Study hopes to divert 911 callers from costly hospital visits

Photo Credit: TRIBUNE PHOTO: JAIME VALDEZ - Todd Thawley, a firefighter with Portland Fire & Rescue, dons his coat before departing Fire Station 11 in Lents in a two-person Rapid Response Vehicle. The SUVs are increasingly used to respond to lower-level, non-emergency medical and other calls.   When a medical call comes in to Portland’s 911 center, dispatchers routinely send a city fire crew and then an ambulance to drive the caller to a hospital emergency room.

But about one out of seven of those callers don’t have a true medical emergency, says Portland Fire & Rescue Chief Erin Janssens. Transporting them to the hospital “ER” is costly, inefficient and not the optimal place to meet their needs.

An ambulance ride can cost upward of $1,000, and a typical emergency room visit can cost $2,000. A $40 taxi ride to a clinic would be a lot cheaper and get them a more suitable level of medical care — without a three-hour wait in the ER while doctors treat people with true emergencies. And connecting people to a primary care doctor is often the best way to address their underlying medical issues, such as learning how to manage their diabetes. If EMS providers can reduce the overuse of the 911 system, that can free up others for truly serious emergencies.

For the past 12 months, the fire bureau and its partners have been engaged in a pilot study to find a better way to handle 911 callers who don’t belong in a hospital emergency room.

Early results of the Alternative Destination and Transportation pilot study show some promise, but also illustrate that transforming the Portland area’s health care delivery system has a long ways to go.

The good news is the idea seems to work, says Randy Lauer, general manager of American Medical Response for Oregon, a leading ambulance company.

“We haven’t had any bad outcomes,” Lauer says. There’s been no instance of someone diverted from the ER who suffered a medical catastrophe as a result.

“The paramedics are starting to have that mindset of having the appropriate care at the right time,” says Ken Burns, battalion chief for the EMS section of Portland Fire & Rescue. “Before, it was just ‘get in the ambulance.’”

But a good number of 911 callers insist on going to an emergency room, even if paramedics who come to their house determine it would be better to send them to a clinic or doctor’s office. And many people call 911 on weekends or evenings, when it’s hard to get an appointment with their doctor or clinic.

Age and insurance-related restrictions also have limited the number of people eligible for the pilot study referrals. “It starts to winnow down the opportunities to use the system,” Janssens says.

As a result, only about 100 people have been candidates for alternative destinations so far, Lauer says.

And many of those didn’t want to give their written consent to go to an alternative destination, while many others couldn’t get appointments with their doctor or clinic on short notice.

So, Janssens says, rather sheepishly, only about 16 people have actually been transported to alternative sites instead of ERs under the pilot program so far.

Still, the results do point the way to reform of this one slice of the health care system, according to Janssen and others.

“I think it’s a great concept. It’s really what we need to do going forward,” Lauer says.

“It’s a great launching point,” Janssens says. “I think in the future it will become more of the norm.”

“We’re looking at it as a glass half full,” Burns says. “We learned quite a bit of information about how to move forward.”

For starters, the pilot test helped emergency medical services or EMS staff learn how to identify candidates who may not really need to go to the ER.

Dr. Jon Jui, medical director for Multnomah County’s EMS program, worked with Clackamas County Medical Director Terry Schmidt on new protocols to use at the 911 center. They created a 71-page guide for dispatchers and paramedics on how to identify “lower acuity” medical situations.

For instance, a caller complaining about eye pain would get referred to the ER if they had a chemical burn or history of glaucoma; but if it was determined to be a painful response to a topical anesthetic, they might get referred to a clinic instead.

If a caller complaining about severe pain in their teeth also had a fever or difficulty swallowing or breathing, they’d get referred to the ER. Otherwise, they might be referred to a dentist instead.

The new protocols are used by the 911 center to decide whether to send a full four-person fire engine crew, which leaves immediately, or a two-person Rapid Response Vehicle, typically an SUV that seeks to arrive within 20 minutes.

For the pilot, the two-person crews are used. They arrive on scene and find out more than the dispatch center caller could glean in the 60 to 90 seconds available before sending out a vehicle.

Twenty fire bureau paramedics, plus 20 American Response System paramedics, were trained in how to use the new protocols.

Regional EMS providers are discussing lessons learned during the pilot study and how to use them in ongoing efforts to reform the system, says Darrell Knott, Multnomah County EMS administrator. He’d like to see a detailed analysis of how the program can affect health care claims costs.

Janssens says she’d like to see a new, modified pilot that allows broader participation. For instance, there’s hope the Medicare system can join in, as it provides health care to those 65 or older who are big users of ambulances, and the federal system stands to save money if it rethinks how it reimburses for ambulance and follow-up health service.

Janssens also hopes that medical providers can arrange better ways for participants to get clinic appointments on short notice, perhaps using urgent care facilities.

There’s also a need to keep educating the public, she says, so citizens are more willing to go to clinics and doctor’s offices instead of ERs if it’s not necessary.

In December, the Portland City Council will hold a work session to discuss ways the fire bureau can capture revenue from its EMS services. Janssens says she’ll propose some new initiatives at that point.

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