One of the greatest challenges facing EMS systems across the country is how we will address increased demand for services when faced with a shrinking pool of available funds and qualified staff. Medic, the Mecklenburg County EMS agency, located in Charlotte, N.C., has spent the better part of the past two years evaluating a radical new approach for dealing with this emerging scenario. The goal is to create a truly patient-centered system of care that consistently delivers the right resources to the right palce at the right time.
The organization_s leadership team refers to this new approach as the "Omega Project," and it very well might change the way that Medic, and many other EMS systems around the world, respond to 9-1-1 calls in the future.
The Population Problem
Established in 1978, Medic receives about 100,000 calls into their 9-1-1 call center annually, resulting in the delivery of prehospital care to more than 75,000 people. Jointly managed through a collaborative arrangement between Mecklenburg County, the Charlotte-Mecklenburg Hospital Authority (CMHA) and Presbyterian Hospital, Medic employs more than 400 individuals who respond to the needs of more than 900,000 full-time residents spanning 542 square miles.
The greater Charlotte, N.C., area is one of the fastest growing regions of the country. A mild climate, reasonable housing costs and excellent schools have put the area on virtually every "Top 10 Places to Live" list published in the past two years. This is not new information for the Medic team because call volumes have increased significantly over the past 12 years.
At the current growth rate, Medic_s annual call volume is projected to triple over a 12-year period (2000Ï2012). Despite this increase and the impact of substantial inflationary factors, the funding allotted to Medic on a per-transport basis has remained and is projected to stay relatively constant over the course of this time frame. The organization has become as efficient as any EMS agency could ever hope to, while maintaining some of the most impressive patient outcome statistics in the industry.
In the face of these growing challenges, Medic experienced years of efficient growth and success. However, Medic_s team decided in 2005 that it needed to evaluate new approaches to the science of call response to continue providing the same level of patient care it has become accustomed to delivering.
In today_s economic environment, it_s simply not practical to throw additional ambulances at every problem. More is not always better; only better is better. Having taken this option off of the table, Medic_s team delved deeper than ever before into its inbound call data to see what useful information could point the team in the right direction. What they found was a relatively high percentage of calls that could be classified as "non-emergency" in nature.
Despite the non-emergent nature of these calls, each received a paramedic-level response, minus the lights and sirens on approach. The non-emergent calls varied in nature, including toothaches, sprained toes and everything in between.
Nearly all calls warranted some form of medical response, but the question was whether they all needed the same level of responder as a "Delta" call. Taking things a step further, we asked whether each of these calls even warranted an EMS response at all. The answer to both was "no," so we began to develop an alternative response plan to address the needs of this patient population, a population that was tying up valuable EMS resources in a manner that was neither effective nor efficient.
In 1993, Medic began employing the Advanced Medical Priority Dispatch System (AMPDS) developed by Jeff Clawson, MD, and the National Academies of Emergency Dispatch (NAED). The AMPDS protocol allows certified Emergency Medical Dispatchers (EMDs) to effectively evaluate a patient_s condition over the phone and assign an appropriate response code to field personnel. It also enables EMDs to begin providing life-saving instruction to the bystander over the phone while they await the arrival of an EMS team.
AMPDS uses a detailed algorithm that walks the EMD through a series of qualifying questions, each leading to the next logical inquiry. This first triage filter provides enough information for the EMD to quickly ascertain if a given patient is acutely ill, injured or at risk of developing a life-threatening problem. With this information, the EMD can issue an appropriate alert to the paramedic teams in the field, having already determined the level of response required.
The responder classifications outlined within the AMPDS protocol are:
Delta:ALS emergency response;
Charlie:ALS non-emergency response;
Bravo:BLS emergency response;
Alpha:BLS non-emergency response, and
Omega:Referral or alternate care.
Until recently, all inbound calls handled by Medic_s EMDs were classified as Delta, Charlie, Alpha or Bravo. MEDIC officials now focus on the potential effectiveness of instituting the Omega protocol in a proactive effort to more appropriately respond to the prehospital care needs of the community.
A 9-1-1 caller who doesn_t actually have a medical emergency but is likely in need of some level of medical intervention or assistance would fall under the new Omega classification. The hypothesis is that properly qualified Omega patients can be redirected or assisted through a secondary triage center in a more appropriate, cost-effective manner, ultimately relieving much of the undue pressure that plagues many EMS systems today.
Richmond Leads the Way
Prior to jumping in with both feet, Medic_s team scoured the country in search of similar models that were being employed by other EMS systems. They found only one such program, in Richmond, Va. Under the leadership of then Executive Director Jerry Overton, the Richmond Ambulance Authority (RAA) began the Community Health Access Program (CHAP) in October 2004. The program integrated RNs into RAA_s 9-1-1 response center and followed a secondary triage strategy that utilized a specialized protocol designed for callers deemed to be experiencing non-emergency medical situations. After 17 months of off-line testing and quality review, RAA successfully stopped their first ambulance response to a 9-1-1 request meeting their specific criteria on March 1, 2006.
RAA continues to successfully utilize CHAP and, although not all eligible calls result in an alternative pathway to care, about 20% of all 9-1-1 calls received by RAA_s call center are ultimately deemed appropriate for secondary triage.
MEDIC Moves Ahead
Medic officials were inspired by the results seen in Richmond and made the commitment in fall 2006 to formally review the potential benefits of implementing a secondary triage process. Medic officials have long used statistical data to drive the decisions and modifications affecting their EMS system protocols, and the team began the long process of studying the operational changes and resources that would be required to accommodate such a transition.
In October 2006, Medic_s EMDs fully added the AMPDS Omega protocol classification to their evaluation criteria. Calls meeting this criteria were dispatched as Alpha level to the field and handled accordingly.
Internally, the classification of Omega was captured by the EMD database, enabling Medic_s team to later research all calls over a given period of time to see how many calls actually met the new criteria. By the end of 2007, the call center had logged more than 4,000 records that were classified as Omega calls.
Medic officials then approached the institutional review boards (IRBs) of both the Carolinas Medical Center and Presbyterian Hospital to present the framework of the Omega Project for approval to continue with the study. This approval included the understanding that Medic would need access to patient files for more thorough follow-up regarding their hospital diagnosis and outcomes following Medic intervention. Both IRBs approved the study, allowing MEDIC to proceed with Phase I and II.
Phase I:Of the 4,000 Omega-eligible calls received, 1,700 were randomly sampled for further evaluation. Medic_s team then worked with officials from both facilities, gaining access to each Omega-designated patient_s hospital record emergency department (ED) evaluation, diagnostic procedures and final diagnosis, so the hospital data could be compared with that from AMPDS and the EMS crew. This step in the evaluation process was critical to ensure each patient_s required level of care and overall outcome supported the Omega classification.
A review of the 1,700 Omega calls revealed clear subgroups with significant reoccurrence. The largest subset of the Omega patients (62%) complained of general non-categorical sickness with no priority systems. Rounding out the top five groups of Omega-level complaints were calls for falls (15%), minor trauma (6%), diabetes (3%) and psychiatric illness (3%).
Each Omega call was mapped using state-of-the-art GIS mapping software. This process revealed that Omega calls mirrored the same demand and distribution patterns associated with 9-1-1 emergent requests, in addition to being equally proportioned throughout the urban and rural areas of Mecklenburg County. Therefore, it was determined that implementation of the Omega protocol wouldn_t necessitate a change in strategic vehicle deployment.
Phase II:The project introduced a secondary nurse triage system to handle the incoming calls that are designated Omega. Medic utilizes existing nurse call centers operated by Carolinas Medical Center and Presbyterian Hospital. They had already invested the training and resources into developing their own call centers, and all three parties agreed it was in everyone_s best interest to coordinate and maximize these existing resources.
Because this new protocol is still in the evaluation stage, EMDs continue to dispatch paramedic units to all non-emergency calls to administer appropriate treatment and transportation. The introduction of the nurse call center allows Medic officials to test the effectiveness of care administered over the phone, as well as patient reaction.
The Medic_s team believes complete implementation of the Omega Project will help eliminate a significant portion of unnecessary, non-emergency paramedic team responses in the field. This reduction could be as much as 10% of Medic_s overall call base, or 10,000 calls annually. At the same time, by introducing the second-tier nurse triage call center, Medic officials also think they can provide the public with a level of care most appropriate for their condition.
When people in the community aren_t sure where to turn for medical attention, they call 9-1-1. EMS systems throughout the country spent years ingraining the "call 9-1-1" message into the hearts and minds of their residents, so these types of calls are to be expected. Instead of becoming frustrated with callers who need non-emergency medical attention, Medic officials are considering their role as helpful gate keepers and hope to be more useful to community members by directing them to the assistance they need.
Medic officials are now exploring where this alternative assistance should come from. The shift to an EMS system that evaluates and cares for patients will have effects throughout the rest of the medical community. EDs across the country are currently overcrowded, and much of that overcrowding comes from patients who aren_t in need of emergency medical assistance. A change in usage of the AMPDS designation protocol could help alleviate some of the burden placed on EDs. However, these patients will still need a place to go to.
Solving this problem will likely involve every facet of Mecklenburg County_s medical system. In the meantime, Medic_s team plans to continue evaluating the results from Phase II of the Omega Project, with hopes for taking the complete program live by the end of the year. The result wil be a welcome end to paramedic teams responding to calls where they aren_t needed, allowing valuable resources to remain available for timely response to actual emergencies.JEMS
Barry Bagwellis assistant director of operations at Medic, the Mecklenburg County (N.C.) EMS Agency. He can be contacted firstname.lastname@example.org.
Jeff Keithis director of public relations at Medic. He can be contacted email@example.com.
For more on the Richmond CHAP prgram contact Lee Ann Baker firstname.lastname@example.org.
Learn more fromBarry Bagwellat the EMS TodayConference & Expo, March 2Ï6 in Baltimore.