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EMS transports patients to clinics seeks to relieve ED crowding
Potentially unstable patients may be seen more quickly
In the first phase of a two-phase process, paramedics with Grady Emergency Medical Services in Atlanta now have the option of transporting patients with less-urgent ailments to Grady Health System clinics instead of the ED. Emergency leaders believe this strategy will provide the most appropriate care for these patients and help alleviate some ED crowding.
"This first phase is designed to shorten the time to definitive medical care for stable patients with conditions that are treatable in clinics, and help overcrowded EDs by distributing them to the best point of care," says Arthur Yancey, MD, MPH, associate professor of the Department of Emergency Medicine at the Emory School of Medicine and the medical director of the Grady EMS. "We think that in a related result, it will shorten the wait time to definitive care for potentially unstable patients who are in the hospital ED."
In this phase, trained paramedics may designate the patient as eligible for one the clinic destinations. "As far as criteria for transport, once the medic evaluates and confirms stability and matches the complaint on the scene with that of the call from dispatch, and if the patient is not having additional emergency complaints, the patient can be eligible to go to an ambulatory clinic," says Yancey.
These patients have to be over age 18, mentally stable, with a steady gate, able to sit in a chair, and willing to be evaluated and treated at one of the three Grady ambulatory health clinics, he says. Yancey says typical conditions include boils; bumps; a request to cut off rings from fingers; earaches; gout; objects lodged in the ear, nose, or vagina; sexually transmitted diseases (STDs) and penis problems; rashes and skin disorder; sore throat; and toothache.
When Phase II begins, sometime before the end of this year, the process will add the ability for the EMS call taker to refer the 911 caller to a nurse advice service within the Grady system. The nurse then will evaluate the calls through a secondary triage process using protocols complementary to the formal Emergency Medical Dispatch system (EMD) and make clinic appointments for these patients over the phone.
The impetus for the program came from the Grady CEO, says Leon L. Haley Jr., MD, MHSA, chief of emergency medicine and vice chairman of clinical affairs for Grady Health System and associate professor in the Department of Emergency Medicine at Emory University. "He was just trying to look at our resources use from an EMS perspective," Harley says. "There may be too many people in the ED who could be better served in the clinic."
While the program was designed primarily by EMS leadership, "Since Dr. Yancey happens to be a faculty member in our Department of Emergency Medicine, he shared with me the protocols and processes he was working on," he adds.
Haley is not quite as sanguine as Yancey about the prospects for ED crowding relief. "There will certainly be some patients who are able to be taken to a clinic, but I doubt whether there will be a huge impact on throughput," he says. Haley adds, however, that "if it can truly make an impact and create a different setting for patients in a lower acuity condition, anything that EDs can do to support that is great."
For his part Yancey points to a study conducted of a similar approach in Seattle, which showed that 44.6% of all EMS patients went to the ED, compared with 51.8% without the clinical alternative.1
Pilot program may add ED nurses
The Houston, TX, EMS had a similar goal of relieving ED crowding. However, because of quality concerns, the two-year-old pilot program is considering replacing its nurse call line with ED nurses, according to David Persse, MD, physician director of the Houston EMS and the Public Health Authority.
Currently, the call line is staffed by registered nurses that do not have ED experience. "We need the critical thinking of experienced ED nurses participating in this program," Persse says.
Part of Persse's concern about a "tragic outcome" and the possible need for ED nurse consults stems for an incident that occurred under the current system. It involved a 19-year-old patient with many chronic medical problems. "His aunt called 911 and described a 19-year-old who was awake and alert and having abdominal pain. She described a healthy 19-year-old with stomach pain," Persse recalls. The nurse heard the patient moaning in the background but did not question it. She stuck strictly to the protocol. At end of the algorithm the advice line uses, she recommended they go to the ED right away and asked if they had car. "At that point the Mom got on the phone and became angry, an ambulance was sent, and the patient died five days later of complications from chronic medical problems," says Persse. "The whole call lasted eight minutes, but the media attributed the outcome to the length of the phone call."
The way the system works is this: If the receiver of the 911 call determines after a quick screening process that this is a low-risk patient, the receiver turns the patient's call over to the nurse, who can immediately send the call over to an ambulance dispatcher. "They already have the address and patient information in a queue," Persse says. "When the dispatch button is sent, it's all automatic," Persse explains. "They could be sent to the ED immediately, if necessary."
If the patient does not necessarily require an ambulance, the nurse asks if the patient has transportation. If not, the nurse can provide a cab, since the EMS has a contract with a local cab company.
Like Grady, the Houston EMS involved local EDs in the development of the process through the Harris County Healthcare Alliance, with whom the EMS consulted. [Editor's note: If you have any additional suggestions for alleviating ED crowding, we'd love to hear about them. Please send your comments to: Steve Lewis, Editor, ED Management, at firstname.lastname@example.org.]
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Satellite ED 'sells' the EMS
Apparently not all EMS providers are enthusiastic about transporting patients to alternative sites, even if that site is a satellite ED. That was the case in 2004 when Swedish Health Services of Seattle opened the first satellite ED in the state.
"They said, 'How can we bring patients here if you're not connected to a hospital?'" recalls Nancy J. Auer, MD, FACEP, vice president for medical affairs and then-chief medical officer at Swedish Health. "Our bias was it was better to stabilize patients at a full-fledged ED with state-of-the-art equipment than transporting them longer distances."
Auer overcame their reluctance by taking them on a tour of the facility, which not only had the latest in equipment, but even had its own decontamination facility. Then, she says, "We set up parameters about the type of patients everyone felt comfortable having there."
The EMS followed the registry for a period of six months to see if the patients had received adequate care, and when they saw the results were positive, they relaxed their restrictions a bit and followed the registry again for another six months.
"It worked so well, we put up three more freestanding EDs in the community," says Auer.
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