Red Lights and Sirens – Finally Time to Use Less?

Christopher Dick, BA-Biology, NREMT-P, ND Rural EMS Counts SME

Red lights and sirens (RLS) responses and transports have never been shown through scientific study to improve patient outcomes. However, scientific studies dating back even to the 1950’s, have shown RLS use increases the rate of collisions of ambulances, increases rates of injuries and severity in these collisions, and increases the rate of non-emergency vehicle crashes. These same studies show 4.5-5% of all ambulance calls are true emergencies and result in potentially life saving interventions (PLSI) being performed. Lastly, these studies show we save only 1-4 minutes in improved response or transport time depending on whether an ambulance responds in a rural, suburban, or urban environment. While we have improved and use less RLS during patient transports, our industry has not adopted widespread reduction in our RLS use during 911 responses.1 Why, if we have known for years that RLS have little to no impact on patient outcome, do we continue to use them most of the time in our response to 911 calls? Is it because we have always done it and we were trained to do it? Is it because we believe it saves lives? Is it because we think the public expects it? I argue it is a combination of those things, and we can do better to protect our patients and the public we are entrusted to “first do no harm” to.

Fifteen years ago, during my good fortune of leading a small, rural agency in the mountains of CO, we wrestled with and addressed this sticky topic. At the time, we responded to approximately 1000 EMS 911 calls per year. This is not different from a lot of call volumes across rural services or regions in ND. One of our supervisors, Brian Donaldson (now an EMS agency leader in WI) who was never afraid to ask questions or shake things up, came to me with an observation and a proposal. He said to me, “We are responding to 85-90% of our 911 calls with RLS. What if we reduced that number and our risk to our patients and public by changing what we respond RLS to?” Intrigued, I asked him to tell me more.

Like anyone proposing a major operational change, Brian had done his homework and reviewed and compiled research in support of the proposed change. He showed me, through scientific data, that in a response area like ours we were at most saving 30-45 seconds by using RLS to respond. We determined, after reviewing the data from a lot of the studies I referenced at the intro to this article, it no longer made sense for our agency to put responders and the public at increased risk to make up a little bit of time for so very few “true” emergency calls where PLSI are performed. So, we got to work revising our protocol and operating guidelines for RLS response.

Since we did not have Priority Dispatching available at the time in our dispatch center, we decided we would respond to the following types of dispatches RLS:

· Airway/Respiratory, Cardiac, Stroke/Suspected CVA, Diabetic, Seizure, Imminent childbirth, and penetrating trauma emergencies

· Pt. determined to be in extremis through initial dispatch info

· Responder discretion

We would no longer respond RLS to the following call types:

· Car accidents with no patient in extremis

· Clinic or other licensed health care facilities with 24-hour nursing/physician care

· Extremity trauma, mental health/domestic calls, abdominal pain, nausea/vomiting, generalized sick calls

· Limited dispatch info indicating any true emergency

Did we get pushback initially after this change? Yes, but only from our fellow LE and Fire Department responders. We received no pushback or negative feedback from the lay public. Through education for the public with one newspaper article on the changed protocol, they seemed to embrace the change and we heard nothing but positive from them about less noise through town and less risk to the public. Through continued training and discussion about how we were responding moving forward with our LE and Fire partners they came to understand we were still going en route immediately and were responding timely. We were just doing so quieter and with less risk and chaos. After 3-6 months responding according to the guidelines above, the naysayers quieted completely. After these changes our RLS responses moved from 85-90% of our calls to closer to 50% of our calls. Our staff appreciated the change over time and our increased dedication to their safety.

If you have read this far, you may be asking, “So how are we doing in 2020 nationally and in ND?” A study published in Prehospital Emergency Care in late summer 2020 examined RLS use from national ESO data from 2018 across 1187 EMS agencies. The ESO data examined a sample set of 3.84 million ambulance responses. Of these 3.84 million responses only 6.9% had a PLSI. However, 85.8% of all the 911 responses used RLS to scene. This is not vastly different from an exhaustive NHTSA research paper, by Douglas Kupas, MD in May 2017, into RLS use across the United States showing RLS use in 911 responses of 75%.2 Looking at raw ESO data from 2019 in North Dakota only we fall near these numbers. In almost 63,000 responses, data shows we responded emergent 71% of the time. In 41,000 patient transports we used RLS only 10% of the time.

In a 2017 webinar about the NHTSA study, consensus from experts was that we should develop industry benchmarks of 50% RLS use in 911 responses and 5% or less RLS use in patient

transport. I agree wholeheartedly with these benchmarks. When I look at all the previous research on this topic and couple it with the experience I gained from the “experiment” we did and implemented in rural CO, I think it is crazy if EMS agencies are not reviewing their RLS response and looking at ways they can meet these proposed benchmarks.

Often when responders discuss this topic one question always arises, “Are we at increased liability when we don’t respond RLS?“ In other words, “will patients sue me if I don’t come to their emergency RLS?” I always counter them with this, “Highly unlikely, but I do know they will sue you if you respond RLS to an isolated broken arm and you hit someone’s child riding their bike or T-bone someone’s grandparent driving to church.” While no one protocol or standard operating guideline will fit every response area in ND, every agency should examine their current protocols or SOG and work to reduce unnecessary RLS response and transport. We owe this to our patients, our co-workers and the public!

Be safe and never stop improving!

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