Patrick,

I agree with you, in part.  Many calls on 911 for EMS response are certainly due to inadequate access to primary care, including transportation issues, lack of insurance, lack of available primary care physicians, etc.  Those may be addressed by providing direct medical services in under-served communities.  However, due to the success of public education regarding 911, many patients and citizens will continue to dial it in the absence of medical services or absence of knowledge regarding alternatives.

In that light, EMS systems must make efforts to provide the "right response" to 911 callers, particularly low-acuity, non-emergent patients who can be effectively assisted by telephone nursing, including basic triage, referral information, medical advice, self-care instructions, and very often just reassurance that a condition can be treated within 24 hours or a couple of days, rather than immediately by a EMS crew in a fire engine or Aid unit.  Engines and Aid units with transport capabilities occupied by tending non-emergent patients can be unavailable for response or delayed to true emergencies such as fires, cardiac arrests, trauma, strokes, etc.  To provide the best possible care for all patients, EMS is responsible morally and fiscally to investigate and field more cost and resource-effective options.  Louisville is on the right track, even if other initiatives for improving public health can be put into place.  EMS must cope with the health care system as it is, not as we might like it to be.

As I noted in a previous post, in King County WA, we continue to work on options for low-acuity and under-served patients, including a 24 hour consulting nurseline (available to all, not just health insurance clients), a Community Medical Technician response unit (two EMTs in non-transport SUV), and taxi-transport vouchers for non-emergent patients that do not require an ambulance and have no transportation options.

Jim

Bill, well-said and summarized.  The example you provided is representative of many Americans, who might make more appropriate care choices if they were provided with information, both beforehand and also during medical incidents when they may have forgotten or are too stressed to recall their options.  The challenge with EMS public education is providing a message that is easy to grasp and internalize, but does not cause patient confusion or doubt about reporting true medical emergencies.  I personally recall many calls from elderly patients experiencing chest pains who were questioning if they should even dial 911.  For cardiac arrest and stroke, seconds are precious and we do not want callers to delay reporting.  We therefore are very careful about what pub ed approach to take for non-emergency calls and have not yet settled on any new strategies.

Patrick, it's true that nurse triage won't solve all the problems that contribute to overuse of EDs, but no single solution will.  There will need to be a variety of approaches and ingredients for effective change to occur.  I don't believe that EMS demand and ED overuse are distinct, separate issues.  They are both inter-related elements of the entire "non" Health Care System, as Bill points out.  Even the National Health Service in the UK is challenged by non-emergent demand for emergency medical resources such as ambulances and EMS personnel.  They have also piloted tele-nursing systems with varying results and patient acceptance.

Roger, thanks for your info.  You have links to EMS nurse triage info and reports that I hadn't yet seen.  I notice that your site references Philadelphia's telenurse proposal in several places.  Their Director of Financial and Policy Analysis Kent Reichert contacted me while he was researching their proposal last year.  But the last I heard, they have not yet implemented anything. 

Patrick - I have not yet had the chance to completely review your analysis, but one thing that struck me was:

Further, the 2009 EMS Annual Report to the King County Council indicates that “29% percent of all BLS patients are not transported,” so I infer that individuals are transported are more likely to need actual ER services than individuals who arrive at ERs using other forms of transportation.

This assumption cannot be made without a closer review of medical records for the transported patients.  I do not yet have supporting data, but we have learned anecdotally that a good number of BLS patient transports to EDs are not medically necessary.  Many patients are transported by ambulance to EDs because they do not have any other method of traveling, they believe they will get to the "head of the line" if they are brought in by EMS, they insist on transport even when EMTs believe it is not necessary, or they have not been informed of other treatment options besides transport to an ED (PCP at later time, clinics, etc).  When in doubt, some EMTs arrange a transport to EDs simply to avoid liability.

We have found that similar low-acuity patients transferred to a nurseline (NL) are provided with decision-making assistance and treatment resource information that EMTs either do not have or do not provide due to time constraints.  I think we can agree that a certain percentage of ED load is caused by lack of information for patients. A relatively low investment for information and triage supplied by a nurseline service provides a significant return in both improved patient care, conservation of EMS resources for higher acuity patients, and a side-benefit of decreasing unnecessary ED visits by patients who can be treated appropriately elsewhere.  In 2010, for $71,000, our NL will provide service for approximately 2,000 callers, or $35.50 per caller (Approximately 2% of BLS calls in King County outside of Seattle). On average, 10% of patients transferred to NL are transferred back to EMS for response.  If the remaining 1,800 patients serviced by NL were instead transported by EMS at a 71% rate (2009 EMS Annual Report), 1,278 patients would present at the EDs, most for treatment that could have been provided more effectively in other settings. $35.50 per patient seems a small price to pay for these effective diversions.

Again, I support NLs as a cost-effective element of the solution to ED loads --- not the only solution.

There is no question business model used it critical. We have several we now consider to avoid the costs you are talking about. If you try to hire, train, setup call centers with all the bells and whistles this will be a very expensive endeavor, at least initially. The home call model may work in rural or limited populations, but not very well for densely populated metro areas. The Philadelphia model of call management shown in the Controller Report linked on my web site has the right elements of having calls handed back to 911, if the symptoms begin to characterize a potentially emergent or risky situation. In high call volume this needs to be a robust process so response times to those calls are kept at a minimum to also limit risks. Classically not all Nurse Call lines have worked because the general population calls 911 anyway most of the time. In Alberta they have assigned 811 for all nonemergent medical calls statewide. This is very smart because this limits risk too. The patient is actually qualifying their situation as nonemergent to the provider or call center. In America this is likely not going to work for some time, if selected, because most just call 911...

Roger Heath

Primary care centers could benefit also from telephone triage.  Instead of just booking the clients that who first.  It would help them prioritize who needs to see the physician and who could see the midlevel practioner.   As well as identify who needs to see immediatly.