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Todd Stout, Founder and President, FirstWatch Response times are one of many potentially important measures of an EMS system's performance. While the current discussions seem to focus on the fact that they are clinically significant in only a very small percentage of our calls, I believe that for the foresee- able future, response times will remain emotionally significant for the patient, their family, bystanders, etc. So if we believe the patient experience is impor- tant, or if reimbursement is based partially on patient satisfaction at some point, response times will remain relevant. Another factor that can't be dismissed is that there is a decent percentage of calls where a delayed response time may not affect the patient or family, but would leave another responding public safety agency on scene waiting for an ambulance to arrive. Third, for at least some calls, fast response times really do matter clinically, so for those calls, moni- toring response-time compliance is still important and should remain so. I believe it's just as wrong to say "response times don't matter" as it is to say "all response times matter"; perhaps we just need to exam - ine the evidence to determine which calls they matter for and what those times should be—and even stratify response-time requirements based on call types. Finally, response times were an accepted measure of quality in EMS for many years. And the variables and inputs that need to be adjusted to improve response times are actually fairly straightforward. So while the importance of response times may be changing, if a system has struggled to have good response times, it's likely to struggle just as much with meeting other, more difficult-to-address qual- ity measures. For the reasons above, I believe response-time goals (perhaps with better stratification) should still be part of good system design. EMS systems are com- plex in any situation, so I should be clear that no single aspect of a system should be the entire focus of system design. Skip Kirkwood, MS, JD, Director, Durham County (NC) EMS It is fashionable to say, "The evidence shows response performance doesn't matter." That is not a complete or correct statement of the science. There is little to show that the ambulance response interval, by itself, improves clinical outcomes. However, that's the beginning of the discussion, not the end. Most of these studies focus on whether the patients on one side of the line do better than those on the other. Since response performance is part of the total time from event to definitive care, prompt response is important to a patient suffering from stroke, STEMI, trauma or other time-sensitive infirmity. Some time-sensitive interventions (like defibrillation in cardiac arrest) do not require an ambulance, so we need to look at EMS systems, not just ambulance response performance. There is much work yet to be done on this topic. Measuring an EMS system's performance requires far more than a single performance measure. If you ask customers, prompt response matters. How prompt? Who knows? It's probably never been studied from that perspective. But other things matter also. The quality of clinical medicine matters, although patients and their families are probably ill-equipped to judge that. Good, meaningful internal quality improvement programs are essential to defining a "good" EMS system. Competent employees matter, and competence should improve with experience, so employee turnover, satisfaction and engagement are important measures. And good stewardship of the public's money also matters, so a variety of financial performance measures are also important. We need to first agree on a set of benchmark per- formance measures we can use fairly and equitably across all the business models in EMS. Then we need to use those to educate our communities as to pre- cisely what makes a "good" EMS system. Only when we can do that will we be able to push the "speed demon" out of first place as the measure of an EMS system's performance. Chris Cebollero, MS, Senior Partner, Cebollero & Associates In EMS we seem to live and die by the clock, but there has been no real proof that a response-time standard truly makes a difference. Ever since the late 1970s, when a report written by Dr. Mickey Eisenberg stated that quick initiation of CPR and prehospital medi- cal treatment were serious elements in the survival of sudden cardiac arrest patients, it has been falsely quoted as setting a response standard of 8:59. In today's EMS field, first responder agencies arrive on scene within five minutes for most calls. Patients with life-threatening conditions now have certified responders able to place rescue airways and use AEDs long before a transport unit arrives. For at least some calls, fast response times really do matter clinically. — Todd Stout The clock is always going to be a factor in the EMS field. — Chris Cebollero, MS Measuring an EMS system's performance requires far more than a single performance measure. — Skip Kirkwood, MS, JD EMSWORLD.com | JUNE 2015 49