Whats your take ???

[Ms.Medic]

I'd like to see what everyones take on this is....

AROLYN FEIBEL, STAFF
The Houston Chronicle


Should you call an ambulance for a sprained wrist or child's fever? A spider bite?

The medical consensus is no, but every year thousands of people in the Houston area dial 911 for non-emergencies.

Hoping to cut back on the number of ambulances responding to non-emergency calls, the City Council voted Wednesday to hire round-the-clock "tele-nurses" to work with 911 dispatchers.

For callers who do not have a true emergency, a nurse will offer first-aid advice over the phone, or help them find a clinic or doctor.
<snip>

 

[AJ Hidell]

Houston is among the first cities to try tele-nurses for 911 calls. Richmond, Va., has a similar program, Persse said.

LOL! I love how every city to try something thinks they are the first ones. This is certainly nothing new. Dallas tried this over twenty-five years ago, ended up killing at least three people, getting sued in a big way, and scrapped the program. The city was judged liable for a patient's death. One nurse lost her license and a wrongful death lawsuit, and was literally run out of the state by numerous death threats. A fire captain and assistant chief were fired or demoted. All the other nurses quit, and the city quietly ditched the whole program. This is why most physicians do not practice telephone medicine. In order to evaluate someone, you need to actually see them. Anything less is taking a serious chance with their lives and your license.

Who knows. Maybe Houston is so much smarter than the rest of the world that they have actually discovered the key component to making this work. After all, in theory, it is a valid concept. But more likely, they're simply intent on repeating the same mistakes that others have suffered to finally determine that it was a waste of time, money, and lives. Hopefully they have the common sense to look at what has already been done before trying to reinvent the wheel. They should start by Googling "Lillian Boff". Here's a good article to start with:

http://www.aintnowaytogo.com/911Call.htm

 

[Veneficus]

LOL! I love how every city to try something thinks they are the first ones. This is certainly nothing new. Dallas tried this over twenty-five years ago, ended up killing at least three people, getting sued in a big way, and scrapped the program. The city was judged liable for a patient's death. One nurse lost her license and a wrongful death lawsuit, and was literally run out of the state by numerous death threats. A fire captain and assistant chief were fired or demoted. All the other nurses quit, and the city quietly ditched the whole program. This is why most physicians do not practice telephone medicine. In order to evaluate someone, you need to actually see them. Anything less is taking a serious chance with their lives and your license.

Who knows. Maybe Houston is so much smarter than the rest of the world that they have actually discovered the key component to making this work. After all, in theory, it is a valid concept. But more likely, they're simply intent on repeating the same mistakes that others have suffered to finally determine that it was a waste of time, money, and lives. Hopefully they have the common sense to look at what has already been done before trying to reinvent the wheel. They should start by Googling "Lillian Boff". Here's a good article to start with:

http://www.aintnowaytogo.com/911Call.htm

"Texas: It's like a whole nother country"

Wasn't that the tourist promotion slogan?

Al these nurse on call lines are algorythms. Usually they end at: "if you really think it is an emergency, then you should go to the hospital." When the patient gets there they of course think they get some kind of expedited treatment because "the nurse told them to come in."

Something that agencies providing EMS need to get through their thick heads is that the public doesn't need a service that only handles "true medical emergencies" they need a service that thye have access to. We all know more than 90% of all "emergencies" are not. This line of "paramedics were wasted and didn't go to somebody who truly needed them" is complete BS and either ignorance or arrogance.

Somebody will spout some crap about response time. But lets have a look at the mythical 8:59 rule. I was told that o2 debt start immediately upon an insult. 6-8 minutes of debt before permanent injury. So you get there x% of the time a minute after, the vegetable garden must really love your efforts.

I love how angencies talk about how they serve the public but want to decide how and when. Where do I get a job where I decide what work I will do and when? Get paid for sitting around waiting for something "important" to happen?

Is it a waste of money to use the "emergency system" for healthcare in the US? You bet it is, but there is not another system that is readily available. Welcome to "serving" the public. If an ED doc with more education andtraining than most EMS providers will ever have can spend time treating non emergent patients doing things like interpreting HCG tests, dolling out flu dxes, seeing the child with a "fever" I'd like to hear the skill and knowledge you possess that exempts you from such menial tasks?

As for the "nurse line" AJ touched on it. Unless you have a fund for "acceptable losses" deciding an emergency over the phone, it's only a matter of time before people die. Hell I can't always get an accurate history staring a patient in the face. (for some reason nonmedical people never share the same attention to medically significant details that I do)

I guess the benefit is you are creating employment during these tough times. Also adding a "middleman" to a 911 call (for the patient who might truly need your help) and how long do you think it will take for the callers to figure out exactly what they need to say to get the ambulance anyway?

"I'm having chest pain and difficulty breathing I need an ambulance"

when they have a different compliant on arrival, what are you going to do then, accuse them of not having chest pain and difficulty breathing? recoup the cost of a "wasted" run? Lots of luck with that.

The problem isn't abuse of EMS the problem is EMS not meeting patient needs.

 

[fortsmithman]

Here in Fort Smith our dispatchers are the RNs and LPNs at the hospital. They do not offer any advice over the phone they only dispatch us out to the scene.

 

[AJ Hidell]

Here in Fort Smith our dispatchers are the RNs and LPNs at the hospital. They do not offer any advice over the phone they only dispatch us out to the scene.

Then what exactly do they do that requires a nurses expertise?

 

[fortsmithman]

Then what exactly do they do that requires a nurses expertise?

None because our service uses the hospital nurses as dispatchers because it's free to the service. Here in the NWT we only have 4 or 5 other communities that have any kind of EMS in the communities without it's the guy with a van or pickup or quad and sled or snowmobile an sled that takes the pt to the nurses station. The NWT is one of the largest areas in Canada by land mass but population we only have approx 41000 persons.

 

[AJ Hidell]

None because our service uses the hospital nurses as dispatchers because it's free to the service.

Ah, okay. That makes sense. I encountered that same situation at a couple of rural, hospital-based EMS systems, where the calls for service went straight to the nurse's station. It actually worked well, and was a lot more effective and efficient than dealing with busy cop dispatchers, to whom EMS is just extra work for them.

 

[PapaBear434]

Put RN's or Practitioners on the ambulances, and make them mobile Doc-in-the-Box's. My personal opinion is that you can't do a proper assessment over the phone for a lot of these folks, and you need to be face to face. But if you do this, give Paramedics treat and release powers, so they can make the determination that "Yeah, it looks like a bad bruise on your leg. Probably because you bumped into your end table so hard. Nothing looks broken or strained, so here is some Motrin, go see your Doctor on Monday if it still hurts."

 

[medic417]

It would be better if Houston properly educated their Paramedics. Then because there is no way to get proper diagnosis over the phone all the time an ambulance with a Paramedic should respond all calls. After examination they do not need the ambulance, assist them finding the services they need. Initially this will be time consuming so not for the lazy Paramedic. But after a few years will lead to many fewer calls to 911 as the public will learn where to call and go for non emergent conditions. But for emphasis no diagnosis over the phone and every caller will be seen by a properly educated Paramedic.

 

[Veneficus]

Put RN's or Practitioners on the ambulances, and make them mobile Doc-in-the-Box's. My personal opinion is that you can't do a proper assessment over the phone for a lot of these folks, and you need to be face to face. But if you do this, give Paramedics treat and release powers, so they can make the determination that "Yeah, it looks like a bad bruise on your leg. Probably because you bumped into your end table so hard. Nothing looks broken or strained, so here is some Motrin, go see your Doctor on Monday if it still hurts."

Everytime I suggest that solution, people go nuts.

When I worked in industrial medicine (as a paramedic) we did that all the time. (except we had to make the appointment for them if they required a doc) The goal wasn't a trip to the doc or the hospital, the goal was "back to work." (not just for the company, but for the individual who couldn't afford to take tme off to see if they really had a serious problem or not)

 

[Ms.Medic]

It would be better if Houston properly educated their Paramedics. Then because there is no way to get proper diagnosis over the phone all the time an ambulance with a Paramedic should respond all calls. After examination they do not need the ambulance, assist them finding the services they need. Initially this will be time consuming so not for the lazy Paramedic. But after a few years will lead to many fewer calls to 911 as the public will learn where to call and go for non emergent conditions. But for emphasis no diagnosis over the phone and every caller will be seen by a properly educated Paramedic.

I like this idea much better,,,just my opinion. Who better to tell the patient that they dont need to go to the hospital via ambulance, than the paramedic right in front of them, who have the general impression of the patient...now granted,,,that's a lot of liability, and it would take much more training and "not being lazy" of the medics, but why should we have to pass over judgement and the decision to an rn who does not see what we see. Only to tell them what we would tell them in the end anyway...."now do you still want to go with us, its your decision".

 

[Ms.Medic]

LOL! I love how every city to try something thinks they are the first ones. This is certainly nothing new. Dallas tried this over twenty-five years ago, ended up killing at least three people, getting sued in a big way, and scrapped the program. The city was judged liable for a patient's death. One nurse lost her license and a wrongful death lawsuit, and was literally run out of the state by numerous death threats. A fire captain and assistant chief were fired or demoted. All the other nurses quit, and the city quietly ditched the whole program. This is why most physicians do not practice telephone medicine. In order to evaluate someone, you need to actually see them. Anything less is taking a serious chance with their lives and your license.

Nice AJ !!!

 

[karaya]

This very topic was already discussed a couple months ago here:

http://www.emtlife.com/showthread.php?t=10994&highlight=houston+nurses

This is newer in concept and different than the Dallas debacle. This is a tele-nurse system whereas the Dallas program actually used nurses as dispatchers. Unlike the Houston, Richmond and Philadelphia programs, which transfer non-emergency calls to a fully staffed nurse call center. Richmond's program has been in effect for over a year and there never has been an incident where an actual emergency was transfered to the call center.

Back to the Dallas incident; under today's EMD guidelines, the moment the man told the dispatcher "she's having difficulty breathing and cannot talk" an ambulance would have been dispatched immediately. Under Houston's program, should a call be transfered to the tele-nurse and the caller still wants an ambulance, one will be sent.

It is estimated that Houston looses over $50 million dollars a year on non-emergency calls. Spending $6.8 million to save even a third of the non-emergency calls is still a significant savings to the Houston taxpayers.

 

[reaper]

This very topic was already discussed a couple months ago here:

http://www.emtlife.com/showthread.php?t=10994&highlight=houston+nurses

This is newer in concept and different than the Dallas debacle. This is a tele-nurse system whereas the Dallas program actually used nurses as dispatchers. Unlike the Houston, Richmond and Philadelphia programs, which transfer non-emergency calls to a fully staffed nurse call center. Richmond's program has been in effect for over a year and there never has been an incident where an actual emergency was transfered to the call center.
Back to the Dallas incident; under today's EMD guidelines, the moment the man told the dispatcher "she's having difficulty breathing and cannot talk" an ambulance would have been dispatched immediately. Under Houston's program, should a call be transfered to the tele-nurse and the caller still wants an ambulance, one will be sent.

It is estimated that Houston looses over $50 million dollars a year on non-emergency calls. Spending $6.8 million to save even a third of the non-emergency calls is still a significant savings to the Houston taxpayers.

While it may be working, That is a statement that I cannot believe. A few are going to slip through, no matter how good the dispatchers are!

 

[karaya]

While it may be working, That is a statement that I cannot believe. A few are going to slip through, no matter how good the dispatchers are!

That may be. But, if you look at the Houston program, if an emergency is detected by the tele-nurse, the call is then transfered back to the 911 center. Seems like some thought was put in for safeguards. Perhaps, Richmond has the same?

 

[Ridryder911]

I remember the Dallas and other incidences that always leaves a multimillion dollar lawsuit. Must cheaper to place additional units and fix the system.

Tele-nurse or ask a nurse is just simplistic information and again, all will end by describing to be seen by PCP or notify 911.

No respectable nurse will give an impression or diagnosis made over the phone. Sure, some simplistic advice as the same one could read in any women's magazine or reader's digest.

R/r 911

 

[Veneficus]

I'd very much like to see how those costs are tabulated. I don't doubt they report that as cost, but I know when I worked for a FD we would divide the costs (which included the vehicles and salary) based on the number of calls per year. If you have 6 firefighters sitting in the station with 7 trucks, it really doesn't "cost" the $500 and some dollars we used to quote per run that wasn't an "emergency," because all except the gas and consumables (like monitor pads) was being paid if there was a call or not. The less calls we had the more the "price per call" went up. Additionally Everyone from farms (aka agriculture) to the local zoo over estimates the costs when trying to make their case. Without filling out a TPS report, how many industries attempt to lower the amount of productivity to hours worked for employees ratio?

As you pointed out, if the person talks to the nurse and still wants an ambulance, where is the cost savings? If you are sending an ambulance to a person with a cold who has "difficulty breathing" because who in their right mind wouldn't when somebody called and said that, where is the savings?

I think in order for that to work, the nurse would have to be able to set up an appointment or refer the caller to whatever resources they need. Which can only happen if those resources exist. How much will that cost and who is paying for it? The answer certainly isn't "nothing and nobody."

Furthermore, if you decrease the runs by 50% what is the reason not to decrease staff and units by 50% also?

If somebody has a solution that is not simply a band aid for the larger problem, I'd be interested to explore it. The trouble is EMS does not exist in a bubble. If you deny transport or even a response, you do not eliminate the need for healthcare. Who is going to pay the cost when a simple problem like an ear infection in a child turns into meningitis? That bill will make the glorified taxi ride look cheap. Who is fronting the money for urgent care clinics or PCPs to make a living for people who cannot pay or get an appointment in a reasonable amount of time?

If we "save" money not responding to calls, do we put that money into mass transit (so people can get to the doctor or ED) or other infrastructure for healthcare?

If your city is spending $50 million a year on "bogus calls" that is your cost for timely access to care for people who for whatever reason rely on the Emergency system to meet their healthcare needs. The alternative is to let those who cannot afford access go without.

You really want to save some money? stop all public EMS and healthcare, if you can't pay, you can't play. Don't worry about long term disability costs, those people will die before it becomes a burdon.

Sounds harsh to say it like that, but no less harsh than telling an individual you refuse to help them by giving them a ride. But then you could put them in jail for failing to "properly" care for their kids and elders.

I know, I know, it would be a terrible burdon for socialized medicine for those undeserving, nobody wants to become better educated to help these people where they live instead of driving to the hospital, there is a critical shortage of ALS provders, and "just what if the big one hits" while we're busy dealing with routine issues?

Maybe somebody thinks if we simply stop responding to these people (aka calls) the problems will just go away?

 

[AJ Hidell]

This is newer in concept and different than the Dallas debacle. This is a tele-nurse system whereas the Dallas program actually used nurses as dispatchers.

Not really. They were simply EMS call screeners.

Unlike the Houston, Richmond and Philadelphia programs, which transfer non-emergency calls to a fully staffed nurse call center. Richmond's program has been in effect for over a year and there never has been an incident where an actual emergency was transfered to the call center.

Okay, I think I see what you mean now. The nurses will not be call screeners, or anywhere in the dispatch continuum, but simply a resource for those deemed to be non-emergency. I'd like to say that sounds like a more viable plan, but I really don't see how. Now instead of two levels of bureaucracy, a caller must now go through three levels to finally get an ambulance if they don't say the magic words in the first few seconds. No matter how you slice it, you're still assessing a patient that you've never seen, never touched, and often have never even talked to. Bad form.

Back to the Dallas incident; under today's EMD guidelines, the moment the man told the dispatcher "she's having difficulty breathing and cannot talk" an ambulance would have been dispatched immediately.

That was the guidelines then too, but obviously it still broke down. And that's the point. It is just one more delicately subjective tier that can fail in the dispatch process. Yes, a medic on the scene can flub the assessment too. But if they do, at least they did so after an opportunity to actually assess the patient in person.

It is estimated that Houston looses over $50 million dollars a year on non-emergency calls. Spending $6.8 million to save even a third of the non-emergency calls is still a significant savings to the Houston taxpayers.

Boo hoo. Whatever happened to the IAFF's claim that they are best suited to provide EMS for a community? Whatever happened to "we're here to serve our community"? Whatever happened to, "we just want to help people"? If they're not up to the job, shouldn't they turn it over to someone who is? This is exactly why fire based EMS is teh fail.

 

[amberdt03]

LOL! I love how every city to try something thinks they are the first ones. This is certainly nothing new. Dallas tried this over twenty-five years ago, ended up killing at least three people, getting sued in a big way, and scrapped the program. The city was judged liable for a patient's death. One nurse lost her license and a wrongful death lawsuit, and was literally run out of the state by numerous death threats. A fire captain and assistant chief were fired or demoted. All the other nurses quit, and the city quietly ditched the whole program. This is why most physicians do not practice telephone medicine.

is this why hospitals don't offer the "nurse line" anymore? i never knew big d tried that, granted it was done before i was born so maybe thats why. lol.

 

[karaya]

Seems like there are several points raised as to why a city should not use a system similar to Houston. But, this program seems to be picking up more interest, especially due to the success of Richmond and Philadelphia's program. Cincinnati and Houston are just two more major cites to adopt this program.

The proof is in the pudding as they say, and so far there appears to be some credible success to warrant other cites to look at what may be a financially manageable and efficient program.

Here are some more links to the Houston and Cincinnati programs:

http://www.enquirer.com/editions/pdf/OH_CE_030109.pdf

http://a.abcnews.com/Health/Story?id=5008343&page=1