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ambulances

Ambulances and ERs

Very interesting story about the overuse of ambulances in Houston and how the city is trying to deal with it.

But in truth little works in a system that has been broken for years. Over the past generation, patients began to see emergency rooms as doctor’s offices, taking ambulances to get there.

It’s the most expensive ride to the most expensive kind of medical care in the world.

An ambulance trip costs at least $1,000. Just walking through the ER doors adds another grand and a half.

More troubling is a recent study by the University of Texas’ School of Public Health that showed 40 percent of patients streaming into Harris County’s overburdened ERs don’t need to be there; either their condition is not urgent or they are using the ER for something that can be or should have already been handled by a primary-care doctor or clinic.

The reasons behind this shift are not fully understood, buried somewhere in a tangle of public misperceptions, lack of access to primary care and habit.

[…]

Last year in Houston, 318,630 calls to 911 got routed to the fire department, with medical calls outstripping fires by nearly seven times. About 80 percent resulted in trips to the hospital. It is not known how many were true emergencies, but one indicator is how often lights and sirens were used en route to the hospital. The best guess is more than half are not urgent, fire officials say.

The result has created a crisis, especially for public hospitals. At Harris Health System, there were 144,891 ER cases between March 2014 and February. Of those, 61.5 percent of patients were indigent or uninsured.

“It’s unsustainable,” says Dr. David Persse.

He has seen all sides. In the 1980s, he worked as an EMT and paramedic in Buffalo, N.Y. He then went to Georgetown University to study emergency medicine. He came to Houston in 1996 and is now physician director of Emergency Medical Services for the Houston Fire Department and head of Houston’s Public Health Authority.

Six months ago, he helped launch a first-of-its kind project that had been percolating for years. It is called ETHAN, for Emergency Tele-Health and Navigation, a common-sense concept that mashes EMT tradition with emergency-room triage and wraps it in modern technology.

When a fire truck or ambulance arrives on a 911 call, a quick assessment is done. If the patient appears critical, he or she is transported. But if the complaint does not seem to rise to an emergency, a doctor trained in emergency medicine is called to talk to the patient by video chat on a specialized tablet.

The doctor searches troubled voices, inconsistent stories and the grainy images for clues. If the condition could be handled by a primary care physician or at a clinic, the doctor makes the appointment on the spot and arranges city-paid transportation by cab – a sliver of the cost of an ambulance. If the patient still wants to go to the ER, the ETHAN doctor has the power to insist they go by cab or find another ride.

Not only does this cut costs, it gets ambulance crews back into service faster.

Since the December launch, there have been about 1,000 ETHAN calls. By some estimates, it has already saved the city $1 million.

Once patients are in the ETHAN system, they are contacted by a public health nurse or counselor for a follow-up home visit to make sure they have a doctor and keep their appointments. Living conditions are assessed to see if other types of assistance are needed. The goal is to keep people from returning to the ER.

There’s more, so read the whole thing. I suspect a big portion of this is lack of access to primary care, which is undoubtedly related to lack of insurance for many people. Cities and counties are left picking up the tab for that, which can be laid at the feet of our Governor and Legislature. Still, even in a context where we had Medicaid expansion and broader insurance coverage, there would be a need for this. It’s a smart idea, and I hope it continues to pay off.