Strategies for Dealing with Nuisance Calls/Frequent Fliers

[medicaltransient]

That sounds like an administrative problem if it's 911 abuse. As long as they are aware continue to practice your assessment and exam.

 

[Tigger]

Several of our frequent fliers are now on a plan where they are still welcome to call us but they are charged 50 dollars on the spot for an evaluation.

It works.

 

[TransportJockey]

Wasn't Denver health giving out taxi vouchers at one point for calls like that?

 

[Clare]

This sounds like a psychosocial issue rather than one of direct medical pathology.

Yes, we have a number of pt here who call because of things other than medical.

If it is an obviously non-medical event Control will decline attendance explaining ambulances are for medical emergencies.

If the patient is obviously using the system inappropriately then a patient management plan is developed.

Here is the text of a brief regarding one such patient

In the period from 1 February to 31 May 2014, a patient with a history of chronic pain syndrome made 21 ambulance calls; 19 (90%) of which required an ambulance response, resulting in 7 transports to the emergency department (33% of calls).

After identifying this patient as a frequent caller, local Operations management in conjunction with Clinical Development and the patient’s GP, implemented a Patient Care and Response Plan. Following implementation of the plan, from 1 July to 31 October the patient made 59 ambulance calls, 47 (80%) of which were managed over the phone by a Clinical Support Officer (CSO) on the Clinical Desk without an ambulance being dispatched. Phone advice given by the CSO included guidance on medication administration and advising the patient to follow up with her GP.

On 12 occasions (20%), an ambulance was dispatched as the patient was unable to be contacted by the CSO on call back, or the patient hung up during phone triage meaning the plan could not be followed. These calls were allocated a GREEN response. Of those 12 ambulance responses, the patient was transported to the emergency department only once (2% of calls), for a condition that was not covered by the plan. Clinical advice for ambulance crews contained within the patient’s plan has supported crews in making robust, informed decisions regarding transport and reduced transports to ED by 85%. As a result of this plan, the patient is now receiving a consistent standard of care in her community.

By keeping the patient in her home where appropriate, she does not encounter the inconvenience of having to find transport for the 40 minute drive home from the emergency department which is particularly problematic for her. The patient is also being treated by community health professionals (GP, nurses and pharmacist) that are familiar with her condition.

By minimising ambulance responses to chronic conditions, the availability of ambulance resources is maintained for emergency calls, reducing response times and improving outcomes for time-critical patients. Reducing repeat ED presentations for the same condition enables hospital staff to focus their care towards seriously unwell patients, helps maintain bed capacity and improves acute patient flow, shortening emergency department stays - a key goal of the Ministry of Health.

Local management teams and Clinical Development will continue to identify frequent callers and work with the patient’s GP and other health professionals to implement appropriate Patient Care and Response Plans to improve patient outcomes.

 

[Tigger]

Wasn't Denver health giving out taxi vouchers at one point for calls like that?

Yes. We at AMR in the springs have them too, but now they are only so we don't have to give firefighters a lift back to their stations. It's a near-fireable offense to give them to "non-emergency" patients now, sadly.

 

[TransportJockey]

Yes. We at AMR in the springs have them too, but now they are only so we don't have to give firefighters a lift back to their stations. It's a near-fireable offense to give them to "non-emergency" patients now, sadly.

That's probably one of the dumbest things I have heard. The apparatus that the hosemonkeys got to scene on don't follow you to the hospital? Every place I've worked that let us take fire riders (except for one) had the apparatus follow 55 to the hospital to get their FF

 

[Chewy20]

Our frequent flyer has called over 500 times in the past 3-5 years. Forget the exact numbers. Mind numbing in the least. Her only care plan is that she does not get a choice as to which hospital she goes to.

 

[chaz90]

Yes. We at AMR in the springs have them too, but now they are only so we don't have to give firefighters a lift back to their stations. It's a near-fireable offense to give them to "non-emergency" patients now, sadly.

...CSFD is now riding taxis back to their stations if they transport a call with AMR? Oh boy.

 

[Tigger]

...CSFD is now riding taxis back to their stations if they transport a call with AMR? Oh boy.

The on duty medical division lieutenant is supposed to take them back (they are on 24/7 as "EMS supervisors" [lulz]) if they are available. But sometimes that doesn't happen and AMR has to pay for them to go back. Because they provided so much help that they need more than 1.3 million AMR already pays the city to operate there. Oh and why don't you just take a crap ton of supplies out of my ambulance because you "can't remember what we used last call."

I will say that their community paramedic program is working pretty well, and I actually do applaud their commitment to it.

 

[Tigger]

That's probably one of the dumbest things I have heard. The apparatus that the hosemonkeys got to scene on don't follow you to the hospital? Every place I've worked that let us take fire riders (except for one) had the apparatus follow 55 to the hospital to get their FF

The companies that are relatively close to the hospital follow, but are still in service. The outlying companies never follow, they go back in service with three.

 

[triemal04]

Jeebus...I've heard a lot of things about Colorado Springs over the years and they're all in the same vein. How does the AMR shop keep people working for more than 2 months? Or all jobs in Colorado that hard to come by that you guys will accept being treated like the *****es of the city?

 

[Tigger]

Jeebus...I've heard a lot of things about Colorado Springs over the years and they're all in the same vein. How does the AMR shop keep people working for more than 2 months? Or all jobs in Colorado that hard to come by that you guys will accept being treated like the *****es of the city?

Well I'm just part time so it's a little easier.

Truly though, the operation is pretty damn good for private EMS. Good protocols, lots of autonomy, solid equipment, and involved (in a positive way) medical direction and clinical education. Pay is decent as well.

I don't have an issue with them because I accept that FD provides an average level of care and I don't expect more than that. They're also pretty good about stepping in and doing the grunt tasks on scene, they write most of the refusals, and let us get back into service quickly if it's clear we aren't needed. With critical patients it's another story though, the last thing you want is an awful crew puffing their chests out about having scene control and then mucking everything up.

What is unfortunate is that AMR is relegated to ambulance transport only. Fire is the sole provider of "non-traditional" EMS, so we have no input on their plans to reduce system abusers and things like that, despite having some truly awesome providers that would excel at that.

 

[phideux]

This sounds like a psychosocial issue rather than one of direct medical pathology.

Yes, we have a number of pt here who call because of things other than medical.

If it is an obviously non-medical event Control will decline attendance explaining ambulances are for medical emergencies.

If the patient is obviously using the system inappropriately then a patient management plan is developed.

Here is the text of a brief regarding one such patient

In the period from 1 February to 31 May 2014, a patient with a history of chronic pain syndrome made 21 ambulance calls; 19 (90%) of which required an ambulance response, resulting in 7 transports to the emergency department (33% of calls).

After identifying this patient as a frequent caller, local Operations management in conjunction with Clinical Development and the patient’s GP, implemented a Patient Care and Response Plan. Following implementation of the plan, from 1 July to 31 October the patient made 59 ambulance calls, 47 (80%) of which were managed over the phone by a Clinical Support Officer (CSO) on the Clinical Desk without an ambulance being dispatched. Phone advice given by the CSO included guidance on medication administration and advising the patient to follow up with her GP.

On 12 occasions (20%), an ambulance was dispatched as the patient was unable to be contacted by the CSO on call back, or the patient hung up during phone triage meaning the plan could not be followed. These calls were allocated a GREEN response. Of those 12 ambulance responses, the patient was transported to the emergency department only once (2% of calls), for a condition that was not covered by the plan. Clinical advice for ambulance crews contained within the patient’s plan has supported crews in making robust, informed decisions regarding transport and reduced transports to ED by 85%. As a result of this plan, the patient is now receiving a consistent standard of care in her community.

By keeping the patient in her home where appropriate, she does not encounter the inconvenience of having to find transport for the 40 minute drive home from the emergency department which is particularly problematic for her. The patient is also being treated by community health professionals (GP, nurses and pharmacist) that are familiar with her condition.

By minimising ambulance responses to chronic conditions, the availability of ambulance resources is maintained for emergency calls, reducing response times and improving outcomes for time-critical patients. Reducing repeat ED presentations for the same condition enables hospital staff to focus their care towards seriously unwell patients, helps maintain bed capacity and improves acute patient flow, shortening emergency department stays - a key goal of the Ministry of Health.

Local management teams and Clinical Development will continue to identify frequent callers and work with the patient’s GP and other health professionals to implement appropriate Patient Care and Response Plans to improve patient outcomes.

Your frequent flier made 21 calls in a 4 month period??? Lightweight, we got some regulars that come on a daily basis, sometimes once a shift. I know we got some that in that same 4 month period will rack up at least 100 visits, and that is just to one ER, we have 3 ERs here that the regulars rotate through. And since the majority of them are on medicare/medicaid, when they call 911 and come in by ambulance, we usually have to call logisticare to give them an ambulance ride back home again.

 

[sirengirl]

There is going to come a time that you are running a call on this "patient", when a critical call comes in. You could have been 2-5 minutes away, but since you are running on the person who you just did two hours ago, the next available unit is 10-15 minutes away. Big difference in EMS? Not usually, but big difference to the family of that patient, who needs you there and pay to have you there as quickly as possible

I work for a larger county, but we obviously have the same problem. We only have 17 ALS units 24 hours, sometimes we have an 18th one for half the day. We cover more than 340,000 residents in just under 900 square miles, 90% of our population lives within the urban areas. Our problem is that we are severely under-staffed and don't have enough trucks. We have a rotating roster of mandatory holdover- if there's an opening, and you're at the top, surprise! you don't get to go home today. Now considering that, plus that we ran 48,000+ calls last year, and we've already hit 30k for calls and it's only July- this makes for very grumpy medics. Combine this with all our frequent fliers, BS calls, ETOH, the astronomical rate of ODs we've been seeing, and the fact that the LEOs in the area use us like whipping boys to deal with every smelly or annoying person they don't want to deal with, and my workplace isn't ideal.

And then this exact thing happened.

We had 3 units available for the entire county. One hospital on diversion, swamped with patients, EMS units holding walls waiting for beds for 2-3 hours each in the only other available hospitals. The closest unit to the north end of the island was a mutual response from an ALS transport fire department that is the far south end of the county. For an active drowning. By the time they got there he was unsalvageable. Because our units were tied up with slow ERs, drunks, frequent fliers, a few legit patients, and a whole lot of beaurocratic nonsense. Our medical director won't allow us to have a community paramedic program, the county commissioners won't increase our budget for more ambulances and payroll, and we've already seen the negative implications on patients.

I strongly encourage you to document, document, document. It's the only proof you have. Anyone who writes a report on this patient needs to write down everything. Things said, done, medications taken or not taken, body language, everything. It's the only way to prove 911 abuse. It took 5+ years for 2 of our neighboring counties to put legal action against a woman who is literally known in every county within driving distance. After her stint in jail, no one has seen her. Maybe that would help your situation. Don't let it get to the point that it costs someone their life because the nearest help was 20-30 minutes away, instead of 4 like they should have been.

 

[GirevikMedic]

Setting the ball rolling on 911 abuse case sounds like an obvious first step here. Of course, this means (depending on how things are done where you're at) involving immediate supervisors up to and/or including company and/or agency medical directors, dispatch and LEOs.

The boys (and girls) in blue could provide the biggest hurdle through no fault of their own. In my previous area we had a (almost) daily caller, always called for CP and/or SOB though it was really a case of being drunk and probably needing psych eval for depression. He was never in any sort of medical distress and it got to the point that the ER would bounce him out the door straight from our gurney. Despite everything PD was as frustrated as we were. Their hands were tied because of the fact that when he called 911 there was deemed a legit complaint (CP, SOB) legally so unless he did/said something where PD could justify a 5150 (which was always family's concern) in their presence, a case of 911 abuse could never be established.

Mental health is obviously a factor here. Whether it's just loneliness/depression or an inability to understand and cope with life (TBI, low IQ etc.) try to remain compassionate for that reason.

That being said, our last issue was dealt with through the ED and his parents were contacted to discuss the issue (he was an adult). Every time he called 911 ems arrived and he would have to call his mom prior to transport. At first he quit calling, but then it picked up again (daily) and his family decided to take responsibility and moved him home.
Another one we had quit calling once homecare was set up to come by twice a day (mostly just to chat). That is still cheaper than an ambulance and ER stay.
We have some others that poloce are actively trying to deal with but no luck. All I can say is don't be the hero and try to end their habit, it's not worth your job.

Something to definitely consider with these types.

Treat it like a training exercise. Like a nr medical or trauma assessment.

 

[Alpiner]

I'm assuming the frequent callers have government assisted healthcare where they pay nothing out of pocket.

What kind of burden would it have on the taxpayers for someone who takes 500+ trips?

 

[phideux]

I'm assuming the frequent callers have government assisted healthcare where they pay nothing out of pocket.

What kind of burden would it have on the taxpayers for someone who takes 500+ trips?

The burden is enormous, the waste is outrageous. I worked the ER all weekend. Had one girl, had a UTI a week or so ago, treated at one of the other ERs for that one and given antibiotics, of course that gave her a yeast infection that of course, became an emergency at 0200hrs. She calls 911 for her ride to the hospital I'm triaging her and ask her why she didn't just buy some OTC meds for it, she says she didn't have the money, I told her instead of spending 5 bucks on some OTC stuff, she's gonna run up a several thousand dollar bill for her yeast infection,she says no, it's free, I have Medicaid. In the end she got a prescription for the meds so she wouldn't have to pay the 5 bucks for it, and an ambulance ride back home from Logisticare. Yet she can afford to smoke a pack and a half a day.
Had another winner, took a couple of sleeping pills to help her sleep, got out of bed about 45 minutes later to pee, felt dizzy, felt like she was gonna pass out. So 911 call, ambutaxi ride to the ER, she's telling me her story and it brings out "sarcastic Frank" my evil twin, who sarcastically starts telling her you weren't feeling dizzy, you weren't about to pass out, you took a sleeping pill, that's called Falling Asleep, triage ended there and she got put in the chairs, she ended up falling asleep out in the waiting room, and when it was all done several hours later, another Logisticare, Medicaid ambulance ride home.
And these 2 aren't the real frequent fliers, these 2 come maybe once every week or two. We have quite a few regulars that we will get on a daily basis, sometimes twice a day for a few weeks, then we won't see them for a month or so while they hit one of the other ERs for a few weeks, then all of a sudden they're back again. We'll have whole families check in, Grandma, Mom, 3 kids, usually in the wee hours of the morning when they should all be home in bed, because everyone in the house has a cold and don't feel good. Moms dragging babies out at all hours of the night, for a Fever. You ask the standard question, how high is the fever, the standard answer more times than not is, "I don't know, I don't have a thermometer, but they feel hot". More times than not when you take their temp it's normal, but they still want to be seen anyway, and because the way the rules or laws or whatever are, we can't turn them away, or refuse an evaluation or treatment. But it's ok, it's free, they have medicaid.
With just the waste I see in the one ER, I can imagine it multiplied throughout the thousands of hospitals and ambulances in this country, and I realize that there is untold Billions and Billions of dollars of waste with the frequent fliers. But to them it's OK, "it's free, I have Medicaid".
Yet if I have an emergency, and need to be seen in my own ER, and I use my insurance that I pay for, I have a $300.00 co-pay, and a $3000.00 deductible.