Matt Zavadsky from PWW Advisory Group delivered the closing keynote at the 2024 California Ambulance Association Annual Convention in Anaheim, California, where he reinforced that EMS system design and delivery is evolving faster than ever, driven by an economic model that’s crumbling, a workforce in crisis and lessons learned during the COVID-19 pandemic.
In his provocative session, titled “Back to the future: Is ‘regression’ the key to our future?”, Zavadsky tackled this topic head-on. His central question: Is it time to return to simpler practices that were once considered out of date? As it turns out, the answer may surprise you.
The end of the 8-minute response myth
One of the sacred cows in EMS has been the 8-minute response time target. For decades, we’ve measured our success by how fast we could get to a scene, convinced that lives depended on it. This standard emerged from a 1979 study, which found that if CPR was initiated within 4 minutes and defibrillation within 8, survival rates from cardiac arrest would skyrocket.
However, research, including studies from Denver in April 2002, July 2002, 2005 and 2009, as well as from other urban centers, has shown that the 8-minute rule may not be as life-saving as we once thought.
As stated in the 2005 study, “Paramedic response time within 8 minutes was not associated with improved survival to hospital discharge.” The study points out that the focus should be on early CPR – within 4 minutes – rather than racing to hit an arbitrary response time.
Yet, many EMS systems continue to use response time as the be-all and end-all of performance metrics, even though patient outcomes don’t necessarily improve.
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Host Kelly Grayson makes the case for eliminating “arbitrary” response time standards; where do you stand?
ALS vs. BLS: Challenging old assumptions
For years, EMS agencies have operated under the belief that advanced life support (ALS) is always superior to basic life support (BLS). However, as Zavadsky explained, this assumption doesn’t always hold up under scrutiny. A landmark study from Harvard showed that cardiac arrest patients who received BLS care had a 13% survival rate compared to 9% for those treated with ALS.
This doesn’t mean that ALS is unnecessary, but it does mean that EMS systems need to rethink when and how they deploy ALS units. “It’s about matching the level of care to the patient’s actual needs,” Zavadsky noted. In many cases, well-trained EMTs can provide the necessary care without the added complexity and cost of sending paramedics on every call.
A shift in focus: Patient outcomes over speed
In an era where public expectations are often misaligned with clinical realities, EMS leaders face the challenge of educating both their communities and policymakers. For too long, we’ve allowed ourselves to be judged by response times rather than meaningful clinical outcomes. Zavadsky urged the audience to shift the conversation: “We need to educate stakeholders to safely transition your system from the current state to the future state.”
The emphasis should no longer be on how fast we arrive, but on the quality of care we deliver. Patient survival, particularly in cases of cardiac arrest, depends more on timely, effective CPR than on how quickly an ambulance reaches the scene. The studies back this up: faster response times don’t always result in better outcomes.
Economic realities driving change
The financial burden of maintaining all-ALS systems and meeting strict response time goals is unsustainable, particularly in today’s climate. With the EMS workforce in crisis and reimbursement rates failing to keep pace with rising costs, Zavadsky argued that EMS systems must adopt more cost-effective deployment models. This includes moving toward tiered response systems, where BLS units handle the majority of low-acuity calls, freeing up ALS units for critical interventions.
“Most systems today are economically challenged,” Zavadsky said. “The shorter the response time expectations, the more resources you need sitting idle, burning money but not creating any revenue.” Simply put, EMS agencies can no longer afford to continue business as usual. We need to be smarter about how we allocate resources and design our systems.
Lessons from the past for the future
Zavadsky’s session made it clear that what we once considered best practice may no longer be relevant, and what was once viewed as archaic could now be the key to improving patient outcomes and system sustainability. “We created this mess, so it’s up to us to change it,” Zavadsky stated, calling on EMS leaders to embrace data-driven decisions over outdated norms.
Key takeaways for the future of EMS
- Response times aren’t everything. The 8-minute response standard is no longer the gold standard. Instead, focus on initiating early CPR within 4 minutes, which has a far greater impact on patient survival.
- BLS can be just as effective as ALS. The idea that ALS is always better is being debunked by current research. Many patients benefit just as much, if not more, from BLS-level care.
- Educate your stakeholders. Changing the public’s perception of EMS is critical. EMS leaders must communicate that response times aren’t the only or best measure of success.
- Economic realities demand change. The current EMS model is not financially viable. Transitioning to a tiered response system can save money, increase efficiency, and improve patient care.
Conclusion: Time for a new approach
As Zavadsky pointed out, ideas that once seemed like heresy are becoming acceptable as the realities of EMS system design shift. The question we must ask ourselves now is: Are we willing to embrace change for the sake of better patient outcomes? The path forward may require revisiting old ideas with new eyes, but the evidence is clear: it’s time for a smarter, more efficient approach to EMS.
This isn’t about regression.
It’s about progress.
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