Breaking the Cycle of Overuse

Christian Hospital in St. Louis County, MO is aiming to break the cycle of non-emergency use of their emergency department by addressing the root of patients’ problems—via their EMS system.

In a program that launched Monday, Feb. 3, designated 911 calls receive an advanced care paramedic who determines whether there is a true emergency at the scene. If not, the paramedic can choose to treat the patient at home, help them get a same-day appointment with their primary care physician, or connect them to another appropriate resource. Paramedics can also provide vouchers for transportation to appointments.

Christian Hospital EMS Chief Chris Cebollero notes the program is not just about handing the patient a referral and saying goodbye; it’s about taking that next step with the patient and facilitating their attainment of the most appropriate form of care.

He suggests the old models of EMS and ED care delivery are partly to blame for the current cycle of overuse. People became accustomed to being taken to the hospital whether they needed it or not, because that was the system.

The stats show the problem with that approach. Since August, 600 utilizations of EMS or the ED came from just 22 patients. One patient alone used the system 150 times in a year.

“We precipitated this behavior; now we have the opportunity to rewrite history,” Cebollero says.

How the Program Came About

One of the questions they asked, Cebollero says, was, “Were we doing the best for our patients?” The answer was “No.”

Christian Hospital’s ED is the busiest in the state of Missouri, he says, and sees 116,000 people per year, with 56,000 of those coming in for non-emergencies.

“We were just kind of putting a band-aid on their problem, and weren’t helping their problem,” he says.

Cebollero uses the example of a patient suffering breathing difficulty. Previously, a paramedic might have provided albuterol and the ED might have administered a steroid, but then no one was following up to make sure the patient’s underlying health issue was being addressed to prevent repeat incidents.

“We were part of the problem; we needed to do something different,” he says.

The program appears to be off to a successful start. In the past week they had 170 patients triaged out of the ED, Cebollero says. The patients either went to their physician, chose to leave because they didn’t have a true emergency or were referred to the hospital’s temporary health resource center.

Health Resource Centers

A central part of the program involves temporary health resource centers at Christian Hospital and Northwest Healthcare. Patients can be brought there to get connected with partner organizations such as Planned Parenthood and Meals on Wheels.

These are not regular clinics; walk-up patients will not be accepted, and the goal is to close them after about 1 year, once the need has abated, so that people aren’t just shifted there from the ED.

“The folks that come are not coming forever,” Cebollero says. “If you come through, our goal is to set you up with a primary care physician.”

A Unique Program

Cebollero says this method of triaging callers out of 911 is an innovation that is unique in the U.S. It begins when dispatchers determine how to prioritize them and find that they fall under the “Omega” designation, which some other cities do as well, but then in this program, those patients can be treated and left at the scene when appropriate.

“Some say it’s a big liability that we leave people on the scene,” Cebollero says, but he says that it isn’t because an ambulance and an advanced care paramedic still respond and utilize medical direction and training to determine an appropriate course of action.

He notes that it helped doing this as a hospital-based EMS system, whereas other systems would require EMS and hospital coordination. “I think it was a lot easier for us because we’re all-encompassed and housed together.”

As more hospitals look to triage people out, they’ll be looking to EMS for help, Cebollero says.

EMS will need to integrate with their healthcare partners, he suggests, and continue to adapt as the landscape changes over the coming years. “Paramedics will be doing medicine in a scope they’ve never done before,” he says. “This is what the future of EMS looks like.”

Feedback

Christian Hospital officials have communicated the program with community leaders and attended city council meetings, church group meetings, etc. to discuss it with the public. “We’ve heard no negative feedback at all,” he says—an amazing feat for any topic. The community is recognizing that this is a positive and necessary change that needs to be undertaken.