MPDS - Medical Priority Dispatch System

[Jon]

MPDS Reliably Predicts Low Acuity Categorization

Hinchey P, Myers B, Zalkin J, et al: "Low acuity EMS dispatch criteria can reliably identify patients without high-acuity illness or injury." Prehospital Emergency Care. 11(1):42-48, 2007.
The Science
During a six-month period, the authors of this study examined the emergency medical dispatch records of almost 24,000 dispatches. Medical Priority Dispatch System (MPDS) was used to categorize the calls. 2,703 calls were recorded as Alpha (lowest priority) of which 582 were excluded because of missing data. Of the remaining calls, only 21 were felt to have high acuity signs or symptoms by the responding paramedics. Of those, only eight were transported emergently.
They concluded that MPDS reliably predicted low acuity categorization greater than 99% of the time.


http://www.jems.com/columnists/Wesley/articles/282109/

 

[Jon]

I haven't looked at the study itself, but by the summary, this seems VERY good news. Freeing up ALS resources is a good thing, I think... and although the higher emergency levels have a great number of false positives, they are built into the system... it beats a bunch of missed "high priority" calls.

 

[firecoins]

of course my local ALS provider wants the money for responding to every call

 

[Stevo]

well dispatch is the initialization of response, but it's also every ems'ers responsibility to recognize the need for the next level's intervention

~S~

 

[Ridryder911]

Too me it is foolish to have different levels. ALS should be available and there for each patient. One cannot predict the outcome or changes within the patient during transport. Then if one needs ALS it already there.

BLS is great for initial response to again initially stabilize patient for transport. But to limit the extent of care that would be available is not wise. It does not cost that much more for the truck to be ALS as well for transport at a BLS level. Medics should not be considered as a premier thing that is too good or services premier for every call.

I have been on at least two calls that were dispatched and appeared routine only to have aggressive intervention while enroute. Since ALS was immediately available there were no consequences and was handled without delay.

When looking even at a medical broadspan even clinical non-urgent settings are able to provide ALS temporary and have direction to do so. It is not wise for patients that needs to be evaluated at an ER not to immediate availability of those that can perform that level.

R/r 911

 

[jrm818]

Rid:

How do you respond to the apparent success of two-tierd EMS systems - I'm thinking specifically Seattle and Boston here - which (intentionally) do not provide ALS on every call. I'm not talking about initial BLS response with eventual ALS transport here - I'm talking about systems which only call for ALS backup when the BLS transporting unit decides it's necissary.I know it has been suggested that overuse of ALS for mundane calls (my tooth hurts - help me!) may decrease ALS competency - this has been thorougly hashed out with refrence to intubation specifically.

It was my impression from other threads that you thought that two-tiered systems were appropriate in some applications - was I wrong? I'm not looking to restart the ALS v. BLS fight here - rather I'm looking for clarification on your position - although I have a sneaking suspicion that fight will begin anyways...

 

[Stevo]

well Ryder, we'd certainly have ALS if it was a matter of homeland security

priorities....priorities...

~S~

 

[Jon]

Amen JRM and Stevo.

Rid:
Why does LA County have airway problems, and medics that don't get lots of tubes? Because they've got TOO MANY MEDICS.

Why are Boston and Seattle 2 of the best EMS Systems? Becuase they have a few medics who get LOTS of practice.

 

[BossyCow]

Too me it is foolish to have different levels. ALS should be available and there for each patient. One cannot predict the outcome or changes within the patient during transport. Then if one needs ALS it already there.

BLS is great for initial response to again initially stabilize patient for transport. But to limit the extent of care that would be available is not wise. It does not cost that much more for the truck to be ALS as well for transport at a BLS level. Medics should not be considered as a premier thing that is too good or services premier for every call.

I have been on at least two calls that were dispatched and appeared routine only to have aggressive intervention while enroute. Since ALS was immediately available there were no consequences and was handled without delay.

When looking even at a medical broadspan even clinical non-urgent settings are able to provide ALS temporary and have direction to do so. It is not wise for patients that needs to be evaluated at an ER not to immediate availability of those that can perform that level.

R/r 911

Compare your scenario to a common occurance where I live. We have rural volly EMT's who run on average about 30 calls a year. To them, every anxiety attack is Cardiac and needs ALS support. Every car wreck is full c-spine and ALS. Vomiting and Stomach flu are ALS. Of course this dependence on ALS support varies depending on who responds to the call. But there's a cost for this. The pt's insurance gets billed. Our district gets the bill for all those who can't or won't pay. Also, we are a 20+ minute run to the hospital. We call for ALS support and take a medic unit sometimes 30 miles out of their response area, generally to have them tell us it's BLS and to take it in ourselves.

I understand being cautious and I know that ALS is a great tool. But in the extreme rural areas, it's not an option for either the privates to dedicate an ALS rig for us or for the local district to provide ALS.

Training is our best friend since the low call volume can't be enough to learn from experience. We are fortunate to have a few EMT's who have gone on to work for the local private service and bring their experience into the department, but it's still a crap shoot who's available for any particular call. I don't see the reason for training EMT's so they can dial ALS for the patient instead of providing good BLS care.

 

[Ridryder911]

I do understand the dilemma and there is no easy answer. That is why there is a dilemma. However; we need to err on the patients best behalf.

What happens if that N & V really turns out to be a silent AMI and even the "stomach flu" gets an IV from me. Chances are they need the fluid and I will administer an antiemetic so yes, it is an ALS call.

Where I work, there is a medic on every call. In fact usually 99% of the time two medics, and we cover about 787 square miles with 3-4 ALS trucks.

I do not understand your billing system unless you are using a "membership" type approach or have an existing clause to pay the remainder of the bill. Nearly all EMS will bill the patient for the remainder services after the primary payor has met its obligation (usually 80%). As well there are different level of charges, so BLS calls do not get ALS charges. Most also charge at captivated rates (average charge) so if one starts one IV or five it is the same base price and their is no averaging out the costs, (except mileage).

Having ALS on BLS calls is okay, as long as there is someone is able to respond and initially deliver care (such as a first responder system) until ALS arrives or rendezvous with them.

R/r 911

 

[jrm818]

Rid:

I'm not questioning at all that we should err on the patient's side here. It seems, however, that it is not at all clear that all ALS response acutally is in the patient's best interest. I can't argue with your anecdotal evidence - but have there been any studies done which acutally indicate better patient outcome due to all ALS response across an entire system and a large sample of patients and problems? From what I've seen the opposite may very well be true - and having an ALS only system may acutally hurt patient outcome, especially with critical cases, when it really counts. I don't know one way or another which is better - but I am legitimately curious as to whether there is any real system-wide research on the issue.

And even for your anecdote - does the stomach flu patient really need fluids or an anti-emitic immedietly? The risk of dehydration en-route is pretty low, and while obviously no one wants a pt. puking all over the back of a rig, its not exactly a life-threatening occurance. Nice to have - but not really necissary unless you have an extraordinarly extended transport time - in which case I suspect two-tiered systems would call ALS anywyas.


Maybe the solution is re-thinking the way levels are done, as I konw you have suggested, so that the "basic" level has a higher level of skills and education, and "ALS" is a very high level of care used only for truly critical cases. That runs into economic issues, however - which unfortunately cannot be ignored. After all, the ideal would probably be an MD/RN team with a race-car driver responding to every call.

 

[Ridryder911]

Let me play Devil's advocate.. what is the difference between treating deydration and any nausea in the ER and in the field. ... Nothing.

Why should the patient suffer any such symptoms (especially with movement) the same treatment is carried out, just 30 minutes earlier.

Like I said, it is a dilemma and no clear answer. There is no right answer..

R/r 911

 

[jrm818]

I agree there is no clear answer - but in the spirit of playing devil's advocate (a game which I confess I very much enjoy...one of my more irritating vices):

If providing ALS care for every patient required a net increase in the number of medics on staff in a given area, it is not at all unthinkable that each individual medic will actually decrease the number of serious ("codes") calls they respond to, number of placed ET tubes, etc., since the number of pt's requiring advanced interventions will not increase proportional to the increase in medics. This could decrease competency to the point where an ALS provider will provide less than optimal care in a truly emergent situation - where lives are truly at risk.

Thus one is left to weigh the temporary comfort of a few less-emergent pt's with the life or long-term well-being of another. That is a much greater dilemma.

Like you said - no easy answers.

 

[BossyCow]

This is our 'billing system' in a nutshell. And let me apologize in advance for the lunacy I am about to describe as though it were an actual system for receiving a fee for service. We are a small rural agency. We are a fire protection district and a county tax district. This means that we put a fee for fire protection on the property taxes of those who live within our 'district' as defined by the county regulations. As a 'junior taxing district' we do not assess the fees or taxes ourselves. We receive a payment from the County Tax Assessor. This means that the service we provide, we are only legally able to provide for those who reside, and pay taxes to us. We have mutual aid agreements with neighboring districts. But for the district that has ALS, the exchange is 'not mutual'. This means that if they need our tender on a big fire, they will provide us with a tender too. If we need BLS, they will provide that. But, if we need ALS from their district, a service that we do not provide, they were legally obligated by the State Auditor to charge us for the service.

This caused a virtual hemorrhage of money out of our district. Every time we requested a paramedic for evaluation of our patient, the district received a bill for about $900.

Our charter did not allow us to charge the tax payers for a service they were already 'paying for' through their taxes. Our board of directors also did not want the expense of becoming an 'employer' with all the federal and state obligations that entailed. They felt that the economic gain of billing would be offset by the other expenses. Step in a ... drumrolll please.... contracted agency for third party payer. This is an elaborate system where an outside agency for a percentage fee, does all of our billing. But wait.. doesn't our charter disallow billing? Yes.. but only directly to the patient.

You see.. the insurance companies bill our taxpayers for medical insurance. This insurance sometimes has coverage for ambulance transport. So, we do not bill the patient. We bill the patient's insurance company. Now, in those cases where the patient is uninsured, there is no billing done. In those cases where the patient is medicare or medicaid, the billing is handled the same as an insurance company. The insured never sees the bill. Its all handled by the third party payer contractor and the district receives a check of the fees charged less their percentage.

I have a few issues with this. First off, if the patient is uninsured and the ALS agency is used, the district still gets the bill. They figure that this is offset by those fees received by those who have insurance. So, basically, the insurance company is picking up the slack for those who are uninsured. From what I know of insurance companies they are not going to continue to do this forever without passing that cost on to the insured patients in the form of higher premiums. Which will drive up the cost of providing care, which will make it even harder for those without insurance to afford it.

The other issue is that state law disallows providing a service to one taxpayer at a higher or lower rate than another. If we all pay for water, power, sewer whatever, we all have to pay the same amount based on the service provided. In this case, everyone in our district pays for service, but those of us with insurance are paying more. Not so, says the 3rd party payer contractor.... we are not paying at all.. it's merely our insurance companies!

With an area of a bit over 50sq miles and roughly 1500 people in that area, we are not going to have ALS anytime soon, or even paid EMS. The nearest city system, where my husband works as a career ff/emt-p, doesn't even fully fund its ALS. They augment their personnel with volly ff/emt's instead of adequately funding their EMS.

I have to wonder what happened to "Gee folks.. if we all paid a little bit, we could have an ambulance and hire some folks to provide EMS" and turned it into ... "We have a highly paid administrative infrastructure which allows us to fully manage the EMS system within the fiscal restraints of these uncertain economic times."

Part of the solution definitely needs to be educating the public on what we do and how the system works. But fighting that kind of apathy is a bit like tilting at windmills. It's tough to tell the volly EMT's that the system really needs professionals, and they can either give up their jobs and come work for $9 an hour (the going rate for an EMT at the local private agency) or they will not be able to put lights in the grill of their truck and walk around in a Fire Department T-shirt and have a radio on their hip.

Like you said so well Rid... it's a dilemna!

 

[cw15321]

I am a volunteer medic, but our State does not allow us to put lights on the truck :sad: and would consider myself a professional. However I am not going to be giving up my day job for the huge pay cut!!!

The biggest issue is the money in the EMS system. Our county finds it hard to justify paying a crew (one medic one emt) to sit in station 24/7 when you run only 2 to 4 calls per 24 hour shift. Of the calls that we do get, I know there are calls when we are not going to get any money. When we get paid for calls, if the insurance company thinks they are "BLS" then we will only get $75. So basically this becomes something that the county has to pay for with little or no return. This is hard to "sell" to the tax payer especially if the tax base is not that huge due to the rural nature of the area, lack of employment, low wages etc.

So if people did not volunteer in this area, then the next county would have to cover the area as that does have a "city". This means that if you need an ambulance then you will have a 30 to 45 min wait for an ambulance service, which is happening where I live. Very scary if you ask me...


That's my two cents take it or leave it.

 

[yowzer]

I've only worked in a tiered system, with few medic units available. especially in the rural areas. (Outside of Seattle, the bigger cities have 1 or 2 2-medic units, the smaller-sized ones have 1 per 2 or 3, and the small towns and rural bits 1 about every few hundred square miles). The medical dispatch protocols keep getting revised to reduce the number of times ALS is automatically sent -- and it's still at 15-20 times a day. The medics downgrade more patients that they do see to BLS than they actually transport. They'll give medications in the field and then pass off to BLS for transport for some things. They don't like transporting anything that's not immediately life threatening. As a result, at the BLS level, while we sure do get the usual BS calls, we also get the occasional sick person. I've had people get worse on me in transport, but nobody's died yet.

I'm a fan of the tiered system -- when I can afford medic school, I don't want to graduate and then keep on doing mostly BS BLS transports for people who need a taxi or their spouse to give them a lift than they need EMS-- but I think the ALS to BLS ratio's a little off here. My opinion is not shared by any King County medic I've talked to, or the powers that be in the county EMS office.

In particular: It means that people who are hurting go BLS because the medics won't transport a person with, say, a hip fracture, for the sole purpose that they could be given something for the pain to make it a more comfortable ride. It's frustrating and cruel. More medics make that more feasible because taking a unit out of service for the transport doesn't create a huge gap in coverage. I suspect a 1:3-4 ALS to BLS ratio is about ideal.

 

[Ridryder911]

. When we get paid for calls, if the insurance company thinks they are "BLS" then we will only get $75.

If that is the case, you are billing wrong. I would definitely look into getting some professional help from maybe neighboring services (non-competition) and look into rates and coding procedures. I would not be surprised that your billing procedures are far behind.

We bill for BLS calls in a rural area and receive at the least $200-400 a call. With $ 8.00 a mile. ALS calls payments recieved is at least $600-800 from Medicare. It all comes down to proper paper work and charting, as well as knowing proper billing rates.

Good luck!

R/r 911

 

[BossyCow]

If that is the case, you are billing wrong. I would definitely look into getting some professional help from maybe neighboring services (non-competition) and look into rates and coding procedures. I would not be surprised that your billing procedures are far behind.

We bill for BLS calls in a rural area and receive at the least $200-400 a call. With $ 8.00 a mile. ALS calls payments recieved is at least $600-800 from Medicare. It all comes down to proper paper work and charting, as well as knowing proper billing rates.

Good luck!

R/r 911

Absolutely, if you code the billing correctly, the insurance company will pay the proper amount. How does an insurance company 'think it's BLS' without information you have given them that makes that determination.

We did run into some issues since we are a BLS agency but patients are transported ALS. We meet up with a medic enroute and often with critical patients, the medic climbs into our rig and we transport. Their agency cannot bill the patient for ALS because they did not transport. We are not an ALS agency and some of the government billings are questioned. Most of these issues have been resolved by the use of the contracted agency. A local ambulance company also does contracted billing for volly agencies. Something you might check out. They already have the staff and the knowledge, adding in a few more bills for a percentage of the take is often a good way for them to augment their accounts receivable.