EMS Today 2019 Quick Take: Alternative transport destinations

Applying global solutions and the CMS ET3 model to EMS’s low acuity patient population with alternative destination transport

NATIONAL HARBOR, Maryland — Identifying time-critical emergencies and the need for regionalization of care inspired the creation of specialty referral centers (SRCs), leading to trauma centers, STEMI specialty and stroke centers. 

But on the other end of the spectrum lies a cohort of patients with low acuity diseases or injuries. In a session at EMS Today, Alan Butsch, MA, NRP; and Roger Stone, MD, MS, FACEP, FAAEM, FAEMS, discussed reversing the SRC model to invoke reverse specialty centers (RSCs), allowing EMS to choose alternative transport destinations besides the hospital ED.

Left to right: Alan Butsch, MA, NRP; and Roger Stone, MD, MS, FACEP, FAAEM, FAEMS.
Left to right: Alan Butsch, MA, NRP; and Roger Stone, MD, MS, FACEP, FAAEM, FAEMS. (Photos courtesy of https://www.montgomerycountymd.gov)

Butsch, battalion chief, Montgomery County (MD) Fire & Rescue Service; and Stone, medical director, Montgomery County MD Fire Rescue; faculty, University of Maryland School of Medicine, Emergency Medicine MIEMSS Region V Regional medical director, explained that the reverse specialty center is another tool in the triad of right place, in the right time, for the right care.

Top quotes on alternate EMS transport destinations

Here are some of the quotes that stood out during Butsch and Stone’s presentation on alternate transport destinations.

“We don’t want to turn EMS into a taxi service, nor should we diminish our role in caring for high acuity patients.” — Roger Stone, MD, MS, FACEP, FAAEM, FAEMS

“We’re using a sledgehammer to kill a gnat.” — Alan Butsch, MA, NRP

“Time is the great healer or the great destroyer.” — Roger Stone, MD, MS, FACEP, FAAEM, FAEMS

Top takeaways on alternative transport destinations for EMS

Butsch and Stone examined the changing U.S. healthcare system, global solutions to similar challenges, and how alternative transport destinations for EMS ties into the new CMS ET3 model. Here are the top takaways.

1. Bend the utilization curve away from EMS transport to the ED

Stone began by telling the audience what alternate transport destinations does not mean for EMS. “We’re not advocating that EMS transport is a free for all to any place that holds itself out as a place that provides medical care,” he said.

But as call volumes and demand are increasing, the questions become, “how are we going to meet that growth?” and “should EDs continue to have to carry that load by themselves?”

The paradigm of 911 call leads to EMS response to transport to ED is “Cadillac care,” Butsch related. “We have expensive and well-built systems. If you’re having a heart attack, stroke or trauma, we do a great job of getting you there in a timely manner.” This works well for a small subset of the population that need it, he added, “But, what about Mrs. Smith?”

There is a spectrum of low acuity illness that is smoldering, where there’s not an immediate threat, but if the patient doesn’t get medical attention in the next 18-24 hours, there is going to be a bad outcome (e.g., an appendix).

But there are many patients that rely on EMS when they don’t need to. The public’s poor healthcare literacy contributes to call volumes, Stone noted. “Many of them only know about 911. No matter what we do, we are always going to be responding to the patient’s belief that they are sick or injured.”

Healthcare itself is changing at the macro level as systems deemphasize hospitalization, Stone noted.

"It’s time to bend the utilization curve of emergency transport services away from the one-size-fits-all, ED-centric model, and add more tools to the toolbox," he said. "We need to be bringing the right patient to the right place within the right timeframe so that patients get a disposition that matches the need and urgency to the patient’s pathology."

2. EMS needs another solution for low-acuity patients

Butsch noted other countries have taken the lead on triaging emergency calls. Australia’s triple zero (their 911 equivalent) call triaging system quickly identifies high priority cases and dispatches an ambulance to life-threatening incidents. Less urgent, not time-critical calls, are addressed in a secondary triage by paramedics and registered nurses, who ask questions and may provide another option:

  • Non-emergency transport
  • Connecting with a doctor or pharmacist
  • Providing health advice to support the patient to treat their condition safely at home

Only 85 percent of calls to triple zero result in an ambulance being dispatched, Butsch reported. “They’ve all realized there’s a better way to take care of that 10-15 percent of patients that don’t need to go to the emergency room.”

3. Pilot program in alternative transport destinations identifies need for narrow protocols

Butsch told the attendees how Montgomery County Fire and Rescue’s began an alternative transportation program 3-4 years ago. What started with a proposal to recruit a cohort of primary care, urgent care, free clinic and nursing observational care partners, became a pilot program to see if EMTs could triage to two urgent care centers.

Montgomery County’s experience identified these key decision points in an alternative transport model:

  1. Urgency and complexity. How quickly does the patient need attention, and what resources are needed to diagnose and treat this patient? The destination must have matching capabilities.
  2. Receiving party. Before transporting, EMS needs a guarantee that a medical professional is available to see patients at the destination.
  3. Payer issues. One benefit of transporting patients to an urgent care center over the ED is the lower cost associated, but Butsch pointed out having multiple destination options is clouded by insurance networks. This prompted a move to ask for insurance information at the time of the 911 call to identify payer issues.

In the triage process, they found EMS could have some influence on the decision safely, when relying on EMS first, then a physician. In their pilot program, they took 400 patients who met the alpha omega protocol. They trained one group in a triage protocol, and asked them how they would triage patients as safe for urgent care, and compared the results to an untrained group’s decisions, based on outcomes and ICD-10 codes. “Our own protocol was just a bit better than flipping a coin, in terms of sensitivity and specificity,” Butsch said.

This means changing the protocol and adding layers of safety; strong inclusion and exclusion criteria. We need narrow protocols to specific scenarios or involve a PA or physician in the decision due to the complexity of the patients, he noted.

Butsch noted there are at least three systems – in San Francisco, San Antonio and Colorado – that use an inebriation checklist to divert some patients to a sobering center, reducing the burden on EDs.

4. Alternate destinations aligns with ET3 reimbursement model

“CMS agrees – you call, we haul should not be the only reimbursable option we have in EMS,” Stone said, referring to the newly announced Emergency Triage, Treat and Transport Model (ET3) for reimbursement. 

We think there is space for this in EMS, Butsch noted, “we have to be careful how it happens. Triage decision is pretty darn critical, but it can be managed in some cases by EMS, in others by an advanced level provider; that’s part of the ET3 model.”

Stone suggested, though integrated health is difficult for EMS systems to incorporate in their general practice, there may be easier steps, like matching frequent EMS users to coordinated care. “Dip your toes in without spinning up a whole system.” Look at the possibility of robust care facilities that deliver care for low acuity patients. 

Additional resources on alternate destinations and ET3

Learn more about alternate transport destinations and the Emergency Triage, Treat and Transport Model with these resources from EMS1:

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