DC EMS No Longer Transporting Non-emergencies

[DeadCactus]

D.C. Ambulances Will No Longer Transport Patients For Non-Emergencies | WAMU

Basically an infield triage system to shunt people to clinics. I believe similar concepts have been trialled at least as study protocols. Not sure if any major systems have ever implemented something like this. Curious how it will go.

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[Tenk]

Hopefully it goes amazingly well and it changes the system entirely.

 

[TheComebacKid]

There are several recent studies supporting its use. Notably for psych patients based on a protocol implemented in Alameda County, as well a tele-health approach as in Houston, TX.

Telehealth Impact on Primary Care Related Ambulance Transports. - PubMed - NCBI
Emergency Medical Services Use Among Patients Receiving Involuntary Psychiatric Holds and the Safety of an Out-of-Hospital Screening Protocol to "M... - PubMed - NCBI

This stuff is a game changer and will likely have a huge impact. EMS ftw.

 

[carbonizedeyesockets]

I hate to say it, but DC FEMS isn't exactly known for having a stellar EMS system. I am doubtful that this will work. Nice to see them keep a medical director for more than a year. They couldn't hold on to any of the prominent EMS specialists that they hired, so they had to go with a former infectious disease doc who works urgent care fulltime.

 

[theseeker4]

Sounds great, but all it will take is one bad outcome from someone who called 911 with a seemingly minor complaint who was denied transport to the hospital to be plastered all over the news for them to change the policy, and probably have a huge lawsuit payout. I would love for this to work, but in this day and age, with trial by media and "viral" social media lynch mobs, not going to last or spread.

 

[WilcoWorld]

a former infectious disease doc who works urgent care fulltime.

no doubt practicing excellent antibiotic sterwardship

 

[WilcoWorld]

Sounds great, but all it will take is one bad outcome from someone who called 911 with a seemingly minor complaint who was denied transport to the hospital to be plastered all over the news for them to change the policy, and probably have a huge lawsuit payout. I would love for this to work, but in this day and age, with trial by media and "viral" social media lynch mobs, not going to last or spread.

Of course you're correct & this is a potential problem. However, if you make your refusal of transport protocols specific enough you could do this safely while achieving a substantial decrease in non-emergent transports.

 

[deleted859535]

Sounds great, but all it will take is one bad outcome from someone who called 911 with a seemingly minor complaint who was denied transport to the hospital to be plastered all over the news for them to change the policy, and probably have a huge lawsuit payout. I would love for this to work, but in this day and age, with trial by media and "viral" social media lynch mobs, not going to last or spread.

Even worse is that some of the same folks who make up a "viral social media lynch mob" are some of the same people who would misuse 911 services in the first place.

I can think of one particular dental pain who came by EMS I saw a long time ago. He got discharged in about 30 minutes after routine standard of care type stuff. But leave it to the one in 100,000 case where someone dies of Lemierre syndrome who wasn't emergently transported to the ED, and away we go! Judgement by people who don't get the need for such a policy in the first place and who don't do what they do.

 

[namethatsmell]

Props to them for trying to change culture.

I suspect the amount of chest pain will skyrocket.

 

[thegenius]

D.C. Ambulances Will No Longer Transport Patients For Non-Emergencies | WAMU

Basically an infield triage system to shunt people to clinics. I believe similar concepts have been trialled at least as study protocols. Not sure if any major systems have ever implemented something like this. Curious how it will go.

I read a study once in residency, which was between 5-10 years ago, where the study asked EMS personnel whether they thought the pt being transported to the ER had a emergency medical condition. I think they compared it to what the ER doctor determined after the medical screening examination. Unfortunately there was a large discrepancy between the two.

Which really upset me because I want less riff-raff coming in by EMS but I believed at the time EMS judgement wasn't the right way to go about it.

 

[thegenius]

I wonder if there has been any thought to having a doctor go to select 911 / EMS calls to determine if they need 911.

There would be a number of exclusion criteria like
- 1 yr > age > 65 yrs
- abnormal vital signs
- any internal thoracoabdominal complaint
- trauma
stuff like that...

The doctor determines if they go to the ER.

I wonder if this would violate EMTALA

obviously also wonder if it would be cost effective

 

[Zebra Hunter]

I read a study once in residency, which was between 5-10 years ago, where the study asked EMS personnel whether they thought the pt being transported to the ER had a emergency medical condition. I think they compared it to what the ER doctor determined after the medical screening examination. Unfortunately there was a large discrepancy between the two.

Which really upset me because I want less riff-raff coming in by EMS but I believed at the time EMS judgement wasn't the right way to go about it.

Which is why protocols would take these decisions out of EMS's hands. Strict VS parameters, CC's that automatically necessitate transfer, etc.

 

[Zebra Hunter]

I wonder if there has been any thought to having a doctor go to select 911 / EMS calls to determine if they need 911.

There would be a number of exclusion criteria like
- 1 yr > age > 65 yrs
- abnormal vital signs
- any internal thoracoabdominal complaint
- trauma
stuff like that...

The doctor determines if they go to the ER.

I wonder if this would violate EMTALA

obviously also wonder if it would be cost effective

EMTALA requires an emergency department. EMTALA does not apply to someone you are seeing out in the field. Also, we frequently performed physician refusals during residency during our EMS ridealong months, as well as receiving calls from EMS asking for physician refusal for patients they believed did not necessitate transport.

 

[thegenius]

Which is why protocols would take these decisions out of EMS's hands. Strict VS parameters, CC's that automatically necessitate transfer, etc.

My guess is that they won't do protocols for eligibility of ER transfers....because we get people coming in with a hangnail by EMS

probably liability reasons

Funny...people would rather pay higher taxes, have longer waits for everything in life just not to get sued.

 

[thegenius]

EMTALA requires an emergency department. EMTALA does not apply to someone you are seeing out in the field. Also, we frequently performed physician refusals during residency during our EMS ridealong months, as well as receiving calls from EMS asking for physician refusal for patients they believed did not necessitate transport.

Makes sense.

Doesn't happen out here in California, at least in the county where we work. Our EMS crews say they have to transport anyone with any complaint, no matter what.

 

[Zebra Hunter]

Makes sense.

Doesn't happen out here in California, at least in the county where we work. Our EMS crews say they have to transport anyone with any complaint, no matter what.

This is the same where I currently work, as well. The reality is I probably only get about 1 in 20-30 patients that truly abuse ambulance services. It's usually the chronic pain patients and occasional homeless guy, so I don't see this as a huge need where I'm currently at; however, I'm sure the guys at the university hospital down the street have a different experience.

 

[Apollyon]

About 3-4 years ago, after EMS was told they didn't have to immobilize all trauma, they stopped immobilizing everyone. This includes a guy that fell down 10 stairs, and said his neck hurt.

C2 fracture.

I'm still a paramedic, besides doc. Just like our CRNA-turned-anesthesiologist colleagues say, the breadth and depth of what they did not know prior is breathtaking. This will end poorly.

 

[miacomet]

Sounds great, but all it will take is one bad outcome from someone who called 911 with a seemingly minor complaint who was denied transport to the hospital to be plastered all over the news for them to change the policy, and probably have a huge lawsuit payout. I would love for this to work, but in this day and age, with trial by media and "viral" social media lynch mobs, not going to last or spread.

This, 100%. DC is a high liability area.
What annoys me is they usually exempt peds from systems like this, and kids are among the least likely to have a real emergency. Any idea if they are excluding peds from this?

 

[southerndoc]

The best system would allow paramedics to call taxis or divert to a private ambulance provider for non-urgent transports (aka Seattle Medic One).

 

[Hamhock]

I read a study once in residency, which was between 5-10 years ago, where the study asked EMS personnel whether they thought the pt being transported to the ER had a emergency medical condition. I think they compared it to what the ER doctor determined after the medical screening examination. Unfortunately there was a large discrepancy between the two.

Which really upset me because I want less riff-raff coming in by EMS but I believed at the time EMS judgement wasn't the right way to go about it.

The best system would allow paramedics to call taxis or divert to a private ambulance provider for non-urgent transports (aka Seattle Medic One).

My understanding is that EMS personnel must contact an RN before refusing transport. This still doesn't fix all concerns expressed by 'thegenius', but it's more than just EMS. There's the RN and I am sure some fairly strict protocols.

Additionally, it seems that at least medicaid patients can be diverted to Uber/Lyft/Taxi.

Let's all hope this works...

HH

 

[deleted109597]

This is why we need to revamp EMS completely. It needs to start with their education. Too many medics are the result of diploma mills, and don't even have associates degrees, much less a bachelor level of training. Compare this to most other countries.
We rail all day every day about NP training, but the first (and often most important for some conditions) person to see you has less college than I had humanities classes. They're the one trying to intubate you. They're determining stemi or not. They're choosing stroke center or other hospital.
You can do what DC wants pretty easily AND save money. A decent trained person (PA/NP for 100k, MD/DO for 3-4 times that) making those decisions would more than pay for themselves in no-transports. And they usually get cab vouchers or something similar anyway, so they can still go to the hospital if they choose, just not by EMS.

 

[InternistDO]

I read a study once in residency, which was between 5-10 years ago, where the study asked EMS personnel whether they thought the pt being transported to the ER had a emergency medical condition. I think they compared it to what the ER doctor determined after the medical screening examination. Unfortunately there was a large discrepancy between the two.

Which really upset me because I want less riff-raff coming in by EMS but I believed at the time EMS judgement wasn't the right way to go about it.

I'm not surprised by this at all. When I was an EMT, I had no idea that 90% of the diseases we learn about in medical school even existed, nevermind how to recognize them. Abdominal pain? I knew about appendicitis, cholecystitis, and bowel obstruction. I don't think I would have been able to tell the difference between them and gastroenteritis unless it was written on the patient's forehead. Volvulus? Bowel ischemia? Never heard of them until med school. Looking back, I'm sure that a tremendous amount of patients I dismissed as being "not that sick" were actually quite sick. In EMS most of the conditions you treat are very obvious--severe respiratory distress, chest pain, trauma--and so even deadly things that are even a little bit sneaky are not noticed in the field or even covered in class.

About 3-4 years ago, after EMS was told they didn't have to immobilize all trauma, they stopped immobilizing everyone. This includes a guy that fell down 10 stairs, and said his neck hurt.

C2 fracture.

I'm still a paramedic, besides doc. Just like our CRNA-turned-anesthesiologist colleagues say, the breadth and depth of what they did not know prior is breathtaking. This will end poorly.

To be fair, we had almost all our immobilization protocols changed when I was still an EMT. The ACS finally accepted that backboards had no proven clinical benefit and changed their recommendation to c-collar only. So, minor MVA with neck pain? C-collar only. Fall down twenty steps with neuro deficit? Also c-collar only.

No disagreement on the breadth and depth part though. I'm firmly in the camp that EMS should be a degreed field, like nursing. As it is now there are plenty of places even in urbanish areas where your first responders might be two volunteer college students with a 120 hour EMT class.

 

[southerndoc]

This is why we need to revamp EMS completely. It needs to start with their education. Too many medics are the result of diploma mills, and don't even have associates degrees, much less a bachelor level of training. Compare this to most other countries.
We rail all day every day about NP training, but the first (and often most important for some conditions) person to see you has less college than I had humanities classes. They're the one trying to intubate you. They're determining stemi or not. They're choosing stroke center or other hospital.
You can do what DC wants pretty easily AND save money. A decent trained person (PA/NP for 100k, MD/DO for 3-4 times that) making those decisions would more than pay for themselves in no-transports. And they usually get cab vouchers or something similar anyway, so they can still go to the hospital if they choose, just not by EMS.

Prehospital intubation is a dying procedure. Too many studies have shown how harmful it is or at least how it's not beneficial.

It's hard to get paramedics that have more training because the money just isn't there. Pay is abysmal in many counties.

 

[CajunMedic]

There would be a number of exclusion criteria like
- 1 yr > age > 65 yrs
- abnormal vital signs
- any internal thoracoabdominal complaint
- trauma
stuff like that...

One of the larger services I worked for had a similar system in place. Field medic could call one of the 2 med control physicians on the radio and request a "physician directed referral" to refuse transport. Field supervisors and above could do a "Paramedic Initiated Refusal" under the same narrow criteria. Worked great until someone got lazy and refused a transport to the wrong person, the mayor found out and the whole thing was scrapped.

This is why we need to revamp EMS completely. It needs to start with their education. Too many medics are the result of diploma mills, and don't even have associates degrees, much less a bachelor level of training.

This has popped up in the EMS trade publications and social media in the past couple of months. The crapstorm for suggesting it is unreal at times

I'm not surprised by this at all. When I was an EMT, I had no idea that 90% of the diseases we learn about in medical school even existed, nevermind how to recognize them. Abdominal pain? I knew about appendicitis, cholecystitis, and bowel obstruction. I don't think I would have been able to tell the difference between them and gastroenteritis unless it was written on the patient's forehead. Volvulus? Bowel ischemia? Never heard of them until med school. Looking back, I'm sure that a tremendous amount of patients I dismissed as being "not that sick" were actually quite sick. In EMS most of the conditions you treat are very obvious--severe respiratory distress, chest pain, trauma--and so even deadly things that are even a little bit sneaky are not noticed in the field or even covered in class.

Same here. I had a "lightbulb moment" in my first year that had me wondering about how many patients I had potentially harmed or things I had missed.

 

[miacomet]

Prehospital intubation is a dying procedure. Too many studies have shown how harmful it is or at least how it's not beneficial.

It's hard to get paramedics that have more training because the money just isn't there. Pay is abysmal in many counties.

Canada has highly trained critical care paramedics earning up to 125k CDN. Their PCP medics earn 70k CDN. Surely we can afford the same, no?

 

[InternistDO]

Prehospital intubation is a dying procedure. Too many studies have shown how harmful it is or at least how it's not beneficial.

It's hard to get paramedics that have more training because the money just isn't there. Pay is abysmal in many counties.

I've been hearing it's dying for years, but everyone around me (the Northeast) keeps doing it. I agree that the data isn't there to support it, but it's a sacred cow of EMS and it seems medical directors are reluctant to remove it completely. Perhaps I'm just out of the loop though.

I agree that it will be hard to do much to improve EMS without increasing pay. My old partner had moved from Southern California, where he made $8.50/hr doing 911 BLS. I know someone else who made $14/hr as a medic in Florida. Hard to ask someone to get a degree for that kind of pay.

 

[theKingLT]

I'm not surprised by this at all. When I was an EMT, I had no idea that 90% of the diseases we learn about in medical school even existed, nevermind how to recognize them. Abdominal pain? I knew about appendicitis, cholecystitis, and bowel obstruction. I don't think I would have been able to tell the difference between them and gastroenteritis unless it was written on the patient's forehead. Volvulus? Bowel ischemia? Never heard of them until med school. Looking back, I'm sure that a tremendous amount of patients I dismissed as being "not that sick" were actually quite sick. In EMS most of the conditions you treat are very obvious--severe respiratory distress, chest pain, trauma--and so even deadly things that are even a little bit sneaky are not noticed in the field or even covered in class.

No disagreement on the breadth and depth part though. I'm firmly in the camp that EMS should be a degreed field, like nursing. As it is now there are plenty of places even in urbanish areas where your first responders might be two volunteer college students with a 120 hour EMT class.

Volunteer EMT college student here and I agree big time. I was always told in class that most "real learning" would come working in the field under a senior medic. But they don't tell you many areas lack ALS all together or that some services suck so bad every medic on payroll is less than 2 years out of school. Leading calls with as little as we know is scary at times and I can't imagine having to refuse transport to patients on top of that. It would be great to not be bogged down by unnecessary transports but I think it would be a nightmare trying to implement.

As for EMS being a degreed field, I'm all for it, but pay has to go up first. There are too many areas with shortages already

 

[deleted109597]

Pay is abysmal in many counties.

Not in useful ones, like Australia, NZ, or most of Europe.
We aren't comparing South America or Africa here.

 

[deleted109597]

I've been hearing it's dying for years, but everyone around me (the Northeast) keeps doing it. I agree that the data isn't there to support it, but it's a sacred cow of EMS and it seems medical directors are reluctant to remove it completely. Perhaps I'm just out of the loop though.

I agree that it will be hard to do much to improve EMS without increasing pay. My old partner had moved from Southern California, where he made $8.50/hr doing 911 BLS. I know someone else who made $14/hr as a medic in Florida. Hard to ask someone to get a degree for that kind of pay.

CMS changing from transport to the practice of medicine for EMS would be a huge thing. Remember, they don't get paid for doing anything. They get paid to transport. To a hospital. That's it. (interfacility transfers are different). So their pay is crap because society at some point decided they didn't care about EMS. It was public safety, not medicine. But then paid less than police or fire.
And I have no qualms about saying "F*** fire"

 

[InternistDO]

Volunteer EMT college student here and I agree big time. I was always told in class that most "real learning" would come working in the field under a senior medic. But they don't tell you many areas lack ALS all together or that some services suck so bad every medic on payroll is less than 2 years out of school.

Once I went paid I only worked for ALS services (medic/basic trucks). I worked with a lot of great paramedics, but the education is still very focused on a small handful of immediately life threatening events. You're never going to learn about a massive chunk of emergency medicine because you just take it to the hospital without recognizing it.

CMS changing from transport to the practice of medicine for EMS would be a huge thing. Remember, they don't get paid for doing anything. They get paid to transport. To a hospital. That's it. (interfacility transfers are different). So their pay is crap because society at some point decided they didn't care about EMS. It was public safety, not medicine. But then paid less than police or fire.
And I have no qualms about saying "F*** fire"

Yeah. The new CMS ET3 rules allowing for billing for non transport and alternative destinations will hopefully be a nice change for this, but we'll see.

 

[alpinism]

I read a study once in residency, which was between 5-10 years ago, where the study asked EMS personnel whether they thought the pt being transported to the ER had a emergency medical condition. I think they compared it to what the ER doctor determined after the medical screening examination. Unfortunately there was a large discrepancy between the two.

Which really upset me because I want less riff-raff coming in by EMS but I believed at the time EMS judgement wasn't the right way to go about it.

I think the point is to target obviously nonemergent complaints and abuse of EMS services.

Some examples from last week brought in by Detroit EMS:

-needs colostomy bag
-missed last few periods
-shelter food tastes bad
-itching from bedbugs
-medication refills
-work notes

 

[thegenius]

I think the point is to target obviously nonemergent complaints and abuse of EMS services.

Some examples from last week brought in by Detroit EMS:

-needs colostomy bag
-missed last few periods
-shelter food tastes bad
-itching from bedbugs
-medication refills
-work notes

LOL terrible. Just terrible. I can't imagine there is a single jury member who would say it's an EMTALA violation if the chief complaint is "shelter food tastes bad"

 

[Apollyon]

Not in useful ones, like Australia, NZ, or most of Europe.
We aren't comparing South America or Africa here.

Counties, not countries.

 

[deleted109597]

Counties, not countries.

I see that now.
Yes, pay sucks in some counties. It's zero in some.
But that doesn't mean we shouldn't have educated people making medical decisions. Otherwise, why not just let RNs be their Primary Care Providers, and not even NPs?

 

[deleted109597]

LOL terrible. Just terrible. I can't imagine there is a single jury member who would say it's an EMTALA violation if the chief complaint is "shelter food tastes bad"

Juries aren't deciding it.
Also, all you have to do is screen them. It's not like you need to fix the non-emergencies.

 

[bravotwozero]

I think the point is to target obviously nonemergent complaints and abuse of EMS services.

Some examples from last week brought in by Detroit EMS:

-needs colostomy bag
-missed last few periods
-shelter food tastes bad
-itching from bedbugs
-medication refills
-work notes

LOL, good old Detroit EMS. In addition to having to transport stupid non urgent complaints, they also have crap stolen from their trucks, like cpap and oxygen tanks...

 

[southerndoc]

I've been hearing it's dying for years, but everyone around me (the Northeast) keeps doing it. I agree that the data isn't there to support it, but it's a sacred cow of EMS and it seems medical directors are reluctant to remove it completely. Perhaps I'm just out of the loop though.

I agree that it will be hard to do much to improve EMS without increasing pay. My old partner had moved from Southern California, where he made $8.50/hr doing 911 BLS. I know someone else who made $14/hr as a medic in Florida. Hard to ask someone to get a degree for that kind of pay.

We've initiated the process to remove it, and one of the larger metro Atlanta services has already removed it.

3 things in EMS will get you sued: bad driving, bad airways, and leaving the patient behind without transport.

 

[Atlas Shrugged]

I never understood why police and fire fall on the government, but EMS does not. Have better standards of training and better pay; make it a real career path.

 

[emergentmd]

This will end badly for all of the reasons above.

Another reason is eventually, the EMS crew will have an incentive to bring all patients in. I can see it now.

This new EMS triage works great. Calls/Transports are down to 10% which are the only true emergencies. We now can cut EMS/Fire by 80% because there are no calls left. Oh oh... I better protect my livelihood.

 

[FiremedicMike]

I think the point is to target obviously nonemergent complaints and abuse of EMS services.

Some examples from last week brought in by Detroit EMS:

-needs colostomy bag
-missed last few periods
-shelter food tastes bad
-itching from bedbugs
-medication refills
-work notes

Correct me if I’m wrong, but ET3 only addresses the financial aspect of the above transports.

I’m slightly frustrated that the headlines are making it seem like the only reason these runs are being transported is due to the financial aspect “the only way they can get paid is if they take them to the ER”. Sure, that may be the case with some departments, but most departments transport those patients out of fear of getting complaints which translate into disciplinary action more than a desire to collect $207..

A lot of the folks I know feel that it’s easier to just toss them in the back of the truck and go as opposed to trying to argue with them on the side of the road.

 

[lalalallala]

Sounds great, but all it will take is one bad outcome from someone who called 911 with a seemingly minor complaint who was denied transport to the hospital to be plastered all over the news for them to change the policy, and probably have a huge lawsuit payout. I would love for this to work, but in this day and age, with trial by media and "viral" social media lynch mobs, not going to last or spread.

Right now the DC EMS can't respond to actual emergencies because of the insane amount of people using EMS as an uber. I work in an ER in DC and really wish I was exaggerating. I agree with you that the media look may not be good but right now people are being harmed because of the EMS wait times due to these people using EMS unnecessarily. It's a bit of a lose-lose situation but I know that EMS and ER workers are very happy that this was passed

 

[lalalallala]

"I don't have a car and I couldn't find a taxi with a car seat so we called the ambulance" - the amount of times I have heard this....

 

[hundreddaysoff]

And I have no qualms about saying "F*** fire"

Just curious... why do you have no qualms about F***ING fire?

(my background is not in EMS/public safety)

 

[hundreddaysoff]

This will end badly for all of the reasons above.

Another reason is eventually, the EMS crew will have an incentive to bring all patients in. I can see it now.

This new EMS triage works great. Calls/Transports are down to 10% which are the only true emergencies. We now can cut EMS/Fire by 80% because there are no calls left. Oh oh... I better protect my livelihood.

I have this concern as well, especially for the private ambulance companies, which are the majority of my transports around here.

I also expect there'd be some (hidden?) pushback/lobbying from HCA and other big hospital companies about this. Less transport = lower ER census = bad if you're in the C-suite. At least that's what my medical director says. The same consideration "should" prevent me from MSE'ing in triage chronic pain people/homeless/end-stage anxiety/asymptomatic HTN/other pts I can't help, as if I piss them off they'll go to the competitor hospital next time and our census will decrease.

Finally, it's interesting to think about how EMS triage protocols would play w/ Jerry Brown's new anti-homeless-dumping law in CA:

News: California Law Setting Discharge Rules for Homeless... : Emergency Medicine News

"You mean you won't take my kid to the ER for a cough but you just took that bum down the street??"

 

[InternistDO]

Just curious... why do you have no qualms about F***ING fire?

(my background is not in EMS/public safety)

Traditionally fire departments have pushed against increased educational standards for EMS because it makes it harder to cross train firefighters as paramedics for those departments that do both.

Coupled with the fact that in many areas firefighters can make double what private medics make with better benefits means that there can be some friction between the two.

 

[deleted109597]

Just curious... why do you have no qualms about F***ING fire?

(my background is not in EMS/public safety)

As above.
Fire has a purpose. But fire safety is light-years ahead of what it was in Ben Franklin's time. Fire needs to be separate from EMS, or at least if they're combined, they need to do more than give EMS lipservice and continue to waste budgets on new ladder trucks and fire suppression training.

 

[GeneralVeers]

The reason EMS transports all of this BS crap, is not for liability reasons. All of the EMS companies, private and government-affiliated make money on most of the transports. They aren't going to refuse an easy transport on a medicaid patient because that will be loss of $$$ to their bottom line. The EMS guys tell me all the time they'd like to refuse transport but their bosses will fire them if the do. As with most things it's all about $$$