System Abuse, Call Volume & EMS

[AFS1970 504]

I was thinking about some of this while reading the thread about the situation in Englewood, but as I wrote the reply, I realized it was a topic all its own.

While increasing call volume may have contributed to the need for paid staff, and system abuse has certainly been a large part of that call volume increase, I don't think anyone in management really wants those calls to go away. This is simply because we allow departments to bill for EMS, instead of having the local governments provide it, like they do (in general) Police & Fire services. As long as those system abusers equal income, there is a vested interest in transporting them. Since welfare / Medicare / Medicade and in some cases insurance will pay for those bills if the patient does not, there is no reason to turn them away.

A free service has more stake in remaining available for emergencies and as such will be more likely to undertake the public education campaign needed for such a change. Since a free service, is likely under bigger budgetary restraints, they can’t expand rapidly as call volume increases, so they need to conserve resources more.

Another thing is that prioritizing calls really only works well in a multi-tiered system. In Stamford all ambulances are ALS staffed by at least one Paramedic. So even though we have state mandated EMD, and we are strongly encouraged to find the right priority code for the call, after they are coded, they all get the same ALS response. So triaging out the calls is only good if there is a non-response option which we do not have. I have tried arguing in favor of sending a call to a transport company but have been told on multiple occasions that “we have to send them an ambulance because they asked for one”. The callers know this full well, and feel free to call for toothaches, stubbed toes, the common cold, ect. True call prioritization will lead to reform, in that the low priority calls will be handed off, handled slower, or possibly be delayed while an emergency call is handled. Especially in a small single ambulance town, where the impact will really be felt.

I have many friends who are in EMS, both in Stamford and other places, both Career & Volunteer but as long as EMS is not government supported, no agency is going to want a call coded non-response if it means it will be passed off to another private company which is effectively their competition. Small VAC’s that receive donations are often reluctant to turn down a call, in fear of loosing potential donations. In a way, system abusers are the lifeblood of such a system, because they guarantee call volume, even if there are no emergencies today.

[SageVigiles 1,194]

I agree, the system needs to be reformed so that non-emergency calls get a lower priority so that if a true emergency occurs, emergency resources can be put to better use. Its a waste to send ALS personnel to the "not feeling well" calls, and it puts other potential victim's lives in danger. Small towns with only 1 or 2 ambulances can't afford to do that without putting people at risk.

[Guest alsfirefighter]

I was taught 2 principles in firefighting and EMS that I still love and stick to today:

1. There is no such thing as a rekindle...just bad overhaul.

2. There is no such thing as "system abuse"....just lack of public education.

What we deem non-emergent calls to some are. What another person deems ambulance necessary, when I wouldn't call for one if my leg was cut off, doesn't concern me.

How can we say the "system abuse" is some of the problem...when there is no problem getting multiple crews for MVA's, penetrating trauma and so on. Right after an agency goes mutual aid for a general illness....aka...vomiting 5 minutes prior to that?

If you want it to stop educate the public. Stop going lights and sirens to everything and walk them to triage when you get there. There will still be low priority calls...call it job security, but the percentages will get better with time if everyone is on the same page and does what is needed to be done.

[Guest]

Per usual, i'm with ALS on this one - in fact he took the words out of my mouth.

We, as EMS providers, cannot sit back and be critical of someone's decision to call 911 - they have every right to utilize the service they pay for.

Once again, ALS makes a great point. It’s easy to sit back and say that system abuse drags EMS down, but let’s not kid ourselves. It’s the rule, not the exception, that you’ll hear department, after department get paged out for "injuries from a fall." 20 minutes later a VAC finally decides to muster a crew, and off they go. 30 minutes later, the agency that was originally dispatched for the fall gets toned out for a MVA w/extrication and they are out the door before you can say ambasol.

I hear it all the time, and it drives me through the roof. How could an agency sit back and ignore a "routine" call and then be out the door before you know it on a real juicy trauma. Its unethical, unprofessional, and downright wrong - i would argue its borderline criminal. Yet they will willingly accept your tax money, donations and positive press, praising them as heroes. While i could care less about getting my name in the paper, it would be nice to get some respect once and a while - after all, i respond to EVERY call I’m assigned to, I can’t choose.

As far as "free" services. There really aren’t any "free" services. The budget for FDNY*EMS is probably made up largely, if not totally funded by tax dollars. Ask anyone that has worked, or is currently working municipal EMS, they’ll tell you there is no shortage of shucking crack heads and drunks back and forth to the hospital every week.

Education really is the key. I know the NAEMT put out, or at least, published a PSA. While corny, its the first attempt i have seen to try to educate the public on what we do. My mother recently told me that the Westmore News in Rye Brook/Port Chester did a very nice spread on Port Chester-Rye-Rye Brook EMS and went over everything from what they do, their training, their pay (and the fact that most of us have to work multiple jobs!) etc. Utilize triage and the waiting room, and if time/situation permits, try to explain our situation!

sorry for the rant

Edited February 16, 2007 by 66Alpha1

[AFS1970 504]

No one should be sorry for ranting in this thread, as I started it with a bit of a rant. I had not even considered the thought of the no one showing up for the minor call then everyone showing up for the major call aspect of this. It has been a long time since we had Ambulance staffed that way in Stamford, so I often forget about those calls.

I was not in any way saying that there should been a non response of someone. I do think that if there is a non emergency service in the area, that some calls once triaged through a valid system could and most likely should be shunted down to the non emergency units.

As for there being no shortage of hucking crack heads and drunks back and forth, of course thereisn't, and the bigger the city/town, the more there will be. I also agree that public Education is a good approach to start with. However like I said there is no motivation in the upper levels to educate or triage out paying customers.

[helicopper 1,050]

ALS and Alpha are on the mark as usual.

A couple of other thoughts...

As was stated, EMS is never free. Either the system is tax subsidized, supported by direct billing, or donations/fund raising. Regardless of where an EMS agency gets its money, there's an expense to the operation. If it is a volunteer agency there are no salaries to pay but there is still insurance, fuel, equipment/supplies, etc. that need to be covered.

As for call volume, the higher the volume the more difficult it is to keep response times down. It doesn't matter whether you're dealing with paid crews or volunteers - the standard should be the same. And that is the fundamental problem in EMS. There are no consistent standards. Years ago a proposal was made to the Regional EMS Council to adopt a response time standard consistent with AHA and other guidelines. The volunteer contingent at the REMSCO opposed any response time criteria because they couldn't meet it.

Rather than improve the system and reduce response times, they argued that volunteer agencies could not and should not be held to standards of commercial agencies. Who did that benefit? Certainly not the patient waiting 20-30 minutes for an ambulance.

We have no system - there is no consistent standard of care and even in a county as small as Westchester there are disparate response times, levels of care, and no assurance that an ambulance will even get out the door. We're the worst system abusers because we keep fighting against a comprehensive system. How can we sit here and call the people who call for our assistance system abusers? That's our JOB! Sure, we get BS transport calls and Medicaid taxi runs but you know what - that's part of the JOB! We can't pick and choose! ALS hit the nail on the head when he described the sick call that can't get covered and goes mutual aid and five minutes later two full crews respond to an MVA with entrapment. Some systems went to no dispatch information with initial tones to prevent this. They just tone out for a crew and advise that they have a call.

We sit in judgment on those who call for an ambulance for what we deem a non-emergency but we don't judge the agencies who can't get out the door at all. Who's the system abuser?

Stop using lights and siren to go to every call - and worse to the hospital with every call - and deposit people in the waiting room when they didn't need more than a ride. Take the benefit of using 911 away from them and many will stop calling. (Thanks ALS, credit for this is yours!)

Let's actually lobby for reforms that will give us a system - one that is worth the kind of respect we all want.

the rant continues...

[Guest partyrock]

Stop using lights and siren to go to every call - and worse to the hospital with every call - and deposit people in the waiting room when they didn't need more than a ride.  Take the benefit of using 911 away from them and many will stop calling.

←

A couple of people have mentioned this, but how do you decide which call is going non-emergency. People are far too unreliable in the information they provide to EMD. My personal favorite is "My wife is sick send an ambulance" walked in the door to see the woman drop out in full arrest. Came to me as a low priority sick. Going cold that time of the day would have been 10 minutes plus getting to her. Instead we were there in 4. In the end it didn't change anything but she had the best possible chance. Defib within minutes of arrest, CPR immediately, and ALS in less than 10.

I think we can do more to ease the burden by not transporting every patient. If they want to go you're going to have to take them. I don't want to be the tech who turns away the frequent flier who is actually sickand winds up dead. I've seen what happens when the ER staff does it. If you can remedy the situation on scene (ie: asthmatic, injury) people should be able to sign off and go to the ER.

[Guest alsfirefighter]

Party,

I understand what you are saying..but how does any system that utilizes a priority call system. If you get a call for "my wife is sick" the dispatcher should know when they are EMD qualified to ask more questions. Then again maybe she was "just sick" when the spouse was calling. Have I had some similiar experiences...yes...but with low percentages. The what ifs could stop anything in this world. If it is a chronic problem, your dispatchers need better QA/QI to stop this from occurring. It is my experience that prioritizing calls is more on the conservative side more then anything when sending units.

But when I still get units using lights and sirens when I even request that they come in cold to a scene....problem.

Ankle injury...problem.

Finger injury...problem...and so on.

[Guest partyrock]

You can ask all the questions in world if the person on the phone isn't going to participate there's only so much you can do. There are many "emergencies" that should definately have a non-emergency priority. This is just a place I prefer acting on the side of caution. I'll act after I get to the patient. They recieve situation appropriate care and I'll highlight the benefits of going to their MD or the clinic instead of 911. Occasionaly they get it. They walk when appropriate and will go right outside to wait after triage.

As for going lights after being told not to, thats a huge pet peeve and led to some intertesting converstaions after a call. Some people need to grow up and stop getting their jollies from the flashing lights and noise box.

[helicopper 1,050]

You can ask all the questions in world if the person on the phone isn't going to participate there's only so much you can do.  There are many "emergencies" that should definately have a non-emergency priority.  This is just a place I prefer acting on the side of caution.  I'll act after I get to the patient.  They recieve situation appropriate care and I'll highlight the benefits of going to their MD or the clinic instead of 911.  Occasionaly they get it.  They walk when appropriate and will go right outside to wait after triage.

As for going lights after being told not to, thats a huge pet peeve and led to some intertesting converstaions after a call.  Some people need to grow up and stop getting their jollies from the flashing lights and noise box.

←

The "sick call" is probably one of the gray areas that will have to get an emergency response even when 99% of the time it is not a life-threatening condition. However, when the call is for a conscious 25 year old with a knee injury on a baseball field, why exactly do we need lights and sirens? Why do we need an FD first response, ALS fly-car, and BLS ambulance?

But we should also look at the actual statistics about the use of lights and siren in our response. Studies have shown that we only save a minute or so in most cases. Is this iron clad and fool proof - of course not. But it does show that we don't need them as much as we THINK we do.

You're also right about people needing to heed the info from people already on the scene. If someone else (PD, FD, other EMS) is there and they report a conscious and alert patient, there is no need to be waking everyone else up to get there.

[WAS967 97]

Response problems (lack of crews, lack of units, etc etc) aside, lets look at the other side of the coin.

At present when people call an ambulance we only one of two choices in disposition: they either refuse to go to the hospital and we RMA them or they desire to go to the hospital and we take them. We have no recourse for the patient that does not demonstrate a medical need to go to the hospital (and thus medicare/aid will not pay for). Other cities have toyed with and I believe even deployed a system where EMTs can triage a patient as "no transport necessary" and they actually have the option to not transport. I think it may have been Chicago where they actually gave people bus tokens to use to get to the hospital if needed.

Of course the ultimate issue that comes up is liability and what not. Everyone worries about getting sued for triaging a patient to a bus/taxi and then having them drop dead. But there is just as much possibility of that happening by going down the RMA route (and thus why RMAs are by far the biggest segment of disposition to end up in court).

EMD and priority dispatch are a step in the right direction. We are finally seeing calls being dispatched BLS only in Westchester. I'd love to see it go the next step and move to where the response is also dictated by the priority system as it is in Putnam.

For now I have no problem going cold to an "ankle injury" or a "leg pain" call and hope that if I am genuinely not needed that the BLS crew will call me off. I'm not going to kill myself getting to a call that is minor even tho some policy says I should respond hot to everything. And I won't have a problem telling 60 Control that I'm diverting from an obviously BLS call to take in a chest pain that I am closer to than another unit.

Edited February 17, 2007 by WAS967

[Guest]

While priority dispatch is a step in the right direction, it is no way the answer to the problem. Ask any medic in Putnam, and I’m 99% sure he/she has issues with the way the call "priority" is generated. I would say, 80-90% of the Bravo/Charlie calls they are sent on they end up turning over BLS. With only 4 medics countywide and the issues with agencies getting out, medics are either left waiting on scene or are stuck driving the bus (Medic 3/4) as an EMT techs. From my limited understanding of the system, it has to do with the way in which the computer compiles the input data and spits out the call disposition.

As far as responding Code 3 to "low priority" assignments. I understand and do sympathize with what partyrock is saying. Of the year and change i've been in Putnam, i encountered this situation once. I was assigned mutual aid to another district for a "knee injury from a standing fall." By the time i called out, the guy was probably down for about 30-40 minutes between the 3 primary dispatches, my dispatch and non-emergency response. Needless to say, the guy was having "the big one." After that i was a bit aprehensive to how i responded to "non-emergency" calls for a few weeks , the frequency of a similar situation happening again, where i work, is low and i'm pretty confident in the policy that says non-emergency response to a non-emergency "alpha" call.

I guess my overall point is, we can only operate from what little information we have. If that information is flawed or inaccurate, its not our fault or responsibility - nor is it necessarily the dispatcher's fault, some people are just plain stupid - to put our lives at potentially unwarranted risk. While the same is true for jobs that come over as medical emergencies and turn out to be nothing more than your average cold, i suppose there is a level of accountability. It seems allot less "grey" if i were to respond Code 3 to a dispatched medical emergency rather than responding Code 3 to an "ankle injury." Maybe this is my own self-made justification....i don’t know...

Edited February 18, 2007 by 66Alpha1

[Guest]

I work in a system where calls areEMD'd and some things are coded as non-emergency responses. Depending on the priority we have a different amount of time to get to each call, and ambulances can be diverted to calls of a higher priority if they are the closest appropriate rig. While every once in a great while we get bit in the a** by a person who is having a life threatening emergency on a priority 4, more often the system works and we get the ambulance to the person who needs it immediately as opposed to the person who is late for their dentist appointment next to the hospital and needs a ride (happened to me last week). The big problem with it is that our true everyday regulars have learned to beat the system and report chest pain when they call 911 everyday, knowing that it will get them an ambulance sooner.

Even if we accept the idea that this problem is not in large part due to 911 abuse, and is simply a result of poor education, we still need to do something about it. Having a critical patient wait for an ambulance because the closest one is on the way to a stubbed toe or a baby who has been crying for an hour is unacceptable, and until we can educate the public we as providers need to make these decisions for them. The best thing that I know of is a priority based response that gets an ambulance to the sickest people the quickest. This system is by no means perfect, but it is far better than doing nothing to address the problem.

[Guest partyrock]

Here's something someone in my house brought up to me. Maybe we don't want call volume and system abuse to decrease. When I say we, I'm refering to the higher up, the powers that be. The private run companies are looking to turn a profit. Yeah, the uninsured don't help but the the more runs you get the more you can turn to the municipality for and the more you can squeeze out of medicaid. I know that NYC gets one lump sum for medicaid from the state based up on their numbers from years prior, does the same thing apply to cities where EMS is contracted out? We mark our performance with response times and run totals. Police brag about crime reduction and fire depts shoot for reductions in fire damage and death.

[Guest]

Interesting concept partyrock, never really thought of it that way. But, unlike fire/police I don’t see the job of EMS as preventing death and injury. While death and injury are something that are preventable in many cases, it becomes the personal choice of the patient/patients family whether or not they are going to take action to prevent such occurrences. Basically, those deaths/injuries deemed preventable are at the mercy of free will. I see it as the government’s responsibility to inform the public as to the dangers of certain behavior – hence why we have the surgeon general. However, the government’s obligation stops short of mandating (aside from the use of illegal substances, etc.) what you can and cannot eat/drink or partake in. Preventing crime and fire are very universal/public things. Telling someone to stop drinking or smoking or eating fast-food b/c they could die or injure themselves is a very personal and I don’t think many would take kindly to that. So, the overall point im trying to make is that I don’t really see any way to reduce death/injury and overall run totals. People are free to do, for the most part, what they wish - right, wrong or indifferent its their right.

Edited February 20, 2007 by 66Alpha1