You called 911 for this?!

I am reminded of a satire video I saw a few years ago, a play on the song by Lady A “I Need You Now.” (Link to video)In it, the satirists change the words to “My Knee Hurts Now,” the gist of it is a lady who calls 911 for the seemingly trivial complaint of knee pain, naturally at 1am. A quarter after 1 to be exact. I have seen otherwise decent EMTs and paramedics get truly upset and borderline angry because someone had the nerve to call EMS for something that they deem unworthy of their life saving skills. Most of us have had at least one moment of frustration after a busy day when we are cold, tired, or hungry, or all three, and we just don’t want to run this really minor call that appears to not need an ambulance.

That said, I found a change in mindset helped with that frustration for me. Consider WHY the patient called 911. Not their chief complaint, but why they chose to go by ambulance for their complaint. Consider they do not have a car, and they do not have the money to pay for a cab or an Uber, how do they get to the hospital? Or, they do have a car, but no health insurance and therefore no primary care physician. Where are they going to get healthcare? Let us say they are mobility impaired and cannot get out of their house. What if all they have ever known is that if they have a medical problem, they call 911. When they do, an ambulance will come pick them up, and take them to the hospital where they will get treatment, right now, all the time, without exception. In my experience, the most common reason people call for nonemergent complaints are access issues. 911 and the ED are the only ways they can access healthcare; they can get help for their condition right now.

A paper by Jason Jones of the University of Nebraska concludes:

“Non-emergency use of EMS resources is a growing issue in the US. As the number of requests continue to increase, many agencies may experience increased difficulty meeting the demands of the communities they serve. Patients request EMS, and subsequently treatment in the ED, for non-emergency problems for a myriad of reasons; most notably poor access to primary care or alternative acute care, convenience, lack of transportation, financial flexibility, and perceptions of severity and quality of care. For many patients, the reason can be reduced to a lack of means in obtaining appropriate medical care. EMS agencies ultimately serve as a vital component of the nation’s healthcare safety net and careful consideration must be applied to any interventions that may unintentionally disrupt this function. Given the fragmented nature of healthcare in the US, EMS agencies have a unique opportunity to facilitate connection of patients to available resources and to fill gaps in care that have not yet been addresses by existing systems of care.”

The entire paper is linked below.

Being nonjudgmental in our delivery of care is all our responsibility. We treat people, not patients. While some complaints may seem trivial to some, it just might be the worst day of that person’s life. We are the professionals, the safety net for broken system, which has been exacerbated by COVID and staffing shortages. Minor complaints may tax a system, but that is not that person’s fault, that is a system problem. Be kind, be professional, and be present.

What are some solutions, in my opinion? Enhanced non-transport, telehealth and alternate destination options for patients. The first part of any of those options is that we do no tell the patient which option they are choosing, we provide the options to the patient so that they can make an informed decision. Currently in Wake County we transport primary mental health patients to mental health faculties, and have done so for over a decade. Our protocols and partnerships are proven to be safe and effective, and can be expanded to other patient populations as well. We are also participating in the CMS Emergency Triage, Treat and Transport program allowing Medicare patients to have the option of telehealth or to be transported to urgent care. Our “ Falls in Assisted Living Centers” (https://pubmed.ncbi.nlm.nih.gov/29230475/) also allows patients to stay in their facility, not need to be transported when appropriate and still receive the best care. Our nurse navigation line has been helpful as well, diverting 1,000 plus calls this year from the 911 system. Expanding these programs to Medicaid and private payors would be huge, allowing EMS to be reimbursed for transports other than to the ER.

EMS systems must adapt and be creative in their delivery of service. Increasing demand, decreasing staffing and further strains on the healthcare system call for innovative solutions. 

 Jones, Jason, "Non-Emergency Utilization of EMS: Contributing Factors and Strategies to Promote Effective Care with Appropriate Resources" (2020). Capstone Experience. 128. https://digitalcommons.unmc.edu/coph_slce/128

Another good paper:

Mahmuda, Sabnam & Wade-Vallance, Adam & Stosic, Alix & Guenter, Dale & Howard, Michelle & Agarwal, Gina & Mcleod, Brent & Angeles, Ricardo. (2018). Understanding Why Frequent Users of EMS Call 9-1-1: A Grounded Theory Study. Health Promotion Practice. 21. 152483991879950. 10.1177/1524839918799504. Introduction:

Frequent users of emergency medical services (EMS) have disproportionately high 9-1-1 call frequency. Evidence suggests that this small group burdens the health care system, leading to misallocation of already-limited health resources.

Aim:

To understand frequent users' perceptions and experiences regarding EMS, as well as the driving factors underlying their frequent use.

Method:

A grounded theory approach guided our qualitative research process. Participants older than 17 years who called EMS five or more times in the past year were consecutively sampled where each participant was contacted in the order they appeared on our list of potential participants for interviews until data saturation was achieved. Transcripts were analyzed to derive common themes among frequent EMS callers.

Results:

Frequent EMS calls often resulted from chronic medical conditions creating recurrent crisis situations, mental health issues as well as mobility issues, frequent noninjurious falls, and social isolation. Combined with these factors, perceptions of the purpose of EMS and social circumstances also contributed to the creation of complex health issues that influenced frequent EMS use. These findings can advise the development of future paramedicine programs and health promotion interventions.

Link: Study

CMS ET3 Page: https://innovation.cms.gov/innovation-models/et3