Many of the issues discussed in this article are being addressed through innovative community paramedicine programs, especially by EMS leaders who are striving to achieve the IHI Trip Aim.
The radio in the emergency department crackles to life. The incoming ambulance is alerting us to its imminent arrival to the ER. Could it be a gunshot wound? Perhaps a STEMI? Or a patient barely hanging on to life after a terrible MVA? Will we need to mobilize our resources to receive a critical patient and be on the ready to act quickly?
We have some great nurses in our ER, and tonight’s charge nurse is particularly capable. Her ears perk up at the sound of the radio, so she stops what she is doing to walk over to listen to the transmission. It’s another crazy, busy night in the ER, with patients waiting up to seven hours to be seen, so she’s got her hands full. Seven ambulances fill the bay in the back and they just don’t seem to stop coming.
As I pass by the radio room, I pause to listen to the paramedics relaying their information. The charge nurse shoots me a look, conveying her annoyance, as they report that the incoming patient has “suffered” a sprained ankle two days previously.
WHAT????!!!
What a waste of time and resources, for sure. The patient is seen by one of our doctors and discharged home, the mode of transportation being a friend’s car. If a patient can arrive by ambulance and go home shortly thereafter via a ride from a friend — perhaps stopping off for a beer on the way — this system is out of control. Where have we gone wrong? What can be done to ameliorate this situation?
In my curiosity, I’ve asked many people just these questions. A few have tried to tell me that it is just a problem here in America because of “our health care system,” although I find some of their reasoning to be fallacious. In fact, a Medline search will yield articles from around the world with many countries trying to grapple with the same problem, including Australia, England, and Japan.
Why do people use ambulances to come to the ER?
Before visions of Johnny Gage from Emergency’s Station 51 leap to your mind, read this list of common, non-emergent reasons people call an ambulance to transport them to the ER:
- I didn’t have a ride
- There was an argument at home
- I thought I might be seen more quickly
- I wanted my family to know I was really sick
- I needed a prescription refill
Just by looking at the statistics at my own hospital, it seems a number of patients use the ambulance simply because they can. I sometimes ask patients why they come to the ER in an ambulance and rarely do they feel that their problem is life-threatening.
Take a look at what one study in London revealed [1]:
- 75,000 calls annually (approx. 16 percent) were unanimously considered to be inappropriate
- 93,000 additional calls (approx. another 20 percent) were considered “possibly” unnecessary
That’s a huge waste of time, energy, and money. Since I know that an ambulance ride generally isn’t very cheap, somebody else must be picking up the tab, if it isn’t the patient.
Even Sweden is not without problems. A June 2007 article found a significant number of EMS transports did not need any pre-hospital interventions, and hence could have arrived safely via many other routes [2]. They recommended that EMS agencies develop clear criteria for dispatch to assist people in the proper utilization of ambulances.
So why is ambulance misuse and abuse a problem? To name a few issues:
- Overstaffing of ambulances is needed to weather the burden.
- Patients with real medical problems are forced to wait, and their care gets delayed.
- It is hard on morale for EMS providers if, after years of training, we are relegated to becoming a medical taxi. While driving a taxi is a worthy career choice, it does not take the same level of training, and is an inappropriate use of EMS talent.
- Imagine the waste of insurance dollars on ambulance charges that are unnecessary, or the loss to ambulance companies when/if a patient doesn’t pay for their misuse of the system.
How did this happen?
It is my belief that there has been a societal shift over the last 20 years.
- As a society, we have weakened our definition of just what is an emergency.
- We have a McDonald’s mentality — “I want a cheeseburger, and I want it now” — without any delays.
- We seem unable to say “no,” in large part because of fears of legal liability if we say no.
- When there are attempts to place reasonable limits of utilization, there seems to be an outcry of “Wait, you can’t do that! What about …? It’s not fair!”
Are there any solutions?
I hope so, but the real question is will we have the guts to change things? I think that more than anything else, we want our efforts to “count,” and for us to be seen as a value to our community. It does seem to me that ANY service not perceived as valuable to a person will be used inappropriately if the service is “free.” I think we will need to find ways to make these services hold more “value” in the eye of the consumer.
Studies in other countries showed that even a nominal fee that comes from the patient’s pocket reduces excessive utilization. Many people think twice about the necessity of their trip to the ER if they have to spend even a small amount of their own money. Perhaps we should consider a nominal charge.
Solutions I think about at 3 a.m. in the ER:
- Hold the users accountable. In California, just about everyone has a cell phone. Apply a charge to their cell phone bill. I am sure they will be much more motivated to pay their cell phone bill long before they pay any ER bill.
- Our local fire department announced they would no longer roll on every EMS call if dispatch deemed they were not needed. Good idea!
- Better idea: allow dispatch to use advice nurses who can advise patients, arrange for follow-up appointments, and alternative modes of transportation.
- Encourage more treat-and-release policies for EMS so that they do not have to transport every patient, but still get reimbursed for the encounter.
- Allow on-scene EMS to assess the need for ambulance transport.
Having worked in ER over 20 years, I understand how the ER has become our nation’s safety net for health care. I also understand that to even talk about looking into ways to protect and husband our health care resources (which include everyone from first responders to ER nurses and doctors) gets people all riled up. Nevertheless, I do believe that if we are not part of the solution, we are part of the problem.
Ok, now a challenge to my readers: you are out in the trenches, and no doubt run into similar situations. What are your suggestions? How can we fix our problems? Leave me a note, or email me, and I’ll put some of the good ideas in a future article.
References
1. J Accid Emerg Med. 1998 Nov;15(6):368-70.
2. Eur J Emerg Med. 2007 Jun;14(3):151-6.
