Intervening at the Point of Contact

EMS would be a lot easier if the only problems patients had were medical.

The reality is a lot of EMS patients—especially frequent users of EMS systems—have more going on than broken bones or bad hearts. EMS providers often face patients who have substance abuse and/or psychological problems. Despite hours of training and sometimes years of experience, EMS providers usually aren’t adequatelytrained, equipped or certified to definitively manage these types of problems and get patients the long-term care they require.

One EMS system that is working to better address these patient populations is Grady EMS, a hospital-based agency affiliated with Grady Memorial Hospital in Atlanta, GA, which also provides 9-1-1 service throughout Atlanta in Fulton County. Over a recent three-week period, Grady EMS piloted a program intended to serve the needs of patients who are homeless or have substance abuse and/or psychological problems that prompted them to call 9-1-1. After studying 9-1-1 call data, Grady found those three issues represented the highest call volume they saw.

According to Arthur H. Yancey II, MD, MPH, FACEP, medical director for Grady EMS and associate professor, Department of Emergency Medicine, Section of Prehospital and Disaster Medicine at the Emory University School of Medicine, the pilot was able to effectively decompress the patient load at the sole psychiatric emergency evaluation center in the county.

“In the three-week trial we successfully reduced the number of patients being transported to the evaluation center by 50%,” Yancey says. “We also wanted to direct these patients to ideal resources that could definitively manage or take care of their problem, rather than have them go through a busy emergency department that’s primary purpose is handling life-and-limb problems. And we wanted to try to free up our own transport resources so we could actually respond to calls that truly need the equipment, pharmacological resources and EMS expertise we offer.”

The problems faced by these patient populations are found in many EMS systems, but the burden these patients presented to the 9-1-1 system in Atlanta prompted Grady’s program, Yancey says. Grady EMS partnered with the United Way to assist patients whose primary problem is homelessness. It also integrated its own resources with a local psychiatric crisis service call center for the substance abuse and psychiatric patients. Eventually, Yancey says, Grady hopes to interface with local psychiatric crisis service outreach personnel at the 9-1-1 dispatch level, such that calls coming into 9-1-1 about these type problems in medically stable patients could be funneled to the crisis service call center, so their intervention staff can take over care at the outset.

For the initial pilot, however, the local psychiatric crisis service outreach personnel comprised a co-response, driven to the scene by specially picked and trained Grady EMS personnel in an SUV. The psychiatric patients were evaluated medically by the transport unit crew. If the patient had a trauma problem, such as self-mutilation, they were transported to a level 1 trauma center, and their psychological problem was handled secondary to their injury. If they had a medical problem associated with a psychological problem, they were transported to a medical center where both problems could be taken care of.

“If, after the medical evaluation, we found no medical or injury problem, the crisis service would take over evaluation on scene and determine if the patient required a mandatory psych hold and needed to be transported to Grady Memorial Hospital, the only psych emergency evaluation center in the county,” Yancey says. “Or, if the patient’s problem could be deescalated on scene and handled on an outpatient basis, the patient would be directed to an appropriate facility or given an immediate referral, made by the local psychiatric crisis service personnel from their laptops that were web-linked to appropriate resources.”

The rationale for the program, Yancey explains, is that the earlier in the process these kinds of patients can have their problems addressed, the more effective treatment becomes. “Once in an ED setting, these patients get discouraged because of the time it takes to further evaluate their problems,” he says. “And it’s an added demand on hospital services. If there’s a take-home message for handling these problems, it would be that these patients’ calls for help are best handled and addressed up front—meaning on scene. That’s where you can provide undivided attention to the patient and have their focus directly on you too.”

Yancey says all EMS systems can look to outside resources to form partnerships aimed at providing definitive care and expertise applicable to patients’ specific non-medical problems. He even points to traditional relationships, like between 9-1-1 emergency medical dispatch and poison control, nurse advice services or the medical examiner’s office.

“There are exciting things happening right now in EMS,” Yancey says. “We’re expanding EMS beyond its original core mission of one paramedic treating one patient and transporting them via one ambulance to one hospital. So much of a patient’s care needs takes place outside of that; we have to look for more effective and efficient ways to address those issues.”