The city of„Baltimore began stationing a supervisor in the Maryland Institute for Emergency Medical Services Systems (MIEMSS) Emergency Medical Resources Center (EMRC) in early 2007 and later in its own dispatch center to strategically direct ambulances to specific hospital emergency departments during peak times. The idea was that a routing “gatekeeper” or “czar” could cut ED wait times and ambulance return-to-service times by efficiently distributing EMS patients to EDs while considering such factors as patient safety, current ED wait times and the number of EMS units waiting at or en route to various facilities.
The result:„ During the times when a gatekeeper was in EMRC, turnaround times for Baltimore City’s units from the Baltimore-area hospital EDs dropped by an average of 16 minutes (from an average of 58 minutes to an average of 42 minutes). “That’s statistically huge,” said Maryland EMS Medical Director Richard Alcorta, MD. “When you look at 16 minutes on probably some 100,000 calls a year, that represents a lot of people hours.” The city developed and instituted the program as a pilot project in collaboration with the MIEMSS.
The gatekeeper uses a computer to monitor hospital system status via the MIEMSS County Hospital Alert and Tracking System, keep track of units via the area’s computer-aided dispatch system and track data for each rerouted patient. The gatekeeper routes only Priority II and Priority III patients — not Priority I patients, who always go to the closest appropriate facility, or those needing transport to a specialty center (e.g., a trauma or burn center). Patient requests to go to a facility that has already taken care of the patient are honored unless they require transport to a facility more than 20 minutes farther than the closest appropriate hospital.
Because of Baltimore’s success, Alcorta, MIEMSS and the state’s five EMS regional councils hope to institute similar programs in other areas of the state that are experiencing long waits to offload patients in EDs. Alcorta had envisioned implementing such a program at least in Montgomery, Prince Georges, Carroll and Charles counties along with Baltimore City and in the District of Columbia, which now uses this centralized routing intermittently.
To move the project forward in„Maryland, the regional councils created a Routing Subcommittee, which drafted protocols for an ˙Active Centralized Jurisdictional Routing Project.Ó
“We plagiarized most of what„Baltimore„City and the„District of Columbia have done,” Alcorta said.
But then the plan ran into trouble.
“When it came time for implementation, most departments bailed out because there’s a cost involved, because you must take a supervisor from the field and put them into the dispatch center, and there’s also some training [of supervisors and EMS personnel] involved,” Alcorta said. The program also requires departments to collect certain data elements. “So when [the departments] went to the chiefs or operational command with the idea, [the authorities] said, No.”
But Alcorta is still hopeful. “We are now working with individual counties and collaboratively with the services to see if there’s a way they can do this,” he said.
Meanwhile, the„District of Columbia has instituted a mobile gatekeeper process, using„EMS supervisors “to monitor how busy their units are and how long the delays are in handing off patients,” Alcorta said. “When they find a hospital is holding ambulances for long periods of time, they can activate the routing process, and the gatekeeper will tell [crews] to continue on in or go to this different hospital. They have demonstrated an improved return-to-service time for„EMS units using this process.”