Prevention of the Abuse of 911 System

[Asclepius]

Actually that is one of the most common misconceptions. Research and the latest education on pain management has demonstrated that most health care professionals way underestimate the patient's pain response.

Even when you ask many health care professionals many assume unresponsive patients do not feel pain, which is totally incorrect.

Administering or technically prescribing any analgesics should be based upon a thorough history, physical examination. Yes, there are plenty of seekers out there, and yes we realize the B.S. of it all, but even those (abusers) do have pain.

Yes, experience does increase awareness of potential abusers, but again .. really what we administer, the amount is minimal.

R/r 911

This discussion was inspired by a different thread on pain meds. I'm wondering, since we all agree that there is a problem with the abuse of the EMS system and Emergency room...has anyone had any ideas on how to maybe prevent or curb the abuse?

Listening to Michael Savage on the radio one night on a drive home, he suggested putting a member of ICE (Immigration and Custom Enforcement) in every hospital in the nation. While that is extremely expensive proposition, I wonder just how expensive it would be when we think in terms of the burdens of the hospital and EMS agencies being used by non-insured and illegal aliens. Maybe if we could eliminate some of that expense we could then focus on the abuse more wholly. At the very least, it is a suggestion and that's what I'm looking for; ideas and suggestions.

 

[EMTMandy]

Post deleted

 

[firecoins]

Michael Savage is not the best person to take advice on stopping abuse of the 911 system. Putting ICE in hospitals would prevent illegal aliens with legit emergencies from seeking help. I am not going to discuss immigration on the site but if you enforce the borders alot of that problem gets avoided away from the ER.

 

[Asclepius]

Michael Savage is not the best person to take advice on stopping abuse of the 911 system. Putting ICE in hospitals would prevent illegal aliens with legit emergencies from seeking help. I am not going to discuss immigration on the site but if you enforce the borders alot of that problem gets avoided away from the ER.

I wasn't trying to start a discussion on immigration either. I was just simply pointing out a thought process that I heard mentioned. This is a serious topic and I'm genuinely interested in hearing other people's suggestions or ideas.

 

[JPINFV]

[sarcasm with fake crying] But we can't deport them. Afterall, how will Mexico take care of their own citizens if we do that?
[/sarcasm with fake crying]

http://www.tucsoncitizen.com/ss/family/74193

 

[Ridryder911]

I know it sounds rhetorical but the same old wording always comes back ... education.

A few years ago, Joint Commission and Accreditation of Hospitals Organization (JCAHO) which is one of the leading leaders of accrediting hospitals instituted required education to physicians and nurses alike on pain management. This was after several years of various studies and research documentation. The reason being, patients were being under treated. Most patients were not being treated until pain became severe, or analgesics were being withheld upon the request of the provider (not patient). Not realizing, break through pain is much more difficult to control as well requires more analgesia/medication than if treated timely and upon request.

The same reason (patient controlled analgesia) PCA pumps have demonstrated that patients actually use much lower doses than if have to be requested. As well, there is very little evidence that links drug dependence upon analgesics when given PCA's. Much different than when prescribed and not administered properly.

Although, we do see some with the so called "drug seeking behavior" true documentation of such is very minimal in comparison. In fact many hospitals and professional organizations have recommended that term be used very restrictive. Again, the etiology may not have been discovered. I do agree that the major portion that exhibit that type of behavior appears to be from EMS to ER area.

I realize it is easy to assume, and yes especially those that ask for particular medication(s), or have allergies to every medications except narcotics. I usually attempt to administer analgesia based upon the MOI, history, and physical assessments. As well watching such physical indicators as pulse rates and other physical symptoms.

R/r 911

 

[John E]

It is not the job of the EMS provider to worry about the legal status of the patient. Nor is it the job of the EMS provider to worry about alleged abuses of the 911 service. It is the job of the EMS provider to provide medical care for those in need. The rest is political.

When a patient is refused health care due to their immigration status, it's a sad day for humanity, regardless of how much the system has been abused by others.

I'd rather listen to the likes of John Donne than the likes of the Michael Savage's in the world.

"No man is an island, entire of itself
every man is a piece of the continent, a part of the main
if a clod be washed away by the sea,
Europe is the less, as well as if a promontory were,
as well as if a manor of thy friends or of thine own were
any man's death diminishes me, because I am involved in mankind
and therefore never send to know for whom the bell tolls
it tolls for thee."

John Donne


John E.

 

[JPINFV]

I will agree that immigration/citizenship status should not be a concern for emergency care nor be a factor in how EMS workers approach patient care unless it is of clinical importance.

That said, as a major issue affecting the US, all US citizens should be concerned about, and working towards, fixing this problem.

 

[VentMedic]

It is difficult to look at just one area or one group when there are many societal/governmental factors at work to complicate this complex problem.

When governments streamline agencies such as mental health and county/municipal clinics, they really don't have a viable option for the people using these services.

The lack of insurance has made preventative medicine difficult. Even getting children their vaccines can be a problem in some areas. And yes, many people who are here illegally do have the fear of being caught by immigration and don't get the routine care they need. This in turn can lead to a devastating and costly hospitalization in the long run.

The Virginia Slim/Marlboro years have given us costly smoking related diseases. Many people are becoming disabled before retirement age and now may live on a fixed income and/or dependent on whatever benefits the government provides. Their living conditions overall deteriorate as they no longer can afford decent housing or transportation. These people may once have been the business middle class who smoked at their desks in nice offices.

Obesity and its health related problems are also disabling people at a young age.

People are living longer but with more chronic illnesses.

Prescription medications are difficult to get even with, and especially with, the new Medicare plans.

Medical science has been saving preemies and children with birth defects that would have died 30 (or even 20) years ago. The chronic problems in this group have put a hardship on families by lowering their earning potential when only one parent can work. There are also many insurance issues at both the private and government subsidized levels when it comes to kids.

The number of work related, and not, injuries across the board has increased as the fitness level of workers change.

Each one of just the few problems facing U.S. healthcare affects EMS in some way as people become lost and desperate in healthcare system that does not understand what taking care of patients is about. I do not see a change anytime in the next 20 years even with the big talk of some Presidential candidates.

Just like EMS, each state has its own opinions and priorities.

Now for the pain issue. EMS probably sees only a fraction of the people who are dependent on pain medication. The majority may have insurance and are under the care of one or several physicians who prescribe the medications. This may also include health workers (RNs, EMTs and Paramedics) who inadvertently got hooked due to a back or shoulder injury. Unless it affects their work, employers often look the other way.

The U.S. has become a society of ignoring problems and then complain when they make headlines or some politician points them out during his/her campaign. It is not just healthcare but also global warming, education and infrastructure are all issues. People then want a quick fix when there is an impending foreseeable crisis.

 

[Asclepius]

I will agree that immigration/citizenship status should not be a concern for emergency care nor be a factor in how EMS workers approach patient care unless it is of clinical importance.

That said, as a major issue affecting the US, all US citizens should be concerned about, and working towards, fixing this problem.

I agree with you here. I was not trying to make this discussion about immigration status or about pain medication only. However, hospitals all over America are being stressed due to alien use of the emergency room for things that should be handled by primary care and it is hurting some so badly that they are closing their doors and going out of business. That is an abuse of the 911 system that cannot be ignored.

Likewise, as Vent pointed out...I am always amazed at how many people in our line of work who smoke. The people we see and transport with chronic respiratory issues seems like an adequate deterrence to smoking, yet I know many prehospital providers who have to adjust their nicotine levels routinely. I honestly do not understand it.

Another common abuse of 911 is the patient who calls for transport to the hospital simply because they don't have a car or money for a cab. This happens a lot in my system, as I'm sure it does in many systems. The patient believes that medicaid will pay for the trip. Even when explained that they do not meet medical necessity and they will likely receive a bill for the transport, they still opt to take the ride in the ambulance because the payment isn't required at the time of service. This kind of stuff hurts the smaller agencies and/or municipalities, because they likely will never see the balance paid in full. I know our agency is forced to write off a lot of these bills, because it costs more to pursue the collection than it does to just cut your losses.

These are the kinds of things I am interested in hearing ideas about fixing. Have you heard of any creative innovative ideas on curbing these abuses? I know education is a key factor, but like I said...even telling the patient right to their face that they're going to receive a bill and it will likely not be paid by their insurance doesn't detour them. So what else do you have?

 

[Markhk]

In my area, abuse of the 9-1-1 system has cropped up when there is the misconception that an ambulance ride will get you seen faster by a physician.

We always tell patients, if they ask, that they will be seen on the basis of seriousness of their illness or injury. However, I have been shocked when docs in the ER routinely ignore triage, freelance themselves around, and walk up to the code 2 patient we just brought in (before we even give a transfer report to the RN).

I can understand docs wanting to be helpful, but when they freelance themselves like that, they continue the cycle of "an ambulance will get you seen faster".

 

[firetender]

It is not the job of the EMS provider to worry about the legal status of the patient. Nor is it the job of the EMS provider to worry about alleged abuses of the 911 service. It is the job of the EMS provider to provide medical care for those in need. The rest is political.

That and the rest of your post John E.: BINGO!

It's a scary thought for me to hear anyone in EMS targeting any segment of the population -- ANY human being for that matter -- as not deserving medical care or (especially) access to emergency treatment.

For this thread to go in that direction does us all a disservice. It's not a foolish gamble to say that whomever takes a position like that is highly likely to have to spend an inordinate amount of time sorting through his/her predjudices before getting to the point of being able to provide the level of service that is warranted by the situation.

I'm saying you deal with what IS, and what you can do and that doesn't mean being a Detective to sort out who deserves care and who does not.

I agree there are problems in the area and I don't deny that I've struggled with them myself -- there are people who've worked with me that could offer instances of my hypocricy I'm sure!

So to be constructive about this, and because I DO know there are abusers out there, a Central, Regional database could be devised where any participating hospital could post "Notes" on identified patients of a suspicious nature. As soon as a practitioner sees a red flag waving, he or she could put in the name (of course there are details of identification that need to be worked out, like perhaps profiles beginning with a physical description of the patient) in the database, read and then add notes.

There's nothing wrong with alerting others to suspicious behavior of INDIVIDUALS, as long as it does not entail withdrawal of treatment.

 

[Katie]

So to be constructive about this, and because I DO know there are abusers out there, a Central, Regional database could be devised where any participating hospital could post "Notes" on identified patients of a suspicious nature. As soon as a practitioner sees a red flag waving, he or she could put in the name (of course there are details of identification that need to be worked out, like perhaps profiles beginning with a physical description of the patient) in the database, read and then add notes.

That's a very interesting idea. Again though what would the cost of something like that be and how accessible would it be? Legal issues might be a problem as well in terms of pt confidentiality. Good idea though if it could be worked out.

In general I think it would be pretty hard to prevent abuse. Where something exists people will abuse it. We are with pts for a very short time in the grand scheme of things. We can't deny care but at the same time use common sense and we don't need to do what the pt tells us to, rather what we're authorized and trained to do.

 

[firetender]

We are with pts for a very short time in the grand scheme of things. We can't deny care but at the same time use common sense and we don't need to do what the pt tells us to, rather what we're authorized and trained to do.

Your profile says you're a student. HAH!

That's a wonderfully succinct statement about where our focus needs to be.

 

[JPINFV]

In my area, abuse of the 9-1-1 system has cropped up when there is the misconception that an ambulance ride will get you seen faster by a physician.

We always tell patients, if they ask, that they will be seen on the basis of seriousness of their illness or injury. However, I have been shocked when docs in the ER routinely ignore triage, freelance themselves around, and walk up to the code 2 patient we just brought in (before we even give a transfer report to the RN).

I can understand docs wanting to be helpful, but when they freelance themselves like that, they continue the cycle of "an ambulance will get you seen faster".

Um, so physicians are unable to do triage?

 

[Markhk]

I'm not saying a physician should not triage. But when the physician's role in the ER is to treat patients (rather than triage which is usually left to a RN or the charge nurse), the doc should not be waiting by the door to meet and greet an interesting patient wheeled in by us, bypassing the triage line that the nurse has already established.

Freelancing docs may seem helpful and responsive, but again, to my point, gives patients the wrong impression that you get seen faster when you get brought in by ambulance.

 

[Ridryder911]

I'm not saying a physician should not triage. But when the physician's role in the ER is to treat patients (rather than triage which is usually left to a RN or the charge nurse), the doc should not be waiting by the door to meet and greet an interesting patient wheeled in by us, bypassing the triage line that the nurse has already established.

Freelancing docs may seem helpful and responsive, but again, to my point, gives patients the wrong impression that you get seen faster when you get brought in by ambulance.

Actually, newer models of ER management and time streaming has demonstrated that physicians or physician extenders (NP or PA) should perform the triage in ER. After several studies, such people performing triage can initially prescribe and treat without additional labs, work ups, and the patient time in the ED has been reduced from an average of 6-8 hours to around 45 minutes!

Majority of the patients do not need gowns, pulse oximetry, monitors, etc.. rather a simple quick examination with prescription in hand. Nurses can continue care with an additional physicians either continuing care with NP or PA performing the documentation.

This is the new selling point for many ER management groups.. look for it in the future.

R/r 911

 

[CAMedicJohn]

In San Francisco a couple of years ago a pilot program gave paramedics the option to refuse ambulance transport in lieu of a taxi voucher. However the program was discontinued due to abuse, liability, and politics.

I don't know the final statistics on the ED visits though.
:wacko::wacko::wacko:

 

[eggshen]

I think it's SF that's doing it and I think the aconym is H.O.M.E. team or along those lines. From what I understand it is a program geared towards sorting out system abusers and getting them into programs and out of ambulaces and ERs. You should check it out.

As far as illegals being system abusers and seekers I'll say that here we have a largish immigrant population (both legal and otherwise) from south of here. I'll also say that a majority of the abusers I have encountered over the last fifteen years are not illegal, hell they're not even immigrants. Same goes for the homeless population. Come to think of it I prefer a population where a polyglot is the norm rather than the exeption.

Egg

 

[ffemt8978]

I hate to generalize and stereotype, but I've noticed a trend in my area.

"911 Abusers" fall into two general categories - the unintentional and the intentional.

Around here, our immigrant population (legal and otherwise) use and abuse the 911 system. But the reason for this seems to be that they don't know where else to turn when they need help. To me, this seems to be an unintentional abuse of the system.

The intentional abusers of the system are generally NOT immigrants (unless you go back 3-4 generations). These people call 911 for a ride to the hospital to get their scripts filled and get a free meal/bed. They know there are other numbers they can call, and other services at their disposal but they refuse to use them because these services expect to be reimbursed for this. These are the people that know what key phrases to tell you so that you have to transport them, and then tell the ER a completely different story.

Reducing the unintentional abuse can be accomplished through education and outreach programs. Solving the intentional abuse problem is a lot harder.