How do you decide where to transport?

[epipusher]

Patient choice

 

[Tigger]

Unfortunately, this is an obvious problem of EMS not understanding the hospital problems.

While every effort is made by EMS to return to service or take another call as that is part of their responsibility, it really does harm patients.

I have personally been in a busy ED when a patient was found dead and nobody even saw that patient prior to their death.

As the hospital staff gets stretched thin, patient care suffers in all areas. The standard of care degrades into "the best we can do."

It is an interesting conundrum. The only 2 viable solutions is for EMS to accept a hospital divert and sometimes transport hours out of coverage area or remove the hospital as the only destination of EMS.

In addition to the training and education problems with this, there is also significant economic interest on the part of both the emergency doctors (who often get paid by the patient) and the hospital itself. (Which is why you get both a doctor bill and a hospital bill when you go to the ED)

But no matter what, any temporary solution will have to involve both parties.

Alternatively it forces the hospitals to become more efficient with their practices and be more aggressive about opening up inpatient beds and other alternatives to "everyone in the ED gets a bed." The American College of Emergency Physicians also discourages the use of routine diversion.

Since the regulations have been enacted wait times in EDs have not increased. Some hospitals have also reopened licensed beds and hired additional RNs and physicians.

 

[Veneficus]

Some hospitals have also reopened licensed beds and hired additional RNs and physicians.

This is actually the major problem from the hospital perspective.

I have no doubt ED physicians don't like patients going to somewhere else that will get paid for them.

There is also things hospitals have adopted like Clinical Decsion Units and attached urgent care. (sometimes called fast track)

However, usually there is no physical space for these things until the facility is upgraded. This of course costs a lot. Which is just not possible in an economically strained healthcare system.

Strangely enough, many EDs only get about 10-15% of their pt load via EMS, the problem is that in a for profit system, things are run very lean and there is no surge capacity. Consequently, on a busy day for EMS, the hospital simply cannot handle it.

 

[Tigger]

This is actually the major problem from the hospital perspective.

I have no doubt ED physicians don't like patients going to somewhere else that will get paid for them.

There is also things hospitals have adopted like Clinical Decsion Units and attached urgent care. (sometimes called fast track)

However, usually there is no physical space for these things until the facility is upgraded. This of course costs a lot. Which is just not possible in an economically strained healthcare system.

Strangely enough, many EDs only get about 10-15% of their pt load via EMS, the problem is that in a for profit system, things are run very lean and there is no surge capacity. Consequently, on a busy day for EMS, the hospital simply cannot handle it.

I don't understand your argument here. By being on diversion, hospitals lose potential revenue sources (patients), though as you point out, EMS really does not account for a large amount of patient volume.

Even so, expanding the hospital (if financially feasible, and it has been in Boston) allows the hospital to take more patients, which in the long run is going to offset the cost of additional staff and infrastructure improvements. This is especially true of cities with several academic centers in close proximity to one another. If a patient knows that one hospital is especially slow (and many do know), then they just won't go to that hospital.

As for the efficiency changes instituted, I fail to see how say drawing labs early in the day (allowing for earlier discharge) does anything but good and open beds that would otherwise be needlessly occupied.

 

[leoemt]

I currently volunteer for an organization that has about 6 hospital within a 20 minute transport time. It has generally been our policy that we allow the patient choose where they would like to go. On occassion, if the patient's condition is severe enough, we take the privledge of choice away.

Recently I started working in the southern part of NJ and we only have one hospital in county, meaning the choice does not exist. My question is, does your agency allow patients to choose their destination within reason or simply transport to closest appopraite?

We have 8 hospitals in the city limits. Every hospital can stabilize. Knowing the hospitals specialty can help make the choice. Also knowing insurance can help. For example Group Health patients will go to Virginia Mason.

Part of your job as EMS provider is to get the patient to the right level of care. It is imperative that you know what your hospitals provide.

 

[Veneficus]

I don't understand your argument here. By being on diversion, hospitals lose potential revenue sources (patients), though as you point out, EMS really does not account for a large amount of patient volume..

The point I was trying to make is that there are many complex factors in play which make simple solutions impossible.

Even so, expanding the hospital (if financially feasible,..

This is the key phrase, you need the money upfront.

 

[Veneficus]

We have 8 hospitals in the city limits. Every hospital can stabilize.

Modern medicine is not about stabilizing, it is about maintaining maximal function.

In the days of cardiac cripples, stabilizing was the norm. Those days have been gone for almost 30 years.

 

[leoemt]

Modern medicine is not about stabilizing, it is about maintaining maximal function.

In the days of cardiac cripples, stabilizing was the norm. Those days have been gone for almost 30 years.

Modern medicine does no good if you can't stabilize a patient to get them to a higher level of care. EMS is to get a patient to the appropriate level of care in the least amount of time, sometimes they get taken to a lower level facility first then transferred to a higher level of care. Ever hear of interfacility transports?

To be certified as a hospital, they must meet certain requirements. Not every hospital has to have a Cath lab but they all have to be able to do basic ALCS for example.

We have one Level 1 trauma center here and it is the only one in 4 states. What do you think happens when someone gets hurt in say Montana? They stabilize them at the regional hospital and airlift them here to Seattle for definitive care at Harborview.

Sometimes stabilization is the most appropriate level of care at the time.

 

[Aidey]

You're changing the terms of the debate. You said you have 8 hospitals within the city limits, and that any can stabilize. Vene pointed out that stabilization isn't always the end goal. You came back with the fact that Harborview is the only Level 1 trauma center in 4 states. That is a way different situation than trying to decide which hospital within the Seattle city limits to transport to.

 

[leoemt]

You're changing the terms of the debate. You said you have 8 hospitals within the city limits, and that any can stabilize. Vene pointed out that stabilization isn't always the end goal. You came back with the fact that Harborview is the only Level 1 trauma center in 4 states. That is a way different situation than trying to decide which hospital within the Seattle city limits to transport to.

I didn't change the terms of anything. I misunderstood vene. My original thought was that you take a patient to the appropriate level of care. However even though every hospital can stabilize - knowing the specialties of each hospital can help you decide where to take a patient, even if that means bypassing other hospitals.

I understood vene to be implying that stabilizing patients is outdated and inappropriate. So my reply to vene was that we take people to hospitals everyday for stabilization and then transfer to the appropriate facility for treatment.

Clear to you now?

Stabilization is never the end goal - treatment is the end goal. Could have sworn I have said that before.

I would like to know how sending someone to harborview from out of state is different than knowing what hospital to choose in the city? Every hospital has its specialty and that includes harborview. You will go to the appropriate hospital for your condition. My job is to know which hospital that is.

 

[the_negro_puppy]

We take to the closest appropriate public or private hospital.

This can mean one with a trauma service or cath lab.

Our public hospitals sort of have catchment areas where their patients should come from.

Ambulance rides are "free" here so we cannot justify driving past multiple hospitals just because a patient 'likes' one hospital better.

 

[Aidey]

I didn't change the terms of anything. I misunderstood vene. My original thought was that you take a patient to the appropriate level of care. However even though every hospital can stabilize - knowing the specialties of each hospital can help you decide where to take a patient, even if that means bypassing other hospitals.

I understood vene to be implying that stabilizing patients is outdated and inappropriate. So my reply to vene was that we take people to hospitals everyday for stabilization and then transfer to the appropriate facility for treatment.

Clear to you now?

Stabilization is never the end goal - treatment is the end goal. Could have sworn I have said that before.

I would like to know how sending someone to harborview from out of state is different than knowing what hospital to choose in the city? Every hospital has its specialty and that includes harborview. You will go to the appropriate hospital for your condition. My job is to know which hospital that is.

When Vene replied to you, you were discussing local hospitals within the city limits of Seattle. In that case, when you have multiple hospitals available, transporting to a less than optimal one under the sole reasoning of "stabilization" is not good medicine. In that setting, it is inappropriate, which was the point Vene was making.

When your level one trauma center is a few hundred to a few thousand miles away generally the only reasonable option is to transport to the closer hospital. I am almost positive that is not the situation Vene was referring too. Having one level 1 trauma center within a very large area is not the same as having 8 hospitals within your city limits.

 

[Steveb]

In my city there are 4 hospitals and one children's hospital.One hospital has a cardiac ward so, most serious cardiac calls go straight to that hospital unless the patient is under 18...all other calls the dispatcher decides which hospital to send the patient based on hospital wait times.