News flash: Often people who call 911 for medical help are not experiencing true emergencies, yet individuals experiencing no more than indigestion or paper cuts frequently end up in emergency departments (EDs). Thanks to an innovative new program in the nation’s capital, however, emergency physicians in Washington, DC, are likely to find themselves prescribing fewer antacids and applying fewer Band-Aids in the future.
Since April 2018, trained triage nurses have been working with DC’s 911 call-center team to help evaluate callers with medical concerns; when appropriate, the nurses redirect low-acuity patients to urgent care facilities, walk-in clinics, and even primary care physicians. In June, one such patient was ultimately treated by Elizabeth Egan, MHS, PA-C, a physician assistant at Whitman Walker Clinic in the northwest quadrant of DC.
“Though she was complaining of dizziness and hadn’t slept the night before, otherwise she didn’t have any physical complaints, and her vital signs were normal,” said Ms. Egan. What’s more, as Ms. Egan soon learned, the woman’s symptoms were triggered not by illness but by social media. “Her boyfriend, who lives in another country, had posted a picture on Facebook, saying he’d married someone else,” Ms. Egan explained.
“They’d been together for 5 years, and she’d just seen the guy 2 weeks before, and she took him back to the airport after that, so you can see why she would be distressed.”
Ms. Egan did her best to help the patient: “We talked about how this really emotional situation was contributing to her feeling bad, but it was very nonemergent.” Finally, after advising the woman to see her primary care physician as soon as possible, Ms. Egan gave her hydroxyzine to help her sleep and sent her on her way.
DC’s new program was designed to ease the stress on the district’s overtaxed emergency medical response system, among other things. Approximately 166,000 calls were made to 911 in the district last year; about a quarter of individuals transported to EDs for evaluation were eventually determined not to be in need of any emergency treatments. In the eyes of Robert P. Holman, MD, medical director for DC’s Fire and Emergency Medical Services Department, that discrepancy looked like an opportunity to reduce crowding in EDs and lessen the load on DC’s ambulance corps.
He and his team started looking into new ways to respond to nonemergency patients. They soon learned about nurse triage programs operating in a small number of other areas in the United States.
These areas include Fort Worth, TX; King County, WA; Las Vegas and Reno, NV; Louisville, KY; and Syosset, NY.
Intrigued, Dr. Holman and his team began working on establishing a similar initiative in DC. They consulted not only with some of the other existing program leaders but also with 26 intergovernmental partners.
“We faced many obstacles,” Dr. Holman said. Initially, he thought the biggest problem would be the question of transportation, perhaps in part because people often call 911 not because they believe they’re experiencing a true emergency but, as others have observed, simply because they need a ride.
“We did not think that patients would be successfully diverted from the emergency medical system and the EDs unless we developed a system of transportation to federally qualified health centers and the urgent care clinics,” he explained. Nonetheless, Dr. Holman and his team managed to overcome the conundrum.
“What is distinctive about our program is that we were able to get the Medicaid fee-for-service and the 3 Medicaid managed care organizations to modify their transportation contracts to fit our program,” he explained. “Previously, when they provided nonemergency medical transportation, the patient would have to arrange this ride more than 72 hours in advance. Working closely with these payers, we got them to agree to provide [nonemergency medical transportation] directed by our 911-based triage nurses on a same-day, urgent basis. Their transportation vendors are all using Lyft.” He added, “Our first patient was picked up by her Lyft driver 1 minute after she called.”
The district spent $1 million to launch its pilot, money that went toward nurses’ salaries and call-forwarding technology. Dr. Holman won’t have data on the program’s cost-effectiveness or its efficacy until early 2019. But he hopes that the new approach will do more than merely ease the burden on those who provide emergency medical help.
“Most importantly,” he noted, “we are hoping to make changes that lead to better patient care by shifting patients from fractured emergency department–based care to comprehensive, primary care sites.”
How have other nurse triage programs in the United States fared? At least one—overseen by the Richmond Ambulance Authority, which provides emergency medical services (EMS) for the city of Richmond, VA—ran into serious problems. That initiative launched in pilot form in October 2004 and went live 15 months later, after no adverse outcomes were found. But several years in, it shuttered, eventually winding down in 2011, stymied not by the problem of transporting patients to nonemergency facilities but rather by the challenge of finding facilities—clinics and so on—willing to work with Richmond Ambulance Authority to treat nonemergency patients.
The Richmond effort was “a bit ahead of its time,” according to Chip Decker, BBA, Richmond Ambulance Authority’s chief executive officer. “Unlike today, there were no robust alternative health care pathways available,” Decker noted. “Without those pathways, more often than not, we ended up transporting the patient to the emergency department.”
Other programs, launched later, have had more staying power, like one run by MedStar Mobile Healthcare, the trade name for a governmental administrative agency that provides emergency and nonemergency ambulance services for the Fort Worth, TX, area. The MedStar initiative has been in place since 2012.
“Seven or eight thousand patients have come through since then,” said the organization’s chief strategist, Matt Zavadsky, MS-HSA, NREMT, “and no one has died or gotten worse because they went through nurse triage.”
Similar programs kicked off in Reno, NV, in 2013 and in Las Vegas in July 2017; as in Fort Worth, the Nevada initiatives have recorded no adverse outcomes. Fort Worth estimates that it has saved individual payers and insurance companies $4 million in the years since its program began; Las Vegas puts its savings at $835,0000. Similarly, Reno issued a white paper that calculated an approximate savings of $5.8 million over 53,000 calls between October 2013 and June 2016.
If the bottom line is so attractive, why aren’t there more programs like this in the United States? Here’s an answer that may sound paradoxic at first: “The primary barrier is financial,” said Kevin Munjal, MD, MPH, assistant professor of emergency medicine in the Department of Emergency Medicine at the Icahn School of Medicine at Mount Sinai in New York, NY. “There is no reimbursement for any phase of the EMS triage, response, assessment, or treatment. There is only reimbursement for transportation.”
In other words, most outfits that provide EMS do not get paid per patient; they get paid per ambulance ride. “This makes it exceedingly difficult to invest in improvements in quality or new innovative models of care if the number of transports might go down as a result,” Dr. Munjal said.
Mr. Zavadsky would agree. As he put it, “If you don’t transport, you do not get paid. The economics are difficult, unless you find innovative ways to fund the program. In our case, we have several contracts with hospitals and other payers that cover the cost of the program and lost revenue from reduced transport.”
A related problem, according to Mr. Zavadsky, has to do with which entity might be administering a nurse triage program. “Many EMS agencies do not ‘own’ the dispatch function,” he noted. “They are overseen by an agency focused on law enforcement that is generally not as focused on doing EMS innovations such as this.” He pointed out that in localities where EMS does control the dispatch function, innovation tends to be easier. He added, “In DC’s case, it took a strong and passionate leader like Dr. Holman to get the program implemented!”
That said, Dr. Holman thinks he may have had an easier time of launching his program because DC is such a unique governmental entity. “The district functions like a state in many ways,” he said. “This allowed us to work with the ‘statewide’ offices of the Department of Health Care Finance just across town. If we were in San Diego, we would have had to work with the Medicaid office in Sacramento in order to develop the changes in [nonemergency medical transportation] that have been essential to this program.” In other words, he said, “The small geography of our ‘city,’ the district, greatly facilitated our nurse triage development efforts because of the ease of getting crucial partners in the same room.”
Critics such as Peter Viccellio, MD, professor and vice chair for the Department of Emergency Medicine at the Stony Brook School of Medicine in Stony Brook, NY, complain that, when all is said and done—if you take a nuanced look at the entire course of treatment—nurse triage programs are likely to end up costing more, in total, in the long run.
“Let’s take a shoulder pain from supraspinatus tendinitis,” he said. “The emergency department visit costs more than a general practitioner visit, at first glance. But if I make the diagnosis and treat the patient, the cost of the ED visit covers diagnosis and treatment. If you send the patient to the [general practitioner], what’s the chance that they send the patient to an orthopedist, the orthopedist orders [magnetic resonance imaging], does shoulder injections, etc? What’s the cost of that?” Dr. Viccellio went on to say, “The fixed costs of an ED are high, so you lower costs by using the hell out of it.” Another problem facing these nurse triage programs is that they represent a perceived risk, as Mr. Zavadsky pointed out. EMS organizations may be worried that if they use nurses to triage patients, those in need of urgent care might be diverted erroneously. Indeed, that concerns Dr. Viccellio. And as Dr. Holman acknowledged, “There are no randomized studies looking at a 911-based triage nurse fielding low-acuity emergency calls.” Nonetheless, Mr. Zavadsky argued, “The reality is these programs are exceptionally safe and patient experience scores are excellent.” Dr. Munjal would agree. Asked whether programs such as these should be more widely implemented, he answered, “Yes, of course. They have a huge potential to increase our emergency response capacity while providing patients with access to a more appropriate setting for their care.”
Section editor: Truman J. Milling, Jr, MD
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist.
The views expressed in News and Perspective are those of the authors, and do not reflect the views and opinions of the American College of Emergency Physicians or the editorial board of Annals of Emergency Medicine.
© 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.