Review Of: Scott A. Bier MD, Douglas J. PharmD, DABAT. Am J of Emerg Med:2010;911–914.
This is a qualitative retrospective chart review of toxic exposures in Austin, Texas, to determine how Austin/Travis County EMS (ATCEMS) utilized poison control centers (PCCs) when they were unsure of how to proceed with the treatment of patients. The time frame for the study was between 2004 and 2006, and it produced a total of 386 cases that met inclusion criteria for review (654 were reviewed). The most common recommendation was observation at home, and only 6% of the cases required administration of a medication. Only 63, or 16%, of the 386 patients were actually transported. The investigators conclude that approximately $205,000 were saved in unnecessary transports costs when PCC was consulted. They further concluded it’s unreasonable for EMS providers to know what to do in every toxic exposure situation.
Medic Marshall and Doc Wesley discuss the financial impact of using PCCs to reduce unnecessary transports.
This is an interesting study and definitely worth conducting on a larger scale. From a street perspective, I believe poison control centers are an under-utilized resource. Too often, patients are transported to the hospital for evaluation because the EMT or paramedic isn't comfortable leaving someone at home to be observed. This brings up another problem—if the patient isn't being transported, the EMS agency isn't getting paid.
Though the investigators conclude there is a cost savings of $205,000 a year in unnecessary transports, one could play devil's advocate and say that equals $205,000 in lost revenue. So, even if unnecessary transports are decreased, what incentive is there for EMS agencies to rely on a PCC for consultation to not transport a patient? The answer? There is none. So, the question becomes, can a PCC provide some other form of value to EMS? Though it would be difficult to study, it would also be useful to look at the reverse side of the equation and analyze how often an EMS agency is billed at a higher rate because they contacted a poison control center and were directed to be more aggressive in their treatment of the patient.
Dr. Wesley Comments:
This is one of the first studies to attempt to quantify the value on alternatives to patient transport. Contacting the PCC resulted in a substantial likelihood that the patient wouldn’t be transported. However, the authors readily admit that there are several limitations to this research.
First, EMS only contacted them for about a third of exposures. Why is that? Secondly, the PCC won’t take liability for patient outcomes. Instead, they rely on their premise that they’re only providing consultation and don’t have medical control authority. The EMTs must still contact medical control, who in most cases, don’t have the reference resources of the PCC and may elect to follow PCC recommendations or have the patient transported. Finally, this model works in a public utility model, where no monetary incentive to transport exists. Until insurance companies pay for non-transport, there is little reason for fee-for-service agencies to adopt additional non-transport alternatives.
However, the fact that this issue was investigated is encouraging. The only viable future for EMS is to pursue cost-effective measures. Perhaps in the future, the PCC and public health agencies such as maternal and child health, programs for the elderly, and drug and alcohol rehab programs, will develop a contractual relationship with medical control authorities, which address the risk management issues to provide patients with a better alternative to an unnecessary ambulance and emergency department bill.