COVINGTON, Ga. — As the zone license holder, Piedmont Newton Hospital is contractually obligated for the next four decades to provide “adequate” and “sufficient” EMS services for Newton County — whether it be directly through the hospital or by way of a subcontractor — but some public officials and community members feel that isn’t happening.

“We’re in serious trouble,” Covington City Councilwoman Fleeta Baggett said during a June 6 meeting. “We are in serious trouble. No one seems to know what to do. I’m at a loss. I’m losing sleep over it. Every time I hear a siren go off, I can’t get my breath.

“The day (April 21) that we had the plane crash at General Mills, there were two trucks running,” she said. “That could have been catastrophic.

“Somebody has got to figure this out, because the next step that I make is not going to be pretty. And that’s not a threat, that’s a promise because I, in good conscience, cannot lay my head down on my pillow one more night with this going on like this.”

Piedmont Newton Hospital entered into an agreement in 2021 with National EMS through parent company Priority Ambulance, the state’s largest private ambulance network, to subcontract the county’s EMS services.

In recent weeks, members of the Covington City Council publicly voiced their displeasure with National EMS, which is also 911 provider to neighboring Rockdale and Morgan counties. Specific issues included sub-par response times and a devastating lack of ambulances and personnel to staff the ambulances.

Officials of Priority Ambulance and National EMS said work was being done to consistently improve response times, and staffing issues were real, largely due to a labor shortage felt nationwide.

But while all parties may be trying to work through such issues, what about services now? Are National EMS and Priority Ambulance — and even Piedmont Newton Hospital — operating in ine with terms of their agreements? Are EMS services being provided currently in Newton County “adequate” and “sufficient” by nature of their contracts?

The Covington News recently conducted an in-depth review of various contract documents and reports to find out.

The News issued formal requests for computer aided dispatch (CAD) reports from National EMS via Priority Ambulance and the Covington-Newton County 911 Center to analyze average response times over the course of 2022. The News also requested and received a copy of the contract between Newton County and Piedmont Newton Hospital, and a copy of the contract between Piedmont Newton Hospital and National EMS via Priority Ambulance to analyze terms of each agreement and gain a better understanding of what services are to be expected from each entity. After spending several hours reviewing each document, The News posed questions to each entity to clarify various terms within each contract and address concerns raised by public officials and community members.

Here’s what we learned:

County, Piedmont Newton Hospital locked in for 50 years

Piedmont Newton Hospital and the Newton County government entered into a 50-year, intergovernmental contract Jan. 16, 2018, to provide “adequate” ambulance and other emergency medical services “within the entire geographic area and territorial limits of Newton County 24 hours per day during the term of this agreement at no charge to the county…”

Steps must also be taken to ensure that whoever is directly providing the ambulance services — whether the hospital or a subcontractor — maintains “sufficient well-trained EMS personnel and well-maintained vehicles and equipment sufficient to respond to all calls for ambulance or other emergency medical services within the service area at all times.”

But what does “adequate” or “sufficient” mean? Could the county make the case services are not meeting such standards and request to renegotiate or terminate the agreement? When asked how terms such as “adequate” or “sufficient” could be legally defined in this context, county attorney Patrick Jaugstetter declined to comment.

Also within the terms, “the county shall continue to provide a 911 emergency call center and services at no charge” to the hospital or a subcontractor. The hospital or subcontractor must also “continue to be allowed to park and utilize county fire stations for the ambulances … without charge or rental,” the contract stated.

In addition to the intergovernmental agreement, the county and hospital agreed to terminate all previous contracts between the parties, dating back to 1972.

The current contract was agreed upon after Piedmont Newton Hospital reportedly considered relinquishing the EMS license to the state. 

In the summer of 2017, county commissioners initially decided that they would not pursue the EMS license and, instead, would allow the state to assign a provider. But commissioners decided to reverse that decision after public opposition, and they announced in late June 2017 that they would contract with Grady EMS until a permanent provider could be found.

In August 2017, Piedmont Newton officials reversed course and announced that the hospital would retain the license and continue to provide EMS in Newton County without a subsidy. Before, the county had paid reportedly $1.7 million for the service; however, commissioners later opted to cut funding.

Current CEO David Kent was not with Piedmont Newton Hospital at the time the contract was entered. Since 2017, Piedmont Newton Hospital has had three different CEOs, including longtime CEO Jim Weadick (retired in June 2017), Dr. Eric Bour (stepped down in October 2019) and Kent (named CEO in April 2020). 

During a late May meeting with the Covington City Council about the EMS service woes, Kent said he would “be happy to consider” relinquishing the EMS license. He said the hospital had only retained the license because they felt it was the “right thing to do, to stay involved.”

Guidelines for any potential termination of the contract were unclear. Per terms of the contract, the agreement is to remain in place for 50 years “or until otherwise amended, modified and/or terminated by and between the parties.” And before the agreement expires, the parties are to “use their best efforts to renegotiate” the agreement “so as to arrive at terms pursuant to which residents in Newton County will continue to be provided ambulance and emergency medical services.”

Piedmont Newton, National EMS agreement is five years

Piedmont Newton Hospital entered a five-year contract agreement with National EMS effective May 2, 2021, to “be the exclusive provider of emergency and non-emergency advanced life support (ALS) ambulance service as needed in the coverage area on a 24-hour per day, seven day per week basis.”

As part of the agreement, National EMS is required to “furnish and operate at least four 24-hour and one 12-hour ALS ambulances acceptable to [the hospital] throughout the term of this agreement.”

There are also specific requirements for ambulances being used in Newton County. Ambulances provided “shall not be older than five years from the vehicle’s original purchase date as a new vehicle … and shall not be in service beyond 250,000 miles.”

Either party may terminate the agreement without cause at any time during the initial term or any renewal term, so long as the non-terminating party is given a proper 180 days notice. In the event of a “material breach” by the other party, “provided that said material default is not cured to the reasonable satisfaction of the non-breaching party within 30 days after such written notice is given.”

Should the hospital choose to terminate the agreement without cause before the first two years of the contract, the hospital will be obligated to reimburse National EMS for capital expenditures in the amount of $448,289, “but shall be adjusted by depreciation each month in the amount of $7,471.” When the contract was first agreed upon, National EMS purchased equipment and vehicles from Piedmont Newton at fair market value in order to serve the system.

Piedmont Newton Hospital does not pay an ongoing monthly subsidy for National EMS’ services, National EMS spokesperson Amanda Jennings said.

“As the contractor to Piedmont Hospital-Newton, National EMS provides all operational aspects of the EMS system, including vehicles and staffing, on a fee-for-service model,” she said. No specific dollar amounts paid by Piedmont to National EMS were provided to The News.

National EMS meeting ambulance requirements despite staff issues

According to the contract, National EMS is required to staff ambulances “with an appropriately state of Georgia certified and trained paramedic and emergency medical technician (EMT).” All staff are to be employees of National EMS and not Piedmont Newton Hospital.

This does not mean both a paramedic and an EMT are required to be staffed to every ambulance in service to operate within the contractual guidelines.

“In the state of Georgia, an ambulance is designated as advanced life support (ALS) if it has the following staffing configurations: either one EMT-Basic and one Paramedic, or one EMT-Basic and one EMT- Advanced,” Jennings said. “The clinical scope of practice is regulated by the state department of health, and the scope of practice for EMS certification levels can vary from state to state. In the state of Georgia, the clinical scope of practice for the EMT-Advanced is wide and allows for this EMS professional to perform all functions required to upgrade the ambulance to ALS by law. Based on the scope of practice in Georgia, the Centers for Medicare and Medicaid (CMS) also recognize these ambulances as ALS and allow us to request federal and state reimbursement at an ALS level.

“There are a limited number of clinical functions that only a paramedic can perform,” she continued, “including field endotracheal intubations, drawing blood for testing in the field, managing chest ports, central lines and medicated IV fluids and administered certain medications, among other. These functions are infrequently needed to be performed in a 911 field setting.” 

In recent months, company officials said National EMS, and Priority Ambulance as a whole, has been challenged with staffing shortages. 

“There are staffing shortages for ambulance services; staffing shortages of EMTs; staffing shortages of paramedics; just as there are staffing shortages for nurses and other medical [roles] throughout the hospital,” Priority Ambulance Leadership Foundation Board of Directors member Gary Coker said in a May public meeting. “These challenges existed before COVID came, and now as COVID has gone — though not quite gone, at least it’s better than it was — it exaggerated these challenges, and so what you’re seeing are some of those things coming out.”

Coker said National EMS works to keep four and a half ambulances on the road at all times — meaning four are supposed to be in operation 24/7, and one ambulance is on the road Monday-Friday during the “peak times.”

Coker said the local ambulance service did drop to only three ambulances on the road at one time, but that was due to COVID, which “killed us for a certain period of time because paramedics and EMTs would have to stay out” for specific amounts of time to meet protocol. 

To address the paramedic shortage, National EMS puts paramedics in a “quick response vehicle” at times to “allow the paramedic to respond on a call to meet with either a basic life support (BLS) ambulance providing nonemergency service to the hospital to quickly add an additional ALS unit to the 911 system in case of volume surge, or to rendezvous with an EMT-Advanced-staffed ALS ambulance on-scene if additional assistance was required,” Jennings said.

“And that’s because of staff shortages,” Coker said. “That’s not because we want to do that. That’s not our objective. It’s certainly not because we’re trying to pay less for the EMT to run than the paramedic. We have the budget there ready and set to go. It’s simply because we can’t get enough people in to work.”

Jennings said National EMS sets a goal to have as many paramedics on the ALS ambulances as possible. To combat the nationwide EMS shortage, including EMT, EMT-As and paramedics, National EMS runs internal paramedic certification courses for its employees on an annual basis at no cost to them in order to upgrade their certifications and has an aggressive hiring program for paramedics in the state, region and nation, she said.

Jennings said National EMS was able to hire three new paramedics in Newton County in May.

EMS officials also addressed the criticism of allegedly not meeting the standard of care as it pertains to the number of ambulances in service each day.

Baggett suggested during a June council meeting that National EMS was playing a “shell game” in how ambulances were scheduled for service. She said a June 6 report from an anonymous Priority Ambulance employee showed only one BLS ambulance was to be in service for 24 hours, one ALS ambulance would operate for 12 hours, one BLS ambulance would operate for 10 hours and another ambulance would run transport with ALS for an unspecified amount of time.

“What that means is at some times during the day, there will only be one truck running in this county,” Baggett said. “And what they’re doing is masking the CAD report.”

However, a CAD report from National EMS showed otherwise.

“It is possible that the individual who provided this information does not have access to review the full picture of resources available in the county,” Jennings said. “After reviewing the June 6 schedule, we have determined that there were seven ALS ambulances serving Newton County during the peak day-time hours and three ALS ambulances during the night-time hours when there are significantly fewer calls in the system. Of these ALS ambulances, there were a total of three paramedics out of seven ambulances on the day shift, and all three ambulances on the night shift were staffed with paramedics.”

“As noted [before], it is important to understand that the EMT-Advanced’s clinical scope of practice designates the ambulance as an ALS ambulance by law through the Georgia Department of Health,” she added. “All ambulances [in service that day were] 911 ALS resources.”

Jennings said three Central EMS units were dedicated to the Newton County 911 system June 6, in addition to ambulances running nonemergency requests.

National EMS response times in compliance and improving

In addition to staffing requirements, National EMS is also contractually obligated to meet specific response time standards — another issue ailing city officials.

National EMS is to respond to “urban areas” of the county (including the city of Covington) within 10 minutes of receiving the call, and 15 minutes to respond to “rural areas” of the county. A call is considered received when the address, cross street and call information are provided and National EMS employees provide confirmation of receipt. National EMS is required to respond in the appropriate time at least 90% of the time to be in compliance, per the contract.

“The parties acknowledge that, as the community grows and changes, revisions to the urban and rural designations … might need to be made in writing by mutual agreement,” the contract states.

When the contract was first agreed upon, both parties also acknowledged Piedmont Newton “does not have access to fulsome historical response time data. As such, [National EMS] is unable to precisely predict its future response times. Therefore, the parties agree to a 120-day discovery period at the outset of this Agreement, during which time [National EMS] shall make changes in the operation and data gathering process. This period shall be known as the “Performance Discovery Process and during this period, the [National EMS] shall not be deemed in default under this Agreement for failure to meet the Response Standards set forth herein. At the completion of the Performance Discovery Process, the parties will meet to review [National EMS]’s analysis and determine if the Response Standards should be revised.” 

National EMS is operating within those guidelines and consistently improving, Jennings said.

“Working closely with the Piedmont [Newton] Hospital leadership, National EMS has improved average monthly response times within the city more than 30% since assuming operations one year ago,” Jennings said. “The average monthly response times for the urban area encompassing the city of Covington is 8:54 for the time period of January-May 2022.”

The countywide average from January to May is 12:05, a report stated.

National EMS operates on a two-level priority classification system with “Priority 1” considered “life-threatening, time critical emergencies” such as “heart attack, stroke and trauma.” A “Priority 2” is deemed “urgent calls that are not immediately life-threatening.”

“The priority level of 911 calls is determined by the caller’s acuity — the severity and urgency of a patient’s medical need,” Jennings said. “Every patient that calls 911 desires and receives prompt, professional assistance; however, with a finite amount of 911 resources available in the county, the community health is best served by identifying acuity through a nationally recognized standard and process that prioritizes life-threatening, time critical emergencies or Priority 1 calls … over urgent calls that are not immediately life-threatening or Priority 2 calls.”

In the urban zone including Covington, National EMS’ average response time for Priority 1 calls was 7:50, and was 10:42 for Priority 2 calls. 

“Performance standards are different in every community in Georgia and in the United States because every community is unique in its makeup; however, our response times are within state averages for comparable communities to Newton County,” Jennings said. “In comparison of the eight neighboring counties in Region 3 for January-May 2022 based on the Georgia Department of Health’s database, Newton County’s countywide response data ranked third with only two counties having lower average response times.”

In comparison, response times reported by Covington-Newton County 911 Center were relatively higher.

Within the same timeframe, countywide response times that could be deemed Priority 1 by National EMS, such as cardiac arrest, traumatic injury, penetrating trauma and stroke, averaged between 12 and more than 15 minutes. However, 911 Director Trudy Henry said the county’s response times were likely not very accurate for EMS.

“They do a lot of swapping calls around and sometimes becomes difficult to keep up with,” Henry said. “They also fail to let us know when they are on the scene sometimes. My staff meet with National EMS to work through some of these issue. We have a plan to work towards to hopefully help.”

Another reason for inaccuracies is due to a different computer aided dispatch (CAD) system used by each entity. The 911 center uses a Spillman system, and National EMS uses a RescueNet system, which is owned by Zoll.

The Spillman system is a software system owned by Motorola. Other county public safety resources, including police and fire department, are also dispatched using this system and is not isolated to EMS.

“Both systems have the capability of recording incident calls, identifying the status and location of responders in the field and effectively dispatching responder personnel,” Jennings said. “The key difference is that the data from each CAD is housed separately and in a different format.”

Jennings confirmed National EMS and the county are working on a project to standardize the way data is recorded and also the classification of emergency calls between the two agencies. She said the goal is to “ensure the right resources available to the calls with the highest clinical need as quickly as possible.”

In addition to meeting regularly with the county to further refine its operation, National EMS and Piedmont Newton Hospital also meet once a month — another contract requirement — “to discuss performance and other issues which may arise.” If requested, National EMS can provide public updates concerning the services provided under contract, the agreement stated.

And Jennings said that work would continue.

“In order to provide the best patient care and serve our community, our goal is to work with the hospital, county and other EMS system partners to meet performance goals and expectations in multiple key performance areas, including clinical outcomes, staffing and response times, among many others. 

“Within the current contract, we staff ambulances as needed to meet the demands of the system — often staffing above the five peak day-time hours included in the contract as our initial schedule.”

While issues seemingly surround the county’s EMS Services, Kent said he was confident in National EMS’ ability to serve the community moving forward. 

“Based on our data regarding the performance of National EMS in Newton County, which we review on a monthly basis to ensure any issues are addressed,” Kent said in a statement to The News, “we have confidence in the quality and competency of the service they provide Newton County communities.”