EMS Diversions - what it costs

[Just Plain Ruff]

Here is an article http://www.epmonthly.com/features/current-features/the-true-cost-of-ambulance-diversion-/ that shows some pretty telling statistics regarding EMS diversions by hospitals.

Read the article and discuss.

[island emt]

A few years ago diversion was quite common for us.

We have two hospitals in the next town 20 miles up the peninsula on the mainland.

They both have small ER's with 6-10 beds and all serious trauma , chest pain & strokes would be diverted to the level 1 an additional hour south. then all of a sudden they figured out that they were losing out on patients that would generally be admitted to the med surg or ICU units which were big paying customers that were being sent south..

I'm guessing that the bean counters were looking at all the lost revenue that was being diverted.

Now about the only thing we bring south are STEMI's going direct to the Cath lab and major multi system or serious head traumas as the level 1 has chest cutters and neuro on staff 24/7. The other regular transport south is patients on dialysis as the local hospitals can't handle renal pts.

[paramedicmike]

It would be interesting to see how this plays out in a system like Island's with only one or two hospital choices versus a larger system with four or five or more hospital choices.

I'm not entirely sure what the author means by a potential loss of relationship with EMS based on increased rates of diversion. In smaller systems it's your only option. In larger systems I wonder how much of "goes around comes around" comes into play.

Admittedly, though, the numbers listed are higher than I expected.

[ERDoc]

There was another article in one of the EM newspapers that talked about a study that, I believe, showed diversion worsened pt outcomes. I cannot find it right now but I'm sure it can be found on pubmed.

EDIT: Maybe I was wrong about that, but I did find this:

http://www.ncbi.nlm.nih.gov/pubmed/23352752

Edited November 27, 2013 by ERDoc

[systemet]

I found that terrifying to read. It's strange to see patient care quanitified in such abstract and economical terms. I realise this is a reality of health care in both public and private systems -- but doesn't this create a system of mixed incentives? One would assume that the point of diversion is to manage ED flow, and move the workload to less busy ERs, in order to provide more timely care for the patient, and avoid stacking critical patients in an overwhelmed facility. If this is economically disincentivised, then the hospitals are under duress to accept as many patients as possible, even when they're unable to provide their normal level of care.

Given how few EMS patients are actually time-critical, I wonder if you'd be able to detect a meaningful outcome difference for all the noise in the stats?

[island emt]

I'll add in another thought here. My wife is a med surg nurse and works second shift .When she goes in at 14:30 the ER will call up to the floor and tell them they have 6-8 pt's coming up for admission. Many of these have been in the ER all day and had tests, X-rays, Cat scans etc. They wait until the end of the shift to dump them and clear their plate downstairs, while jamming the med-surg floor with all the new intakes that have to be done at once.

We took in a lady with stroke like symptoms at 3 AM last week. She was in Cat scan before we left the ER.

My wife got her as a new admit for observation @ 8 PM that night after she sat in the ER all day & evening.

[paramedicmike]

Depending on where you are patients are boarded in the ER simply because there are no beds available up on the units. This isn't the ER holding on to these patients. This is simply a lack of availability of beds in the unit.

The ER wants these patients out as soon as possible. It serves no purpose to keep and board these admissions in the ER. It takes up a bed that can be used to assess and treat someone else. It also ties up nurses taking care of patients that need floor/ICU nursing care.

The ER in which I work hates boarding patients where they were initially seen. It affects metrics that hospital administration uses to gauge effectiveness of the staff, satisfaction scores, billing and more. Don't think we don't hear about it (even though it's not our fault and there's little we can do about it). And it's a drain of ER resources.

I can't speak to the politics of your wife's hospital. But there has to be more to it than the ER holding on to people.

Given how few EMS patients are actually time-critical, I wonder if you'd be able to detect a meaningful outcome difference for all the noise in the stats?

This comment had me thinking.

Sure. Very few of our patients may not be time critical. However, given the number of admissions from EMS delivered patients that still indicates a pretty decent level of patient acuity.

I think it would be interesting to note just how acute some of the patients are and break down the time critical cases versus not time critical cases. How do these differences play into the larger role of EMS, EMS education and our future direction as health care providers?

[systemet]

I think it would be interesting to note just how acute some of the patients are and break down the time critical cases versus not time critical cases. How do these differences play into the larger role of EMS, EMS education and our future direction as health care providers?

I think that very very few of our patients are time critical. Examples of time-critical patients probably include:

* STEMI patients who have not received fibrinolysis, or whom are best served by primary PCI, or who require rescue PCI.

* Suspected acute AAA / TAA.

* Predicted difficult airway with anticipated need for intubation, e.g. significant laryngedema/angioedema

* Suspected ischemic stroke inside fibrinolytic window, or "fairly close with good prognosticators/baseline:, i.e. anyone who might get 'lytics.

* Respiratory failure / NIPPV patients continuing to decompensate

* Possibly treatment-refractory status epilepticus.

* A subset of sick status asthmaticus / treatment-refractory anaphylaxis

* Pentrating trauma

* A small subset of blunt trauma patients.

And that's about it. Someone else will probably find a few things I missed. Things that aren't time critical probably include: moderate asthma / COPD exacerbations, most overdoses, including a fair few that are intubated, most blunt trauma, etc.

I think when we really look at a lot of those patients, for example, the average polypharm OD -- once this person's been intubated, they can probably be driven intubated another 15 minutes with relatively low risk. Because they're probably going to sit and have their liver and kidneys, and maybe a few plasma esterases, do most of the work for the next few hours or days. Likewise, many of the "chest pain", or "suspected ACS" patients we've historically got very excited about are just going to sit and homeostase and get a couple of enzyme draws.

Understand that I'm a proud paramedic, but I believe that EMS has oversold and under-delivered. Just like the ER, the majority of our work is primary care, dealing with patients that could have gone to a family medicine clinic. We do relatively little for these patients, but have a window of opportunity to direct them elsewhere. Where we see acutely sick patients, most of the time our care is primarily supportive and the best thing we do is take them to the ER -- where, at the same time, often they provide little more than supportive care until they move to ICU or whatever service is going to provide definitive care.

I think, like everyone else on this forum, and very few people outside of it, that we need to raise our educational standards, and start refocusing on the bulk of our call volume. Typically we deal rather poorly with seniors and geriatric care, we are not great at mental health, or palliative care, or dealing with the social work that form much of the basis of EMS. Some of us get good at this through natural ability and a process of trial and error and repetition. These are obvious areas for improvement.

While this is hardly unique, my system allows me to respond to palliative patients, liase with their palliative care physician, and give them pain control, antiemetics, bronchodilators, or arrange home oxygen, without having to take them into the ER. This is in its early stages, but has been well received. Other systems/regions have looked at developing paramedic/NP teams that are the first point of contact for seniors calling with urgent complaints from designated high volume centers. We're also starting to do a better job of accessing community resources, e.g. homeless shelters, following up on our high volume users, or patients with chronic issues, e.g. high risk seniors needing placement.

I think these are areas where we can improve. Every paramedic wants to do prehospital ultrasound, start art lines and do EGDT, start central lines, etc. Relatively few people want to get better at picking grandma up off the floor. This might not be what most of us expected or wanted when we entered this field. I think many of us have been seduced by the idea that people call 911 for acute medical events, where we can meaningly intervene in the field -- and this does happen, but these calls represent a minority of the events we see. I think the lack of real depth in our initial education has led us to overestimate the severity of many of the patients we encounter, and changes in our societies have led to more urgent versus emergent calls. I think that we need to move away from a public safety role, and towards a model where we form part of the health care system and present the point of first interface with the healthcare system.

.

I'm not sure how well I'm making my point, and I'm certain that these ideas are far from unique or revolutionary, but this is how I see EMS moving forwards in the future.

[paramedicmike]

I think you're making your point pretty well and I agree with what you've said. The comment you quoted was based on the thought that upwards of 60% of EMS transported patients, based on the study in the OP, wind up admitted (system dependent). While the time critical cases are, indeed, few and far between compared to the more run of the mill calls, the acuity is still there. Further breaking down those admits to an ED Obs versus floor admit versus ICU admit et cetera, from an academic point of view, would be interesting to analyze in light of EMS education and how to improve upon it based on what we're actually seeing.

Perhaps it was me who wasn't expressing thoughts clearly. I'm still not sure that I am. It wouldn't be the first time it happened.

Maybe I just need to go to sleep.

[systemet]

I think you're making your point pretty well and I agree with what you've said. The comment you quoted was based on the thought that upwards of 60% of EMS transported patients, based on the study in the OP, wind up admitted (system dependent). While the time critical cases are, indeed, few and far between compared to the more run of the mill calls, the acuity is still there. Further breaking down those admits to an ED Obs versus floor admit versus ICU admit et cetera, from an academic point of view, would be interesting to analyze in light of EMS education and how to improve upon it based on what we're actually seeing.

I agree wholeheartedly. I'm surprised that the admission rate is so high, although I think we'd also agree that the majority of the admitted patients were probably not time-critical in the sense that a 15-30 minute delay would have affected morbidity/mortality.

In terms of improving education, I think we need to alomst start from the beginning, and move it into a university model for paramedics, and a two year diploma for BLS.