This issue’s service spotlight article takes us deep into the heart of St. Louis County in a response area of high-rise commercial buildings, high-rise residential buildings, one family dwellings, the I-170 corridor, St. Louis County infrastructure and buildings, a commuter rail system, and three higher education colleges. This area of St. Louis County is served by the Clayton Fire Department (CFD), which was honored as the 2023 EMS Agency of the Year at the annual MEMSA Awards ceremony in July.
The Agency
CFD provides advanced life support service to the city of Clayton, Missouri located in the center of the St. Louis metropolitan area. The city is about 2.5 square miles. The department runs approximately 3,000 calls per year and serves a population of 17,355 that almost triples during the daytime to 45,000. Their mutual aid system extends services to an additional 60,000 people.
This municipal/city fire-based 911 system was founded in 1897 and began ambulance transportation in 1932 with a retrofitted policy paddy wagon purchased from the St. Louis Metropolitan Police Department. Once pre-hospital medicine became more formalized, they began implementing certified EMTs in the early 1960s. Several Clayton Fire Department members were among the first certified paramedics in Missouri in 1975.
The agency currently has one station and one transporting ambulance along with a heavy rescue pumper, light rescue aerial, and one battalion chief SUV with all apparatus equipped at the ALS level. The department provides service with 39 crew level personnel serving as dual role firefighter/paramedics. All of them are paramedics, except one who is an EMT. Administration is comprised of an additional four people: training chief, assistant chief, fire chief, and administrative specialist.
The department performs advanced level procedures including STEMI recognition and field activation of cath labs, video laryngoscopy, cardiocerebral resuscitation (CCR), sepsis recognition, and advanced treatment including hospital activation. All staff hold certifications in ACLS, PALS, and PHTLS. One member is a critical care paramedic, and three members hold certifications as tactical EMS providers. Several members hold advanced certifications in medical procedures for technical rescue and urban search and rescue situations as part of the heavy rescue delegation. The department is a Level 1 Pediatric Provider and all members are annually certified as sensory inclusive.
Clinical Areas of Improvement
Beginning in 2022, the department established minimum standards of where the department was and began a focus on the high volume and/or high-risk clinical areas. This effort was to focus their care and improve outcomes. Here is a highlight of the areas of focus and their improvements.
Cardiac Arrest/Cardiocerebral Resuscitation – Training focused on-scene resuscitative efforts versus immediate transport as well as good compression rates and depth. This has resulted in a return of spontaneous circulation rate of 27% and a survivability rate of 14% within Clayton for 2022; both well above national averages.
Trauma Care – CFD has put a large emphasis on early treatment and rapid transportation of traumatic injuries including pain relief. Traumatic injuries represent the largest run volume for the department. For 2022, there was an overall drop in scene times by 1 minute and 6 seconds resulting in an average scene time of 14:51 for all traumatic injuries.
Crews noticed an increased rate of patients refusing pain medication due to fear of narcotics, prior addiction, or refusal of IV access (32% increase of refusals in 2022). To continue to meet patient needs, the department has expanded their pain medication offerings to include acetaminophen, ibuprofen, and Toradol; thus showing the continued trend at recognizing public need and adapting.
Systemic Inflammatory Response Syndrome (SIRS)/Sepsis – With an aging residential population, and to decrease the burden on the hospital system, the department made an emphasis of recognizing and treating SIRS and sepsis. Known and suspected cases are provided with IV fluid administration, high flow oxygen, and rapid transportation under a care guideline with proven national results. All patients are followed up with to determine outcomes and an analysis is performed to determine any missed SIRS/sepsis cases. This has resulted in a peak 12.6-day hospital admission reduction in 2022, saving $32,000 in hospital admissions per patient on average.
Strokes – They focused on recognition and immediate treatment of all stroke presentations, including expanding to non-typical signs such as weakness, vertigo, and dizziness.
Advanced Airway Intervention – All respiratory distress cases involving intubation, CPAP, or chest decompression receive an immediate review with the crews to determine the effectiveness of the treatments. Patients are also followed to hospital discharge to determine outcomes and further CFD’s mission for quality improvement.
Acute Coronary Syndrome/Myocardial Infarction – Their average scene time was under 15 minutes for ACS patients; average time to 12-Lead acquisition: 5:21; and they saw a 113% increase in recognition for at-risk patients after training and feedback performed throughout 2022.
Training and Accountability
On-going training for members of CFD occurs every month under Medical Director Dr. David Tan with Washington University EMS Physicians. Dr. Tan performs a monthly lecture and skills, which culminates in an annual credentialing examination for all members.
Throughout 2022, CFD implemented and received immediate feedback on patient encounters and saw increases in the statistics monitoring the care provided. This feedback continued with physician-led patient simulations from their medical control. These simulations provided another means for immediate feedback of the care provided.
Partnering with regional providers to utilize their simulators also added to transparency, overall enhancement, and knowledge sharing. Training outcomes included: recognizing patient changes and intervening within 10 seconds, acute coronary syndrome interventions within five minutes, 12 lead acquisition and transmission within 10 minutes, and CPR meeting appropriate depth, rhythm, and rate 90% of the time. When combining this training with their quality improvement program, they saw positive improvement and continued growth for the department in the area of pre-hospital medicine.
CFD further recognized the need for accountability. Quarterly, members are presented with an overall picture of what the department is doing, where they are succeeding, and where improvements can be made. This accountability is further fostered by the development and implementation of the CFD Medical Advisory Board. This board is made up of regional pre-hospital professionals, emergency physicians, and hospital providers who provide the department feedback on their own data and further the desire for overall improvement.
Community Support and the Community Care Team
“Our citizens seek to have the best that public government can provide for them,” explained David P. Gipson, City Manager of the City of Clayton in his award nomination letter. He went on to say, “[CFP] sees this support every time we host a public event; whether it be the annual St. Louis Art Fair or an open house to celebrate the home opener for the St. Louis Cardinals or Blues.”
For the community, CFD does not stop with response and immediate care to citizens and visitors. They have put into action several safety programs including teaching CPR, tourniquet application, and fall prevention. They have also pushed themselves to become Level 1 certified by the Missouri Emergency Medical Services for Children initiative, proving their passion for caring for our smallest citizens and visitors.
The department established the Community Care Team to determine who the most at-risk patients are and to meet their needs before an ambulance responds or they need hospitalization. The department has also sought out ways to teach the community the importance of early compressions and defibrillation in cardiac arrests. This has resulted in the city being ranked second in the state of Missouri for bystander CPR and AED use during cardiac arrests per the Missouri Cardiac Arrest Registry for Enhanced Survival. They are also active participants and brought the Pulse Point program to the region.
In addition, CFD supports the community as an active participant in the Special Needs Tracking and Awareness Response System (STARS), which provides for evaluation of special needs pediatric patients, so they are prepared for their medical emergencies and specific needs. CFD and the Clayton Police Department are partners in the Community Care Program, which is a partnership that tracks and monitors trends on call types as well as frequent 911 system users to provide them resources that can prevent their emergencies from occurring, including performing well-being checks.
Honored for Progress
“We are extremely proud of the progress we have made in just the last few years,” said Jeff Tobin, CFD Captain. “While we are a small department, we implemented several initiatives to formally recognize our community’s needs and enhance the care that we provide. We are beyond appreciative of this award and are always open to sharing what we do with other entities and how it has worked and benefited us.”