Gathering of Eagles—Part I: Better Ways to Handle Familiar Problems

Each year, peering out over the amazingly progressive audience attendees and the phenomenally talented speakers on the stage at the EMS State of the Sciences (Gathering of Eagles) Conference in Dallas, I ask myself how the meeting could get any better than what I am experiencing at that very moment.

When you’ve hosted an Eagles conference in which two of the speakers were in the emergency department with JFK on 11/22/63 and they are telling their stories for the first time, you say to yourself, We’ll never top that one. Yet annually the audience’s attention, the speakers’ comradery and the exceptional topics and presentations outdo themselves. I think both the audience and the faculty alike are coconspirators in that success. An unspoken but widely-held belief is that they are all part of something very special—and I can attest as a participating witness—they are right about that.

In the following article by talented writer and paramedic Hilary Gates, you will see a biopsy of some of the amazing offerings the Eagles meeting delivers. The healthcare system remodeling work forged by veteran San Diego medical director Jim Dunford and his team has been far-reaching and a great model for the rest of us. Likewise Ken Scheppke’s work in Palm Beach County gives new direction for stopping the revolving door of drug addiction. Finally Mike Levy and Clement Yeh, from Anchorage and San Francisco respectively, give us new hope and strategies for better management of our alcoholic patients.

Thanks here to EMS World, you the reader can also take advantage of their insights and pioneering efforts in EMS system modifications.

—Paul E. Pepe, MD, MPH, University of Texas Southwestern Medical Center and National Coordinator, U.S. Metropolitan EMS Medical Directors Consortium

For many patients, the ED, with its high costs and long waits, is an inappropriate destination. Some estimates show that as many as 56% of ED visits are avoidable with timely and proper preventive care.¹ Why is EMS still providing for some patients the wrong care in the wrong place at the wrong time?²

There is hope as EMS agencies institute alternative-destination protocols and frequent-user management programs under the umbrella of mobile integrated healthcare and community paramedicine. These programs may be part of the answer to that nagging voice inside our heads that says, “I can’t believe I’m taking this guy to the hospital again. There has to be a better way.”
There is. Ask some of the nation’s most forward-thinking medical directors how they’re addressing the problem, and the answer may prompt you to wonder why the entire industry isn’t making these same systematic improvements.

At the 19th annual Gathering of Eagles, held February 17–18 in Dallas, Paul Pepe, MD, MPH, hosted his customary dazzling lineup of medical directors from some of the largest cities and agencies around the country. One of the highlighted topics was the treatment of frequent users and behavioral health patients. When Eagles from San Diego, West Palm Beach, San Francisco and Anchorage explained their innovative approaches, the audience of close to 1,000 was visibly surprised. These medical directors have found novel ways to treat addiction, frequent users and nonemergent patients with modalities different than lights, sirens and a hospital bed.

High-Tech Hotspotting
Presented by Jim Dunford, MD, San Diego Fire-Rescue, CA

Dunford wowed the audience from the start with a first slide showing the importance of robust, real-time data. He projected a map of San Diego, and with one click a time-lapse clock at the bottom fast-forwarded through a day of EMS calls in the city. Corresponding bar graphs grew and shrank in certain areas, indicating “hotspots” for drug use and overdose calls.

Dunford continued by showing a spoke-and-hub graphic titled “San Diego Regional Health Information Exchange”: The hub was EMS, and the spokes were partner agencies (hospitals, health systems, medical groups and clinics) that share their patient data with community paramedics from the local Resource Access Program (RAP). The EHR data is bidirectional. Where most presenters show these graphics as “the future of EMS” or “what we are striving for,” in San Diego it has been a reality for almost five years.

RAP began in 2008 as a pilot project to deal with some of the most complicated patients seen by SDFR. Taking a careful look at the data, leaders found that in 2008, ambulance charges for a group of 933 frequent callers totaled $6.4 million, $4.6 million of which was uncompensated.³ With grant funding, partnerships and lots of hard work, the program “Street Sense” was launched.

Street Sense relies on intensive data mining. Paramedic Anne Jensen, RAP manager, established a frequent-caller dashboard that could be sorted for each user by fields such as time period, call frequency, homeless status and behavioral problems. This tool, coupled with a financial analysis of the cost of the ambulances, fire engines, hospital visits, etc., was key in identifying savings and big expenses.

Another Street Sense tool triggers an alert when one of the enrolled patients has contact with SDFR or its private ambulance partner, American Medical Response. As soon as the on-scene provider begins entering patient information into the cloud-based ePCR, the program notifies the RAP community paramedic with a text message that includes the details of the call.

“Community paramedics usually call the provider on scene and try to begin appropriate interventions over the phone, so no one slips through the cracks,” Dunford says.

SDFR saw a need and attempted a solution but realized their attempts at analyzing the data were time-consuming and inefficient. So they created their own solution: a real-time electronic surveillance and case management platform of ePCR and CAD data.

“Everything is accomplished in small steps,” says Jensen. “There will be hurdles, but that’s part of being an innovator.”

While EMS providers have plenty of skill to identify patients in need, what they often don’t have are the partnerships that will allow them to navigate the patient to the appropriate care.

“Giving our patients these resources helps us change their lives in ways I’ve never seen before,” Jensen says.

Stopping the Revolving Door of Narcotic Abuse
Presented by Kenneth A. Scheppke, MD, Palm Beach County Fire Rescue, FL

The audience at Eagles is undoubtedly familiar with the nation’s opioid crisis, huge increase in Narcan use and arming of laypersons with tools to help overdose victims. Also familiar is the tragic cycle of abuse that tends to occur when users do not receive appropriate rehabilitation, counseling or treatment. So when Scheppke began his talk by showing an actual photo of a revolving door with a drug user cycling through it and then asked, “How ridiculous is this?” it was clear he wouldn’t be pulling any punches.

In yet another instance of not shying away from failures of the system, Scheppke detailed his department’s approach to treating drug users with medication-assisted treatment, specifically with buprenorphine (Suboxone).

Scheppke summed up his frustration with the current “gold standard” in opiate addiction treatment: “Abstinence does not really work.”

PBCFR paramedic Capt. Houston Park came to Scheppke last year with a study from Yale New Haven Hospital that showed a successful program where opiate users were treated with tapering doses of Suboxone. Park was frustrated by what he was seeing as a street provider: a cycle of overdoses—often the same patients—and a staggering 2016 death toll in his county of almost 600 mostly young, otherwise healthy individuals.

Also striking was the county’s 2016 bill for Narcan: $500,000.

While many communities across the country can point to similar increasing use of Narcan with no corresponding decrease in overdose deaths, PBCFR acknowledged the failures of its system and changed its practice.

“When your fire department is spending this much on Narcan but the death rate from overdoses keeps rising, something is wrong,” Scheppke says. Patients who had overdosed were discharged from the hospital with little or no follow-up treatment, sometimes just a directive to “stop using drugs.”

Scheppke believes he’s found a solution in buprenorphine, which, while an opiate, does not have a “perfect fit” with the body’s opioid receptors. Instead the drug creates a limited effect that helps ease withdrawal symptoms.

“Users live in a state of anxiety worrying about the pain of withdrawal,” Scheppke says. “If we give buprenorphine to these patients, they can be treated in the same way a diabetic might take insulin for the rest of their lives.” Doctors would never tell a diabetic to stop using food, Scheppke says, so why is substance use disorder treated differently?

PBCFR benefits from numerous partnerships that help this program succeed. Prescribing physician Marc Schlosser, MD, oversees the program for the Palm Beach County Health Care District, which provides healthcare to the poor and uninsured. The clinic gives patients much-needed counseling, as well as attention to other medical and behavioral issues. Before enrolled patients are discharged from the participating hospital, the JFK Medical Center in Atlantis, Fla., psychiatrist Serge Thys, MD, conducts a behavioral health screening and gives the initial dose of buprenorphine.

After the patient is discharged from the ED, PBCFR’s community paramedics visit them for the next eight days. Accompanied by a peer addiction counselor, CPs administer doses of buprenorphine and evaluate the patient’s vital signs and withdrawal symptoms.

One of the patients remarked that in the past he never felt anyone in the medical community actually cared about him; now he says he is being looked after and has the support to get better.
PBCFR’s Suboxone Pilot Program has enrolled 24 patients, and once it reaches 30 the results and implementation will be scaled up and likely replicated in surrounding communities. The program has been successful so far: while PBCFR lost track of three patients due to homelessness issues, 19 have not relapsed.

“There’s no cure for this disease, only lifelong treatment,” Scheppke says. “This is a public health emergency, and we need to keep pushing the envelope. That’s the reason healthcare exists.”

Sobering Facts for 9-1-1 Providers: The Use and Functionality of Sobriety Centers
Presented by Clement C. Yeh, MD, San Francisco Fire Department, CA, and Michael K. Levy, MD, Anchorage Fire Department, AK

Yeh and Levy continued the theme of facing reality in their talk about the need for sobering centers for acutely intoxicated patients.

Speaking directly to decision-makers, Yeh said, “Let’s face it: Alcohol is cheap and readily available. If your city doesn’t have a sobering center, you’re doing it in the hallways of your ED.”

Levy took a similar tack, noting that without Anchorage’s Safety Patrol program, there would be a greater phenomenon of “human popsicles” in Anchorage.

No matter a city’s climate, it is generally agreed that intoxicated patients with no other medical problems can probably be safely taken somewhere besides the ED.

EMS providers in San Francisco are acutely aware of the irrationality of transporting these patients to the hospital. In an interview with the New York Times, Capt. Dean Crispen said, “It kind of feels like you’re a Band-Aid—that this person has problems that are so much deeper than we’re able to fix.”

In that same article Yeh said, “For a certain population we’re seeing quite a bit of, [sending an engine and a truck] isn’t actually helping.”

The sobering center is a facility where individuals can safely recover from acute intoxication. The centers in San Francisco and Anchorage are publicly funded, allow only adults transported by van, EMS or law enforcement, and are staffed by EMTs or nurses. In San Francisco’s sobering center, most patients arrive by ambulance. In 2015 that number was about 1,400. In Anchorage Levy’s Safety Patrol actually runs more calls than AFD’s busiest EMS unit.

Both Levy and Yeh stressed the safety of these programs. A study of checklist-driven protocols for transport to sobering centers showed an adverse-event rate of only 0.6%.⁴

The checklists dictate that the patient be over 18, either consent voluntarily or have presumed consent, not be on a sobering center “exclusion list” and be medically appropriate, with most vital signs within normal limits and no trauma.

Beyond the actual sobering, these centers become healthcare hubs and centers of refuge. “Patients are using the centers for things like lab draws, laundry, wound care and medication needs,” Yeh says. “They get back on their feet a bit and maybe even take up an offer of social services or addiction counseling.”

Yeh argues it is the responsibility of the entire community (and a function of the medical director’s leadership) to get involved in developing resources like these.

Levy emphasizes the need to clearly define admission parameters and support personnel with education and training and protocols.

Even then, Levy says, “expect some misadventures.” Levy told a few stories about dangerous situations occurring in the back of Anchorage’s Safety Patrol van; these led to cameras and monitors being installed in the vans, so the driver has a view of the patient compartment.

Conclusion

The presentations at Eagles are proof that thinking outside the box, having strong medical leadership, and collecting, analyzing and evaluating data can truly make a difference in addressing chronic users and nonemergency transports. It’s EMS without the emergency.

References

1. National Priorities Partnership. Reducing Emergency Department Overuse: A $38 Billion Opportunity. November 2010.

2. A NEHI Research Brief. A Matter of Urgency: Reducing Emergency Department Overuse. March 2010.

3. Agency for Healthcare Research and Quality. Data-driven system helps emergency medical services identify frequent callers and connect them to community services, reducing transports and costs. June 2014.

4. Ross DW, Schullek JR, Homan MB. EMS triage and transport of intoxicated individuals to a detoxification facility instead of an emergency department. Annals of Emerg Med, 2012; 61:175–184.

Hilary Gates, MEd, NRP, is a paramedic in Alexandria, VA. She is an EMT instructor and teaches in the School of Education at American University. She began her career as a volunteer with the Bethesda-Chevy Chase Rescue Squad. Gates has experience as an EMS educator and symposium presenter and is involved in quality management and training for the fire department.