We’ve all seen non-emergency patients in our Emergency Departments. Further still, we’ve seen those same non-emergency patients arrive via emergency medical transport. Per these authors, the estimated burden of non-emergency or medically unnecessary ambulance transport ranges from 33-50%.
Houston, Texas, has a program of prehospital telehealth support provided by online board-certified Emergency Physicians. This article describes their retrospective cohort from 2015 through 2017, in which 15,067 patient encounters occurred from a total of 865,000 EMS incidents. Patients were eligible for telehealth if they met certain vital sign, chief complaint, and age criteria, and could be transported via non-ambulance alternative.
The good news: nearly everyone the EPs consulted with over telehealth was diverted from ambulance utilization. Only 11.2% of patients were ultimately transported by EMS –while basically the entire remainder utilized a taxi service. The bad news: nearly everyone was still transported to an Emergency Department. Only 5.0% of patients accepted same-day or next-day referral for follow-up at an affiliated outpatient health center. The primary advantage of this service, then, is increasing the availability of the limited ambulance services resource to respond to higher-acuity patients.
There are more than a few issues at play here in our current system with regard to providing, effectively, an unpaid, low-fidelity evaluation and assuming the liability risk. However, in systems with different structures and payment models where the overall costs to the system from ambulance utilization outweigh the other costs, this has a great deal of potential. Whether these results are generalizable is a reasonable concern, although the proportion of patients being referred to non-ambulance transport is not surprising. The entry criteria for telehealth consultation substantially narrowed the eligible population specifically to those whose complaints likely did not merit emergency transport. Finally, whether the EPs needed to be involved is another matter that could potentially be solved by more robust protocols in place to defer transport.
“Telehealth Impact on Primary Care Related Ambulance Transports”
Interesting take-aways, thanks for the summary. The question I’m left with is: why do this by telehealth at all? If the low fidelity assessment is the problem, then why not have the provider who is ultimately making the triage decision be the paramedics on-scene? To increase safety, have the medics closely integrated with a multi-disciplinary health care team that they can do medical consults with.
Ensure that your paramedics are robustly trained (an issue in the United States, I know), then simply have THEM use the telehealth protocols on site. If the patient DOES end up needing an ambulance, well, there they are. If they don’t need an ambulance transport, then the medics can give them a taxi chit to the ER, and/or ensure there is follow-up with their family physician. Either way, you’re only tying the medics up for 20-30 minutes as opposed to (potentially) hours waiting in a hallway for a bed to become available in the ER.
The fundamental question, to me, is why attempt to do this over the telephone at all when we already have a highly mobile health care service that literally exists to do this on-site??
I agree, within reason. There’s something to be said for the training and experience of an emergency physician beyond that of a paramedic – but I agree, within protocols, paramedics could easily be empowered to divert patients from ambulance transport with physician oversight only on an as-needed basis.