News & Updates

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  • 23 Nov 2022 11:34 AM | Matt Zavadsky (Administrator)

    The EMS workforce challenges are affecting agencies of every type!

    Saw this column when it first came out in May, and after listening to fire chiefs from all over the country over the past few months explain the challenges they are having with recruiting personnel, especially paramedics, into the fire service, it seems Ben may be really on to something.

    A local fire department in north Texas that provides ambulance service is offering a $10,000 sign on bonus for FF/paramedics.  Other departments in the state are doing similar sign on incentives.

    I was recently told by a well-respected fire chief from an agency that does not do ambulance service that his #1 recruiting advantage over other departments in his area is that his department does not do ambulance service.

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    Why so many firefighters don’t become paramedics

    Five factors help explain why our current crop of firefighters and firefighter-EMTs never make the move

    May 28, 2022

    https://www.firerescue1.com/career-1/articles/why-so-many-firefighters-dont-become-paramedics-VKO8qSI6qA7pkEwI/

    Within fire-based EMS systems everywhere, the numbers of firefighter-paramedics are dwindling. Fire departments are scrambling to fill their immediate vacancies by drawing in new paramedics. Recruitment campaigns promising great benefits, sign-on bonuses and guaranteed shifts away from the ambulance are filling up social media feeds.

    Ten years ago, when fire department jobs were scarce, campaigns like these would have brought in a flood of qualified candidates. Not so in today ’s world. Everyone is hiring. And many agencies that used to require a paramedic license to even be considered have lowered the required qualifications just so they can fill all the empty seats on their fire engines. Even those vacancies have become a struggle to fill.

    It’s time for fire-based EMS to realize that there simply aren’t enough paramedics out there to fix our problem. The answer lies within – encouraging our existing firefighters and firefighter-EMTs to become paramedics. But to do that we must first be honest and talk about the reasons they don’t become paramedics.

    Here is a countdown of the top five reasons firefighters don ’t become paramedics.

    5. THE NATIONAL REGISTRY

    Firefighters and written tests go together like oil and water. We like to get our hands dirty and prove ourselves through action. The thought of going toe to toe with the National Registry is enough to make any firefighter walk away, especially those who struggled through it to become an EMT.

    4. TIME IS MONEY

    I’ve heard people say,  “going to paramedic school would be a pay cut.” And they aren ’t lying.

    Firefighter salaries, especially those just starting out, are low. At the beginning of my career as a full-time firefighter-paramedic, I qualified to receive government assistance for free milk, baby formula and peanut butter. I remember losing my temper at a grocery store cashier for trying to shame my wife when she pulled out the big paper tickets that covered the cost of those essential items. I had just come home from a 24-hour shift. I hadn ’t slept. It wasn ’t pretty.

    Eventually, like just about every firefighter I know, I took on a second job. A necessity that many of us depend on just to keep our families afloat. I was lucky enough to have gone to paramedic school before I had kids. Had I waited, I might never have.

    3. LIMITED ONLINE OPTIONS

    Online learning is not the future of education, it ’s the right now. Associate degrees, bachelor's degrees and even master ’s degrees are being earned at fire station kitchen tables everywhere. And though paramedic programs are adapting to accommodate the modern-day learner, the amount of content, clinicals and rapid-fire pace have held them back from breaking with the classroom.

    Even though paramedic programs are shorter and typically less expensive, the ease with which other college degrees can be earned online is drawing firefighters looking to advance their careers away from earning their gold patch.

    2. THE AMBULANCE

    When compared to a suppression apparatus, being assigned to an ambulance means longer hours away from the station and more territory to cover. It brings paperwork, liability and the constant battle to remain professional in the face of disgruntled nurses at overcrowded hospitals. And because firefighter-paramedic numbers are so limited, many are being forced to spend the majority of their careers on ambulances. Due to department necessity, they ’re stuck.

    Firefighters and firefighter-EMTs see what is happening. And many are choosing to ride backward rather than risk being assigned to an ambulance for the next 20 years.

    1. ORGANIZATIONAL CULTURE

    “I ’m not going to medic school because I want to be a firefighter.”

    To the outside world, we ’re all firefighters. But for those working within fire-based EMS, we are either firefighters or paramedics. The divide is real. So when firefighters and firefighter-EMTs talk about going to paramedic school, they ’re treated as if they are changing teams. They ’re shamed, ridiculed and reminded of all the hardship they will be bringing upon themselves.

    Unfortunately, some are even coached by senior leadership to avoid becoming paramedics so as not to stagnate their careers by being stuck in an ambulance. Of all the reasons firefighters are choosing not to become paramedics, this is the most toxic. Placing individual ambitions above the needs of our respective communities will certainly lead to the failure of our mission.

    WHAT DO WE DO NOW?

    For all the problems I listed above, there are solutions – some less complicated than others, but none can happen overnight. It starts at the top with those responsible for cultivating a culture of success. Fire chiefs, if you’re wondering why your fire department isn’t growing its own paramedics, the problem isn’t with the seeds; it's in the soil.

    Go to your city councils, your fire boards, your citizens. Help them understand what firefighter-paramedics do and what it will mean if we run out. Garner their support to create an environment where firefighters who are willing to go through the struggle of achieving the gold standard of prehospital care are valued. Fight for your firefighter-paramedics as hard as you fight for that new fire engine. Show them you care. Because if you don’t, why should anyone else? 

    About the author

    Ben Thompson is a captain in Birmingham, Alabama. In 2016, Thompson developed his department’s first mobile integrated health (MIH) program and shared his experiences from building the program at TEDxBirmingham. Thompson was the recipient of the 2016 Emergency Medical Service Provider of the Year Award and the 2018 Joe E. Acker Award for Innovation in Emergency Medical Services, both in Jefferson County, Alabama. He has a bachelor's degree from Athens State University in Alabama and is a licensed paramedic.


  • 16 Nov 2022 6:44 AM | Matt Zavadsky (Administrator)

    This could be another value-added reason for EMS agencies to partner with hospitals to create Mobile Integrated Healthcare (MIH) ‘safe landing’ programs for patients who might be able to be discharged, either from the ED, or from an IP stay, if community paramedics were able to make scheduled visits, and be available 24/7 for any patient needs.

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    Hospitals seek more aid to house patients they can't discharge

    Arielle Dreher

    November 16, 2022

    https://www.axios.com/2022/11/16/hospitals-seek-more-aid-to-house-patients-they-cant-discharge

    Health worker shortages are keeping hospitals from discharging patients for post-acute care and prompting pleas to Congress for per diem Medicare payments to cover the longer stays.

    Why it matters: The requests add to a long list of health industry asks that Congress will have to sort through in the lame-duck session and underscore how the fallout from the pandemic is still rippling through the health care system.

    How it works: Discharging patients to long-term care facilities was challenging even before the pandemic, but COVID-19 dramatically disrupted the process, making it hard for facilities to accept patients in the midst of outbreaks.

    It's costly to keep patients in a hospital when they no longer need to be there, since facilities are typically paid a fixed rate based on a patient's condition or diagnosis.

    The patients who can't be discharged are still too sick to go home and may have mobility issues, conditions like diabetes, or mental health needs.

    Providence Health in Spokane, Wash., for example, is on track to spend nearly $18 million this year on nursing care for patients who no longer need to be hospitalized at its two facilities. A handful of patients have been on the premises for more than 100 days, Susan Stacey, Providence chief executive for inland northwest Washington state, told Axios.

    "We're having workforce issues downstream, so that per diem could provide some targeted temporary relief to hospitals," said Aimee Kuhlman, a vice president of advocacy at the American Hospital Association.

    Zoom in: Long-term care facilities continue to grapple with staffing problems, which limits the available spots for a hospital to discharge to.

    The backlog has left patients with medical emergencies waiting on beds and sometimes dying, the American College of Emergency Physicians wrote in a letter to President Biden this month.

    Some emergency departments that board patients have had backups extending into hallways, waiting rooms, and ambulances waiting to offload patients.

    Normally, an emergency department can handle a challenge of tight capacity, high acuity or a staffing shortage, but when all three come together at once, it can quickly overwhelm an ER.

    "The system is at a breaking point," Christopher Kang, president of the American College of Emergency Physicians, told Axios. His group has asked the administration to establish a nationwide council to address capacity problems and other stresses throughout the health system.

    Yes, but: The requests could be drowned out by myriad other health interests seeking their own relief by year's end.

    Nursing homes, long-term care and home health providers each cite a severe shortage of workers as threatening their business models.

    What we're watching: The siloed health care system has many potential gaps in care, and while the pandemic forced closer collaborations, alliances may be difficult to formalize.

    Facilities that accept Medicaid patients could limit the number of spots for those patients, due to payment rates that are lower than private coverage.

    Skilled nursing facilities are still rejecting patient referrals from hospitals at higher rates than before the pandemic, data from WellSky shows.

    The rejection of hospital referrals also could be a sign some facilities are trying to stay above water and maintain higher standards of care.

    "You shouldn't bring a person in you can't care for because it would cause harm to that individual," said Lori Smetanka, executive director of the advocacy group Consumer Voice.


  • 16 Nov 2022 6:40 AM | Matt Zavadsky (Administrator)

    GREAT news for Maine’s EMS providers!  Almost every finding of this Commission could easily be applied to virtually very EMS agency in the country.

    The legislation that set up this commission, AND requires Medicaid pay parity with Medicare, is attached – Replicate in your state?

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    Commission recommends annual infusion of $76 million to help Maine’s beleaguered emergency medical services

    A 17-member commission recommended that $25 million immediately go to agencies in danger of failing or leaving the communities they serve.

    November 15, 2022

    BY EMILY BADER

    https://www.sunjournal.com/2022/11/14/commission-recommends-annual-infusion-of-76m-to-help-maines-beleaguered-emergency-medical-services/

    AUGUSTA — A blue ribbon commission tasked with studying emergency medical services in the state has suggested an infusion of nearly $80 million a year to keep services afloat.

    At a meeting Monday, members of the commission voted unanimously to recommend that the state of Maine provide at least $70 million a year for five years for the EMS system to support all transporting agencies and $6 million for all non-transporting agencies.

    Maine’s emergency medical services have been in a state of crisis for years, with agencies plagued by steadily declining staffing levels over the past decade, poor Medicare and Medicaid reimbursement rates and high operating costs. Like many other aspects of Maine’s health care system, the pandemic only made the situation worse.

    Democratic Rep. Rachel Talbot Ross of Portland introduced a bill in January that classified EMS agencies as essential services and established the commission, which began meeting in September. Talbot Ross and Sen. Chip Curry, D-Waldo, are co-chairs of the 17-member commission.

    The members voted unanimously to approve the recommendation, save for the two state employees on the panel — Maine EMS director Sam Hurley and Maine Department of Health and Human Services senior advisor Dr. Lisa Letourneau — who abstained from all votes.

    Members also voted unanimously to recommend that $25 million of the $70 million for transporting agencies go to agencies that are in immediate danger of failing or leaving one or more of the communities that they serve.

    This funding would help services across the state “begin to adequately reimburse and provide benefits for our providers in the state of Maine and develop recruitment and retention projects,” Rick Petrie, a paramedic and executive director of Atlantic Partners EMS, said.

    Petrie represents private, for-profit ambulance services on the commission, which also includes state legislators and representatives of the various EMS agencies and health care systems from across the state.

    There are 272 EMS agencies in Maine, according to the latest data provided by Maine EMS, the state licensing and regulation agency that oversees emergency medical services. The multiple types of agencies, or service providers, including private non- and for-profit, hospital-based, community-based nonprofit, and non-fire department-based municipal agencies. There are also three collegiate and two tribal EMS agencies in the state. Most EMS agencies in the state — about two-thirds — are housed within fire departments.

    More than half of all EMS agencies in Maine are transporting services, meaning that they transport patients from a scene to a hospital or other location, and between hospitals. There are just over 100 non-transporting services, meaning they provide treatment at a scene but do not transport patients.

    The commission came up with the $70 million figure using a formula that took into account the cost of service, typical call volume and types of calls.

    “Every service I know of is operating at a loss this year,” said Joe Kellner, the vice president of finance and business operations for Northern Light Health’s home care and hospice division and the chief financial officer for LifeFlight of Maine. Kellner, who represented a statewide association of hospitals on the commission, developed the formula.

    “We know it’s at least $70 million,” he said. “It’s likely quite a bit higher than that because it’s based on efficient service, which is 1,800 calls a year.”

    According to Maine EMS, the majority of EMS agencies answer fewer than 500 calls annually. About a third answer between zero and 99 calls a year.

    “If anything, that number is low,” Kellner said.

    The recommendation language would specify that this funding would be in addition to funding that agencies already receive, such as municipal funding or other subsidies, the members voted. They also stipulated that the state should come up with the funding, not the federal government, which they said would take too long.

    In addition to funding, the commission voted to recommend a permanent commission independent of the Maine EMS Board that could submit legislation.

    The commission will submit its recommendations in a report to the Legislature’s Criminal Justice and Public Safety committee no later than Dec. 7. The commission’s sixth and final meeting will be on Dec. 5. Members will review and approve the report drafted by staff from the nonpartisan Office of Policy and Legal Analysis.

    More information can be found on the commission’s website at https://legislature.maine.gov/emergency-medical-services-study.


  • 7 Nov 2022 7:39 AM | Matt Zavadsky (Administrator)

    WOW! 

    Tip of the hat to Kolby Miller, CEO of Medstar in Michigan for finding this report!

    Outstanding research on the demands being placed on the U.K. NHS Ambulance Trusts.  Lots to unpack in this report, and strongly encourage everyone to take 10 minutes to review it.

    Keep in mind, health, and healthcare outcomes for virtually all types of medical care in the U.K. is substantially better than in the U.S., with 1/3 the expenditure, according to data from the Organisation for Economic Co-Operation and Development.

    https://stats.oecd.org/Index.aspx

    Among the most interesting findings –

    • Of the 10.9 million ‘999’ calls for EMS, only 7.9 million (72.5%) received a response for a face-to-face assessment. 
      • NHS employs extensive use of nurse and other provider telephone assistance in their ‘999’ centers to reduce the need to send a resource into the field.
      • Hear and treat or hear and refer programs help reduce actual responses for face-to-face assessments!

    Note the response priorities and time goals. 

    We have A LOT of work to do….

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    Why have ambulance waiting times been getting worse?

    4 November 2022

    https://www.health.org.uk/publications/long-reads/why-have-ambulance-waiting-times-been-getting-worse

    Introduction

    Ambulance services in England are under immense pressure. In July 2022, all ambulance services in England declared REAP (Resource Escalation Action Plan) level four, reflecting potential service failure. Volumes of calls to 999 are increasing, patients in distress and pain are waiting longer for help to reach them, and ambulance teams feel unable to do their job well.

    The new Secretary of State for Health and Social Care has previously named cutting ambulance waits as his number one priority. As he takes up the role for the second time, he will again need to include ambulances in his list of priorities for the health and care system. Steps taken to date to help address the underlying issues have not yet had an impact on the pressures facing ambulance services.

    This analysis looks at ambulance service performance and explores the contributing factors and priorities for improvement.

    Patients are waiting longer to be treated

    10.6 million calls were answered by the ambulance services in England between April 2021 and March 2022. Around 7.9 million of these required a face-to-face response. This is around one per year for every seven people in England. A city of 500,000 people (around the size of Sheffield) would have around 200 ambulance service call outs per day.

    Ambulance response time targets differ depending how critical the incident is. Table 1 shows the four categories, their targets and response times for 2018/19 and 2021/22. There are targets for the average response time (the average time for all incidents to be responded to) and the 90th centile (the time within which 90% of incidents should be responded to). To ensure that the patient receives attention as quickly as necessary, the ambulance service may respond to incidents with traditional ambulances and other modes of transport including air ambulance and motorbike.

    Response times are increasing across all categories and are now well above target, though less so for the more serious categories, in both absolute and relative terms. This is because when services are under pressure serious incidents are given priority by ambulance services. Figure 1 shows increasing response times across all regions.

    Long ambulance waits put further pressure on the system. For example, those waiting for an ambulance may call the emergency services to find out where the ambulance is, placing further demand on operators to answer more calls. The average call answer times increased from 7 seconds in 2018/19 to 32 seconds in 2021/22. In the same time periods, the number of answered calls increased from 8.74 million to 10.59 million.

    Demand and capacity in the ambulance service

    Figure 2 shows a simplified pathway for a patient needing urgent assessment or treatment at the hospital; for instance, a category 1 incident where an ambulance is needed.

    The response time (typically from when the call is answered to when the ambulance team arrives at the patient’s location) depends on both the demand for ambulances and the capacity of the ambulance service. If demand increases (for example, there are more incidents requiring an ambulance), or capacity reduces (for example, because there is a shortage of crews) the average wait for an ambulance will be longer.

    Demand for ambulances

    Demand depends on both the number of calls received that require a face-to-face response (including sending an ambulance), and how each incident is categorised (for example, multiple resources may be sent to a life-threatening incident).

    Figure 3 shows incidents that the ambulance service attended from April 2018 to September 2022 overall and by category. It indicates that the total volume of incidents is similar to the volume seen in April 2018, but the composition of incident types has changed. There has been an increase in incidents being resolved over the phone (‘hear and treat’) but most incidents still require a face-to-face response. In 2021/22 a higher proportion of incidents were life-threatening (category 1, 12%) or emergency (category 2, 66%) compared with 2018/19 (9% and 60%, respectively). These life-threatening and emergency incidents require more resources than categories 3 and 4. The shift towards these more urgent incidents has increased the demand for ambulance services.

    Ambulance service capacity

    The capacity of an ambulance service can be considered the maximum rate at which it can deal with incidents. This depends on the number of ambulances there are in the system and the length of time each ambulance spends dealing with an incident. As depicted in Figure 2, this is the time taken from dispatch to an ambulance being ready for the next call.

    Workforce

    Between March 2019 and March 2021 the number of full-time equivalent paramedics increased by around 13%, but there has been virtually no increase over the past year. However, as Figure 4 shows, sickness absence in the ambulance sector increased from 5% in March 2019 to 9% in March 2022 – which implies a reduction in capacity of around 4% points. This is higher than the increase seen at other organisation types. The most common reason for sickness absence among ambulance staff is poor mental health, responsible for a fifth of all sickness absence in March 2022.

    Despite increases in the workforce, in the 2021 NHS Staff Survey, only 20% of ambulance staff said there were enough staff in their organisation for them to do their job properly, compared with 30% in the 2019 survey.

    Ambulance cycles and handover times

    Capacity also depends on how long it takes ambulances to complete calls. For example, a 10-ambulance fleet in which each ambulance is able to complete a call in an hour will have a capacity of 10 calls per hour (or one call every 6 minutes). If the length of time it takes to complete a cycle goes up by 15 minutes – for example because the ambulance must spend an extra 15 minutes waiting at the hospital to hand over the patient – the capacity of the service will reduce from 10 calls an hour to eight.

    Handover time greatly affects ambulance capacity. This is the time from arrival at the A&E department to handing the patient over to the care of A&E staff and should take less than 15 minutes. 50% of ambulance patients are conveyed to A&E (others are treated on the scene or taken elsewhere).

    Figure 5 shows that the percentage of handover times exceeding 30 minutes was higher in winter 2021–22 than in previous winters. Longer handover times mean that patients are not receiving the care that they need from the hospital. The Association for Ambulance Chief Executives (AACE) suggests that in July 2022 alone, 40,000 patients may have suffered potential harm as a result of waiting more than an hour to be handed over to the hospital. Handover delays also mean that ambulance teams spend vital time queueing outside hospitals rather than responding to other calls in a timely way. AACE estimates that in July 2022 the total time lost to handover delays exceeding the 15-minute standard was equivalent to 4,000 ambulance job cycles. We estimate that this amounted to almost 20% of total ambulance capacity in July. Handover delays exceeding an hour have also been worsening. According to 2019 national ambulance data that we requested from AACE, more than 1 in 10 ambulances waited over an hour in July 2022 – up from almost 1 in 50 in 2019.

    Impacts on ambulance waiting times

    Since 2018/19 demand for ambulances has grown as a result of shifts in the acuteness of cases and although the workforce has increased, this had been moderated by higher levels of sickness absence. However, the biggest change has been the sharp increase in A&E handover times, putting further pressure on ambulance capacity.

    But can these changes in handover times lead to the sort of increases in average waiting times that we’ve seen – from around 33 minutes in 2018/19 (across all categories) to nearly an hour in 2021/22? Box 1 shows this can be the case. In our simple model, a 15-minute increase in average handover time increased average dispatch time from 4 minutes to 36 minutes. This illustrates the more general point that in complex systems being run close to capacity, relatively small changes in one area can have disproportionate effects in another. Conversely, resolving the drivers of increased handover times would release ambulance capacity and could help reverse the large increases in waiting times.

    Three ways to help improve ambulance service performance

    Based on our analysis of the causes of increased ambulance waiting times, we consider three ways of improving performance.

    1. Reduce handover delays by improving patient flow

    The increase in handover delays is a major contributor to the decline in ambulance service performance, so action to reduce these delays is a priority.

    When an ambulance arrives at A&E, the patient will either be admitted to hospital, transferred or treated and discharged. Waits have been increasing for all patients attending A&E, with patients admitted to hospital in an emergency now more likely to be waiting more than 4 hours (from when the decision to admit them was made) than patients admitted before the pandemic (Figure 7).

    Evidence suggests that the increases in delays for admission are the result of reduced numbers of unoccupied beds – a 1% point increase in bed occupancy decreases the probability of meeting the 4-hour wait target for A&E by 9.5% points. Occupancy levels in hospitals have remained relatively stable since 2018/19 but since February 2022 this has been above 92.5%, resulting in fewer unoccupied beds (Figure 8).

    One reason for high bed occupancy is low and declining numbers of beds relative to demand. England has a low number of hospital beds per capita and in recent years bed numbers have fallen as admissions have risen. Increasing the number of beds, as NHS England is planning, will help but is only part of the solution.

    Bed occupancy can also be reduced by discharging patients from hospital who are medically safe for discharge – the number of which is increasing. Delayed discharges can result from waits for assessments or decisions by allied health professionals and clinicians, waits for non-acute NHS care and waits for social care assessments, placements and funding for domiciliary and residential social care. Waits for social care are the result of chronic workforce shortages, a fragile provider market, and insufficient levels of government funding. In September, the government announced a £500m fund to support discharge from hospital into the community, but this is to be funded from existing DHSC and NHS England budgets. A longer term approach to funding and staffing social care is needed to relieve pressure on hospitals and to better support those needing care.

    2. Expand and support the ambulance workforce

    A fully staffed and healthy ambulance workforce, better supported to do their jobs, is vital. The number of vacancies has almost doubled in the past year and sickness absence rates have increased significantly. The most recent annual NHS staff survey found that 43% of ambulance staff are thinking of leaving their organisation, and only 26% said they are satisfied with their level of pay (down from 29% in 2019).

    Ambulance staff were also most likely to report feeling burnt out (51%), followed by nurses and midwives (41%). 61% of ambulance operational staff report feeling unwell as a result of work-related stress and 46% had experienced harassment, bullying or abuse from patients and/or the public. In response to growing concern regarding the mental health of ambulance staff, guidance and tools have been published by AACE and others on preventing suicide in the ambulance service.

    Increasing sickness absence rates in the acute sector and others (Figure 4) reduce capacity and may have knock-on effects on waiting times for acute admissions, and ambulances. This is neither safe, nor sustainable. Action is needed to ensure retention of valuable staff, recruit new talent and secure a resilient health and care workforce.

    NHS England has also sought other ways to expand ambulance capacity. In August a deal was struck for St John’s Ambulance to provide auxiliary services to the NHS. This contract will see more than 5,000 hours per month of support provided, but this pales in comparison to the scale of the problem. In July alone 152,000 hours (the equivalent to 4,000 job cycles per day) were lost to ambulance handover delays in excess of 15 minutes.

    3. Reduce demand for ambulances through improving access to other services

    Patients who cannot access the care they need may instead turn to the ambulance service or A&E. One example is children and young people experiencing mental health problems, the number of which is growing. Mental health services are not expanding in line with rising needs, leaving many with limited or no support and increasing use of crisis care. The majority of mental health-related ambulance callouts to children and young people in Wales were subsequently transferred to A&E.

    Some trusts have set up ‘emergency mental health departments’ to create a more suitable alternative for people in crisis and relieve pressures on A&Es. The government announced £7m for specialised mental health ambulances across the country to reduce the use of general ambulance callouts for those experiencing crisis. Improved data quality, better linkage of datasets across services and more regular collection of prevalence data would inform service expansion and target support at those in need.

    Conclusion

    Ambulance services in England were under immense strain during the summer months. Pressures here and across the health and social care system are only likely to increase as we approach winter, and there is an urgent need to address the factors contributing to this strain. Solutions to relieve pressure on the ambulance service and improve outcomes are being developed by local trusts, national charities and by the government. However, underlying this complex problem are issues of funding, workforce and service models. Until there is acknowledgment of this much broader context of pressures, attempts at a solution will only address small elements of the problem.

    National, long-term strategies are required to address the crisis in social care that prevents effective patient flow through hospital and causes queues of ambulances outside hospital doors. There must be clear steps put in place to ensure that the workforce shortages that reduce capacity and worsen burn out are resolved. Finally, long-term strategies are also needed to ensure that services including mental health, dentistry and general practice are well-funded and accessible to the patients who need them. Much as seemingly small changes have had huge, injurious consequences for ambulance performance and patient outcomes, solutions targeted at addressing the root causes can help restore performance.


  • 3 Nov 2022 2:26 PM | Matt Zavadsky (Administrator)

    Herein lies a fundamental challenge with our healthcare system….

    While providers and patients suffer with underpayments and balance billing issues….

    This could be the banner article for payment reform as providers struggle to survive.

    ---------------------------

    Health systems suffer while payer profits soar

    Laura Dyrda

    11/3/22

    https://www.beckershospitalreview.com/finance/health-systems-suffer-while-payer-profits-soar.html

    Large health systems are reporting big losses this year while insurers continue to turn billion-dollar profits.

    Humana reported $1.2 billion in third quarter profits, a slight drop from the same period last year. The company has focused on regaining Medicare Advantage market share and increased quarterly revenues 10.2 percent year over year.

    Cigna's third quarter profits jumped 70 percent year over year, hitting $2.8 billion. The company reported $45.3 billion in third quarter revenues and raised its annual earnings outlook based on the results. The company now projects $179 billion for full year 2022 adjusted revenue.

    CVS Health also beat investor expectations in the third quarter and raised its earnings outlook. The company's third quarter revenue jumped almost 10 percent year over year to $81.2 billion, although it reported $3.4 billion in losses after agreeing to pay into a $5 billion global opioid lawsuit settlement over 10 years.

    At the same time, health systems are reporting multimillion and even billion-dollar losses. Chicago-based CommonSpirit Health reported $1.3 billion operating loss for the 12-months end on June 30. Ascension, based in St. Louis, also reported a $1.8 billion loss for the fiscal year's end in June.

    Community Health System reported a $42 million net loss for the third quarter in October and both Dallas-based Tenet Healthcare and Nashville, Tenn.-based HCA Healthcare reported more than 50 percent drops in quarterly net income from 2021 to 2022.

    The profitability mismatch between the nation's largest payers and health systems of all sizes will be front and center during contract negotiations in the coming year. There have already been high profile contract impasses between insurers and large systems, with some leading to contract termination.


  • 25 Oct 2022 9:38 AM | Matt Zavadsky (Administrator)

    Aspirational for the U.S. Healthcare System?  Imagine, using evidence-based, accredited, emergency medical dispatch processes to send the right resource, to the right patient, at the right time!

    Interestingly, single payer systems seem more willing to make investments in systems like this to reduce potentially avoidable acute care utilization…. 

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    $42m to improve ambulance availability and ease pressure on hospitals

    October 25, 2022

    https://australianseniorsnews.com.au/health/42m-to-improve-ambulance-availability-and-ease-pressure-on-hospitals/

    The Queensland Government has today announced it will invest $42.35 million over four years to expand the Clinical Hub, an initiative aimed at improving ambulance availability, reducing pressures on hospital emergency departments and increasing health system capacity.

    Minister for Health and Ambulance Services, Yvette D’Ath said the funds would go to growing the team significantly, which first started as five paramedics and two Emergency Medical Dispatchers (EMDs) back in 2020.

    “The Clinical Hub first started in the early days of the pandemic as a small team making big in-roads,” Ms D’Ath said.

    “By the end of the year we expect the hub to be operating 24 hours a day, 7 days a week with over 64 specialist staff, including senior paramedics, doctors, EMDS, Emergency Medical Specialists and mental health clinicians.

    “This means we have more of the right people making the right calls to provide the right care for Queenslanders and freeing up capacity for the state’s most critical and urgent cases.”

    Queensland Ambulance Service Commissioner Craig Emery said the Clinical Hub initiative was already making a difference.

    “Currently, around 250 calls per day are directed to the Clinical Hub and over 60 of these are offered care which does not require an ambulance attendance,” he said.

    Cases can also be upgraded after a reassessment from the Clinical Hub, once the needs and status of the patient are better understood with a longer, more detailed triage, he said.

    “This system means we can ensure everyone is getting exactly the right treatment pathway.

    “It also means we can free up resources for more urgent emergency cases, whether that’s ambulances on the road or potentially reducing some pressure on emergency departments,” said Commissioner Emery.


  • 17 Oct 2022 7:12 AM | Matt Zavadsky (Administrator)

    Kudos to the team at TRAA for this accomplishment!

    --------------------

    TRAA improves top-priority response times in first month managing operations in-house

    Devan Filchak

    Oct 14, 2022

    https://www.journalgazette.net/local/traa-improves-top-priority-response-times-in-first-month-managing-operations-in-house/article_f7e6346c-4be1-11ed-a914-87dcd38008a6.html

    Three Rivers Ambulance Authority medics reached an 80% response rate to top-priority emergency calls within 8 1/2 minutes in September, the first month after its split with contractor Paramedics Logistics LLC, the organization announced Friday.

    September marks the first month that the ambulance authority has handled its own operations. Three Rivers Ambulance Authority, also known as TRAA, has provided emergency medical services to Fort Wayne residents since 1983 through an agreement with the city and county, both of which appoint members to the authority’s board.

    The ambulance authority handled billing while it contracted out operations to manage paramedics and emergency medical technicians, ambulances and other equipment.

    To be considered compliant, at least 90% of priority one calls – emergencies including strokes, heart attacks, difficulty breathing and major traumas – have to be reached by medics within 8 1/2 minutes.

    Paramedics Logistics, which had been the contractor since 2009, was unable to meet that standard for two years. The ambulance authority’s 80% September rate is 7 percentage points higher than the city’s final month of emergency service by Paramedics Logistics, a news release said.

    Three Rivers Ambulance Authority also asked county ambulance services to step in and respond to a call the least number of times since June 2021, the release said.

    Joel Benz, executive director, commented on the data.

    “Some of the changes we are implementing are already having an effect, thanks in large part to the hard-working paramedics and EMTs within our organizations,” he said in a statement. “Statistically, this was our best month in a year and a half. We still have many challenges ahead of us as an organization, but I believe we are taking steps in the right direction.”

    TRAA’s board declared a state of emergency about a year and a half ago after several months of what were considered unacceptably slow response times on priority one calls. Gary Booher, who had been the executive director for 32 years, retired about a year ago.

    Benz, a local paramedic of more than 20 years and former Allen County Council member, was hired to replace Booher.

    The ambulance authority’s board has made several changes aside from taking over operations in-house, including raising medic wages by $5 an hour and providing paid training for prospective paramedics and EMTs.


  • 11 Oct 2022 4:13 PM | Matt Zavadsky (Administrator)

    Interesting paper from Dr. Newberger and Dr. Braithwaite2

    Supports the use of clinically based, collaboratively developed, high quality 911 call taking medical triage to help dispatch the right resources to the right type of 911 call, especially as EMS response volumes tax existing resources.

    Also, an interesting description of how the U.K. uses this process to assign resources to call, with 90% reliability standards of 10 minutes for life-threatening calls, 40 minutes for emergent, but not critical calls, two hours for urgent calls, and 3 hours for less urgent calls.

    There are examples of innovative EMS agencies taking an evidence-based approach to evaluating their own data based on medical care provided on scene, need for Medical First Response (MFR), and actual patient experience scores based on response times to make changes to their response configurations to balance clinical needs with resource availability and cost.

    Something that perhaps more communities should do!?

    Tip of the hat to Bill Bullard of Healthcare Strategists for finding and sharing this study!

    ------------------

    EMS Prioritization Of Response

    Authors

    Ryan Newberger, M.D.1; Sabina Braithwaite, M.D.2.

    Affiliations

    1 University of Illinois College of Medicine at Peoria

    2 Washington University in St Louis

    May 15, 2022.

    https://www.ncbi.nlm.nih.gov/books/NBK559294/

    Introduction

    Public safety access points (PSAP) are tasked with the responsibility of taking all emergency calls (911 in the US), triaging and prioritizing each call using the provided information, notifying and dispatching the appropriate responders, and offering pre-arrival first aid instructions to callers.  Standardized dispatch systems that are available for querying callers, categorizing calls, and matching the call type to the appropriate response units and priority have been shown to improve metrics such as time to dispatch.[1] 

    In EMS systems with multiple simultaneous requests for service or inadequate response resources to meet the call demand at any given time, decisions must be made which call is believed to be most emergent, and which call is less urgent or can be delayed.[2] Ideally, the call prioritization, as well as the response profile, follows consistent guidelines from the local EMS agency, a regional EMS regulatory body, a national accrediting organization, or even a governmental agency.

    Issues of Concern

    Trends have shown steady increases in annual EMS calls and subsequent EMS dispatches. As a result, appropriate prioritization of calls is necessary both to use limited resources effectively as well as assure that patients' needs are met in a timely fashion.  Also, prioritization can address public safety concerns by reducing the number of calls responded to emergently (lights and sirens) to those which are predicted to be genuinely urgent or emergent. This approach then reduces the risk of injury to both EMS providers and the general public from lights and sirens-related accidents and multiple responding public safety units.   

    Several common frameworks are widely used by PSAPs to categorize and prioritize calls in the United States.[3]  Common elements include having dispatchers ask specific, scripted triage questions to determine the chief complaint and patient's clinical status.[4] Answers to these questions allow dispatchers to link the call type to the anticipated resource needs based on the information provided. 

    Some studies have shown significant improvement in the detection of cardiac arrest with standardization of the triage process and avoiding sole reliance on a dispatcher's judgment.[5]  However, dispatcher consistency in following the standardized scripts remains a valid concern.[3]  Another part of this process is determining which emergency resources should respond to each emergency call, rather than asking the dispatcher to make these decisions on a case-by-case basis. These predetermined response profiles or configurations link to specific call types (i.e., MVC vs. sick case) and which type of EMS unit (Basic versus Advanced Life Support unit) and other emergency apparatus (fire, law enforcement) with the urgency of the response (e.g., routine versus emergent).  While these are suggestions, in practice, they represent a "floor" that the dispatcher can add resources too based on information received, rather than subtracting from the response profile. Once the patient's needs are identified, the pre-established units within the response profile correlating to that complaint can be dispatched.  

    Widely used models in the US rely on variations on a number-letter-number system, with many categories and subclassifications of anticipated disease processes. Several European countries, and some large American cities, use a simplified model with fewer categories focused on determining the urgency and timeframe in which response should occur. This second type of system is more feasible in more homogeneous systems without different levels of medical response capability, i.e., only ALS units. As such, there is a higher emphasis placed on the response time that is allowed for each call.

    In the United Kingdom, for example, the National Health Service Clinical Response Model sorts calls into one of five categories.

    • Category 1 calls are the most severe/critically ill calls and categorize as "Life-Threatening Illnesses or Injuries," which warrant an immediate response, with the expectation that in-person response will arrive within 10 minutes.
    • The next, less serious, category of calls are the category 2 calls, in which response is deemed emergent but not critical with ninety percent of response times within 40 minutes.
    • Urgent calls are considered category 3 and are responded to within two hours ninety percent of the time.
    • Category 4 calls are considered less urgent and generally receive a response within 3 hours.
    • Category 5 is reserved for what are considered "non-urgent calls," deemed not to warrant any in-person EMS response but which instead are transferred to a telephone triage line or referral service to help resolve their issue.[6]

    There is a misperception that the existing dispatch systems and categories have an evidence-based correlation with patient acuity and outcomes, yet the evidence does not support this.[4][7] For example, the lowest acuity levels in two common US systems merely identify that based on the information received from the caller, either no emergent response or a basic life support response is expected to be appropriate. 

    Some systems use these categories to determine eligibility for prolonged response times or nonresponse, as noted in the NHS system. Since the categorization is based entirely on the information from the caller, it relies on the quality of the information received, the proximity of the caller to the patient (with the patient, or a third party "drive-by" caller), the caller's ability to communicate (i.e., language barriers, etc.), and the pertinence and clarity of the questions asked by the dispatcher. 

    Some EMS systems choose to respond to all categories in the same manner, and with the same types of units, others use the categories stratify their response profiles, as noted above. Thoughtfully created response profiles decide whether the complaint warrants a first responder, requires additional personnel (i.e., engine/pumper for cardiac arrest), a BLS ambulance only, an ALS ambulance only, an EMS supervisor or chief, specialized responders (such as police, SWAT, a rescue truck for extrication, a helicopter). In this way, PSAPs can limit over-triage (too many resources) as well as under-triage (too few or too slow) responses.[6] It also specifies the mode of response for each responding unit, either "quiet" vs. red lights and sirens.

    Well-designed response profiles that are created by the collaboration between the leadership of all the relevant responding and dispatching agencies can help assure that the patient's apparent needs are timely met, that EMS and related public safety resources are utilized appropriately, that the general public's safety is considered in the response mode and that inherently more dangerous red lights and sirens responses are limited

    New Innovations            

    In the United States, the National Highway Traffic Safety Administration Office of EMS "EMS Agenda 2050" is a forward-looking guidance document that creates a vision for the advancement of EMS systems.[8] The goal of this document is to use data-driven, evidence-based principles to provide the most sustainable, innovative, socially equitable, and reliable patient care possible. 

    One recent innovation in the US is the redirection of low acuity 911 calls to a secondary nurse triage line, as noted in the NHS example. This strategy allows EMS agencies to diverge from the traditional practice that every 911 call gets a response, regardless of how minor the caller's complaint is.  Rather than perpetuating this mismatch of emergency resources with non-emergent calls, the nurse triage line provides additional medical advice and connects the caller to non-emergent resources to meet their needs.[9] If the acuity of the call is deemed too high or otherwise inappropriate for the on-call nurse, the call is then routed back to EMS dispatch for an in-person response.[5] To date, this strategy has yielded mixed results, with one study showing that in a call center with an annual volume of 90,000 calls only averaged of two calls per day appropriate for nurse-triage with an average of less than one patient per day successfully completing this protocol and thus avoiding in-person EMS response.

    Of those patients who did complete the protocol for a nurse-triage response only, there was a high rate of satisfaction with their experience, with approximately 92% of patients reporting that the non-transport option met their healthcare needs.[10] While it appears that there is more research needed to investigate how to optimize the nurse-triage system best, logic would suggest that its use could be expanded to allow more patients to meet criteria, and thus reduce EMS response volume.

    Another innovation informs EMS call prioritization and response, the use of advanced automatic crash notification (AACN) from car accidents, using sophisticated sensors and crash detection monitors, which automatically provide PSAP with information including the location of the crash, the speed at the time of impact and the forces involved. This data is analyzed automatically by the vehicle to determine the likelihood of serious injury, and the vehicle transmits that data directly to the nearest PSAP. If the AACN indicates that there is a high likelihood of serious injury, the call can be prioritized differently, and a more appropriate response profile than the generic motor vehicle collision response can be dispatched immediately, rather than waiting for responders to arrive on the scene, assess the patient, and request additional resources, including potentially having helicopter EMS on standby.[11]

    Another focus both in the United States and abroad is on frequent callers or EMS system users.  Such callers are identified and flagged, and a multidisciplinary approach is applied to determine the root cause of the frequent emergency system activation and address the underlying need, whether that be access to food, healthcare, in-home support, or other needs.[12] However, as yet there is no definitive study demonstrating a statistically significant benefit to these types of programs.[13]

    Clinical Significance

    PSAP EMS response prioritization systems have been in place for decades and match patient needs to the most appropriate response units and urgency of response. While models vary, the common goal of PSAPs is to provide the most suitable, safe, and timely response to requests for service.  

    The expectation is that for a variety of reasons, the demand for EMS will continue to increase, so the ability to better match anticipated patient needs to resources is critical, since the continued expansion of the EMS to keep pace with demand is not expected

    The EMS Agenda 2050 document highlights opportunities to ease this burden by leveraging technology to meet the patient’s needs while remaining patient-focused. Research on various strategies to show which are most effective at meeting patient needs while appropriately using resources is critical to tailor prioritization of response going forward.

    References

    1. Grisanti K, Martorano L, Redmond M, Scherzer R, Strothman K, Malthaner L, Davis J, Zhao S, Kline D, Leonard JC. Emergency Call Characteristics and EMS Dispatcher Protocol Adherence for Possible Anaphylaxis. Prehosp Emerg Care. 2019 Sep-Oct;23(5):691-699. [PubMed: 30526221]

    2. S, Lane C, Eckstein M. Effect of New 9-1-1 System on Efficiency of Initial Resource Assignment. Prehosp Emerg Care. 2020 Sep-Oct;24(5):634-643. [PubMed: 31664875]

    3. Hodell EM, Sporer KA, Brown JF. Which emergency medical dispatch codes predict high prehospital nontransport rates in an urban community? Prehosp Emerg Care. 2014 Jan-Mar;18(1):28-34. [PubMed: 24028558]

    4. Bohm K, Kurland L. The accuracy of medical dispatch - a systematic review. Scand J Trauma Resusc Emerg Med. 2018 Nov 09;26(1):94. [PMC free article: PMC6230269] [PubMed: 30413213]

    5. Torlén K, Kurland L, Castrén M, Olanders K, Bohm K. A comparison of two emergency medical dispatch protocols with respect to accuracy. Scand J Trauma Resusc Emerg Med. 2017 Dec 29;25(1):122. [PMC free article: PMC5747276] [PubMed: 29284542]

    6. Heward A, Damiani M, Hartley-Sharpe C. Does the use of the Advanced Medical Priority Dispatch System affect cardiac arrest detection? Emerg Med J. 2004 Jan;21(1):115-8. [PMC free article: PMC1756371] [PubMed: 14734398]

    7. Hettinger AZ, Cushman JT, Shah MN, Noyes K. Emergency medical dispatch codes association with emergency department outcomes. Prehosp Emerg Care. 2013 Jan-Mar;17(1):29-37. [PubMed: 23140195]

    8. Gausche-Hill M, Krug S, Wright J. Emergency Medical Services (EMS) 2050: A Vision for the Future of Pediatric Prehospital Care. Prehosp Emerg Care. 2021 Jan-Feb;25(1):91-94. [PubMed: 32091291]

    9. Infinger A, Studnek JR, Hawkins E, Bagwell B, Swanson D. Implementation of prehospital dispatch protocols that triage low-acuity patients to advice-line nurses. Prehosp Emerg Care. 2013 Oct-Dec;17(4):481-5. [PubMed: 23865776]

    10. O’Cathain A, Knowles E, Bishop-Edwards L, Coster J, Crum A, Jacques R, James C, Lawson R, Marsh M, O’Hara R, Siriwardena AN, Stone T, Turner J, Williams J. Understanding variation in ambulance service non-conveyance rates: a mixed methods study. NIHR Journals Library; Southampton (UK): May, 2018. [PubMed: 29870196]

    11. Panchal AR, Berg KM, Cabañas JG, Kurz MC, Link MS, Del Rios M, Hirsch KG, Chan PS, Hazinski MF, Morley PT, Donnino MW, Kudenchuk PJ. 2019 American Heart Association Focused Update on Systems of Care: Dispatcher-Assisted Cardiopulmonary Resuscitation and Cardiac Arrest Centers: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019 Dec 10;140(24):e895-e903. [PubMed: 31722563]

    12. Snooks HA, Khanom A, Cole R, Edwards A, Edwards BM, Evans BA, Foster T, Fothergill RT, Gripper CP, Hampton C, John A, Petterson R, Porter A, Rosser A, Scott J. What are emergency ambulance services doing to meet the needs of people who call frequently? A national survey of current practice in the United Kingdom. BMC Emerg Med. 2019 Dec 28;19(1):82. [PMC free article: PMC6935477] [PubMed: 31883535]

    13. Eastwood K, Morgans A, Stoelwinder J, Smith K. The appropriateness of low-acuity cases referred for emergency ambulance dispatch following ambulance service secondary telephone triage: A retrospective cohort study. PLoS One. 2019;14(8):e0221158. [PMC free article: PMC6691999] [PubMed: 31408496]

    Copyright © 2022, StatPearls Publishing LLC.


  • 28 Sep 2022 6:20 AM | Matt Zavadsky (Administrator)

    Medi-Cal ambulance rides are going to cost taxpayers a lot more

    By AUSTILL STUART

    September 17, 2022

    https://www.ocregister.com/2022/09/17/medi-cal-ambulance-rides-are-going-to-cost-taxpayers-a-lot-more/

    A little-noticed amendment recently approved by the Centers for Medicaid Services for California’s Medicaid plan, Medi-Cal, could cost the state’s taxpayers and patients dramatically. The amendment, 22-0015, raises the reimbursement rate that Medi-Cal will pay for ambulance rides by over $800 per trip. A Medi-Cal patient’s ambulance ride will now cost state taxpayers over $1,000 per trip, up from about $120 per trip.

    The increased reimbursement rates in the amendment could result in a revenue windfall for local fire departments that are increasingly looking to provide emergency medical services (EMS)—not so they can better serve patients, but so they can use EMS as a revenue generator. Notably, despite handling over 70% of ambulance rides in California, private ambulance companies aren’t going to receive this higher reimbursement rate because it is only available to public EMS providers.

    EMS agencies exist to serve all patients with life-saving services as quickly and effectively as possible, not to charge taxpayers high costs and siphon off the most profitable patients to generate money that can be shifted to other projects.

    While Medi-Cal patients may have previously provided less reimbursement than rates paid by some insured patients for their ambulance trips, justifying a ninefold increase in per-trip rate needs clear justification. Yet, proponents and state officials have not provided any data justifying the ambulance ride cost increase.

    California’s county-based emergency medical services system has existed since 1981. The state Emergency Medical Services Authority (EMSA) was created after the proliferation of city- and county-based EMS agencies led to jurisdictional conflicts, and a more unified approach to EMS transport was needed. Since then, the county-based EMS system has served Californians well for over four decades, with EMSA providing oversight and many local governments partnering with private ambulance companies.

    But, today, fire departments view emergency medical services as a way to get more funding. Earlier this year, Senate Bill 443, which died in the state legislature, would have allowed local fire departments to effectively create their own EMS agencies. But fire departments don’t want oversight from the state’s Emergency Medical Services Authority. And they don’t want to conduct competitive bidding for ambulance subcontracts, where private providers would likely provide better services at lower costs.

    Recent experience shows how this unaccountable fire department takeover of EMS happens. For example, in 2019-20, Chula Vista entered an EMS contract with the same company that had provided its ambulance services since the late-1970s. Chula Vista raised rates considerably to nearly $3,900 per ambulance trip. But, the ambulance company providing those services only received $1,720 per trip while the fire district siphoned off over $2,000 per trip. Then, after jacking up ambulance prices, the fire department told city leaders that, rather than hold another competitive bidding process to see what private companies would charge per trip, the fire department should provide all emergency services and keep all of the funding.

    If municipal fire agencies want to take control of emergency medical services away from cities, counties, and private providers, they should competitively bid for the opportunity to do so alongside other EMS providers. They should also be subject to the same standards and oversight, which they aren’t currently.

    Unfortunately, this Medi-Cal amendment raising reimbursement rates to public providers and the previously proposed state legislation, which may return next session, make it look as though fire departments believe they can bully their way into becoming unregulated EMS agencies that charge astronomical prices to taxpayers.

    Ambulance services are obviously often a matter of life and death. If lawmakers and regulators believe the state’s system needs improvement, they should publicly and transparently propose EMS changes and judge providers on a level playing field. If fire departments want to displace existing county EMS providers and private ambulance companies, they should be offering taxpayers higher quality services at lower costs. Right now, it appears they’re offering neither.

    Austill Stuart is the director of privatization research at Reason Foundation.


  • 28 Sep 2022 6:19 AM | Matt Zavadsky (Administrator)

    An idea whose time has come? EMS and local communities should investigate transformative models to reduce psych holds in local EDs – something hospitals and EMS agencies often say contribute to EMS offload delays.

    -------------------------

    Mental Health Crisis Leads Hospitals to Create a New Type of ER

    Recliners and games in “Empath units” are helping move patients with psychiatric ailments out of emergency rooms.

    ByJohn Tozzi

    September 26, 2022

    https://www.bloomberg.com/news/articles/2022-09-26/hospitals-empath-units-replace-the-er-for-mental-health-patients

    With mental health treatment in short supply, Americans experiencing a psychiatric crisis frequently land in a hospital emergency room—brought in by the police or loved ones—and usually stay there until they can be safely discharged or transferred. That means patients can spend hours or even days stuck on a gurney until a spot opens in a psych ward, the only other setting deemed appropriate.

    The approach rarely offers any real treatment for mental health conditions, and it ties up scarce ER beds. That’s spurred some hospitals to try a new idea: mental health crisis units designed to treat people quickly in a more serene setting, so they can stabilize patients and send them home. “There’s no other emergency in the ER where the default treatment is to find them a bed,” says Scott Zeller, assistant clinical professor of psychiatry at the University of California in Riverside. Zeller developed the model, called Empath (emergency psychiatric assessment, treatment, and healing), to improve care while avoiding unnecessary time in the emergency department.

    The idea is an open room with recliners, soft lighting, TVs, and card tables. At the two dozen or so Empath centers in the US today—with dozens more on the way—patients who are medically stable are seen by a psychiatric specialist within an hour and quickly start any needed medication. By speeding up treatment and observing the response, doctors can send more patients home with recommendations for follow-up care, rather than automatically placing them in a psychiatric hospital.

    Since the 1950s, most US psychiatric beds have vanished under the policy of “deinstitutionalization” that followed budget cuts and exposés of inhumane conditions in mental hospitals. The number of public psychiatric beds per 100,000 people dropped from 340 in 1955 to 12 in 2016, according to the nonprofit Treatment Advocacy Center. After the institutions emptied out, hospitals and jails became the de facto replacements.

    Covid-19, which strained hospital capacity while exacerbating Americans’ mental distress, amplified the problem. A study of one pediatric facility found the average length of psychiatric boarding more than doubled, to 4.6 days, during the first year of the pandemic. A survey by the Massachusetts College of Emergency Physicians showed that at the average hospital, almost 30% of ER beds are occupied by people experiencing a behavioral health emergency, with some patients remaining there for weeks.

    Zeller developed what became the Empath model when he was medical director of a psychiatric emergency center in Alameda County, Calif., which served as a regional destination for psychiatric transfers from local emergency departments. Most patients were brought in involuntarily by the police, and the county aimed to move those who were medically stable to the center as quickly as possible. The approach, Zeller found in a 2014 study, meant patients spent less than two hours in the ER waiting for treatment, and only 1 in 4 needed to be admitted for inpatient psychiatric care.

    Part of the solution was getting people out of a setting that can aggravate mental distress. “That environment itself, within the ED, can be very frightening,” Zeller says. “It’s claustrophobic, there are lights and noises and scary equipment and uniformed personnel running all around, and they’re not allowed to move.”

    The setting for the Alameda study was essentially a big waiting room. The hospital bought recliners to make patients more comfortable, organized group activities such as board games, and added stations where patients could get water, snacks, and linens so they wouldn’t have to ask a nurse for basics. “That allows the treatment to work a little better, if people aren’t feeling adversarial, but rather engaged,” Zeller says.

    As the Alameda study got more attention, other hospitals sought to replicate the approach. Zeller and his colleagues started talking about redesigning the concept. “If we were going to be able to build something from scratch, what would we do?” he asked. Hospitals envisioning new facilities could make them feel less clinical and more inviting than the waiting room, with more space, higher ceilings, natural light, and fresh air.

    M Health Fairview Southdale Hospital in suburban Minneapolis opened an Empath unit in March 2021. Lewis Zeidner, director of clinical triage and transition services, says it’s more like a living room than an ER, though it’s adjacent to the emergency department. The unit has 15 recliners and a staff of psychiatrists, psychiatric nurses, and therapists—one clinician for every two patients—around the clock. Hospital admissions for mental health crises have fallen to 14% from 40%, and there’s been a dramatic drop in repeat visits.

    The unit sees 250 patients a month with depression, anxiety, PTSD, and substance use problems. “They’re everyday people who get to a place in their life where things feel more out of control,” Zeidner says. The setting opens a window to evaluate patients and determine whether they should be admitted for inpatient treatment. Before the Empath option, that was usually the only destination if a clinician was worried about a patient’s security. “We want to keep people safe,” he says. “You can’t reverse suicide.”

    After University of Iowa Health Care opened an Empath unit in its main hospital building in Iowa City, the number of suicidal patients admitted and the length of time they waited in the ER dropped dramatically, researchers found. “Once we had it, we were like, ‘Oh my gosh, how did we do this without it?’” says Heidi Robinson, director of behavioral health services for the hospital’s nursing department.

    A separate Iowa study looked at the economics of the approach and found that revenue in the emergency department increased as fewer patients left before being treated. But the boost wasn’t enough to cover the cost of the Empath unit—$1.4 million to open and $2.6 million in annual operating expenses. Zeidner says hospitals tend to lose money on inpatient mental health beds anyway, and the advantages to patients of avoiding those admissions are clear. With the success of its suburban Southdale Empath unit, M Health Fairview is considering another at its downtown Minneapolis location, with room to treat adolescents as well as adults. “There’s a growing understanding,” Zeidner says, “that this crisis is not going away.”


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