Source Article from Washington Post | Comments Courtesy of Matt Zavadsky
Interesting profile on the outcomes from D.C.’s system. A 50% bounce back rate is not terribly different than start-ups in other EMS systems.
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By Clarence Williams
September 23, 2018
D.C. Fire and EMS officials found positive signs in the first 90 days of a $1 million nursing phone line at the 911 call center, but have yet to see big dividends in one of the program’s intended goals: reducing ambulance trips for patients who don’t need them.
D.C. Fire Chief Gregory Dean sent a letter to the department this month highlighting early data from the “Right Care, Right Now” program that staffs a triage line at the 911 center with registered nurses. The nurses are there to diagnose callers who appear to have nonlife-threatening maladies or injuries and may not need medics or a fire crew and a trip to the emergency room.
The fledgling program has been providing quick, private transportation for noncritical patients to clinics using a ride-share service, Dean’s letter said, and 911 callers who were processed through the nurse gave uniformly positive reviews about their experience in follow-up surveys.
However, fire officials acknowledge that the program has not made a significant dent in the hundreds of calls they field daily that tie up EMTs, paramedics and ambulances with issues such as insect bites and toothaches.
“There is a habit or pattern that we need to change. A lot of time people are not familiar with getting to a clinic. They are just used to calling 911. That’s not really what we wanted them to learn, but that’s what they’ve learned,” said Robert Holman, the D.C. Fire and EMS medical director. “We’re trying to establish a new pattern.”
The changes are also intended to offer better health-care options than an emergency room visit provides.
The triage program started in April, with nurses available on the 911 call line from 7 a.m. to 11 p.m. daily at a cost of $1 million for salaries and a technology build-out.
In the first 90 days, Dean’s letter showed, nearly half of all calls routed from a 911 dispatcher to the nurses still resulted in a D.C. fire unit being sent out because nurses sent the call back after hearing a caller describe their medical need.
As nurses grow more comfortable making decisions, the program could help redirect callers to less urgent but still appropriate medical options, Holman said.
“We are happy with the modest impact, but we would like to see this grow a bit more. I don’t think our [department] members are feeling the effects of this just yet,” in relieving first responders from tending to low-priority calls, he said.
Before the launch, officials had estimated that as many as 70 percent of their 911 medical runs involved patients with conditions that are not life-threatening emergencies.
The city’s revitalization and expansion have not waned, which keeps emergency call volumes up and demands high on city emergency services even as the so-far-modest nurse triage program tries to relieve some of that pressure, said Dabney Hudson, president of the firefighter’s labor union. “We’ve gained more calls through growth than they’ve gotten rid of with this,” Hudson said. “We have a capacity issue.”
Between the April 19 launch and late August, registered nurses fielded 1,103 calls to work through issues with 911 callers, who in their initial conversations described a seemingly not-urgent medical need.
Nurses can bounce back patients to a dispatcher if they decide an EMS or ambulance crew should respond. For the callers who need non-emergency medical care, the nurses will book an appointment with a primary-care doctor or clinic in the caller’s neighborhood who can see them within two hours. The nurses will also send a Lyft driver to take Medicaid-covered patients to and from a doctor or clinic.
Of the 1,103 calls routed to nurses for questioning known as triaging, officials said that 130 patients were sent to clinics, 289 calls were canceled, and 131 calls received “self care,” which includes nurses advising a caller to take prescribed medications to stabilize blood pressure or blood sugar levels or to buy over-the-counter ointments for other problems.
In the opening weeks, nurses “were over-triaging back to 911 and they were doing so with an abundance of caution,” Holman said.
“I give feedback on every one of these calls,” he added.
His feedback to nurses included instructions not to send ambulances for strains and pulled muscles in the lower back or migraines and headaches that did not indicate any other serious disorder like a spike in blood pressure.
Holman said that as nurses have gained experience and feedback, the calls resulting in emergency crews being dispatched has dropped from a weekly average of 33 in June to 15 by late August.
Hudson said he applauds the attempt to deal with call volume that cripples the department’s efficiency and burdens the workforce. However, he said union officials warned the department that the nurse program might prove ineffective following interviews and research the union did about failed efforts in Philadelphia and Richmond.
“It’s the same issue every other large city has run into that tried to implement this. The return on investment wasn’t there,” Hudson said. “They just sent a firetruck or an ambulance. Obviously that still doesn’t solve our problem.”
Transportation has been a significant success early on, Holman said, as officials report that on average it took 37 minutes from the time a patient spoke with a nurse to arrive at a clinic for a walk-in appointment. A non-emergency ambulance trip to the hospital, which would include a patient evaluation and processing, can take 40 to 60 minutes officials said, depending on the time of day and traffic.
Officials said nurses tried to call each patient to follow up on their treatment and to “review their customer service experience.” During the first 90 days, officials said they received zero complaints and all 55 patients nurses contacted “provided positive feedback,” the letter said.
Only one complaint arrived after the initial 90-day period, Holman said, and after reviewing that call he believes a nurse rightly refused a transport in August for a man with a sore throat.
“It’s early but we’re very pleased with our customer satisfaction,” Holman said. “We think we’ve built a good system.
We just want to increase the volume so more people can take advantage.”
Destiny Banks was one of the early users.
A Lyft driver took her to the Unity clinic on Minnesota Avenue after she became lightheaded during a therapy session in the spring. Her therapist dialed 911 because Banks was pregnant, had a previous instance of passing out and suddenly could not finish sentences during the session.
She expected to hear sirens and see lights from an ambulance, but within about 15 minutes a Lyft driver arrived to take her to a clinic, which was initially disorienting for Banks.
“I was confused more than nervous. I was okay with it, it was just different,” she recalled.
A clinic employee talked to her on site, and she was seen within about 20 minutes by medical personnel, much more quickly than in any previous emergency room situation, she said.
She was diagnosed as being dehydrated and sent home with instructions to drink more water. Her daughter Avay’e was born Aug. 24, without issue.
The nurse triage and clinic referral “might be weird to other people, too. But I’m glad they put it into play. Not every time it’s a dire emergency that you need an ambulance,” Banks said. And getting to care “was really fast.”
