On Monday, Jan. 12, a leaner Cleveland EMS system emerged. Facing a $23 million city budget gap, the agency saw its ambulances reduced from 18 to 15, and 13 positions eliminated, including six layoffs. Out of both necessity and a longstanding desire to maximize its resources, the agency determined it would no longer automatically dispatch an ambulance simply because someone dialled 9-1-1.
"I've been with the city starting my 29th year now," said Cleveland EMS Commissioner Ed Eckart. "We've been talking about different variations of how to deal with low-priority calls for probably 20 years. Everybody realizes that -- especially in urban systems that tend to have populations that are either uninsured or underinsured -- a fairly significant number of the patients that the EMS system deals with use us as their primary care provider. That's not the best system. It's very expensive, and you're burdening a system that has limited resources. Most important, though, it's not the best for the patients because they're not experiencing continuity of care and they're not establishing a medical home."
Eckart said they began about two years ago to seriously consider different options for ensuring the resources they have are always available for their most critical, life-threatening calls.
"One of our goals in implementing this is to maintain the response time that we've had to our highest priority calls, even though we're running three [fewer] ambulances," he said. "Really, the only way we could do that was to put a process in place that allowed us take these non life-threatening, very low-priority calls and automatically hold them when we get them, regardless of what the call volume is."
The New Policy
Comprehensive call triage in the dispatch center forms the foundation of the agency's new policy. Specific Bravo, Alpha and Omega calls are held until at least 10 ambulances are open and life-threatening calls are addressed. An ambulance will not be dispatched at all for minor complaints (earaches and the like). However, the agency will provide these callers with appropriate referrals and contact numbers to agencies or clinics that can better assist them.
Another policy change: Cleveland EMS no longer transports patients to the hospital of their choice. They now go to the closest hospital of their choice as long as it's within their hospital system. "Because we only have three major systems in the city, and everyone's connected through electronic medical records, [the new policy] helps reduce the out-of-service time for the ambulances," Eckart said.
He emphasized that strong call prioritization practices and a robust quality assurance/process improvement program ensure callers do in fact receive the care they need.
The agency uses the Jeff Clawson MPDS call prioritizing system, and boasts a strong staff compliance (rating in the high 90s) with the protocols. "Our staff is very good at walking people through the process," Eckart said. "When we're holding calls, we will call the person back every 15 or 20 minutes and put them through the call triaging again, just to make sure that something hasn't changed. That's important for two reasons. One, obviously things do change and we want to make sure we catch it. Secondly, we know that people are going to learn the buzzwords real quick. If they go from, ÂI'm having a headache with no associated symptoms,' and they're a 22-year-old male, and when we call them back 20 minutes later that headache has turned into, ÂI'm dizzy now. I'm having pain going down my shoulder, and I've got a history of hypertension,' we'll be able to catch that.
"As we go through the quality assurance process, that provides evidence for us to go back to these people and say, ÂLook, you gave false statements to get EMS to respond to your house.' Maybe we send them a letter the first time out, but eventually we may end up going to the city council to get some sort of legislation passed. Maybe we just need to get a social worker into the house because there are other issues going on that they need help with."
As for the minor complaints that aren't dispatched at all, the agency's QA staff calls each patient after 24 hours to follow up on their condition.
"We've made the commitment to monitor 100% of all incoming calls that get automatically held and the calls that we're not going to dispatch on. The three main questions are: Are they still experiencing the problem they called about? Did they utilize the resources provided to them when they called? And, do they need any additional help finding a medical home in their neighborhood or nearby?
"That helps us identify, first of all, do we have enough resources on the front end when they dial 9-1-1 to feel comfortable that when our call-takers make that referral, they get the kind of help that they need," Eckart said. Going forward, this process will also help the agency determine if partnerships with particular agencies would make the most impact, he said. For example, are a significant number of calls related to elder issues? Are there recurring problems related to substance abuse? Is poor mental health a significant cause of system misuse? Is it simply lack of education on appropriate use of 9-1-1? The hope is that they can aggressively address those issues to reduce inappropriate use of the system.
If this type of triage is necessary, performing it at the dispatch level is the best option, said Carol Cunningham, MD, FACEP, FAAEM, state medical director for the Ohio Department of Public Safety.
"I'd much rather see the triage happen at the dispatch level than at the EMS level on scene, because it's very difficult as a medical director to write a protocol where EMS is on scene and they're going to leave somebody there or turn their care over to a private ambulance service or a lower level of EMS," Cunningham said. "From a liability standpoint, it's better to do the triaging at dispatch than when EMS is on scene. Then you have to deal with patient desertion and that kind of thing when EMS's primary duty is to treat and transport."
The other benefit: "There's history all over the country that shows that if dispatchers are properly trained and have been given protocols to use, they do a good job determining which resources are needed, which is better than sending EMS to every call and then leaving EMS to decide, ÂWell, maybe this isn't an emergency.'"
It will probably be some time before the system sees a change in call volume.
"For years, [Cleveland EMS] responded to everything, and you don't change people's behavior overnight," Cunningham said. "In the ideal system, everyone would know when it's the appropriate time to call 9-1-1. To get to the heart of the problem, you have to educate people about proper use of the medical resources they have."
Cleveland EMS had an aggressive community education program in place long before these new policies went into effect. So, in addition to counseling patients one-on-one during the contact with call-takers and subsequent follow-up, they're using their existing connections in the community to educate the public about the new policies, appropriate use of the system and the resources available within the community.
"We're literally out in the community every day doing blood pressure and glucose checks and cholesterol checks, CPR training and all those kinds of things," Eckart said. "The next step is to get some media material in their hands so that when they're out in the community, they're continuing the message. The goal, he said, is to emphasize that they're actually providing more care for people in need.
The need for education applies to not only the general public but the politicians as well. When Cleveland EMS first proposed the policy change, the local politicians had a mixed reaction. "It's funny. Some of them said, ÂWell, it's about time. I've been asking you guys to do this for years,'" Eckart said. "Others are on the opposite side of that spectrum: ÂHow dare you do this to these people; they deserve the same level of care as everybody else.'"
The answer to this type of criticism, he believes, is more education. "We need to continue to reinforce the message that we're not taking this population of people and ignoring them or discounting them," he said. "We're really giving them more attention by putting emphasis on helping them find the resources that will truly help them. Taking someone to a different emergency room once a week, it's just not good medicine. Then throw in the other problems it creates -- the economics of it, the emergency room overcrowding, tying up the 9-1-1 system -- it just doesn't make sense. As long as we're consistent with the message to the politicians and the community, I think over time people will understand.
Eckart didn't wait for the media to hear about the policy change after its implementation. "The mayor's press office got me a meeting with theCleveland Plain Dealer'seditorial board prior to us implementing this," Eckart said. "I spent a good couple hours over there explaining what we're trying to do, answering questions. The same day we rolled this out, we got a front-page story that was a very positive, proactive story filled with the message we were trying to get out."
Eckart said they do not transport to alternate destinations; however, he expects that their policies will evolve over the next year, and they're open to the possibility.
"We looked at transporting to clinics about a year and a half ago, and we haven't been able to get a true commitment from a lot of the providers in the community of guaranteeing that if we bring somebody there, that they'll be able to see that person that day," Eckart said. "A lot of the clinics now are appointment-only. The difficulty has been getting them to accept walk-ins on a frequent basis. We're still in ongoing conversation with them about that."
As for lost revenue due to decreased transport billing, Eckart said that's not a concern at the moment, because they probably wouldn't have been reimbursed for those calls anyway. "But that's certainly one of the things that we'll look at as we continue to change and adapt our policy," he said. "You always have to look at the economics of things."
Cleveland is not alone. Agencies across the country are experiencing cutbacks due to drops in both tax revenue and increases in the number of uninsured patients. For those considering implementing similar policies, Eckart offers some good advice.
"You have to be open-minded and creative as you're working your way through this, because it's really new ground," he said. "You've got to be willing to make some concessions. A lot of it is about territory. Everybody wants to have their own little kingdom, and sometimes you've got to be open-minded to forming partnerships with organizations you never thought you would years ago, but now it makes sense.
"It's all about making sure people get the right kind of medical care in the right environment and utilizing all the partnerships and resources that we have in the community."
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