The Challenge of Safe Non-transport

1. The Challengeof Safe Non-transport Managing Risk while Optimizing System Efficiency: The Future is Upon Us!

2. Jeff Beeson, DO, EMT-P, RN, DABEMChris Chiara, LP, BSRaymond L. Fowler, M.D., FACEP

3. Who Are We Really?

4. The Logic of Non-Transport • We do it ALL the time • The ACTUAL incidence of error is low • “It’s the tip of the iceberg.” P. Pepe, MD • Can we actually “write down what we do all the time”?

5. SCOPE OF THE EPIDEMIC:PREVIOUS REPORTS • Hauswald M; 2002: PEC 6(4): 383 • Silvestri S et al; 2002: PEC 6(4): 387 • Vilke GM et al; 2002: PEC 6(4): 391 • Pointer JE et al; 2001: • Ann Emerg Med 38:268 • Zachariah B et al; 1992: • Prehosp Disaster Med 7: 359

6. Hauswald 2002 • Prospective survey in Albuquerque, NM • 236 patients • 183 charts reviewed • 97 patients recommended not to need ambulance transport • 23 (24%) ended up needing it • 71 patients recommended not to need ED • 32 (45%) needed it

7. Hauswald 2002 - 2 • ED diagnoses of those for whom “alternative transportation” was recommended included: • Coma - Syncope • Chest pain - Pyelonephritis • Seizure, adult onset - Liver failure • Dislocated hip - Hypoxia • Sepsis - Severe bleeding

8. Hauswald 2002 - 3 • ED diagnoses of those for whom non-ED care was recommended included: • Active labor - Multiple drug OD • Extensive lacerations - Liver failure • Child abuse - Fractures • Assault, multiple injuries • MVC, multiple injuries - Chest pain

9. Vilke et al 2002 • Telephone survey of elderly patients who called 911, then refused transport • 636 patients • 121 reached by phone • 100 participated in the survey • Average age: 72.2 +/- 6.4 yr. • CC: 61% medical, 39% trauma • 40% of non-transports said that they would have gone to the hospital if a physician had come to the phone / radio

10. Non-Transport in EMS Can EMS Systems be as reliable as Poison Control Centers or Pediatric Nurse Call Lines?

11. Managing Non-Transports • What do we do about medics who just DON’T want to see patients? • If we allow a “No Apparent Life Threatening Event Policy” to guide non-transport, we are relying on medic: • Performance • Grace • Charity • Ethics

12. Paramedic Ethical Behavior Is this an oxymoron? Or….is it not?

13. Paramedic Ethical Behavior Reversing the question…. Can we depend upon EMS personnel to act ethically? Do all medics have ethics?

14. Paramedic Ethical Behavior Must /can we create a policy that does NOT presume “paramedic ethical behavior?

15. Fowler’s War Story • Began EM in ‘78, two years before the first ABEM boards • 20 years as an ER medical director and >30 years as EMS medical director • I have seen all the mistakes, and they drive my work http://www.doctorfowler.com/www/lectures/fifteenlawsofEMS2008.pdf

16. The Chief Potentials for a Mistake Assuming you know the diagnosis Implying to the patient that you know the diagnosis Implying to the patient that it is safe to remain on-scene based upon your assessment of the problem

17. Paint Gun

18. It’s all about Patient Assessment • Primary Survey • Initiate history taking and ALWAYS DO IT TO THE BEST OF YOUR ABILITY • Secondary Survey • The “Third Survey”

19. Scene Survey/Mechanism/# pts. LOC/Airway/Cspine Respiratory Rate and Labor Pulses R & Q, N & W Skin CMT/CRT/External Bleeding Neck appearance, JVD, Trachea Chest appearance, BS, HT Quick survey of abdomen, pelvis, extremities, and back

20. Central Cyanosis

23. We hold these truths to beself evident

24. “All” Paramedics are Created Equal

25. REALLY???

26. All certified by the state…All have passed Registry… including clinical skills and a written Exam

27. ThereforeThey’re ALL EQUAL!

28. The State doesn’t differentiate between them!

29. What about physicians? Are THEY all equal?

30. Licensed by the state… Passed national boards…Residency program…Board certified…

31. Everyone knows a Physician you would not let treat your dog…Let alone your family

32. 95% of Training for 5% of Calls

33. 5 4 3 2 1

35. New EMS Model! • Right Resource • Right Time • Right Patient • Right Outcome

36. Vicious Cycle… The vicious cycle of health care for the underserved…….. Increased EMS Use Decreased Health Status Lack of Primary Care Poor follow-up care Poor care coordination Lack of Transportation

37. Community Health Patients • No defined source of primary care • “Navigating the system” issue • Connect the dots • EMS becomes primary care • “My primary care doctor is Dr. XXXX” (an E/D doc!) • Minor conditions become major syndromes • Leads to preventable admissions • Revolving door medicine • Patient’s hospital shop for meds or psych care • Or even points of interest

38. Economic Impact - EMS • FY 2008/09 Analysis • Lost Revenue • 21 “Frequent flyer” patients • 812 unnecessary responses • $975,000 charges (mostly uncollectable) • Ambulance Costs • 1,218 ambulance Unit Hours Consumed • Operational Unit Hour Cost = $116.18 • Total Cost = $141,507

39. Economic Impact - Hospital • Lost Revenue • 812 patients by ambulance to emergency departments • $2,997,904 emergency department charges billed • At ~$3,692/visit* • Minimal Collected • Costs • $345,912 Emergency department costs • Emergency department Visit • At ~$426* *2010 Survey of EPAB Hospitals

40. Resource Impact… • 4,872 E-D bed hours consumed • 1,218 ambulance unit hours consumed • Not available for other calls • Crowded emergency departments = long waits • Ambulance patients + “walk-ins” • Sicker patients = more hospital admissions • Typically uncompensated

41. The Challenge… • How do we as a community: • Deliver the right resource, to the right patient at the right time? • “Connect the dots” for disenfranchised patients? • Help people become more healthy • Personal responsibility • Save resources • Save money

42. Community Health Program • Identify at-risk patients • Frequent users reports internally • Field referrals • Community partner agency referrals • Develop a care plan • Including designating a Medical Home • Only transported THERE! • Visit them proactively • Teach them how to manage their care • In their environment! • Give them an alternative to 9-1-1

43. Community Health Program • Alternative dispositions • Clinic appointment • Including mental health • Mobile Mental Health Crisis Team • Bus Pass • Tracking use on ePCR • Compare to transportation authority ride data • Off bus route? • Non-Medical Transportation contractor

44. Homeless Shelter Calls… • Some people call 9-1-1 • To see if they should have called 9-1-1! • Trained shelter staff to access 10-digit # if criteria met • Like the CHP patients • If “OMEGA” call… • APP goes alone to the call • Arrange appropriate resource and transportation

45. Police Lock-Up Calls • “Jail-itis” calls • BGL checks • Medication checks, et. al. • Used to tie up ambulances waiting for officer to transport • Who would then often release the arrestee • Rather than have PD sit at the hospital • APP responds to ALPHA and OMEGA level calls • If transport needed, officer is called FIRST • Once on-scene, THEN ambulance called via radio for transport

46. CHP Future • Solo Omega Responses • Accountable Care Organizations • Medical Home • Primary Care Involvement • Alternative Destinations • Shared Electronic Medical Record • In Field Evaluation • No Transport Follow Up

47. It is Time for All of Us to Stand UP and Make a Difference!

48. Pay for Performance • Accountable Care Organizations • Medical Home • Work closely with Hospitals/Payers • How do we benefit healthcare

49. The Future Holds? • Alternative Responses • Triage protocol • Non-ambulance transport • Alternative Destinations • Stand Alone/Free Standing • Primary Care • Medical Home • Reimbursement

50. Pediatric Transports • How do you safely non-transport a child • Especially given the variability of patient presentation • ….and the difficulty of assessing fine changes in the “very small”… • ….and family anxiety