DeKalb County, Ga., borders Atlanta and has a population of 720,000 within 260 square miles. The DeKalb County Fire Rescue Department provides fire and EMS. With 164,368 responses in 2006, the department ranked 10th busiest, according to an annual national run survey.

But prior to December 2001, two separate departments provided fire and EMS services. This was cumbersome and inefficient. Merging the services presented significant challenges. The greatest challenge was combining the cultures of two distinctly different organizations. In the end, the merger was a success that can be attributed to the men and women in the departments.

There were many pre-merger issues regarding service delivery and fiscal responsibility. These included, but were not limited to, poor response time, high fire-loss totals, low cardiac-arrest save rate, high overtime costs and high incidents of no ambulance sent.

Identifying the processes and organization of the fire rescue model was an important first step in this merger. Hoping to gain from the experience of others, department officials conducted research to find a fire rescue department that could serve as a model. But because of the size and complexity of DeKalb County, it was difficult to identify a relevant model. While not perfect, using portions of successful programs from several departments allowed officials to develop the DeKalb County delivery system as it exists today.

Key objectives were to integrate the command structure and system operations from two departments with disparate operational and management protocols. The integration occurred over a multi-year, phased-in timetable that was broken into three broad sections: merger 2001, 2003 phase, and 2004 through present.

In 2001, cross-training for paramedics was optional. Paramedics either were placed in fire stations on a 53-hour firefighter shift and paid overtime for work over 40 hours, or, they could obtain firefighter certification. Overtime costs during 2002 exceeded $2 million. Financial incentives were provided for cross training.

The county had insufficient ambulance resources, so a contract was established with a private ambulance company. This provided four additional ALS ambulances during peak hours. Radio codes and signals were consolidated that year. And emergency Medical Dispatch protocols were initiated. However, all calls remained a Level 1 priority. Therefore, if a sprained ankle call was received by the dispatcher moments before a cardiac arrest, the sprained ankle would be dispatched first, misusing ALS resources. A firefighter-level safety officer position was created and one was assigned per shift.

During the 2003 phase, the county recruited and hired a director/fire chief with fire and EMS experience. Firefighter and paramedic cross training became mandatory, resulting in 800 cross-trained personnel. All of the operations personnel were integrated within a single chain of command reporting to the chief of operations. This reduced the number of supervisory positions. The ambulance staffing was changed from paramedic partners to a fire medic and a firefighter/EMT. A second paramedic was dispatched to life-threatening calls.

In that phase, ambulances were changed to rescues by adding firefighting equipment and dispatching them to fires. Frequently, a second rescue was dispatched because the first-in rescue personnel were involved in interior fire attack. By reducing the number of supervisors and changing the ambulance staffing, the department added eight rescues using existing staff. Three EMS commander positions were reclassified as battalion chiefs. A fifth battalion was created providing oversight efficiency for all battalion chiefs.

Previously, fire stations were staffed with one captain; lieutenants managed the other two shifts, reporting to the captain. After the merger, all lieutenants were upgraded to captains and placed under the authority of the shift battalion chief. Rescue captains were given station officer supervisory responsibility, alongside fire captains. Previously, rescue captains worked alone, self dispatching to non-life-threatening calls. They were teamed with a firefighter/EMT on squad vehicles equipped with ALS, firefighting and extrication tools. Today, six squads, distributed throughout the county, are dispatched along with other operations division apparatus.

To ensure position authority, the firefighter-level safety officer position was eliminated. All battalion chiefs received safety officer training, and are dispatched as a second battalion chief/safety officer to all working incidents. The department updated its incident command training, equipment and procedures to ensure compliance with all current NIMS protocols for all fire rescue personnel. To improve the quality-assurance process, rescue captains are tasked with reviewing all ALS patient care reports and a sampling of BLS reports. Fire captains are tasked with 100% review of BLS reports. Rescue and fire captains have EMS oversight responsibility. Five paramedics were placed in the 911 dispatch center, which is a combined police and fire operation. They serve as the system status managers for all department resources. Radio codes and signals were eliminated and plain language used for all radio traffic.

From 2004 through the present the department terminated the previous ALS private ambulance contract and, following an RFP process, a private ambulance service again was integrated into the DeKalb system. This created a truly multitiered system using a public-private partnership. The new contract requires five dedicated BLS units be available 24 hours a day, seven days a week that are strategically located throughout the county, dispatched by DeKalb 911 and responding from fire stations.

In 2006, the private ambulance partner responded to 20,000 BLS calls, allowing DCFR to maintain excellent response times for ALS-level calls. In fact, DCFR received the Georgia EMS Service of the Year Award for 2006. Because approximately 80% of DeKalb County EMS calls are BLS, five DeKalb County rescues were converted to BLS, ensuring ALS resources remained within first-in territories. The department provided ALS equipment to all apparatus. As staffing allows, these apparatus are upgraded to ALS. This action resulted in tripling the number of ALS units from the pre-merger levels.

While it is impossible to discuss the myriad issues faced during this complex integration, the results demonstrate success. The goal from the onset was to increase the efficiency and effectiveness of fire and EMS operations. Strong incident command, faster response times, cross-trained personnel and additional resources have seen DeKalb County's fire losses cut in half and the cardiac arrest save rate triple.

Ron D'Acchioli, fiscal officer of DeKalb County Fire and Rescue Department, contributed to this story.

David Foster joined the DeKalb County Fire Rescue Department as the fire chief/director in January 2003. Foster has 29 years of fire-rescue service. He has served as a firefighter for the U.S. Air Force and fire departments in California, Portugal, Nebraska and Georgia. He has a bachelor's degree in business administration and is a graduate of the National Fire Academy's Executive Fire Officer Program. In 2006, Foster was awarded Fire Official of the Year and the DeKalb County Fire Rescue Department's Medal of Honor. In 2008, Foster received the Metro Atlanta EMS Director of the Year award.