EMS 3.0: Dispatch and Resource Allocation

EMTs and paramedics often scratch their heads when dispatched to “emergency” calls such as toothaches, minor injuries and low-acuity medical complaints. A field provider with one month of experience quickly realizes that many of the calls he’s dispatched to are not really emergencies at all.

What if there were a reliably proven way to quickly gather information from a caller to determine whether a lights-and-siren EMS response is truly necessary? What if the 9-1-1 call-taker had a cadre of resources they could allocate, from a full-on hot response to a referral to a nurse in the call center who could walk a caller through determining the best resource for their complaint?

Panacea? No, it’s reality. EMS systems in other parts of the world that are truly integrated into healthcare delivery networks have been doing exactly this for years. The result is a dramatically different expectation on the part of the caller, much better patient outcomes and significantly lower costs.

Look to the United Kingdom. The U.K.’s National Health Service (NHS) has been doing exactly this for decades. Callers to its 9-9-9 are initially processed using the Medical Priority Dispatch System to quickly allocate the traditional emergency resources if clinically necessary, such as for car wrecks, heart attacks, strokes and major trauma. If a patient needs something else, such as a solo advanced care practitioner to respond, assess and treat a laceration with sutures and antibiotics, that resource is sent.

Callers who meet physician-approved criteria for low-acuity medical calls are transferred to specially trained NHS nurses in the call center. These nurses use a robust computer-assisted decision-support tool to guide the caller through a series of clinical assessment algorithms that lead to recommendations for locus-of-care resources tailored to meet their clinical need. Perhaps an appointment at a medical clinic or their primary care practitioner? Maybe self-care at home for flu-related symptoms or a relentless bout of the hiccups?

It’s not just the U.K. handling calls this way—it’s the majority of Europe and Australia. These countries have figured out the most effective way to integrate the dispatch and resource allocation function into their call centers.

So what’s different in the U.S. that has prevented a similar model? Why do we send an ambulance, and in some cases a fire truck, to nearly every EMS call and do our darnedest to convince the patient that unless they go by ambulance to the ED, they could die?

It’s About the Money!

If EMS agencies don’t transport patients to an ED, the system does not get paid. If EMS and fire agencies reduce their response volume, they won’t require as many people, and resources and jobs could be lost. The perverse incentives of our healthcare system force the payers to pay us to do things that often are clinically unnecessary just to be eligible for payment. However, places like the U.K., Denmark and Australia have single-payer systems. That incentivizes payers to allocate the right resource to the right patient in the right setting at the right time.

An ambulance trip to the ED costs the payer money, and if it’s not necessary, it’s wasted money. If the EMS system is able to safely and effectively meet the patient’s medical need over the phone or by using an ACP without needing an expensive ambulance trip to an ED, then the EMS provider is very valuable to the payer and paid well for that service.

Even the pure response allocation concept is money-driven. Despite the dearth of research that demonstrates the clinical outcome value of first response for conditions other than a handful that are time- and life-sensitive, EMS systems across the country include a very expensive first-response component, one that often responds lights-and-siren to every EMS request. First-response leaders who are honest about why they send these expensive resources hot to every call offer three reasons:

• It’s what the public expects;
• If we don’t respond to calls, we’ll lose funding;
• You never know if the ingrown toenail is a real emergency and callers are unaware of the risks.

Seriously? First, we gave the public the expectation that we need to have someone to them in five minutes or less on every call. The public in the U.K. does not have that expectation and is therefore not disappointed when seven people don’t show up for their cut finger. In places like Fort Worth, Reno and Louisville that have implemented 9-1-1 nurse triage systems, the patient experience scores are very high—often with patients saying the process was much better than going to the ED, but they never knew they had another option.

Second, we need to find the value equation for first-response agencies and, honestly, the price point communities are willing to fund. Many places across the country are already calling into question the value of having four people on fire engines and a fire engine on every corner, especially in tough economic times. The International City/County Management Association’s Center for Public Safety has published several studies recommending the downsizing of fire departments.1 Finally, call triage systems across the globe have processed millions of calls through priority dispatch and nurse triage systems and have implemented evidence-based guidelines to make these systems safe and effective.

The other side of the money equation is the hospital side. Under Healthcare 2.0, hospitals had the potential to earn more revenue when more patients come to the ED, so they had little incentive to participate in systems that reduced EMS transports to the ED. Today, under Healthcare 3.0, as hospitals and health systems move toward shared savings models that financially reward reduction of unnecessary expenditures for things like ED visits, they are more interested in exploring opportunities to enhance patient care while reducing costs.

Expansion of 9-1-1 Nurse Triage

There are a few high-performance, high-value EMS systems that use the MPDS fully for what it was designed to do: allocate resources based on the clinical description of the patient. First response, BLS and ALS resources are sent based on the patient’s need, not the political agenda of provider agencies.

Some systems—Fort Worth, TX; Syosset, NY; Reno, NV; Mesa, AZ; King County, WA; and Salt Lake City, UT—are now using the full scope of the program and have incorporated nurses into their triage systems. These systems have demonstrated the value of this approach to care delivery, and consequently payers are funding these programs and patients are loving them. These programs have reduced EMS response volumes by referring patients with low-acuity medical complaints to resources matched to better meet their needs.

As these systems continue to publish research that proves the safety and effectiveness of this care delivery model, healthcare system participants will take further notice. Now is the time for EMS system leaders to start evaluating the dispatch component of the EMS 3.0 value-driven healthcare delivery system. Prove (or not) the value of the two extremes of our response models: everyone to every call, preferably all with lights and sirens, or using the “four rights” model, where patients in cardiac arrest get everything and patients with the hiccups get nurse advice over the phone.

Ed's Note: This article is reprinted from EMS 3.0: The Future of Service Delivery, Reimbursement, Education, Dispatch, Medical Direction, Technology and Regulation.

Jerry Overton serves as the chair of the International Academies of Emergency Dispatch, the organization charged with setting standards, establishing curriculum, and conducting research for public safety dispatch worldwide.

Prior to this, Overton served as the CEO for the Richmond Ambulance Authority in Richmond, VA, for 18 years and had overall responsibility for the EMS system. He also served as the chief executive of the Kansas City, MO, EMS system.

Overton is a past president of the American Ambulance Association. He has acted as a member of the Institute of Medicine’s Committee on the Future of Emergency Care in the U. S. Health System, and is the treasurer for the World Association of Disaster and Emergency Medicine.