Part-5 Alternate Transport Destinations, Staffing Models and 911 vs. non-911 Response

Part-5 of our series for government and elected officials combines several topics that all relate to each other and the functioning of an EMS system. The focus will be on the independent government funded models, meaning public funded EMS agencies that are not fire based.

As we start part 5 of this series, it is important to understand what is meant by an EMS system. For this article, we will be focusing specifically on the calls for an ambulance that come through 911. An EMS system has many different layers and depends on the other three public safety disciplines of public safety dispatchers, police officers, and firefighters to function correctly.

System Layers

• Public Education and Prevention (bike helmets, first aid, CPR)

• Call for help through 911 with the dispatcher determining the type of emergency and resources needed.

• If the resource needed is medical, a standardized emergency medical dispatch program is used to determine the level of the emergency, location of the emergency, what resources may be needed, and if medical instructions need to be provided over the phone.

• Police officers are often the closest to a call and will be sent if indicated by a department's protocols. Many departments equip officers with medical equipment such as automated defibrillators, tourniquets, and some even carry Narcan to reverse overdoses.

• In both non-fire and fire-based delivery models, the use of firefighting personnel is key to a successful system, whether it is providing rapid first response and treatment, additional crew members, technical rescue abilities, or determining the need for a transport ambulance.

Earlier in our series, we discussed alternative transportation destinations. This is an area that seems simple but is actually very complex and may not apply to lower volume services. EMS personnel operate off protocols approved by a medical director, who is usually a physician. Medical protocols guide EMTs and Paramedics in the field on what care they are going to provide after assessing the patient. There is a standardized approach for every patient to ensure consistency in care, which includes procedures and medications used during critical events such as cardiac arrest. The irony is that when these same EMTs and Paramedics assess a patient for a condition or injury that could be treated without transport to the hospital, there are very few mechanisms to accomplish this. While we have the ability and education to do so, we don't for many reasons, including questioning the decision-making on transport to a hospital from field providers.

When you think about the fact that the cost of a hospital visit is high and emergency departments are overloaded, it is hard to understand why low-acuity patients who don't need emergency care end up being transported to the hospital. Sometimes we, as healthcare providers, contribute to the problems we are trying to solve. Hospitals advertise their services to gain market share; the public is encouraged to call 911 for emergencies, but we have different definitions of emergency than the public does. People have same-day surgeries and are discharged from hospitals sooner than in the past. Patients are then told to go to the emergency room or call an ambulance if they have post-operative problems after hours if the concern can't be handled over the phone. Insurance companies, including private and government-funded, require transport to a hospital in order to pay for services provided by an ambulance in most cases. When you combine all of these things, you can start to see where the system doesn't align with what may be best for the patient and the healthcare system.

Let's look at an example of a scenario that plays out in two different ways. A local high school basketball game is taking place on a Friday evening. A player goes to the floor after stepping wrong and injuring their knee. Unable to put weight on the leg, 911 is called as the player remains on the court. A police officer is dispatched to the scene along with the closest fire department apparatus and the closest paramedic ambulance. The report comes in as a player "down" on the court, so the response is with lights and sirens to the scene. Upon arrival, it is found that this patient has pain in the knee area but no other injuries. The knee is splinted, and the patient is loaded onto the ambulance cot and transported to the hospital, where they are placed in the waiting room after an initial assessment by the triage nurse. Two hours later, the patient is brought back into a room by wheelchair and is eventually seen by a physician's assistant. They may take an x-ray to make sure nothing is fractured, provide some pain medication and an ice pack before they send the patient home. The patient is told to follow up with orthopedics during business hours for a further evaluation of the suspected ACL tear. The patient is charged for the ambulance transport, the emergency room visit, the x-ray, the radiology group that read the x-ray, and the physician assistant's services, with the entire ordeal taking 8 hours.

Now let's look at how this same scenario might play out in a modern coordinated system. The dispatcher takes the 911 call and utilizes their emergency medical dispatch protocol system to determine the severity of the call and the resources needed. It is determined that the injury, while incapacitating, is not life-threatening with no immediate intervention needed via phone instructions. The initial resource sent is the closest fire response unit and an ambulance that is coming from a farther distance without lights and siren. The immediate response is from the fire department, addressing the public perception of an immediate response, but the ambulance is not jeopardizing public safety by responding with lights and sirens to meet an arbitrary response time requirement. The on-scene ambulance helps splint the injury and moves the patient to an area for further assessment. The fire department apparatus goes back in service to be available for the next response. The ambulance crew assesses the injury per their protocol and determines there is no immediate need for treatment in the emergency department. They assist the patient to the family car with instructions on pain medication and icing. The crew also provides information and appointment details to the orthopedic clinic that is open the next day in the area through a pre-arranged agreement. If needed, the crew can consult with a physician via a secured video platform. This total interaction took 30 minutes and reduced the cost to only the ambulance charges (not a payable service right now).

So, you might ask why this isn't already happening if it is better for the patient, decreases costs, and helps to control the overcrowding of emergency departments. The most obvious answer is money! While coordination, lack of understanding, and assumed legal issues also play roles, the reality is everyone in healthcare is trying to optimize their reimbursement. We previously discussed that approximately 40% of the patients seen by the Independent Government EMS Alliance Member Agencies are not transported to the hospital.

If treating in place and alternate destinations were payable modes of reimbursement for EMS, it would significantly raise the amount of money paid by private and government insurance to ambulance services. The reality is that the 60% of patients transported to the hospital would be greatly reduced, so the non-transport numbers might grow significantly. Let's say that EMS could eliminate an additional 20% of transports and flip the percentages to 60% treat in place and non-transport and 40% transport to the emergency department. While the staff in the emergency department would probably be very supportive, the reality is the hospital as a whole would see a loss of revenue for ED visits and potentially downstream revenue for follow-up visits. Hospital systems have encouraged only coming to the hospital emergency departments for emergencies and going to their affiliated clinics or freestanding facilities for other types of care, thus keeping them within their system and revenue stream. The perfect answer may seem to be having ambulances transport to these urgent care clinics instead of the emergency departments for certain types of patients. The problem comes back around that the ambulance service won't get reimbursed by insurance for that transport because current rules require transport to a hospital. It then falls back on the patient or government entities' budget to fill in that revenue gap.

While we will discuss staffing models in-depth in a future post, it is important to understand that the impact of the issues discussed today ultimately affects how you, as a government or elected official, provide emergency medical services to your community. There is no right or wrong way of providing emergency medical services. It is, however, important to understand the impact of certain staffing and budget decisions. I will close this section with questions for you to think about. We will be discussing these and other topics in the future.

• What problem are you trying to solve with the implementation or elimination of a program?

• Does the solution you have come up with actually impact the problem? For example, are you creating a home visit program to reduce call volumes that requires you to hire another FTE? Does the impact of this addition reduce volume enough that you can staff less ambulances or keep you from adding additional units in the future?

• Are you completing non-911 type transports from one hospital to another because no other resources are available or because you are trying to offset costs with additional revenue? If it is revenue-related, are you decreasing your 911 readiness capabilities, or is the additional revenue enough to fund an additional ambulance crew?

• Do you understand who your competition is for your staff, and will your decisions impact your ability to recruit or retain staff?