Code 2 Response for Repeat Users?

[docB]

We know that running Code 3 is associated with accidents and little improvement in patient outcomes. Ideas are starting to arise as to how to incorporate this information into practice.

One idea is that enhanced 911 systems can identify habitual users of EMS. Once identified responses to these users could be downgraded to Code 2.

This idea is based on the premise that habitual users tend to have less acute or emergent conditions.

There could be parameters placed to change these responses such as complaints of "not breathing" or sites where repeated calls have yielded real emergencies.

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[BB8730]

Two major problems I see:

1. Although the habitual abusers of the EMS system typically do not have emergencies, they often do have serious underlying health problems that could flare up at any time. I don't have data to back this up - just anecdotal evidence from the 5 years I've worked EMS/ED. Most, if not all of the frequent flyers I had 5 years ago are now dead. Alcoholism, drug abuse, disregard for their health problems (most notably diabetes), poor living conditions, general lack of care for their bodies, etc seem to run rampant in EMS abusers.

2. Triaging call priority based on the the chief complaint by the patient/layperson is a huge gamble. I've been dispatched to full codes that end up being non-transports and I've been dispatched to falls with hip pain that end up being a full codes, as well as everything in between. I take my dispatch reason about 10% seriously and go in ready for anything.

Not to mention that habitual users will probably find a way around the system - using false names, complaining of chest pain every time, etc. To me, a system like this is more hassle than what it's worth and too many lawsuits waiting to happen.

 

[Dwindlin]

Two major problems I see:

1. Although the habitual abusers of the EMS system typically do not have emergencies, they often do have serious underlying health problems that could flare up at any time. I don't have data to back this up - just anecdotal evidence from the 5 years I've worked EMS/ED. Most, if not all of the frequent flyers I had 5 years ago are now dead. Alcoholism, drug abuse, disregard for their health problems (most notably diabetes), poor living conditions, general lack of care for their bodies, etc seem to run rampant in EMS abusers.

2. Triaging call priority based on the the chief complaint by the patient/layperson is a huge gamble. I've been dispatched to full codes that end up being non-transports and I've been dispatched to falls with hip pain that end up being a full codes, as well as everything in between. I take my dispatch reason about 10% seriously and go in ready for anything.

Not to mention that habitual users will probably find a way around the system - using false names, complaining of chest pain every time, etc. To me, a system like this is more hassle than what it's worth and too many lawsuits waiting to happen.

This completely circumvents the crux of the issue, which is going "code" 1) saves minimal time, probably not enough to affect outcomes, and 2) increases risk to everyone. Getting EMS out of this mindset of driving emergent I think would be easier if it were a slow transition (i.e. start with the calls that people hate anyways).

I'm sure most of us have been burned by the frequent flier who is suddenly actually sick (I have). But like I said I think the real issue is emergent driving period.

Didn't NOLA go to entirely non-emergent response for a period of time?

 

[deleted6669]

Didn't NOLA go to entirely non-emergent response for a period of time?

no, that was FEMA in NOLA (ba dump bump).
seriously, I too have been burned by the boy who cries wolf frequent flyer coding on a random call.
don't know how to deal with this situation. we have a frequent flyer in my community who calls 911 2-3x/day.
ems doesn't go to her house any more so she uses pay phones around town. almost every call is bs but she occasionally actually needs a 911 response.

 

[docB]

I think this could be viable. From a community standpoint slightly delaying the emergent call from a habitual user vs. the risk to the general public and EMS providers of the Code 3 response makes sense. Now in reality ambulance crashes are rare so we'd really be talking about delaying scores or hundreds of frequent flier calls before we would prevent even 1 accident. This would be some interesting material to study to try to get an NNH.

Ultimately I think we will be eliminating or severely curtailing code 3 responses in general without any patient specific criteria.

 

[BB8730]

This completely circumvents the crux of the issue, which is going "code" 1) saves minimal time, probably not enough to affect outcomes, and 2) increases risk to everyone. Getting EMS out of this mindset of driving emergent I think would be easier if it were a slow transition (i.e. start with the calls that people hate anyways).

I'm sure most of us have been burned by the frequent flier who is suddenly actually sick (I have). But like I said I think the real issue is emergent driving period.

Didn't NOLA go to entirely non-emergent response for a period of time?

For us that may be the crux of the issue, but I just don't see the data being relevant to a civilian jury and an ambulance chasing lawyer claiming that his/her client was discriminated against, received a non-emergent ambulance dispatch, and subsequently died of a stroke/MI/other. People sue over ambulance delays all the time; intentionally delaying ambulances for certain people will only compound that problem.

Maybe I'm too lawsuit-paranoid, but that's where I see this kind of system heading. I absolutely agree with the data and the logic behind it, but I don't think it's a practical implementation.

 

[Fedekz]

NOLA does the opposite. It's code 2/3 (both are lights and sirens) to everycall regardless of the nature. And it's also code 2/3 response from the scene to the hospital everycall regardless. With only 6 ambulances for the city of new Orleans at night, the call volume is very high and it's non stop. The reason they do that is for budget reasons. More trucks are expensive. The people who work there are the best in the country, in my opinion.

 

[moneytree]

NOLA does the opposite. It's code 2/3 (both are lights and sirens) to everycall regardless of the nature. And it's also code 2/3 response from the scene to the hospital everycall regardless. With only 6 ambulances for the city of new Orleans at night, the call volume is very high and it's non stop. The reason they do that is for budget reasons. More trucks are expensive. The people who work there are the best in the country, in my opinion.

Really?! 6 trucks for 360K pop sounds kind of irresponsible. Who made that idiot decision? That's just tempting fate.

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[BB8730]

And it's also code 2/3 response from the scene to the hospital everycall regardless.

They do that just so they can get their rigs back in service faster? That's crazy.

 

[joeDO2]

They do that just so they can get their rigs back in service faster? That's crazy.

we did the same where at one of the places I worked but I think it was touted as more of a liability issue.....never know when that toe pain turns out to be an MI and they come back and sue for deciding not to expedite transport....at least that was the theory.

 

[docB]

We keep coming back to code 3 transport being done for logistical and liability reasons rather than medical outcomes. These are real problems but I think we can all agree that's not how it should be.

I had a question from one of my paramedic students once asking if code 3 response was indicated even if code 3 transport might not be. My answer was that that's a political question, not a medical one. Response times are generally dictated by contracts and budgets.

 

[Apollyon]

I had a question from one of my paramedic students once asking if code 3 response was indicated even if code 3 transport might not be. My answer was that that's a political question, not a medical one. Response times are generally dictated by contracts and budgets.

This was a paramedic student? By then, and by the time the student was doing clinicals, the student should have had at least some exposure to dispatch and/or EMD.

Response and transport are separate cars in the same train. Dispatch goes on information with variable accuracy - that is why a unit might be dispatched code 2/code 3/red/hot/whatever rubric your system uses. However, when the crew - professionals, trained to do this - arrive and make their decision, to go hot or cold to the hospital is irrespective of the way they arrived.

It is kind of foolish to suggest that one would reconsider the response retrospectively. As I read and reread that which you have written, it strikes me as neophytic or rather basic.

 

[docB]

This was a paramedic student? By then, and by the time the student was doing clinicals, the student should have had at least some exposure to dispatch and/or EMD.

Response and transport are separate cars in the same train. Dispatch goes on information with variable accuracy - that is why a unit might be dispatched code 2/code 3/red/hot/whatever rubric your system uses. However, when the crew - professionals, trained to do this - arrive and make their decision, to go hot or cold to the hospital is irrespective of the way they arrived.

It is kind of foolish to suggest that one would reconsider the response retrospectively. As I read and reread that which you have written, it strikes me as neophytic or rather basic.

Well this was a student who was still in didactic. It is neophytic but that's where a lot of these guys early in their training are coming from. They still get really excited about the bells and whistles, literally. I go in early and talk about the misperceptions about the EMS data that's emerging, specifically that prehospital intubation may hurt outcomes, ACLS may not be better than good BLS, etc. Paramedics, especially young, eager paramedics hate to hear those things on a visceral level.

So really this question which was posed during a class discussion without a lot of forethought about the ramifications of it was about if I thought ALL code 3 was going away.

 

[Apollyon]

Well this was a student who was still in didactic.

But don't paramedic students in your state have to be EMT-basic, at least, first, before going to paramedic school? Or was this class with people that were starting out on the top level?

 

[docB]

But don't paramedic students in your state have to be EMT-basic, at least, first, before going to paramedic school? Or was this class with people that were starting out on the top level?

The do have to be EMT basic but the experience requirements vary. Some people can get hired as an EMT by an agency and sponsored through paramedic training with little field experience.

 

[jwk]

But don't paramedic students in your state have to be EMT-basic, at least, first, before going to paramedic school? Or was this class with people that were starting out on the top level?

In our area, they can do both at the same time, in a combined program.

 

[Apollyon]

In our area, they can do both at the same time, in a combined program.

Do they get the EMT cert on the way, or is it, if they drop out early, they get nothing?

 

[BB8730]

Found this:

...seconds turned into minutes in a fatal March 19 medical call, when a Collier County EMS ambulance crew arrived on scene nearly 15 minutes after the 911 call was placed and 10 minutes after Naples firefighters arrived.

...Jackie Dean of 13th Street North called 911 after her 82-year-old mother, Daisy May Cannon, complained of weakness and began vomiting on March 19.

After Naples firefighters arrived first and took her mother's vital signs, Dean said she had to wait too long for an ambulance to arrive for hospital transport.

The delayed response was due in part to the "alpha" or low-priority label given to the call, according to official reports. Ambulances don't respond "hot" with lights and sirens for alpha calls.

Source: http://www.naplesnews.com/news/2011/apr/02/collier-ems-response-times-naples-woman-dies-Tober/

The woman actually coded after she was in the ambulance and the EMS agency denies that the delay contributed to her death. Nonetheless, this shows how the non-emergent response system attracts criticism.

After doing some researching, the tiered-response system really sounds like it is the way to go (if the issues can be mitigated). EMS workers have twice the risk of death of the average worker: mostly due to ambulance crashes, and >70% of crashes occur while traveling code III. Also, all of the studies I found conclude that the increased response time only affects the outcomes of a very small number of patients. Hopefully we can continue to reduce the lights and sirens archetype and increase the safety of EMS workers and other drivers on the road by reducing code III driving.

Another little gem I found:

Next, it was suggested that many people join the fire/EMS service because of the emergency response. In fact, Wilbur (1995) reported on one department where a member quit because they adopted a non-emergency response policy on selected call types.

Source: http://www.usfa.fema.gov/pdf/efop/efo38659.pdf

I feel like some people on my department are like that person.

 

[docB]

You are 100% correct about the fallout from slowing down. But there is an equal amount of fallout and liability every time there is an ambulance accident. The media is fickle. From a public health standpoint it's better for us to tell the politicians whats medically best or at least data driven and let them make the call.

 

[BB8730]

You are 100% correct about the fallout from slowing down. But there is an equal amount of fallout and liability every time there is an ambulance accident. The media is fickle. From a public health standpoint it's better for us to tell the politicians whats medically best or at least data driven and let them make the call.

Yep I agree. One of the sources I found (can't remember which) talked about this. They said that the lawsuits from code III driving-related incidents far outweigh the potential lawsuits from slower arrival/transport times. If that's true, I'm all for it.

 

[TarHeelEMT]

I like the idea. Although my experience is biased by working primarily in small cities and rural areas, Code 3 responses are only a modest time saver in most circumstances, and any improvement in patient outcomes is of course possible to document but certainly even more marginal than the time savings. When you consider the risks code 3 responses pose to EMS and other drivers, I'm in favor of cutting back on code 3 responses in all but the most dire circumstances.

 

[Fedekz]

Really?! 6 trucks for 360K pop sounds kind of irresponsible. Who made that idiot decision? That's just tempting fate.

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There is mutual aid inside the city 24/7 though, there are private services who station trucks in the downtown area because they occasionally have a nursing home call, or hospital transfer.

But yeah, at night after a certain time there are 6 trucks. I don't think the cities residents suffer though, the trucks are always running, but there is usually at least 1 available. If all trucks are on calls, they don't hesitate to "roll" the call over to another service who is already inside the area. They work with what they have, and do an amazing job with it. They run calls nonstop, as many as 16, to 26 during mardi gras in a single 12 hr shift. With that much interaction, they become in my opinion one of the best services out there. High burnout rate, but still - they do a great job.