EMS concerns trouble Fort Bend County
High turnover, idled ambulances spur changes
Fort Bend County’s director of emergency medical service issued a blunt warning last fall about the ambulances responding to life-and-death situations in the fast-growing suburb.
“We have been unable to adequately staff all units,” Daniel Kosler wrote in an October email seeking pay raises for paramedics. “Turnover and increased mandatory (overtime) has a potential to significantly impact quality of care and increase medical errors.”
After more than a third of Fort Bend’s paramedics left in a single year, county commissioners in January approved raises that averaged 22 percent and restructured the department to hire some emergency medical technicians, whose training is not as advanced as paramedics. Around the same time, Kosler announced he was resigning.
The EMS department’s struggle to keep pace with growth while contending with numerous departures cascaded into concerns about medical care, according to a Houston Chronicle review of thousands of emails and three years
of documents obtained through a public records request. The county has asked the Texas attorney general permission to withhold requested EMS data, including response times, arguing it is confidential under state health law.
County leaders hope the pay raises will end contentious disputes that led to a 2013 federal labor investigation and also is blamed for low morale that idled ambulances because the county could not hire as fast as paramedics were leaving.
Dr. Mary Des Vignes-Kendrick, the county’s health and human services director, said she has tasked the new EMS director, Victor “Graig” Temple, with a top-down evaluation of EMS operations, including reviewing ambulance locations, evaluating response times and meeting with hospital leaders. She said she launched the review to make improvements, not out of a concern there are problems with care.
Temple said he is working to rebuild trust with the ambulance crews and assess whether they’re meeting medical standards.
Pay disparities
Fort Bend EMS had hiring problems as early as 2008, but the fallout from the federal investigation and a botched county response proved to be the breaking point for many paramedics.
In a 2013 email to every EMS employee, paramedic Matt Williams outlined why he and dozens of others were leaving. First and foremost was pay.
“We have paramedics making under $13/hour. The private transfer trucks in the area are paying $18/ hour for brand new paramedics who are just out of school,” he wrote. “Now let’s take me, a seasoned paramedic with over 20 years experience, and I am only worth an extra 94 cents” per hour more than private companies pay starting paramedics.
Williams and five other paramedics sued the county after the U.S. Department of Labor found Fort Bend had broken federal rules on sleep time compensation and underpaid ambulance crews. The county agreed to repay paramedics for two years of missed pay, a combined payout of about $72,000. The paramedics who sued were paid $35,000 total in a December settlement, six times more than they’d have gotten under the federal deal.
In late 2013, the county changed how it paid EMS employees to avoid future violations. Paramedics would be paid for more hours, but at a lower rate. Employees complained the changes would make matters worse, but county officials and Kosler did not share those criticisms with commissioners before the final vote. Twenty-seven EMS employees departed between October 2013 and last October.
“They voted with their feet,” County Judge Robert Hebert said. “They were walking over to new jobs. I personally was never advised there could be this response.”
Late last year, Fort Bend surveyed 15 Texas ambulance services, most in the Houston area, and found its hourly pay was, on average, 30 percent lower than competitors. Some agencies paid emergency medical technicians, or EMTs, more than Fort Bend paid paramedics.
For instance, a beginning paramedic with Montgomery County Hospital District was paid a minimum hourly rate of $19.43 compared to $13 in Fort Bend. Under the plan approved in January, wages start at $15.60.
Jobs unfilled for months
Before the raises, it took over three months to fill dozens of jobs, with one paramedic post open 291 days. Some leadership roles went unfilled for a year.
Emails sent by Kosler, a 40-year veteran who was among the first certified paramedics in the county, and other EMS officials suggest the wage disputes affected response times and quality of medical care.
“You get what you pay for,” wrote Williams, who could not be reached for comment.
Those who remained had to forgo vacations and work thousands of hours of overtime.
Similar to other ambulance services, Fort Bend
schedules paramedics for 840 overtime hours each year. With regular time, that adds up to working 55 hours a week. But because Fort Bend couldn’t hire enough people, many paramedics clocked nearly 2,000 hours of overtime each year, which averages out to working 80 hours a week, according to county payroll data for 2012-14.
“They are overworked, underpaid and feel unappreciated,” paramedic Chris LaCourse wrote in a November 2014 email. “Employees that feel unappreciated start to ... be more unprofessional and will not treat patients correctly.”
The turnover also meant Fort Bend could not staff all 13 ambulances. From October 2013 to last October, two first-responder units were parked for five months and a critical care unit was unmanned one day, Kosler wrote in an email.
With fewer units available, paramedics had little or no down time between calls in addition to having fewer days off between 24hour shifts.
Acute fatigue impairs driving ability, increases on-the-job injuries and might affect medical judgment, said Dr. Richard
Bradley, chief of EMS and disaster medicine at the University of Texas Health Science Center. “Time off and rest is critical to psychological health and functioning in the EMS community,” he said.
Although Kosler wrote in emails that he feared those consequences, he said in an interview before his February retirement that he didn’t believe quality of care had suffered. “We have professionals with our department,” he said. “When they’re on the job, it’s their job to provide the best care they can.”
High response times
Kosler had warned county leaders that a failure to stay competitive with pay would hurt the department’s ability to keep up with growth.
The EMS now serves an area of more than a halfmillion people.
Fort Bend’s ambulance fleet has been the same size since 2010, even as the county’s population has grown 16 percent. Many of the 100,000 new residents live in communities more than 10 miles from an EMS station.
Because of the placement and shortage of ambulances, response times in burgeoning communities were higher than the county’s goal of “10 minutes or less 90 percent of the time,” an industry standard. For critical events like heart attacks, minutes matter.
Temple, a career paramedic who was formerly an assistant fire chief in Anchorage, Alaska, said he was drawn to the Fort Bend job in part to improve morale and address operational struggles. Temple believes the pay raises have gone a long way toward repairing morale, and does not expect to see significant turnover going forward.
The department’s preliminary budget request submitted to commissioners last week includes a $3 million, or 31 percent, increase from the previous year, although about $1 million of that can be attributed to the recent pay raises.
Hebert and commissioners have said they might need to review the fees they charge insurers for EMS services, generating revenue that could be reinvested in services.
“The court is going to have to support them. They can’t do it by themselves,” Hebert said. “We have to find the money to make it happen.”