Inappropriate Use of Emergency Medical Services Transport: Comparison of Provider and Patient Perspectives

Objectives: To determine the extent of inappropriate ambulance use from the perspectives of both emergency medical services (EMS) providers and patients utilizing EMS transport, assess level of agreement, and identify variables associated with inappropriate ambulance use. Methods: A prospective cross-sectional study was done of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban university hospital ED. EMS providers and patients completed a survey with questions regarding their perceptions of whether the need for ambulance transport was an emergency or a nonemergency. Patient demographic information and availability of alternate means of transportation to the hospital were also evaluated. Results: Eight hundred eighty-seven patients were included in the study. EMS providers thought that 501 patient transports were appropriate and represented true emergencies, whereas 689 patients believed their medical problems were true emergencies. A significant number of patients (n = 415, 47%) had access to alternative transportation to the hospital. Blunt traumatic injury and altered mental status were the most common reasons for EMS transport. Patient characteristics significantly associated with EMS provider perception of a true emergency were male gender, age >51 years, higher education, chest pain/cardiac complaints, shortness of breath/respiratory complaints, and Medicare insurance. Characteristics significantly associated with patients who perceived themselves to have true emergencies were black ethnicity, higher education, shortness of breath/respiratory complaints, and Medicare insurance. There was 75% agreement between EMS providers and patients on appropriateness of ambulance transport (kappa = 0.84). Conclusion: Inappropriate ambulance use is a significant problem from both EMS provider and patient perspectives. Certain patient characteristics are associated with a higher probability of appropriate and inappropriate uses of EMS transport. A large number of patients transported by ambulance have alternative means of transportation but elect not to use them.     

Refusal of Out-of-hospital Medical Care: Effect of Medical-control Physician Assertiveness on Transport Rate

Objective: Previous studies have shown that contacting an on-line medical-control physician increases the transport rate of patients who attempt to refuse medical assistance. The authors studied the physician-patient interaction to determine the type of interaction that was more likely to result in patient transport. Methods: A prospective, observational study of patient-initiated refusals of medical assistance (RMAs) was performed in a suburban volunteer emergency medical services (EMS) system, with 12 receiving hospitals county-wide. Medical-control contact was required for all patient-initiated RMAs. Consecutive patients who attempted out-of-hospital RMA over a 3-month period were monitored. Structured data instruments were completed by the medical-control operator and medical-control physician for all patients who attempted RMA. Data collected included patient demographics and contact information, scene characteristics, history and physical examination data, length of time of interaction, and the physician's assessment of the need for transport and the patient's capacity to refuse transport. The operator and physician independently graded the physician's assertiveness in talking to the patient on a continuous 10-point scale. Results: There were 130 patients who attempted RMA; 69 (53%) refused transport even after discussion with the medical-control physician, while 61 (47%) were transported to a hospital. The patients who were transported did not differ from those not transported with respect to age, chief complaint, vital signs, or presence of police on scene. Using the operators' independent assessments, the physicians were more assertive when they graded the patient as being more ill (needs transport, 8.8; may need transport, 7.7; doesn't need transport, 4.1; p < 0.01). When the physicians were more assertive, the patients were more likely to agree to transport (assertiveness >8, 81% transport; assertiveness <8, 19% transport; p < 0.01). Conclusions: Contact with a medical-control physician appears to markedly improve the transport rate for patients who initially attempt to refuse out-of-hospital medical care. This is especially so when physicians are more assertive in recommending transport.     

Effects of Emergency Medical Services Agency Ownership Status on Patient Transport

Objectives: Medical insurers have clearly defined which ambulance services will be reimbursed and which will not. Thus, ambulance agencies that provide emergency 9-1-1 services must be highly cognizant of their organization's revenue needs. This presents a distinction between publicly funded and privately funded organizations. This study seeks to identify any differences in the transport decision among agency ownership types. Methods: This retrospective study captured all 9-1-1 ambulance requests in the state of Virginia for the years 2009 through 2013. Each request was answered by either a publicly funded ambulance service or a privately funded ambulance service. The outcome variable of interest was patient disposition and the key explanatory variable was organizational ownership type. Multivariate logistic regression was utilized for data analysis. Results: Of the 4.6 million 9-1-1 requests, approximately 30% were attended to by a private ambulance service. After controlling for potential confounders, ownership type was found to have a statistically significant effect on the transport decision. Private for-profit ambulance services were 4.5 times more likely to transport a patient than were their publicly funded counterparts (OR: 4.56, 95% CI: 4.47–4.65). Private non-profit organizations were twice as likely to engage in patient transport (OR: 2.12, 95% CI: 2.09–2.14). Private for-profit ambulance organizations were also found to be less likely to allow for patient refusal (OR: 0.54, 95% CI: 0.53–0.55) or to medically treat on-scene without subsequent transport (OR: 0.48, 95% CI: 0.45–0.50). Conclusions: Given the reimbursement practices of medical insurers, private ambulance services are incentivized towards patient transport. Operational revenue for these services is not generated through public budgeting processes but through user fees. Thus, private agencies are more reliant on billable services than are their publicly funded counterparts.     

Determinants of Pediatric EMS Utilization in Children with High-Acuity Conditions

Background: Underutilization of emergency medical services (EMS) for children with high-acuity conditions is poorly understood. Our objective was to identify differences in demographic factors and describe caregivers' knowledge, beliefs, and attitudes regarding EMS utilization for children with high-acuity conditions. Design/Methods: This was a mixed-methods study of children with high acuity conditions, defined as requiring immediate medical or surgical intervention and intensive care admission, over a one year period. Demographic data were collected through a retrospective chart review. Qualitative analysis of semi-structured interviews from a purposive sample of caregivers was conducted until thematic saturation was achieved. Results: Three hundred seventy-four charts were reviewed; 19 caregivers were interviewed (17 in-person, 2 via telephone). The 232 (62%) children not arriving by EMS tended to be younger (1.58 years vs. 2.31 years, p = 0.02), privately insured (30% vs. 19%, p = 0.04), and lived further from the hospital (16.80 miles vs. 12.45 miles, p = 0.001). Patient gender, ethnicity, comorbidities and caregiver language were not associated with EMS underutilization. Immediate invasive medical interventions were more often required for EMS utilizers (85% vs. 60%, p < 0.001). EMS utilizers were more likely to require intubation (78% vs. 47%, p < 0.001) and cardiopulmonary resuscitation (CPR) (26% vs. 2%, p < 0.001), and had shorter hospital stays (4.70 vs. 8.16 days; p-value < 0.001). Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Caretakers expected EMS would provide timely, safe transportation that expedited medical care and emotional support. Medical knowledge and prior experience with EMS influenced decision-making about arrival mode. Timeliness, cost, socioeconomic and demographic characteristics, loss of autonomy, and the logistics of EMS activation and transport were the most commonly reported barriers. Conclusions: Young age, private insurance status, and greater distance from the hospital were associated with EMS underutilization. Understanding caregiver expectations, knowledge, and perceived barriers may have important implications for the use of EMS for children. These findings reveal opportunities for improved public education on EMS systems to enhance appropriate EMS utilization for children with high acuity conditions.     

Relationships between Ambulance Transports for Alcohol Intoxication and Assault

Objective : To evaluate the association between ambulance transports for assault and those for alcohol intoxication.
Methods : A retrospective analysis of emergency medical services (EMS) calls was performed. The authors used logistic regression models to compare patients transported for alcohol intoxication with a control group of patients transported for respiratory distress (asthma or shortness of breath) with respect to whether they had been transported on a separate occasion for a chief complaint of assault.
Results : Patients transported for alcohol intoxication had 9 times the risk of transport for assault as compared with the control group (OR = 9.3; 95% CI = 6.4, 13.6). The odds of transport for assault among the alcohol patients increased 17.1% with each alcohol transport (OR = 1.17; 95% CI = 1.14, 1.20) but decreased for the control group (OR = 0.34; 95% CI = 0.26, 0.44). Repeat transports for assault were more common among the alcohol patients than among the control group (OR = 3.3; 95% CI = 1.1, 11.3). The mean number of assault transports was higher among the alcohol patients than among the patients never transported for alcohol intoxication (p < 0.0001).
Conclusions : Patients transported on multiple occasions for acute alcohol intoxication are at relatively high risk for assault. This risk group should be targeted for focused assault prevention interventions that include components designed to reduce incidents of repeat alcohol intoxication.     

EMS Systems: Foundations for the Future

Emergency medical services (EMS) occupy a unique position in the continuum of emergency health care delivery. The role of EMS personnel is expanding beyond their traditional identity as out-of-hospital care providers, to include participation and active leadership in EMS administration, education, and research. With these roles come new challenges, as well as new responsibilities. This paper was developed by the SAEM EMS Task Force and provides a discussion of these new concepts as well as recommendations for the specialty of emergency medicine to foster the continued development of all of the potentials of EMS.     

Preferences for EMS Transport andPediatric Emergency Department Care

Objectives. To characterize the reasons pediatric emergency department (PED), patients access emergency medical services (EMS) for transport to the pediatric ED. To describe the acceptability of other modes of transport andalternative sites of care. Methods. We included a convenience sample of the responsible adults accompanying pediatric patients who arrived via EMS to the PED of an academic medical center. We administered a survey to evaluate why they chose EMS andtheir feelings about alternative modes of transport (e.g., medical van, taxi) or alternative sites of care (e.g., urgent care center, primary care physician's office, or getting an appointment within 24 hours). Results. One hundred thirthy-eight surveys were completed. Pediatric patients averaged eight years of age. Trauma (44%) andseizures (17%) were the chief complaints. The primary reasons for EMS use were perceived medical necessity (54%) andsecurity of transport by EMS (17%). Only transport by EMS was found to be acceptable. The responsible adults expressed acceptance of the PED (median = 7, 1 = not acceptable, 7 = very acceptable) as a destination, more than their child's primary care doctor's (median = 4), urgent care centers (median = 3), or no transport anda physician appointment within 24 hours (median = 1). Conclusions. Adults access the EMS system for children because of concerns regarding the acuity of illness andfor the security of EMS transport. They were generally uninterested in transport by any mode other than EMS. However, they would accept transport to alternative sites for immediate care.     

Impact of Interventions for Patients Refusing Emergency Medical Services Transport

Objective: To evaluate the effect of a documentation checklist and on–line medical control contact on ambulance transport of out–of–hospital patients refusing medical assistance. Methods: Consecutive patients served by four suburban ambulance services who initially refused emergency medical services (EMS) transport to the hospital were prospectively enrolled. In phase 1 (control phase), all patients who initially refused medical attention or transport had an identifying data card completed. In phase 2 (documentation phase), out–of–hospital providers completed a similar data card that contained a checklist of high–risk criteria for a poor outcome if not transported. In phase 3 (intervention phase), a data card similar to that used in phase 2 was completed, and on–line medical control was contacted for all patients with high–risk criteria who refused transport. The primary endpoint was the percentage of patients transported to the hospital. Results: A total of 361 patients were enrolled. Transport rate varied by phase: control, 17 of 144 (12%); documentation, 11 of 150 (7%); and intervention, 12 of 67 (18%) (chi–square, p = 0. 023). Transport of high–risk patients improved with each intervention: control, two of 60 (3%); documentation, seven of 70 (10%); and intervention, 12 of 34 (35%) (chi–square, p = 0. 00003). Transport of patients without high–risk criteria decreased with each intervention: control, 15 of 84 (18%); documentation, four of 80 (5%); and intervention, 0 of 33 (0%) (p = 0. 0025). Of the 28 patients for whom medical control was contacted, 12 (43%) were transported to the hospital, and only three of these 12 patients (25%) were released from the ED. Conclusion: Contact with on–line medical control increased the likelihood of transport of high–risk patients who initially refused medical assistance. The appropriateness of the decreased transport rate of patients not meeting high–risk criteria needs further evaluation.     

Impact of Ambulance Diversion Policies in Urban, Suburban, and Rural Areas of Central Maryland

As a method to control patient flow to overburdened hospitals, effective emergency medical services (EMS) systems provide policies for ambulance diversion. The Maryland state EMS system supports two types of alert for general hospital use: red alert, aimed at limiting the delivery of patients who may require intensive care unit (ICU) admission, and yellow alert, aimed at preventing further overload of already overtaxed emergency departments (EDs). OBJECTIVE: To examine the effect of those alert policies in different geographical environments, urban, suburban, and rural. METHODS: Alert data for 23 hospitals in Central Maryland and ambulance arrival data for approximately 138,000 ambulance calls during calendar year 1996 were combined and analyzed. The impacts of diversion practices in the geographic areas were compared. RESULTS: Red alert reduced volume in all patient acuity levels in all geographic areas by a statistically significant 0.4 patient/hr. Yellow alert diverted low-acuity patients at the rate of 0.13 patient/hr (p<0.001) in urban areas and at the rate of 0.16 patient/hr (p<0.001) in suburban areas, but had minimal impact in the flow of patients in the rural environment. CONCLUSIONS: The ED diversion policy has some limited effect in preventing further patient volume in urban and suburban areas, but has virtually no impact in rural areas. However, an ICU diversion policy diverts patients of all acuities uniformly and inordinately diverts patients not likely to require ICU admissions while having only minimal impact on patients who do require ICU resources. The impact of red alert is uniform in all geographic areas. The impact and efficacy of ambulance diversion policies should be evaluated to ensure they are having the intended effect. While perhaps initially effective, the impact of alert policies may change over time.     

EMS Provider and Patient Safety during Response and Transport: Proceedings of an Ambulance Safety Conference

Abstract

The out-of-hospital setting is unique to health care and presents many challenges to providing safe, high-quality medical care in emergency situations. The challenges of the prehospital environment require thoughtful design of systems and processes of care. The unique challenges of ambulance safety may be met by analyzing systems and incorporating process improvements. The purposes of this paper are to 1) outline the nature of this problem, 2) introduce a framework for this discussion, 3) provide expert opinion from a two-day ambulance safety conference, and 4) propose a plan of action to address the safety issues identified in the literature and expert opinion at the conference. Utilizing the Haddon Matrix as a framework, we present the safety issues and proposed solutions for factors contributing to an injury event in the emergency medical services (EMS) transport environment: host, agent, physical environment, and social environment. Host refers to the person or persons at risk, in this case, the EMS personnel or the patient. The agent of injury refers to the energy exerted during the course of an injury, and may be modified to include unrestrained equipment that contributes to the injury. The physical environment refers to the characteristics of the setting in which the injury takes place, such as the roadway or the physical design of the ambulance. Finally, the social environment refers to the social, legal, and cultural norms and practices in the society, such as peer pressure and a culture that discourages the use of safety equipment.     

Association of Out-of-hospital Criteria with Need for Hospital Admission

Objective: To validate high-risk historical and physiologic out-of-hospital criteria as predictors of the need for hospitalization following ED evaluation.
Methods: Consecutive patients entered into the Suffolk County advanced life support system were enrolled. Previously proposed historical and physiologic "high-risk" criteria for hospitalization were prospectively collected. Criteria were associated with the need for hospital admission following ED evaluation.
Results: 1,238 patients were enrolled; 391 were released from an ED after transport. Most patients (843/1,238; 68%) were admitted to a hospital; and four died in the ED. Factors associated with an increased likelihood of admission or death among the transported patients were: bradycardia (90% admitted, p < 0.02); hypotension (80%, p < 0.03); hypertension (89%, p < 0.03); and age > 55 years (81%, p < 0.0001). Unresponsiveness and other abnormal vital signs were not associated with admission on univariate analysis. Logistic regression analysis identified two other factors associated with admission or death: tachycardia (72%, admitted, p < 0.01) and head injury (78% admitted. p < 0.001).
Conclusions: Abnormal pulse or blood pressure, head injury, and age > 55 years are associated with patients' requiring hospital admission after accessing the emergency medical services system. These criteria may aid the design of out-of-hospital refusal-of-care policies.     

P ROSPECTIVE D ETERMINATION OF M EDICAL N ECESSITY FOR A MBULANCE T RANSPORT BY P ARAMEDICS

Objective. It has been estimated that between 11% and 61% of ambulance transports to emergency departments are not medically necessary. This study's objective was to analyze paramedic ability to determine the medical necessity of ambulance transport to the emergency department. Methods. Paramedics prospectively assessed adult patients transported to an emergency department during a six-week period. The setting was an urban, all advanced life support, public utility model emergency medical services (EMS) system with 58,000 transports per year. Paramedics determined medical necessity of patient transport based on the following five criteria: 1) need for out-of-hospital intervention; 2) need for expedient transport; 3) potential for self-harm; 4) severe pain; or 5) other. On arrival in the emergency department, the emergency physician made a blinded determination based on the same criteria. Kappa statistics were used to assess agreement. Results. Data forms were completed on 825 of 1,420 (58%) patients transported. Emergency physicians determined 248 (30%) transports were not necessary, paramedics 236 (29%), with agreement in 76.2% (K = 0.42) of cases. Paramedics undertriaged 92 patients (11%). Rates of agreement on the five criteria were: 1) 71.9% (K = 0.43); 2) 77.7% (K = 0.22); 3) 89.6% (K = 0.40); 4) 89.6 (K = 0.32); and 5) 82.2% (K = 0.29). Conclusions. Paramedics and emergency physicians agreed that a significant percentage of patients did not require ambulance transport to the emergency department. Despite only moderate agreement regarding which patients needed transport, the undertriage rate was low.     

Do Emergency Medical Services Dispatch Nature and Severity Codes Agree with Paramedic Field Findings?

Emergency medical services (EMS) systems increasingly seek to triage patients to alternative EMS resources. Emergency medical services dispatchers may be asked to perform this triage. New protocols may be necessary. Alternatively, existing protocols may be sufficient for this task. For an existing dispatch protocol to be sufficient, it at least must accurately categorize patient condition and severity based on an external standard. OBJECTIVE: To examine the extent to which nature codes (NCs), or patient condition codes, and severity codes (SCs) currently assigned in one urban 911 center agree with paramedic field findings. The null hypothesis was that there is no routine agreement (75%) between dispatcher-assigned NC or SC and paramedic-assigned NC or SC for the same patient using the same protocol. METHODS: Emergency medical services dispatch nature and severity code data and matching out-of-hospital data were prospectively gathered over six months. Dispatch data included the NC: caller-identified problem, and the SC: dispatcher-assessed severity. Each NC is modified by one of three SCs (1, 3, or 9): 1 is emergent, 3 is urgent, and 9 is neither. Paramedics verified and/or corrected dispatcher-assigned NCs and SCs using the same dispatch protocol. RESULTS: One thousand forty usable cases fell into 33 unique NC/SC combinations. The designation of SC 1 was assigned 275 times, SC 3 was assigned 736 times, and SC 9 was assigned 24 times. The SC was missing five times. The overall NC agreement was 0.70 (95% CI = 0.697 to 0.703). The overall SC agreement was 0.65 (95% CI = 0.645 to 0.655). The NC agreement exceeded 75% for ten (59%) NC/SC combinations. The SC agreement exceeded 75% for five (29%) NC/SC combinations. There was both NC and SC agreement for four (24%) combinations: urgent breathing problems, urgent diabetic problems, urgent falls, and urgent overdoses. The greatest NC/SC disagreement occurred within emergent and urgent traffic crashes. Paramedics adjusted SC toward lower severity 29% of the time and toward higher severity 5.4% of the time. There was no upward SC adjustment for eight (47%) combinations. CONCLUSIONS: Certain dispatcher-assigned NC and SC codes and NC/SC combinations achieved the study threshold. Overall agreement failed to achieve the threshold. The lowest SC level was rarely assigned, preventing a meaningful analysis of all severity levels.