Emergency Medical Services (EMS) have expanded their capability over several decades. Despite advances in pre-hospital training, patients must still be transported to emergency departments (ED). Modern paramedics are capable of much more than the 1960s ambulance driver (Campeau, 2008). We deliver advanced care in pre-hospital and interfacility settings. Providing more than comfort measures, we stabilise serious conditions. Differential diagnoses allow us to make decisions about treatments and whether we should transport to specialty centres (Dobson et al, 2009).
Standing orders afford pre-hospital providers some independence in choices that affect life and death situations. Beyond this, EMS have evolved past emergency medical care. Medical directors and public health entities have utilised our services for vaccination and primary health services (National Association of EMS Physicians and National Rural Health Association, 2012; Mosesso et al, 2003).
Even with all these advances, paramedics often simply transport patients requesting care from a physician to an ED. A literature review by Bigham et al determined up to half ‘of all ambulance transports to an ED are inappropriate’ (Bigham et al, 2013: 362). Many sources of care exist and continue to expand across America; it is time to explore transport of patients to alternative destinations.
Sources of care
Healthcare delivery in the United States is a network comprised of disparate sources. Large systems of clinics and hospitals carve out regions and serve large populations. Burgeoning Accountable Care Organisations (ACO) are healthcare systems that singularly provide a continuum of care (Moore et al, 2013). Healthcare reform and ‘patient-centered’ approaches are changing the manner in which care is delivered (Berwick, 2009).
Americans travel to new locations for care, like retail clinics (Chang et al, 2015). These small clinics are regularly found in pharmacies or department stores. Of patients who self-triaged their condition and sought care at a retail clinic, Mehrotra et al (2008) found less than 3% of patients were sent on to primary care clinics or EDs. Staffed by physician assistants or advanced practice nurses, such clinics handle low-acuity complaints (Mehrotra et al, 2008).
A higher level of care is the freestanding ED. Regardless of some controversy over costs, the convenience they offer is gaining popularity (Berger, 2011). These facilities can be considered satellite EDs, typically staffed with board-certified emergency medicine doctors and emergency nurses (American College of Emergency Physicians, 2013). Dependent on local regulations, some freestanding EDs may accept ambulance patients.
Somewhere in between retail clinics and freestanding EDs are urgent care centres (UCC). These after-hours clinics have existed for decades, but are struggling to find their niche as the aforementioned providers flourish (Plemons, 2010).
Arguably we need not even leave home as availability of telemedicine and concierge medicine increase. However, there are limitations to these new modalities of care. Paramedics frequently respond to patients who, in good faith, call a telephone triage system associated with their health insurance. Their hope is to avoid a visit to the hospital or maybe schedule an appointment with their primary care provider. But at the mention of chest pain or shortness of breath, nurses instruct patients to call 911. Often, these complaints are simply related to a cough. Because of this abundance of caution on the nurses' part, patients believe they must go to the hospital.
Problems with emergency departments
In spite of this diversity of medical care, hospital-based EDs continue to be plagued with crowding (Lawner et al, 2015). To ensure America's poor and uninsured receive some medical care, the Emergency Medical Treatment and Active Labor Act (1986) was passed (Woodworth, 2014). It is suggested uninsured patients inundated EDs because they could not be turned away (Becker and Friedman, 2014). By 2010, 11% of America's hospitals closed their emergency departments (Woodworth, 2014).
The financial impact of uncompensated care strained hospital budgets, which caused ED closures. Now Americans must have health insurance under the Affordable Care Act (2010). Yet there are no indications the newly insured will choose a clinic. Instead patients continue to use EDs, finding them more convenient (Capp et al, 2015), or have a limited knowledge on how to access the healthcare system (Bauer et al, 2016).
EMS systems are not helping to reduce overcrowding. Unfortunately, the system gives paramedics little leeway. Even though there are so many choices where to receive care, Americans continue to call EMS for a myriad of problems, most of which are not life threatening (Brown et al, 2009). A growing percentage of conditions are those that would be better treated in a primary care setting or elsewhere (Diesburg-Stanwood et al, 2004; Weinick et al, 2010).
Paramedics are not allowed to refuse transport for any reason (Feldman et al, 2005). Yet the only destination in most jurisdictions is the ED. Alpert et al (2013) believe Medicare expenditure could decrease by at least $1 billion annually if paramedics transported to other sources of care for low-acuity patients.
What can be done?
In recognition of the critical thinking and decisions paramedics are allowed to make, why not allow paramedics to decide if a clinic is a reasonable choice? Such decisions by paramedics would not be wild guesses or random selection. From state to state, paramedics work under a wide array of freedoms determined by local or state law. One thing in common is protocols, established to guide paramedics in their care.
As local standards of care dictate, medical directors or statutory bodies could devise exclusionary algorithms, protocols to guide paramedics' clinical judgement. Practically nothing would change in this new system. A physical exam and set of vital signs would be obtained to inform the paramedic's decision. Medical history and current medications would be taken into consideration. If no critical or highly suspicious conditions exist, alternative dispositions could apply. Only the transport destination would change.
Another ‘out-of-the-box’ concept might be mobile video conferencing capabilities. Ambulances provide an environment for patients to have a virtual visit with a licensed care provider—a truly mobile integrated health unit. Paramedics could assist the remote practitioner by conducting physical exams. In Germany, experienced paramedics staffed an ED and effectively provided care with the assistance of a remote physician (Rörtgen et al, 2013). Another idea could be extended to a phone consultation with patients under the care of specialists or surgeons. Post-operative patients frequently call an ambulance not aware of any other recourse. However, paramedics could conduct guided exams and assist a surgeon to determine the best disposition of the patient (Boniface et al, 2011).
Evidence-based medicine increasingly finds its way into pre-hospital care (Simpson et al, 2012). For instance, automatic full spinal immobilisation has fallen out of favour simply based on mechanism of injury. Rather, paramedics are allowed to follow an algorithm to determine if a long backboard is necessary (Gonzalez et al, 2013). A similar set of criteria could be used to screen patients with minor medical complaints. Patients who present to paramedics with signs and symptoms suggestive of a non-emergent condition could be transported to different settings of care. However, listing conditions that could be triaged to other sources of care is beyond this commentary.
Exploration of possible barriers for this new system is in order. A set of issues may include state laws, which prevent transport of 911 patients to anywhere other than a certified ED. Likewise, reimbursement for such transports may not be possible at this time. Generally, each area interested in such alternative measures has different resources availability. A primary care clinic may offer sliding scale appointments. Other areas may have several freestanding EDs that are willing to accept ambulance patients. Perhaps patients could be entrusted to find their own transport to clinics when paramedics determine an ED is not the proper place for the patient's condition (Krumperman et al, 2015).
Conclusions
Emergency departments became the destination of last resort after American legislation took effect. Inundated by uninsured patients, a sizeable portion of EDs closed. Now a second wave of hardship looms in the future. More insured patients may desire the convenience of 24-hour care, even if this is not the most appropriate choice. Many people who desire medical care in EDs utilise EMS for transport.
Possible solutions involve new destinations for ambulance transport. Transports could be eliminated altogether, by utilising telemedicine capabilities. Even allowing paramedics to provide self-care instructions for certain conditions could be useful.
Regardless of what solutions are entertained, reimbursement models will need to be changed. Until these happen, EMS has no choice but to deliver patients to emergency departments. This neither alleviates the problem of overcrowding nor gets patients to a primary care physician. To continue along the same path ignores the potential paramedics possess and possible solutions to the strain on emergency departments.