Screening low priority 911 calls

[willow18]

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http://www.usatoday.com/news/health/2010-06-01-emsredirect01_ST_N.htm?csp=34news

By Jessie Halladay, USA TODAY
Hoping to ease crowded emergency rooms and trim ambulance runs, Louisville Metro Emergency Medical Services (EMS) has launched a program that aims to screen low-priority calls and divert patients from hospitals into more appropriate health care.

Under the program, which started April 19, a small number of the lowest priority calls — such as those for an earache or a stomachache — are being turned over to a nurse who is able to spend time with the patient on the phone to figure out appropriate treatment, which may not include a trip to an emergency room in an ambulance.

"We're trying to challenge the way things are traditionally done," says Neal Richmond, an emergency room physician and Louisville Metro EMS director. "Let's find these people better care."

'The time is here for this'

The program, which is among the first of its kind in the nation, is widely used in the United Kingdom and Australia, says Jeff Clawson, medical director for the National Academies of Emergency Dispatch.

Though a handful of cities have explored similar programs, only Louisville and Richmond, Va., which piloted the program, are fully using it in EMS systems, he says.

Clawson says that if the system is used carefully, it can be a powerful way to "preserve precious resources" while still getting patients the care they need. "The time is here for this."

Most patients calling 911 won't notice much of a difference, because all calls will continue to be screened through the automated protocol system already in place, says Kristen Miller, chief of staff for Louisville Metro EMS. On average, the Louisville system handles about 230 to 250 calls a day, she says.

I'm surprised yet not so surprised that this hasn't been used more widely in the US given the malpractice and blame-game climate. Would putting a physician on the line help weed out even more non-emergent visits? I'm sure it will, but is it feasible? Anybody know if it's ever been tried with an doc on the line?

How about if the nurse/doc was not saying whether you need to visit the ED or not, but simply ruled if you really needed an ambulance, kinda like we reserve HEMS just for certain cases...could we start screening out $1000 ambulance rides and tell people to just take a $10 cab.

 

[deleted109597]

Our EMS calls us for medical direction with no transports. Truth of the matter, you aren't there. You can't determine what needs EMS and what doesn't, even from the story. Generally we try to convince the patients to come in because if they have bad outcomes, you're hosed.

 

[Flopotomist]

The problem is the malpractice environment here is very different from the countries that are currently employing this system. It is cheaper for the system in the long run to respond to all calls than to miss that one in a thousand call that is misinterpreted as "low priority."

Plus, a few of the examples above are concerning to me - eg abdominal pain. Yeah - sure, many abdominal pain 911 calls are bogus, but if somebody is having belly pain so bad that they feel that a 911 call is warranted, there is a good chance that something is going on, and I would rather a medic eyeball that person before an over-the-phone decision is made to just not respond.

I am also not sure that EMS systems as a whole are so backed up from low-priority calls that other calls are being missed with enough regularity to implement this plan. It seems like avoiding diversions at the receiving end is a better place to pluck some low-hanging fruit that would increase availability of ambulances.

 

[Dwindlin]

The problem is the malpractice environment here is very different from the countries that are currently employing this system. It is cheaper for the system in the long run to respond to all calls than to miss that one in a thousand call that is misinterpreted as "low priority."

Plus, a few of the examples above are concerning to me - eg abdominal pain. Yeah - sure, many abdominal pain 911 calls are bogus, but if somebody is having belly pain so bad that they feel that a 911 call is warranted, there is a good chance that something is going on, and I would rather a medic eyeball that person before an over-the-phone decision is made to just not respond.

I am also not sure that EMS systems as a whole are so backed up from low-priority calls that other calls are being missed with enough regularity to implement this plan. It seems like avoiding diversions at the receiving end is a better place to pluck some low-hanging fruit that would increase availability of ambulances.

The bolded part is a poor indicator of severity in general, at least where I work. I have people tell me (often unfortunately) that the only reason they called because it's "cheaper than a taxi." No how many times I report it, our cops just don't care (though in their defense they are quite busy with more important things). We're a tax based service and we only soft bill. So if they don't have insurance/medicare/medicaid we eat the bill.

 

[Flopotomist]

I have people tell me (often unfortunately) that the only reason they called because it's "cheaper than a taxi."

A taxi may be the most expensive thing to the system though when a 911 operator routes a patient having an MI to a cab instead of an ambulance and then a giant malpractice suit follows. Until you show me a system that is so overworked that ambulances are not available to respond to calls AND that system has been optimized with more appropriate fixes (eg no diversions, no patients on the stryker waiting to be transferred to the ER staff, no 911 ambulances doing interfacility transfers etc) I am not comfortable telling somebody who has called 911 that they don't get an ambulance.

Does this mean that there will be people who abuse the system? Of course. I am willing to pay that price to allow for everybody to have access to emergency care. Do you really want to have to "make your case" when you dial 911 asking for help?

 

[leviathan]

I wouldn't consider abdominal pain a low-priority call. I mean it certainly can be, but there's no way to assess that over the phone without a huge risk for screwing it up. But certain criteria could probably be met to reduce a small number of calls...

 

[deleted77919]

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[turtle md]

We just had one for a toothache. Couldn't see a dentist today, so called 911. No other c/o, just toothache.

 

[DoctorMedic]

We just had one for a toothache. Couldn't see a dentist today, so called 911. No other c/o, just toothache.

but even that wouldn't you have to be cautious of a MI? I know a primary care refuses to write a Rx for someone they haven't seen. I can only see this leading to lawsuits. Having worked in EMS for 9 years I know there is the fair share of BS calls, but I think a system closer to NC's Paramedic initiated refusal would be much better. As far as I can remember if a Medic thinks the call is complete BS like "i stubbed my toe 2 days ago and ran out of ibuprofen" then they can call the ED doc and refuse to txp.

 

[turtle md]

but even that wouldn't you have to be cautious of a MI? I know a primary care refuses to write a Rx for someone they haven't seen. I can only see this leading to lawsuits. Having worked in EMS for 9 years I know there is the fair share of BS calls, but I think a system closer to NC's Paramedic initiated refusal would be much better. As far as I can remember if a Medic thinks the call is complete BS like "i stubbed my toe 2 days ago and ran out of ibuprofen" then they can call the ED doc and refuse to txp.

You make a valid point. But in a 19 year old otherwise healthy individual, MI was not a concern. I wish our medics could have refused, but here, they cannot.

I think that if medics evaluate and feel it is silly is far better than someone over the phone making a call.

 

[Apollyon]

but even that wouldn't you have to be cautious of a MI? I know a primary care refuses to write a Rx for someone they haven't seen. I can only see this leading to lawsuits. Having worked in EMS for 9 years I know there is the fair share of BS calls, but I think a system closer to NC's Paramedic initiated refusal would be much better. As far as I can remember if a Medic thinks the call is complete BS like "i stubbed my toe 2 days ago and ran out of ibuprofen" then they can call the ED doc and refuse to txp.

When I was in NC, EMS did NOT have to call medical control to initiate a non-transport from their side. Crazy!

 

[illegallysmooth]

Yesterday's EMS produced these two just in the four hours I was there:

Back pain in a 36 yo who is in the ED every 3-4 days with various aches and pains. She walked half a mile to the store to call an ambulance and never looked the least bit uncomfortable. She also started asking people in the waiting room for money to pay her cab home after spending at least $5 for cheetos and mountain dew.

Sore throat. 23 yo male. Viral pharyngitis.

I would like to see some sort of program like this in action. They would have to be very careful about who they direct to urgent care centers, taxis, or otherwise.

I also think that patients with a primary care provider should have at least TRIED to get a call out to them (or the on-call doc) for NON-EMERGENT problems, and perhaps this could be integrated. For instance, when I asked the 26yo female with a CC of "toenails falling off" if she had been seen by or called her PMD, she replied "No, my husband told me to come right to the ER, because they're about TO FALL OFF!" as if she were talking about her arms or something. I wonder if she thought we would surgically reattach them.

Also, a very small copay for Medicaid ambulance rides - I would love to see this.

 

[emtcsmith]

I think a small percent of these calls can be "screened out" but it also must come with further education on what 911 is for. If people respected 911 and didn't call with nonsence none of this would be an issue.

We have people in the urban system that call due to lack of transport, and many of there minor complaints would be something I will probaby still take a family member to the ED for but would have driven them in. Can we solve this problem easy? No, a large percent of EMS calls will always be for non-life threats.

Last, consider this...in the same Urban system that people call for earaches, toothaches, being hungry, etc these are the same people that after being discharged from your ED call back 911 and expect to recieve the same free ride home. You can't cure stupid, and can't expect others to know if you don't tell them what 911 is for.

 

[Dwindlin]

I think a small percent of these calls can be "screened out" but it also must come with further education on what 911 is for. If people respected 911 and didn't call with nonsence none of this would be an issue.

We have people in the urban system that call due to lack of transport, and many of there minor complaints would be something I will probaby still take a family member to the ED for but would have driven them in. Can we solve this problem easy? No, a large percent of EMS calls will always be for non-life threats.

Last, consider this...in the same Urban system that people call for earaches, toothaches, being hungry, etc these are the same people that after being discharged from your ED call back 911 and expect to recieve the same free ride home. You can't cure stupid, and can't expect others to know if you don't tell them what 911 is for.

This sounds all fine and noble on a message board, but the sad reality is most people DO know what 911 is for and just don't care.

 

[DoctorMedic]

This sounds all fine and noble on a message board, but the sad reality is most people DO know what 911 is for and just don't care.

I want to agree, but after working EMS for a college you start to see that esp the younger people don't know. They call for any and everything and most truly believe I'm going to just give them some Tylenol and leave. All because they are too lazy to go to the store at 2am. I have to think these people are truly ******ed or ignorant. Being as they made it into college I'll go with ignorant.

 

[FiremedicMike]

Our EMS calls us for medical direction with no transports. Truth of the matter, you aren't there. You can't determine what needs EMS and what doesn't, even from the story. Generally we try to convince the patients to come in because if they have bad outcomes, you're hosed.

And that's the problem. It's totally not your fault, mind you, but until we get serious tort reform in this country ERs and EMS will continue to be overtaxed and abused.

My background? I've worked for 10 years on a fire department that also provides ALS EMS care for a lower class area. We average about 15-17 EMS runs per shift (closer to 20 runs per shift for the last several months) and the vast majority of them are crap. "I've had a fever for an hour", "I've had a cough for 3 days", "I jammed my fake fingernail into the coffee table, it hurts, is my finger broken?" (not making that one up, I was there). Worse than the fact that we MUST go to EVERYONE who calls, we do it lights and sirens, dropping everything (other than our blood pressure) to tend to those who refuse to tend to themselves. I would say we hover right at around 15-20% of our calls being actual emergent cases. Unfortunately, like the resident above, I've resigned myself to the futility of it all and take everyone who wants to go. Early in my career I would attempt to educate "sure you've had a fever for an hour, have you tried taking some tylenol?" to "sure hop in we'll take you". Of course, as you ED docs know, the majority of these cases are self(non)-pay, so everyone loses. ERs go on diversion, we're now transporting farther which puts us out of service longer, etc etc..

My solution for the short term? Allow for non-emergent, fire department based "rides" to the urgent care/clinic. Currently our system does not allow us to transport to the urgent care, not that it would really make much sense if we're taking an ALS truck, we might as well take them to the ED. When someone calls and tells the dispatcher "I've got a headache, I've had migraines before", we tell them we'll put them on the list and send it to the wheelchair van. That van is active during normal business hours and comes when they are available, non emergent, and gives people a ride to the urgent care/clinic. Sure these people might have to wait an hour 😱, or if after hours they might have to wait until morning 😱😱, but we cannot keep running EMS/Emergency Departments the way they are.

 

[LadyWolverine]

Does it help at all to educate patients (especially repeat-offenders) on appropriate use of the 9-1-1/EMS/ambulance system? Or is this not an appropriate role for EMS providers, triage nurses, or physicians? I certainly saw a significant amount of EMS abuse during my EM rotations. I often wondered if it would make a difference if patients who come in for such glaringly abusive "complaints" had their bluff called. In a tactful, professional manner, of course.

 

[gutonc]

Does it help at all to educate patients (especially repeat-offenders) on appropriate use of the 9-1-1/EMS/ambulance system? Or is this not an appropriate role for EMS providers, triage nurses, or physicians? I certainly saw a significant amount of EMS abuse during my EM rotations. I often wondered if it would make a difference if patients who come in for such glaringly abusive "complaints" had their bluff called. In a tactful, professional manner, of course.

No.

 

[Dwindlin]

No.

x2

Had a patient who once called us for "chest pain" 13 times in 24 hour shift, this was after 2 complete workups that day in the ED. Needless to say she was arrested and spent the night in jail and was fined for 911 abuse. Calls started again as soon as she was released.

Had another patient who would call 911, get taken to the ED, sign out AMA. Then call 911 again from the area surrounding the hospital and ask to be taken to another hospital. Unfortunately took us a while to put together that he was literately using us as public transit.

These are just 2 examples but I have dozens of ones on this level, and hundreds that weren't quite this bad but still frequent enough to be a drain on the system.

 

[deleted109597]

We have people call 911 from the waiting room after being discharged, thinking they'll get another doctor who will give them narcotics.

 

[xaelia]

We have people call 911 from the waiting room after being discharged, thinking they'll get another doctor who will give them narcotics.

It is one of the tiny joys afforded me in life to sign-up for patients who have recently been denied narcotics to reinforce our department's solidarity on the issue.

I suppose I'm going to get shot someday.

 

[FiremedicMike]

Does it help at all to educate patients (especially repeat-offenders) on appropriate use of the 9-1-1/EMS/ambulance system? Or is this not an appropriate role for EMS providers, triage nurses, or physicians? I certainly saw a significant amount of EMS abuse during my EM rotations. I often wondered if it would make a difference if patients who come in for such glaringly abusive "complaints" had their bluff called. In a tactful, professional manner, of course.

I gave up on that years ago. I also gave up on educating patients on their own problems.. "Hi my son has had a fever of 101 for 2 hours..." "have you tried tylenol or motrin" "no.. can you just take him to the ED". Essentially my assessment now, obviously barring a patient who appears to be in distress from the doorway is "Hi what's going on today" "I've been <blah blah> for <blah blah> days" "Ok, would you like to go the ED?" "Yes please". It's just faster, less fuss, and less liability this way.

We have people call 911 from the waiting room after being discharged, thinking they'll get another doctor who will give them narcotics.

I've had a few people make the mistake of telling me that they were waiting in the ED lobby, got tired of waiting, came home to call 911 because "you can get us back faster". I make it an effort to take them back to the lobby.. Guess what, back of the line baby.. I've never personally been on a run in the lobby itself, but I have heard them dispatched several times.

 

[GeneralVeers]

I've had a few people make the mistake of telling me that they were waiting in the ED lobby, got tired of waiting, came home to call 911 because "you can get us back faster". I make it an effort to take them back to the lobby.. Guess what, back of the line baby.. I've never personally been on a run in the lobby itself, but I have heard them dispatched several times.

If repeat offenders come in by 911, or stuff that's clearly non-urgent (prescription refill, chronic pain, etc) I make it a point to have the charge nurse send them out to triage and then the lobby. If you as a patient are going to waste the time of the paramedics and ED staff, I'm going to waste your time in return.

 

[emtcsmith]

I think the overall education of system abusers is so low that any attempt to educate them on the use of 911 simply fails. The welfare population pays nothing for the service so they give it no thought to use it. My absolute favorite are the minor/non-acute/non-emerg calls that are within walking distance to the hospital. I once pointed down the street and said "you realize the hospital is right there." I believe the reply was "what, you want me to walk?"