Waste in EMS

[medicdan]

I have been thinking about this for a while-- and particularly in the frame of healthcare economics. We know that there is a gross amount of waste inherent present in the healthcare system today (and has been a particular target of criticism recently).

What waste do you see in your practice of EMS? What can be done to eliminate or improve it? Where do you see the future of EMS as a function of this improvement? I am not just asking about material or physical waste, but systemic abuses, unnecessary services, medical mistakes, etc. Heck, looking at the big picture, do you think it is inefficient to have two equally trained practitioners (at whatever level) focusing on the care of just one patient?

Looking specifically at the non-emergency (transfer) side of EMS (or TMS), what can we do to cut costs and trim the entire system? Does it make sense for an ambulance to transport a patient six times a week from their home or SNF to a dialysis clinic? Is that an effective use of money (sometimes upwards of $150,000/year just for the transport)? Could we place patients suffering from ESRD in designated “hub” SNFs, so they all can be treated together, inside the facility?

I have a whole bunch of issues, solutions and answers for this question, but I want to hear what you have to say first. I am looking only for serious answers, as these are serious problems.

Thanks,

Dan

 

[VentMedic]

Could we place patients suffering from ESRD in designated “hub” SNFs, so they all can be treated together, inside the facility?

Many are housed in LTC facilities that have a dialysis center. However, due to the number of people requiring dialysis, there are just not enough spaces. As well, most patients don't require a SNF which in itself the cost is more expensive than the transports. Thus, the patients go to nursing homes or other less expensive LTC facilities.

When you start talking about cutting services to the handicapped, disabled and elderly, you are going to go under scrutiny.

Also, if the community does not offer any other services or have cut back on all the other other services due to the economy, what choices to these patient have? Also, EMT don't realize how many dialysis patients do come by other services. Our center sees about 120 patients a day with only 5 - 8 being brought in by ambulance. Those come to our center because we are hospital based and can handle a higher acuity.

Once you get an extensive knowledge on healthcare costs and reimbursement, this could be discussed in terms other than EMTs not wanting to do what they believe to be "BS" calls such as a very sick dialysis patient.

Some hospitals now have their own ambulance and transport services for routine transports which eliminates a lot of hassle from other ambulance companies and complaints about EMTs not wanting to transport their patients from the various facilities. They can also manage the quality of care better.

do you think it is inefficient to have two equally trained practitioners (at whatever level) focusing on the care of just one patient?

As the levels in EMS exist now? For 911 EMS, one provider should be a Paramedic with two Paramedics preferred.

 

[Ridryder911]

Remember, EMS is a business. What do you think pays for the salaries of the 90 day courses or the units they ride in? Do you really think it is the person that just got "shot" or the "indigent" on the street corner?

Sure, it would be nice to say that everyone get health care for free and that EMS should be for 911 only but someone has to foot the bill albeit the next customer, the taxpayer, or insurance corporation.

Do I believe that EMT's are a necessity for most IFT (i.e. dialysis transports, etc) no. They are not really qualified as their main focus never involves those types of patients. In realistic terms, it would be better to have a specific type of course that focus on transport
on those with chronic problems. EMT's are just a cheap way of fulfilling the industry needs.

Really, where else can one receive a job in just less a few weeks of training in the health care?

R/r 911

 

[mycrofft]

Your example is worthy of a thread all by itself.

OK, waste I see:
1. Given two identical items, the one bought as medical equipment costs tons more due to profiteering and fear of medical malpractice suits if a product not labelled as medical is used and any trouble occurs (i.e., Craftsman tool carts make better "code carts" than many special sold items from medical suppliers).
2. I call for fire EMS on a simple "man-down" and get up to ten responders (including two crew chiefs) most of whom do absolutely nothing but watch, and which takes a pumper out of service.
3. "Emperor's New Clothes" Syndrome: someone buys a new widget, it is a disappointment to most but since admission of it not working out could be seen as a failure or mistake, the widget is kept and more are bought.
4. Use of full-fledged emergency ambulances for interfacility transfers.
5. Ruinously high insurance rates creating higher costs to pass on to patients and insurance co's.
6. "Outdates" on supplies which do not actually reflect the serviceability of the materials (see below), prompting discarding of thousands of dollars of materials annually per service if you are keeping your stock "fresh".
7. Mismatch of level of care versus locale; i.e., don't you need ambulances with greater diagnostic and support capabilities the farther you are from hospitals? In real life, rural tends to mean rudimentary, and the "biggest guns" are stationed in cities less than fifteen minutes from major medical centers; additionally, rural hospitals are being shut down).
8. Transport of unnecessary cases to emergency rooms.

The biggest costs to EMS components (as in any medical car setting) are personnel costs. Is there waste there?



NOTE: Is your service discarding unused but still serviceable expendable supplies (i.e., you tear open an OB pack but don't use it, a box of combine dressings outdates but was never opened at all, your company switches an IV or electronic system and now there are ancillary parts heading for the trash)? Ask your local animal shelters, zoo, first aid classes etc if these are of interst to them. Then get your company's approval; taking even obsolete gear is theft, and they might get PR asnd tax benefits.

 

[VentMedic]

Let me post a few links about dialysis patients since they are usually the ones that get criticized by EMTs.

These are some of the issues facing dialysis patients as presented to Congress. It is a little more involved than just providing transportation.

Recommendations by MedPac.

http://www.medpac.gov/chapters/Mar07_Ch02c.pdf

Here's a good advertisement:
http://www.gcnetransport.com/faq.php

Are all Gulf Coast Non Emergency Transport drivers Paramedics?
Yes, although they do not have to be, Gulf Coast NET only hires Florida state certified Paramedics as drivers. We believe anyone who drives and assists someone in our community should have a highly trained medical background for their special needs.

Of course Florida does have an abundance of Paramedics awaiting their chance to get hired at a FD.

Here are alternative solutions that have hit snags.

Dialysis transportation issue 'settled'

"We wanted this because we wanted a fully trained medical person driving the van,” Seibert said. “As it turned out, we’ve now got that.”

http://www.enewscourier.com/local/local_story_035210518.html

Funding woes threaten taxi

A free taxi program for dialysis patients in Surprise is at risk due to a lack of funds.

The program, created a year ago, serves 33 patients who average three van trips a week to area facilities for treatment. The city needs $100,000 to continue the program. With that money in place, the city would also receive $50,000 through a federal grant, said Bob Baratko, human-services division supervisor for the Community Initiatives Department.

http://www.azcentral.com/news/articles/2008/06/23/20080623wvtaxi0623.html

 

[medicdan]

I dont think you understand what I am getting at. I am looking at the system as a whole, not taking out aggression with what I see as "BS" patients. I have just taken a set of American Healthcare (Economics and policy) classes, and I am interested in how the systems can become more effecient (without services cut). Below is an excerpt from a paper I wrote illustrating the big picture.

The costs of ambulance services are a relatively minor part of the overall cost of health care, but in the context of the world’s most expensive healthcare system they represent a significant expenditure (How Medicare pays for services 5) and have ripple effects throughout the system of acute and chronic care. More than $2.4 trillion is spent on health-related services per year in the United States, comprising more than 16.4% of the Gross Domestic Product (Poisal w242). No overall estimate of ambulance costs is available, but Medicare (the country’s largest healthcare program) in 2001, paid over $2 billion for more than 10 million ambulance trips for its 40 million beneficiaries (GAO Sept 2006). Federal Spending on Medicare in 2001 amounted to $240 billion (2001 Federal Budget). Direct payments for ambulance transports, thus, represents just under one percent of the total Medicare budget The costs (and proportion of costs) may be even greater for the Medicaid program (shared by the federation and state governments) and there are reasons to believe that these costs may be escalating even more rapidly than other health care costs. As well, the efficiency of patient transportation has implications for the rest of the health care system – for the efficient use of hospitals, nursing homes, and other health care settings.

How do we approach the overuse of technology (HEMS)? Could we take a more serious look (as some states have, including MD) at how and when we dispatch a medflight chopper for scene response? This is the kind of discussion i'd like to spark.


Sources, by subject (cited above, and otherwise interesting):

The costs of healthcare:
Altman, Stuart H., and Michael Doonan. "Can Massachusetts Lead the Way in Health Care Reform?" New England Journal of Medicine 354.20 (2006): 2093-5.

Obama, Barack. “The Second McCain-Obama Presidential Debate.” Commission on Presidential Debates. Belmont University, Nashville, TN. 7 October 2008.

Poisal, J. A., C. Truffer, et al. (2007). "Health Spending Projections Through 2016: Modest Changes Obscure Part D's Impact." Health Affairs 26.2: w242-253.


(H)EMS Costs:
"Configurations of EMS Systems: A Pilot Study." Annals of Emergency Medicine 52.4 (2008): 453-4.

Desnoyers, John. "Helicopter Crashes and Probability." Annals of Emergency Medicine 48.5 (2006): 634-.

Kehoe, A, Sheenan, L, Davies G, and David L. "Reliability of Dispatch Criteria for Activation of a Helicopter-Based Out-Of-Hospital EMS System." Annals of Emergency Medicine. 51.4(2008): 474-475.

United States. Medical Payment Advisory Commission (MedPAC).How Medicare pays for Services: An Overview. Washington DC: MedPAC,

United States. Government Accountability Office (GAO).Ambulance Services: Medicare Payments Can Be Better Targeted to Trips in Less Densely Populated Rural Areas. Washington DC: Government Accountability Office, 2006.

United States. National Highway Traffic Safety Administration. Emergency Medical Services Agenda for the Future. NHTSA, 1996.

United States. Department of Health and Human Services Office of Investigator General. Medicare Part B Payments for Ambulance Services Rendered to Beneficiaries During Inpatient stays: 2001 through 2003. Washington DC: Department of Health and Human Services, 2006.

United States. Department of Health and Human Services Office of Investigator General. Ambulance Services for Medicare End-Stage Renal Disease Beneficiaries: Payment Practices. Washington DC: Department of Health and Human Services, 1994.

U.S. Renal Data System, USRDS 2008 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2008.

 

[mycrofft]

Overuse of technology and poor cost recovery are high in ER's.

Unnecessary level of care rendered for the poorest-paying sector.
Is your accent on medical transport?

 

[VentMedic]

Again, ambulance transport is just a small part and there is a huge picture to consider.

Take the Ryan White Act as an example. Many in EMS got their feelings ruffled when they read about this Act losing favor in Washington D.C. Those in EMS only heard about the infectious disease reporting. They did not know that it was a billion dollar health care bill and that what their concern was about was a duplication of another agency's guidelines or a state's statutes.

If expenditure is decreased for one service like transportation by ambulance, the startup costs of another service will have to be examined and consideration as to where that funding will come from.

Now, for helicopter transport, many paid little attention to the waste there until it became a safety issue. We have transported many patients based on a credit card payment and not by insurance since some insurances will not pay for a helicopter. I myself keep a credit card with at least $10K available in case of an emergency to where myself or a member of my family may need to be flown back to civilization from some rural little general hospital.

The other issue for helicopter activation was a lack of criteria and oversight by an area's medical director as well as inadequate training of some in EMS as to when it is appropriate to activate. Some activations have even be due to just laziness for not wanting to do a 20 minute drive. The areas that have proper protocols, training and employees who do quality patient care do not have issues with helicopter abuse. Of course, there will always be the transport that may appeared worse on scene that is found to have relatively minor injuries but if the Paramedic made the judgment call based on patient care by his/her assessment, there is little to criticize.

 

[eynonqrs]

Yes there is alot of waste.

There is alot of waste in our system:

Citizens that abuse the 911 system, that call for stupid stuff that can wait until they can see a doctor. (e.g. the Flu, Headaches, Toothaches) No wonder healtcare costs so much, the cost for an ambulance ride and ER services. If people just used common sense. Or better yet in high volume systems why not have a doctor on the rig that can go to calls, evaluate and see if they need to be hospitalized ?

Nursing homes that send pt's out for nonsense only for the hospital to call back an hour later to send them back. Another waste of rescources. If they had PA's on staff or had an MD that was on call that could evaluate and treat right there, that would take alot of burden off the system.

Yes EMS is a business, and transports do make money, not 911's.

Some of my comments on some of the previous posts:

It seems like some think EMT's have no place in the system. It's hard enough to get paramedics in some areas. The problem is that they are not properly teaching EMT's the skills that they should possess. What I was taught 15 years ago is different now, and they are going backwards. EMT's are not "a cheap fix for services". How can you justify having two paramedics on a "911 rig ?" It seems like to some that EMT's are worthless. Did you ever hear that phrase "Paramedics save lives, EMT's save paramedics" ? If paramedics took EMT's under their wings and showed them respect and helped them to learn and use thier skills, there can be more quailty EMT's out there. I had learned a lot from medics that were doing this well before I got involved with EMS.

 

[daedalus]

There is alot of waste in our system:

Citizens that abuse the 911 system, that call for stupid stuff that can wait until they can see a doctor. (e.g. the Flu, Headaches, Toothaches) No wonder healtcare costs so much, the cost for an ambulance ride and ER services. If people just used common sense. Or better yet in high volume systems why not have a doctor on the rig that can go to calls, evaluate and see if they need to be hospitalized ?

Nursing homes that send pt's out for nonsense only for the hospital to call back an hour later to send them back. Another waste of rescources. If they had PA's on staff or had an MD that was on call that could evaluate and treat right there, that would take alot of burden off the system.

Yes EMS is a business, and transports do make money, not 911's.

Some of my comments on some of the previous posts:

It seems like some think EMT's have no place in the system. It's hard enough to get paramedics in some areas. The problem is that they are not properly teaching EMT's the skills that they should possess. What I was taught 15 years ago is different now, and they are going backwards. EMT's are not "a cheap fix for services". How can you justify having two paramedics on a "911 rig ?" It seems like to some that EMT's are worthless. Did you ever hear that phrase "Paramedics save lives, EMT's save paramedics" ? If paramedics took EMT's under their wings and showed them respect and helped them to learn and use thier skills, there can be more quailty EMT's out there. I had learned a lot from medics that were doing this well before I got involved with EMS.

I will give you the fact that NHs are much better off getting a PA or NP to come and look into the ear ache rather than have an ambulance with an RRT come to pick up the trached and vent dependent pt and bring them to a Dr office for a otoscopy and antibiotic script and drag them back. That is waste.

Other than that, you are off the mark.

1. You chose to become an EMT and be there for your community. Your patients did not chose you. Your BS calls may not actually be BS calls. Case in point, old lady gets triaged to waiting room for tooth pain at 1 AM. Maverick PA decides to see her right away because of a hunch, and orders a 12 lead. A STEMI was diagnosed and the pt was sent for rescue angioplasty. Do you know why the PA had a hunch?

2. I have heard the phrase that EMTs save paramedics, and, it is a crock of bull (no negativity directed at you, this is a widespread and false belief). You have no idea what the EMT does not know compared to a properly educated paramedic. I work on a CCT unit and have *never* saved my nurse.

3. Learning procedural crud like "skills" is useless.

I learned how to set up a neb a long time ago, but boy was I surprised yesterday during my neb treatment lecture about how much I just did not know.

4. Patients come first. Better to have two medics on a unit than an EMT in the name of cost cutting. I envision a future where EMTs are just cops/firefighters.

 

[JPINFV]

How can you justify having two paramedics on a "911 rig ?" It seems like to some that EMT's are worthless. Did you ever hear that phrase "Paramedics save lives, EMT's save paramedics" ? .

I can justify dual paramedics by saying that with two paramedics each can back the other up. If one is having a tough time starting an IV then the other one can jump in and give it a shot. If one paramedic sees something and wants to bounce and idea off his partner, he can with a paramedic, but no so much with a basic.

As far as "EMT's [sic] save paramedics," a witty saying proves nothing.

 

[VentMedic]

I can justify dual paramedics by saying that with two paramedics each can back the other up. If one is having a tough time starting an IV then the other one can jump in and give it a shot. If one paramedic sees something and wants to bounce and idea off his partner, he can with a paramedic, but no so much with a basic.

As far as "EMT's [sic] save paramedics," a witty saying proves nothing.

Multi-tasking of IV starts, meds readied and intubation can all be done quickly. Just "hand me" this and that isn't really time efficient in an emergency.

It is also easier to implement advanced protocols such as RSI if there are two Paramedics.

 

[Jon]

Multi-tasking of IV starts, meds readied and intubation can all be done quickly. Just "hand me" this and that isn't really time efficient in an emergency.

It is also easier to implement advanced protocols such as RSI if there are two Paramedics.

Vent,

When I've worked as the EMT on a EMT/Medic ALS ambulance, there are a lot of things I can do to set up for the medic, even though he would preform all invasive procedures. A well-trained Basic can set up an IV, CPAP, get meds ready, do a 3-lead and/or 12 lead, prep them for intubation, etc... while the medic gives the pt. ASA, starts a line, and gives NTG. Many times when I'm on a code... I'm playing medic's gofer, while PD or other EMS providers are doing compressions.


Dan - I like your idea of "hub" nursing homes. Many nursing homes have barber shops and other specialty services in-house - why NOT bring the dialysis center to the patients, at least in some cases. Co-locate so that there isn't as much of a need for transport.

Same goes for physician visits, etc - why do we transport folks to the podiatrists office for basic wound care? I'm sure a podiatrist could bring his show "on the road" and go to a SNF, and see several patients in a short time.


Everyone talks about risks of Aeromedical transport - what is the risk of non-emergent GROUND transport? Espicially in an urban environment? With young, inexperienced EMS folks driving ambulances that have high centers of gravity and understrength brakes?

EMS shouldn't be a transport service, like a taxi or bus company. EMS belongs either as medical clinicans, public safety workers (with PD and FD), and/or as public health folks. I'd like to see a similar set-up as in Great Britian with a seperate, but similar industry of invalid transport.

Those of us that worked transport - how many of us have worked somewhere where the cabinets on the van were kept SEALED for inventory control? Wasn't it really rare that you needed to actually break a seal? Since we don't need most of the equipment on the ambulance for almost all of our routine patients, why do we send an ambulance?


Supply waste:
Look at our scenes after a serious trauma call. We usually have lots of trash on scene. Can we combine packaging so that there isn't as much waste?

Some things are already changing. Packaging ET tubes with stylets already inserted. Packaging suction tubing and yankauers together.

We need stuff to be sterile, and we should pay attention to packaging to maintain sterility, so we don't have to throw out stuff just because we are storing it in a way that compromises the sterile wrapper. I've seen something new for trauma dressings recently as well. Ours are coming with a protective plastic overwrap on top of the sterile wrapper.

I like the idea of donating items, etc. Locally, several services turn expired meds over to my training institute. We then use the meds for training on mannequins... works for us.

 

[VentMedic]

Vent,

When I've worked as the EMT on a EMT/Medic ALS ambulance, there are a lot of things I can do to set up for the medic, even though he would preform all invasive procedures. A well-trained Basic can set up an IV, CPAP, get meds ready, do a 3-lead and/or 12 lead, prep them for intubation, etc... while the medic gives the pt. ASA, starts a line, and gives NTG. Many times when I'm on a code... I'm playing medic's gofer, while PD or other EMS providers are doing compressions.

Jon, I respect the fact that you are an EMT-B. But, until you have moved on in your education to see what you don't know and how just fetching things is not always adequate especially with a critically ill patient, you may not be a good judge of efficiency as it pertains to patient care. Also, until you have worked in a system with medical professionals who have higher education who use it collectively to provide the best possible care for the patient, again you may not be the best to commment. As for prepping a patient for intubation, an EMT can not push the meds that may be needed. That is "prepping" and not just handing the ETT to the Paramedic. I have seen the damage that can be done to an airway when the patient is inadequately prepped and the Paramedic does not have enough hands to maintain the tube and give the necessary sedation. The patient's best interest should be the priority and not the excuses for not having adequate education to do good patient care.

In CA, some CCTs use two EMTs and an RN to transport. It is absolutely embarrassing to watch this at times. The RN has to take time from his/her responsibility to tell the EMT to plug the round thingy in the other thingy. It sometimes is so bad the ICU physician will not allow that crew to transport unless at least one of the hospital staff is in that truck. Yet, this is common due to county regulations for Paramedics and cost saving issues.

Dan - I like your idea of "hub" nursing homes. Many nursing homes have barber shops and other specialty services in-house - why NOT bring the dialysis center to the patients, at least in some cases. Co-locate so that there isn't as much of a need for transport.

Same goes for physician visits, etc - why do we transport folks to the podiatrists office for basic wound care? I'm sure a podiatrist could bring his show "on the road" and go to a SNF, and see several patients in a short time.

There are many patients in SNFs that have a dialysis center attached. However, as these patients no longer require a SNF, they should be moved to a center of lesser acuity and expense as that will also free up the beds for patients requiring the services of a SNF. When patients are placed, if at all possible the dialysis issue is addressed. However, due to the increasing huge population of elderly and disabled patients there is just not enough beds to accomondate everyone.

EMS shouldn't be a transport service, like a taxi or bus company. EMS belongs either as medical clinicans, public safety workers (with PD and FD), and/or as public health folks.

EMS is always saying what is so wrong for them but rarely consider what is so very wrong for the patients in the U.S. healthcare system. Do you honestly think elderly and disabled patients like to be thought of as a burden to EMS and those poor EMTs?

 

[johnrsemt]

the thought of packaging items together works just some of the time: the example was suction tubing and yankeurs: my old service bought them that way, already put together. It would take two people and a team of horses to pull them apart, when we needed to use the tubing with a soft suction catheter for trach or ET suctioning.

alot of these things can be purchased already packaged together, but it ends up more of a waste than a help and savings.

 

[Jon]

Jon, I respect the fact that you are an EMT-B. But, until you have moved on in your education to see what you don't know and how just fetching things is not always adequate especially with a critically ill patient, you may not be a good judge of efficiency as it pertains to patient care. Also, until you have worked in a system with medical professionals who have higher education who use it collectively to provide the best possible care for the patient, again you may not be the best to commment. As for prepping a patient for intubation, an EMT can not push the meds that may be needed. That is "prepping" and not just handing the ETT to the Paramedic. I have seen the damage that can be done to an airway when the patient is inadequately prepped and the Paramedic does not have enough hands to maintain the tube and give the necessary sedation. The patient's best interest should be the priority and not the excuses for not having adequate education to do good patient care.

Vent... I acknowledge that. On the same token, there are many basics out there that are able to function adequately as a part of these teams, and have been trained over time by their co-workers in what they need to do.