do the work. That did not, however, affect Gold Cross’s service.

Mr. Romenesko also mentioned that only 2-3% of calls required upper-level paramedic care. Those situations were few and far between. Additionally, even when there was a second paramedic, often times that second paramedic was just helping by moving bags and lifting things and being a second set of hands.

Chief Hansen held a different perspective. He said there was data to support both positions, that one paramedic was fine or that two paramedics was better. When he had been working in Eau Claire, they had three paramedics on the fire truck and two on the ambulance because when there was a very serious call that allowed important things such as starting an IV, clearing the airway, and drawing medications to all happen simultaneously rather than being done sequentially by one paramedic.

Alderperson William Siebers (District 1) was confused because the Kaukauna Fire Department has its own ambulance, and they are required to have two paramedics. He wanted to know why Gold Cross was different was Kaukauna.

Mr. Romenesko explained that there was a rules change recently that requires an ambulance system to have a minimum of two paramedics on at least one ambulance. Gold Cross had worked closely with the state to determine how this rule would work for them. Gold Cross always has a minimum of one dual paramedic ambulance in service. The rest of the ambulances can have variable staffing. Under the rule, they would actually be allowed to have an ambulance with two EMTs and no paramedic, but they chose not to do so.

He also explained that none of Gold Cross’s ambulances were designated for any specific municipality within their service area, but they had a minimum of two ambulances stationed in the city at all times. Typically, their stations at St. Elizabeth’s Hospital and ThedaCare’s Appleton hospital were staffed 24 hours a day. They also have three additional resources within their system that were floaters and always in the city of Appleton, but the number of ambulances available was variable throughout the day.

Their total service area stretched from Waupaca to the west to Chilton in the east, then Shiocton, Black Creek, and Seymour to the north, down to Oshkosh in the south.

There was some discussion of the committee possibly receiving an update on the ambulance service possibly on an annual basis, but nothing was set in stone.

The committee went on to vote unanimously to approve the agreement.

View full meeting details and video here: https://cityofappleton.legistar.com/MeetingDetail.aspx?ID=1103672&GUID=AE980197-B9C0-4E1C-BD25-ABF8257DC884