Like many urban 9-1-1 response agencies, the city of Los Angeles Fire Department (LAFD) has seen a marked increase in volume in recent years, experiencing a 4.7% increase in EMS incidents from 2013 to 2014, followed by a 7.9% uptick in 2015. This increase has featured a disproportionate growth among low-acuity callers, vulnerable adult superusers, and clients with mental health exacerbations.
The increase in demand also takes place in the context of broader trends, including: increased age segmentation of our workforce, with a large number of members approaching retirement and fewer EMTs and paramedics available to respond to calls; an emergent class of newly insured patients accessing healthcare via 9-1-1; an expanding Medicare population with inherently higher transport rates; and diverse attitudes among subpopulations about what constitutes a medical emergency.
Taken together, these trends push resource availability to the limits. Few municipalities have the agility of financial or human resources to meet this kind of accelerated demand, so operational leaders are charged with doing more with less–becoming more creative with their resources, and finding new and different ways to meet patient needs while still keeping rigs available for the next time-critical emergency.
This challenge naturally summons the need to better understand who our clients really are, and how we can work with other community partners to more effectively match our collective response to each client.
A low-acuity patient is handed off to NPRU personnel.
A New Strategy
There’s an understanding that when you dial 9-1-1 someone will show up who has more resources, more expertise or a better plan. Historically, the better plan came in one flavor: stabilize and transport the patient via ambulance to the nearest ED, where they would be exposed to people with expertise, diagnostic tools and an ability to incorporate them into a network of care. But increasingly, providers in the field have become empowered to consider what needs can be assessed and provided for on scene, and what links to further care can be made in real time. What this will look like in the future, and which providers will wield these resources, is a subject of much experimentation.
Several years ago, EMS leadership at the LAFD began exploring some of these novel models of care delivery–visiting colleagues in agencies across the U.S. in search of approaches that could be blended together to provide the best mix of options to improve patient navigation in our diverse community.
This search for new approaches represented a departure from the standard narrative of EMS, especially in a fire department steeped in tradition. Yet it was supported by forward-thinking political leaders, our providers in the field who saw patients whose needs could be met in a smarter way, and a fire chief who keyed in on the complex healthcare landscape that lay ahead. With this investigation, an alternative to community paramedics emerged as a good option for our community: the use of advanced practice providers.
Advanced practice providers, such as nurse practitioners (NPs) and physician assistants (PAs), have become commonplace in most EDs and primary care clinics, and are increasingly called on to absorb the growing demand of low- and moderate-acuity cases requiring critical, unscheduled care.
Prehospital agencies in Arizona, Colorado, Southern California and other sites have tested the utility of NPs with positive results. NPs, unlike other providers, have a broader scope of practice, training in health teaching and promotion, can write prescriptions and function autonomously. And the effect of teaming up an NP with a seasoned firefighter/paramedic magnifies the effectiveness of both to make a very formidable team.
In January 2016, the LAFD launched its first Nurse Practitioner Response Unit (NPRU), which was christened in South L.A.–taking for its home Fire Station 64 in Watts, one of the busiest and toughest EMS jurisdictions in the country. This station houses the LAFD’s Battalion 13 which has a scarcity of healthcare providers compared to other sectors of the city and contributes to many residents without access to a doctor using 9-1-1.
From 2012—2015, EMS volume in this jurisdiction increased 39%–accounting for 35% of the LAFD’s citywide growth–and the majority of this growth was for low-acuity calls. Battalion 13 also contained the largest number of housed adult frequent 9-1-1 users, and was the second-fastest-growing sector of the city for police placement of involuntary mental health holds. The NPRU was initially funded by an Innovation Grant from the City of Los Angeles, and in July 2016 was folded into the regular LAFD budget.
The NPRU is a converted ambulance with CLIA-waived point-of-care testing capabilities through use of the i-STAT System, a next-generation Sonosite iViz ultrasound and ED materials facilitating immediate treatment of patients with low-acuity medical complaints. It’s staffed on a four-day, 10-hour-per-day schedule by Terrance Ito, DNP, FNP-BC, an NP with both prehospital and L.A. County ED experience, and Aaron Guggenheim, MPH, NRP, a firefighter/paramedic with broad prehospital experience and a public health degree. Together they offer a unique skill set bringing enhanced clinical expertise, diagnostic tools and network capability directly to the patient.
The mission of the NPRU is threefold:
- Mobile urgent care offering immediate on-scene evaluation, treatment and release of low-acuity 9-1-1 callers with primary or urgent care complaints;
- Comprehensive assessment of 9-1-1 super-users, and linkage to follow-up care, including being visited by a social worker within 24 hours; and,
- On-scene medical clearance of select mental health patients, with the option of direct transport to a psychiatric urgent care facility.
All patients receive the appropriate complement of response resources based on the dispatch code; however, in addition, the NPRU may either electively buy into the incident while monitoring radio traffic or be summoned on-scene by other responding units. Frequent users can be referred at any time by LAFD field units, and after an on-scene consent and screening process by the NPRU, the individual is referred to Partners in Care–an award-winning social service organization providing close follow-up and linkage to both medical and nonmedical resources.
For patients with primary mental health patients, the NPRU often responds in concert with other LAPD units, and spent several weeks learning from members of the Los Angeles Police Department’s Mental Health Evaluation Unit. If medically cleared, cooperative mental health patients are taken directly to an Exodus Recovery Urgent Care facility–a Department of Homeland Security partner who has teamed up with the LAFD to expedite prehospital psychiatric patients and get them the care they need faster.
In the first six months of service, the NPRU attended to more than 329 low-acuity 9-1-1 callers, with a treat-and-release rate of 52%. Staff referred a dozen superusers to Partners in Care, with a consequent decrease in their 9-1-1 utilization. They also medically cleared 30 mental health patients on scene-permitting their immediate transport Exodus Recovery, which decreased their time to first psychiatric team contact to 25 minutes. (See Table 1.)
Challenges have included learning to identify appropriate patients, explaining the NPRU’s capabilities to other field units, and assimilating the NPRU into LAFD operations and culture as a new type of resource. LAFD staff are accustomed to routine and standard operating procedures, and the incorporation of new concepts such as “discharge on scene,” “linkage to care,” and “immediate medical clearance” weren’t readily accepted.
Ito, the EMS NP supervisor for the LAFD, reflects on how this unit has evolved from paper to practice over the first six months, and where he sees the unit going in the years to come.
How did you first explore the idea of an NPRU?
Innovations in emergency and prehospital care have always piqued my interest. Medicine has advanced tremendously in the last two decades as equipment and diagnostics have gotten smaller and more portable.
A few years ago, Marc Eckstein, MD, the medical director for the LAFD, mentioned he was interested in implementing a mobile integrated healthcare (MIH) response unit. I was tasked with contacting the Mesa (Ariz.) Fire Department, who had been piloting their MIH project for the past few years.
After an extensive conversation, I felt there was good evidence this was a viable approach that the LAFD should consider testing in a large urban setting. I traveled out to Mesa to observe the unit during real-time operation to get a better understanding of their program. Spending a few days with them illuminated key aspects for successes, ongoing issues and obstacles.
Their preliminary data was compelling, and seeing mobile healthcare delivery in person helped drive that message home. Lessons learned were utilized in the development of the NPRU for the LAFD.
NPRU firefighter and paramedic Aaron Guggenheim, NRP, MPH, assists a patient while nurse practitioner Terrance Ito, DNP, FNP-BC, uses a SonoSite iViz compact ultrasound to complete his evaluation on scene.
The LAFD has a strong sense of tradition. What was your first day on the job like?
Being thrown into a new role in an unfamiliar environment is always challenging. I quickly realized that the fire department is a very different work setting than the ED. The strong work ethic, team approach, and sense of pride to accomplish each mission or goal illuminates how and why the LAFD has been successful for so many years.
Our first memorable treat and release was a pediatric patient with a minor forehead laceration. Normally, he would’ve been transported to an ED to have the wound repaired. After discussing with his mom, we decided to repair the wound on scene. After a 10-minute procedure, the patient returned back to playing with his brothers and sisters. And when our patient liaisons representative called her back, the patient’s parents were very happy with their experience.
As with that first case, we learned quickly that to successfully treat and release patients in the field requires dialogue. Discussions with my partner are key, and many decisions are based on consensus-incorporating clinical findings, policy considerations, appropriateness of on-scene care. In the end, it’s what we’d want for our own family members. That dynamic has been a huge part of the character and success of the NPRU.
Why do people with low-acuity complaints call 9-1-1?
It seems that among some groups, calling 9-1-1 for non-emergencies has become a social and cultural norm. Many of them lacked health insurance for a number of years–and having recently become insured, we’ve found that they’re having difficulty with healthcare navigation.
The bottom line is communities trust the LAFD, and that’s why they call. For those with lower socioeconomic status, the fire department is their only means of access to healthcare, and has been for a number of years.
Ito and Guggenheim assess a low-acuity 9-1-1 caller.
Where do you see the LAFD NPRU five years from now?
That’s a difficult question to answer. The preliminary data supports that the NPRU is able to provide safe and efficacious care while decreasing 9-1-1 transports to the ED by > 50%.
I believe the next steps for the NPRU will be to fortify linkage-to-care mechanisms and assist with healthcare navigation, but also educate certain segments of the public that the 9-1-1 system isn’t a limitless resource.
As more agencies implement MIH programs, a clearer picture will develop on what the future will hold for programs such as the NPRU. Long-term goals for the NPRU include refining our ability to get patients timely appointments with the right provider, scaling to different sectors of the city, and integration of useful technology that will help support a comprehensive assessment and disposition.
Despite the latest technology and advances in medicine, there are some things the NPRU won’t solve. Some patients just need a “tincture of time” to resolve their urgent issue. It’s a principle that technology can’t resolve, and it’s a reality that goes against the drive toward expeditious care in the field.
I think advanced practice providers are uniquely suited to appreciating nuances like this.
A Different Perspective
Guggenheim has been a paramedic for 11 years. He’s been a clinical instructor at the UCLA Center for Prehospital Care since 2005, joined the LAFD in 2006, and recently received his MPH degree from UCLA.
Tell us about your journey from becoming a firefighter with the LAFD to developing an interest in public health.
I’d heard of MIH and community paramedicine, and felt that Los Angeles could benefit from similar programs. I pursued an MPH to learn more about community health and program planning, and intended to combine these skills with my prehospital background to someday contribute to the MIH/CP movement in Los Angeles.
I enjoyed the focus on research, translating science into operational programs, and learning how to explain to other stakeholders what we as care providers do in the field. It was serendipitous that Drs. Eckstein, Sanko and Ito were putting together an MIH program at the LAFD while I was in graduate school, and I was really excited about the opportunity to help grow this new program.
How does the NPRU’s approach differ from your normal role as a firefighter/paramedic?
In terms of patient care, people have been really happy being treated and discharged on scene, sometimes even with a prescription in hand. They’re relieved that they don’t have to wait in the ED, and have peace of mind in having an NP take care of them on scene. By providing a more advanced assessment, we can give more assurance to those who just want to be “checked out” and save them from an unnecessary ED transport.
Part of my job is to provide the prehospital perspective to support the NP’s clinical decisions. He has a lot of new stimuli coming in, and my role is to manage the scene and apply department policies and procedures.
Sometimes options used in the hospital aren’t feasible in the field, and we often have conversations on scene to clarify and identify the best disposition. We’re constantly evaluating our decisions to find new and better ways to use the model to get patients appropriate care.
Where do you see the NPRU in five years?
There’s clearly a need for this type of resource in other areas of L.A. Future units will need to be placed strategically and tailored to the needs of their specific communities, as well as to the resource needs of the department. Ultimately, the NPRU is a way of testing new approaches to EMS deployment and transport.
The flexibility of having various transport options and an expanded scope of practice has proven beneficial. Although I can’t say what the staffing model will look like in five years, I envision a more proactive, flexible and patient-centered model for EMS delivery in L.A.
Recommendations & Lessons Learned
Looking to launch an NPRU? Take small bites: L.A. City’s first year was focused on simply demonstrating proof of concept, collecting data, and making sure our interventions keep patients safe and satisfied. We’re focused on establishing processes, like cultivating our Patient Liaison Program to survey patients and regular chart reviews and feedback sessions. We’ve learned many of these things from our partners in Mesa and elsewhere, and are confident they will pay dividends as we scale up here in L.A.
- Identify the needs of your community, including a comprehensive needs assessment, in any way you can.
- Make a rolling list of your community stakeholders, and seek to learn what services already exist but may be underused.
- Write your ideas down on paper; go through the exercise of drafting a mission statement, plan, budget, proposed funding sources and workflows for selecting patients.
- With your missions in mind, constantly evaluate how new tools and partnerships may help you accomplish your mission, yet beware of scope creep.
- Understand the legal context you work in, and make sure you have the backing of your local regulatory agencies.
- Take the time to develop a plan to explain your work to both internal and external partners.
At the end of the day, our mission is to provide the same level of care that we would hope for our own family members–and a key part of that care is treating our patients with respect and dignity, and helping our clients to navigate a complex, evolving and potentially expensive healthcare world.