What's going on in SB County?

[gonefishing]

As someone who in recent times transferred patients from LAco to some SBco hospitals and have had family in sbco hospitals, theres a problem when the crew is holding the wall for 4 hours with a cold. These hospitals need to step up their game as well as educate the public.

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[gonefishing]

Another thing, ALS should be able to downgrade and hand off to bls.

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[FoleyArtist]

http://amrcommunitynews.com/pdf/SanBernadinoFDTimesv2.pdf

 

[Tigger]

I get that EMS is overused/abused, but the reality is that this is the patient population and the system (from field to hospital) needs to be able to cover it. Education is important, but it will take years to eliminate enough "non-emergent" complaints to make a meaningful difference. By all means it needs to happen, but it is not the fix that is needed.

And fire taking over anything isn't going to help unless they put more cars on the street. That is the real way to build capacity. I love hearing FDs complain about response times and how they should do transport...but how many put their money where their mouth is and put more ambulances into the mix. Our local FD tried, now they run three ambulances that rarely transport and AMR still holds the contract. Prove you can do better.

Also holding the wall for four hours...there's an issue...

 

[Handsome Robb]

One of our cities took over EMS from us.

It firmly solidified our foothold in the rest of the county because all the other cities have watched them have issue after issue.


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[VentMonkey]

I get that EMS is overused/abused, but the reality is that this is the patient population and the system (from field to hospital) needs to be able to cover it. Education is important, but it will take years to eliminate enough "non-emergent" complaints to make a meaningful difference. By all means it needs to happen, but it is not the fix that is needed.

I'm more interested to know, or hear from any services who have employed MIH/ CP programs. While I agree with you, it isn't an end-all-be-all, given the current state California EMS systems are in regarding super users, system abuse, and an over-taxed/ over burdened service something is better than nothing when it comes to dealing with the severity in lack of education on behalf of the public that we seem to not want to provide them. As I had brought up earlier, even statewide PSA's to "get the message out there". This is obviously something that goes beyond local EMS systems, and pushes up to the state level, which clearly does not seem all that interested.

Out of curiousity @Tigger, do either of your services provide CP/or MIH services?

One of our cities took over EMS from us.

It firmly solidified our foothold in the rest of the county because all the other cities have watched them have issue after issue.

A dual role/ trained service? If so, are any of the other fire departments in your area beyond the EMR/ EMT level?

 

[Tigger]

I'm more interested to know, or hear from any services who have employed MIH/ CP programs. While I agree with you, it isn't an end-all-be-all, given the current state California EMS systems are in regarding super users, system abuse, and an over-taxed/ over burdened service something is better than nothing when it comes to dealing with the severity in lack of education on behalf of the public that we seem to not want to provide them. As I had brought up earlier, even statewide PSA's to "get the message out there". This is obviously something that goes beyond local EMS systems, and pushes up to the state level, which clearly does not seem all that interested.

Out of curiousity @Tigger, do either of your services provide CP/or MIH services?

Yes. My primary job was the first agency in the region to do so. The true benefit has come from our mental health patients being treated and transported to a more appropriate destination, not system abuse. We do however attempt to reduce the number of "super-users" by developing patient specific plans for those that are placing an undue burden on the system. There is no criteria for this, just "well we've been to that address five times this week so let's send the CP over there and come up with something." In two years I think that's been done maybe six times. We run 2400 calls per year with about 1500 transports. It's saved a lot of transports from those six patients, but doesn't really address the fact that lots of people use the ambulance a few times a year for silly reasons. MIH programs probably cannot combat this unless they have the ability to co-respond to low level calls and redirect the patient. We do not have the staffing to do this.

However, local data from Colorado Springs suggests that's ok. Colorado Springs Fire has an MIH program that also seeks to better destinate mental health patients and identify super users (hmmmm, where did they get that idea from? Definitely not the teeny little agency up in the hills, no way). They have done a great job in reducing the top 1% of EMS ab/user's 911 calls, but still the question remains, what do you do when a person not previously known to your agency calls 911 with a silly complaint?

An AMR/CSFD partnership attempted to answer that with something called the "Alpha Car." A fire medic and AMR EMT staffed an SUV that was assigned to Alpha (and some Bravo) level medicals in the city's urban core. They responded in place of the engine and ambulance. The very vast majority of the patients were still transported by ambulance. If a patient wants to go by ambulance, that is their right (apparently). And they took advantage of this at great levels, even with the alternative services offered by the Alpha crew. They could give cab vouchers I think for those that couldn't afford other means of transport, which I thought would eliminate a lot of the transports but I guess not. After six months the program was scrapped.

 

[VentMonkey]

@Tigger, thanks. Yeah I understand that undoubtedly this won't hinder people from calling for silly reasons. TBH, I don't see that as much more of an issue when talking reductions in unnecessary taxes of an over-burdened system; this is kind of expected and shouldn't be a main focus in system abuse per se. That said, I don't have any first hand experience with MIH or CP programs, so I may be off.

While I can see mental health patients as being a large part of frequent flyer abuse, to an extent many times they're merely doing what it is they've always done. Redirecting them, seeing that they are properly medicating, and compliant etc. is definitely a positive step in reducing this, or any well-suited patient population from further over utilization of EMS as their ticket into an endless cycle of treat and release from various frustrated ED's without resolve.

Of the patients within your services jurisdiction, was your service doing home checks, and follow ups, and if so how challenging was it to see some of these types of patients through be it psych, poor compliant diabetics, cardiac patients or what have you through until they became compliant with either the medications, and/ or began properly seeking other outlets in healthcare (referrals)?

 

[okayestEMT]

One of our cities took over EMS from us.

It firmly solidified our foothold in the rest of the county because all the other cities have watched them have issue after issue.


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Good ole' Georgetown. Any idea if Pflugerville Fire has started transporting in Travis County yet?

 

[Handsome Robb]

Good ole' Georgetown. Any idea if Pflugerville Fire has started transporting in Travis County yet?

They've got one, saw them at the hospital the other day. Apparently they're just supplementing ATCEMS, not replacing the Pflugerville ATCEMS unit. They just can't be pulled for coverage like the Austin unit can be.

A dual role/ trained service? If so, are any of the other fire departments in your area beyond the EMR/ EMT level?

They run dual medic just like we do. And that's about all I will say in a public forum.

There's one other city that has ALS engines but not every engine or every shift is ALS. They all have the gear but only can use it if one of the guys working that day is a Paramedic credentialed by our MD.



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[Tigger]

@Tigger, thanks. Yeah I understand that undoubtedly this won't hinder people from calling for silly reasons. TBH, I don't see that as much more of an issue when talking reductions in unnecessary taxes of an over-burdened system; this is kind of expected and shouldn't be a main focus in system abuse per se. That said, I don't have any first hand experience with MIH or CP programs, so I may be off.

While I can see mental health patients as being a large part of frequent flyer abuse, to an extent many times they're merely doing what it is they've always done. Redirecting them, seeing that they are properly medicating, and compliant etc. is definitely a positive step in reducing this, or any well-suited patient population from further over utilization of EMS as their ticket into an endless cycle of treat and release from various frustrated ED's without resolve.

Of the patients within your services jurisdiction, was your service doing home checks, and follow ups, and if so how challenging was it to see some of these types of patients through be it psych, poor compliant diabetics, cardiac patients or what have you through until they became compliant with either the medications, and/ or began properly seeking other outlets in healthcare (referrals)?

We are not really at the level of doing home visits yet. We had to get a home healthcare license and that is taking a long time. However, home visits are still part of our super-user program, crews will go check in on them every day or two and make sure things are going ok. We have an MIH education program through the local community college so this is not totally ad hoc. Of the six recent individual protocol patients I can think of, five eventually ended up in an SNF and one has live in home care. None had any care prior to intervention. I expect we will be able to do more when we our main MIH guy goes off the line and takes the role full time.

As a rural service, we don't really have the numbers to show trends. With only a few wound care/diabetic/cardiac frequent flyers, it's hard to know what effect we have. Our psych service on the other hand pays huge dividends. 20% of our call volume has a psych component and I imagine that is typical. Last year we eliminated over 200 ambulance transports of psych patients to EDs. That's again not a big number, but as a percentage of our call volume it is. It saves us money (we transport with an SUV) and the patient money (average cost to the patient is less than $200 and they don't get an ED bill). While we still have one paramedic transporting, our shifts are staffed with five so we can still maintain two fully staffed ambulances instead of the old way, which left us with one and a flycar or single medic ambulance.

 

[VentMonkey]

We are not really at the level of doing home visits yet. We had to get a home healthcare license and that is taking a long time. However, home visits are still part of our super-user program, crews will go check in on them every day or two and make sure things are going ok. We have an MIH education program through the local community college so this is not totally ad hoc. Of the six recent individual protocol patients I can think of, five eventually ended up in an SNF and one has live in home care. None had any care prior to intervention. I expect we will be able to do more when we our main MIH guy goes off the line and takes the role full time.

As a rural service, we don't really have the numbers to show trends. With only a few wound care/diabetic/cardiac frequent flyers, it's hard to know what effect we have. Our psych service on the other hand pays huge dividends. 20% of our call volume has a psych component and I imagine that is typical. Last year we eliminated over 200 ambulance transports of psych patients to EDs. That's again not a big number, but as a percentage of our call volume it is. It saves us money (we transport with an SUV) and the patient money (average cost to the patient is less than $200 and they don't get an ED bill). While we still have one paramedic transporting, our shifts are staffed with five so we can still maintain two fully staffed ambulances instead of the old way, which left us with one and a flycar or single medic ambulance.

This is all good stuff though. Sadly, California cannot get its sh*t together for the life of them to even show follow through with any of the CP trial programs that have been done over the past couple of years.

I think this problem at least in my state lies more on the state, as well as in the local providers hands, as neither really seem to think all that much about this clearly troubling problem, or that it is not going away or getting better anytime soon.

Granted still, most paramedics don't think it's "their job", which is flat out sad IMO. When I took my CCP course I was surprised at how many people were doing it as part of their services CP programs; none of which had any defined structure. So to me this says that at this point, nationally we're still very much at the trail and error stage, however, as you yourself eluded to, it is worth it. It sounds like it takes time and commitment as well as willingness from providers at all levels to accept the fact that if we want a seat at the healthcare table, then we need to embrace such roles.

While this certainly isn't the exciting "blood and guts" of EMS, it certainly is an enormous issue, and another avenue for us to prove our worth as a whole, but just look at my debacle of a state. As you can tell it frustrates me as this is representative of a huge disconnect that varies from provider to provider involved in EMS.

I can't really blame the psych patient who has no other means or ways about them. These are patients that really need such a service, and more so, education and follow-up. How many psych patients have we run on repeatedly on both good and bad days and think: "Man, if only Joe/ Jane was always compliant..."?

Finally, shockingly the IBSC has managed to corner the market on a "community paramedic certification" so perhaps it will help form some sort of curriculum, if not structure in treating the majority of these system abusers to include helping providers understand what it is that we need to offer them, and how to do so. But, EMS as social workers?! (scoffs) Never.

 

[BobBarker]

A lot of comments on their page LOL. Basically, both AMR and SBCOFD are understaffed and both are giving excuses, which actually make sense(bed delays, move-ups into different areas, long transports). San Bernadino County is huge and they were never known for having a lot of money to begin with. If a Trauma/Neuro can't be flown for whatever reason in Victorville, Apple Valley, Baker, etc, they have to be transported by ground which usually takes 30-60min depending on where you are at(STEMI'S/Heart problems in that area usually go to St Marys because they are approved for that and actually do heart surgeries as well, last time I heard). If the medics on the engine need to go too, not only is that area left with 1 less ambulance, but 1 less engine too.
Also, St Marys Hospital in Apple Valley was supposed to expand their services and begin a Trauma Center(Level 1 or 2, but either way it would save transports). Unfortunately, not much headway is on that project. It was actually supposed to be completed in 2016, but they havent even started(last I heard the construction company they were supposed to used went bankrupt, but I haven't been able to verify).
In essence, if there is a bed delay at the hospital, how is AMR or even SBCOFD for that matter, supposed to be responsible for that? If AMR doesn't have their minimum amount of ambulances/staff in the area, that's a problem. If they are not meeting their 90% arrival time obligation, that is a problem. But if they are stuck at the hospital because all 20 beds are full, they can't control that and neither would the fire department be able to if their AO's took over for AMR.
The only way they would be able to help the bed delay situation is to add in to their protocols who can be sent to the waiting room(vitals stable after a RN triage, etc.) rather than be sitting on a gurney waiting for a bed with the crew tied up. That way if a person with a stubbed toe makes you take them to the hospital, as soon as you come in the door they can be taken to the waiting room after a quick triage so your crew can get back.
SBOCFD might not realize that AMR handles calls for them too when their units are tied up/far away