Makenzie Huber/South Dakota Searchlight – Some South Dakotans who call 911 won’t see an ambulance show up for over half an hour on the western side of the state if they have an emergency. That’s because there simply aren’t enough ambulances to cover the West River region.
The problem could worsen as volunteer emergency responders age, fewer South Dakotans volunteer to serve as first responders in their communities, and ambulance services continue facing a funding crunch.
Recommendations to address those challenges are outlined in a recently released report to the state Department of Health. The Regional Services Designation Ambulance System Study is an analysis of the state of emergency medical services across South Dakota, meant to ensure sustainability for the industry.
The report was compiled by Healthcare Strategists in partnership with the department. It’s the third piece of a $20 million infusion of funding into South Dakota ambulance systems approved by Gov. Kristi Noem and lawmakers in 2022, including $11.6 million worth of monitors and defibrillators for ambulances, and a $1.7 million telemedicine program to connect responders to nurses and health care professionals while dispatched on a service call.
The state Department of Health plans to award at least six planning grants by July to address issues laid out in the new report, including recruitment and retention, equipment upgrades, and improving response times.
“The state’s willingness to provide $7.5 million for future grant funding provides a starting point for improvement,” the report summary says, “but there must be a focus for programs that plant the seed of long-term sustainability.”
Response times lag in western South Dakota
About 97% of South Dakota’s 122 agencies are on scene within 30 minutes of a call more than 90% of the time.
But the southwestern region of the state especially is not meeting the 30-minute response time standard. The majority of “late” responses occur southeast of Rapid City, according to the report.
Wanblee on the Pine Ridge Reservation, for example, is over 30 minutes away from Kadoka, where the nearest ambulance service is stationed, said Laura Schad, program information coordinator for Partnership With Native Americans. Factors that can also impact response times in western South Dakota include poor cell phone service, poorly maintained roads in inclement weather or a responding ambulance driver not being familiar with addresses on reservations.
“Google isn’t helpful, and can even be harmful in some cases if an address isn’t linked right,” Schad said.
Potential solutions highlighted in the report include creating a satellite site in the uncovered southwestern region, or recruiting a new community ambulance service. Or, the report says, the state can determine “a 30-minute standard as unrealistic for this area.”
Longer response times have been associated with worse outcomes in trauma cases, with even modest delays becoming life threatening. The goal is to get victims with traumatic injuries from vehicle crashes, for example, to the hospital or trauma center within 60 minutes. That’s because victims are more likely to survive and avoid irreversible damage if they receive such care within “the golden hour.”
According to a study on ambulance services on reservations by the University of Minnesota, which included responses from the Pine Ridge Reservation, the usual time to transfer trauma victims to an emergency department exceeds the golden hour, half of study respondents replied.
Workforce staffing, recruitment and retention struggles
Rural emergency medical services in South Dakota are mostly volunteer-based (though volunteers sometimes receive a small stipend for calls they respond to), with volunteer levels forecasted to decline in the next five to 10 years. That makes recruitment and retention one of the greatest challenges for South Dakota ambulance services.
Some services lack sufficient funding because of the low number of transports and revenue needed to better support personnel. South Dakota ambulance services largely depend on payments from insurers and patients or funding from local governments for funding. Emergency medical services aren’t deemed an “essential service” in South Dakota, meaning the state government isn’t required to provide or fund them.
Just over a quarter of South Dakota agencies respond to more than 500 calls for service a year. About 65% of agencies serve less than 3,000 people, with 36% of the state’s ambulance services serving less than 1,000 people in an area.
One way to reduce drive time and workload for current volunteers, according to the report, is to expand the state’s “Telemedicine in Motion” program. It allows responders to treat patients on site, with the guidance of a nurse or other health care professional connected by online cameras and monitors, and then refer them to another provider for later follow-up care. Many patients are transported unnecessarily to hospitals, the report said.
About 70% of 911 responses in South Dakota are not severe and do not need transports for emergency care, yet many of those cases result in transports. Only 0.1% of 911 responses are high acuity or severe.
“The inference is these patients are likely treated and discharged from the emergency departments and not admitted to the hospital,” the report said. “More importantly, minor injuries and illnesses are ideal candidates for telemedicine opportunities instead of the historical treat-and-transport to the emergency department.”
Emergency room expenses are seven times more costly than an ambulance transport, the report notes, and expanding telemedicine to portable use for ambulance responses could reduce hospital overload, reduce health care costs and improve patient care.
While ambulances wouldn’t be reimbursed for transporting those patients to hospitals, they would be reimbursed for the ambulance response and evaluation. The report did not say if such a change would affect revenue for ambulance services or cut costs significantly.
The report says other possibilities to address workforce problems include:
- Requiring mutual response with fire departments for “truly life-threatening calls.”
- Promoting grants for services to purchase auto-loading gurneys to extend the working tenure of volunteers. About half of ambulance services in South Dakota already have auto-loading gurneys, which are estimated to extend a volunteer’s service period by five to 10 years.
- Creating legislation to incorporate CPR and other life-saving training for all South Dakota middle and high school students and offering college-level credits for high school students who complete emergency medical technician training. Both efforts would educate community members in bystander intervention and introduce teenagers to the profession.
- Improving test scores and passing rates for the National Registry of EMT Examination by offering more instruction and support to potential volunteers. South Dakota has a 65% pass rate for EMTs. The state has a 36% pass rate for paramedics, which is lowest in the nation.
Regionalization and statewide efforts
South Dakota lacks a central committee or network for ambulance services to communicate with other service providers or with the state about the issues they face in their communities. Nor does the state monitor, measure or publish patient care standards for ambulance services.
The report recommends improving quality control by reviewing statewide metrics and establishing top-quality metrics to measure and monitor patient care. The report recommends the state establish five top-quality metrics within the next two years and expand the monitored list of metrics to 20 in the long term.
The report also encourages the state to perform on-site visits with ambulance services every one to two years to increase interaction and communication.
Other ideas to address ambulance service sustainability include:
- Hiring full-time coordinators representing multiple ambulance services in a county or region to commit to recruitment and retention efforts.
- Establishing a statewide working group of emergency medical services medical directors, which currently operate independently of any statewide quality standards, guidelines or criteria.
- Allowing neighboring ambulance services to complete transfers of patients between hospitals. Currently, patients needing transport to another hospital are required by state law to be moved by the local ground ambulance provider or use a helicopter.