While I expected Scott and I to get into the ALS vs BLS first response debate a lot faster, we seem to have trouble moving on from the response times discussion. Or, I keep getting distracted by great questions and comments.
Reader Florian commented on my original post regarding a large American City struggling to meet response times with a question about unit deployment and availability:
"WHY there are not enough units available? Cost, ageing fleet, retired staff etc were touched upon, but what are all the available transport units up to when they are unavailable for other calls? Are they on actual emergency calls? Or calls that could have, and should have been dealt by other services, e.g. community nurses, GPs etc? Should that unit have been dispatched at all, or could they have been given home help advice over the phone?"
Excellent points all Florian and you were right later in your comment that your views are skewed to the UK version of healthcare: Actually getting people the care they need.
When I visited Mark Glencorse in the UK my eyes were opened wide to a new model of delivering care - Respond Not Convey. This simple program allowed medics to divert reclined cot 2 person transport units away from ambulatory patients and those who did not need transport via a reclined cot.
The system allowed for single paramedic resources to relocate patients to their GP, local clinic or even local A&E (ED) depending on severity of condition.
Because of the American system of health insurance those options are almost impossible. While many communities are adopting Community Paramedicine with great success they may also still be locked into a rigid transport model that does not allow single practitioners to transport.
And all because of billing.
You can take someone to the hospital in a horse drawn wagon if you wanted to. Perfectly legal. Just don't label it "Ambulance" and don't try to bill for it.
But back to Florian's comment in regards to the American City noted in the news story.
It is likely that those reclined cot 2 person transport units are busy taking folks to the ED who neither need the cot or the ED. Most 911 calls require only BLS intervention following an ALS assessment. So why keep those practitioners, equipment and units committed?
Billing and a warped definition of liability.
I can't speak to the municipality mentioned in the story but it is likely that any system seeing an increase in call volume without an increase in patients who require intervention needs to address their patient population with alternate services.
Homeless outreach, community prevention programs, asthma programs and community paramedicine can all do a fair job at decreasing the calls to 911, but offer no help when a crew is on the scene of the cut finger who demands an ALS 2 person reclined cot van ride to an ED while the choking down the street gets no ambulance.
Florian, I would bet that this system could benefit from diverting appropriate patients to single unit resources for transport to clinics, urgent cares and EDs but the lawyers would never go for it.
After all, they would want to try to bill for it and you can't bill unless you meet the requirements.
Is an ALS front loaded system with those options more efficient than throwing BLS fire engines at every call? Most definitely, no question about it.
But what would we do with all the BLS resources in the community?
Great question, Florian.
Reader Florian commented on my original post regarding a large American City struggling to meet response times with a question about unit deployment and availability:
"WHY there are not enough units available? Cost, ageing fleet, retired staff etc were touched upon, but what are all the available transport units up to when they are unavailable for other calls? Are they on actual emergency calls? Or calls that could have, and should have been dealt by other services, e.g. community nurses, GPs etc? Should that unit have been dispatched at all, or could they have been given home help advice over the phone?"
Excellent points all Florian and you were right later in your comment that your views are skewed to the UK version of healthcare: Actually getting people the care they need.
When I visited Mark Glencorse in the UK my eyes were opened wide to a new model of delivering care - Respond Not Convey. This simple program allowed medics to divert reclined cot 2 person transport units away from ambulatory patients and those who did not need transport via a reclined cot.
The system allowed for single paramedic resources to relocate patients to their GP, local clinic or even local A&E (ED) depending on severity of condition.
Because of the American system of health insurance those options are almost impossible. While many communities are adopting Community Paramedicine with great success they may also still be locked into a rigid transport model that does not allow single practitioners to transport.
And all because of billing.
You can take someone to the hospital in a horse drawn wagon if you wanted to. Perfectly legal. Just don't label it "Ambulance" and don't try to bill for it.
But back to Florian's comment in regards to the American City noted in the news story.
It is likely that those reclined cot 2 person transport units are busy taking folks to the ED who neither need the cot or the ED. Most 911 calls require only BLS intervention following an ALS assessment. So why keep those practitioners, equipment and units committed?
Billing and a warped definition of liability.
I can't speak to the municipality mentioned in the story but it is likely that any system seeing an increase in call volume without an increase in patients who require intervention needs to address their patient population with alternate services.
Homeless outreach, community prevention programs, asthma programs and community paramedicine can all do a fair job at decreasing the calls to 911, but offer no help when a crew is on the scene of the cut finger who demands an ALS 2 person reclined cot van ride to an ED while the choking down the street gets no ambulance.
Florian, I would bet that this system could benefit from diverting appropriate patients to single unit resources for transport to clinics, urgent cares and EDs but the lawyers would never go for it.
After all, they would want to try to bill for it and you can't bill unless you meet the requirements.
Is an ALS front loaded system with those options more efficient than throwing BLS fire engines at every call? Most definitely, no question about it.
But what would we do with all the BLS resources in the community?
Great question, Florian.
Comments
I'm guessing you hit the nail directly on the head when you mention billing. With the backwards way this country goes about things, instead of proving the more efficient methods get results and then getting funding (allowing innovation), we're going to have to get the billing money first then implement programs, which will probably result in a lot of half-assed attempts at efficiency that fall flat and/or fail. It's frustrating especially since I live and work in an area where the nearby major metropolitan fire department just got 12-leads in 2012 and the press releases sounded like they were reinventing EMS. We don't do innovation, in other words.