Several fire departments are now implementing innovative programs and testing new ways to serve patients who have non-emergency needs.

According to 2002 census data, more than 41 million Americans — nearly 15% of the population — do not have any health insurance. The U.S. Department of Health and Human Services also reports that 44 million Americans lack access to primary health services.

It's no surprise that there's a growing reliance on EMS systems and hospital emergency departments to provide transportation and primary care for those who fall through the cracks. This phenomenon is taking a toll on both emergency departments and EMS systems. An obvious example is the diversion crisis that has occurred in recent years.

The fire service is split on how to view this trend. To some observers, fire service EMS should exist to fulfill an emergency role only. To others, fire service EMS is just another logical entry point for individuals seeking treatment in the health care system.

Money problems

There's little debate that when an ambulance is used to transport a non-acute patient to an emergency room, it then isn't available to respond to true emergencies that may occur. But increasing demands for service do not result automatically in additional funding and resources for the fire department.

This is an obvious problem in urban areas where so-called “system calls” are common, but it's also a critical issue for small and rural communities where the closest hospital may be a significant distance away.

In rural areas, the requirement to transport all patients to a full-service hospital instead of a clinic or doctor's office can mean that the ambulance is out of the community for an extended period. And because many rural communities rely on volunteers, providers are away from their families and jobs for extended periods.

In urban areas, when an ambulance is tied up transporting a patient to the hospital, other ambulances may need to be transferred or called into the area. The districts normally served by these units then must be covered by other ambulances, creating a domino effect that causes havoc for system status managers during peak usage hours and negatively affects response times.

There's also little debate over the cost of providing ambulance transportation for non-emergency patients. For systems that charge a fee for ambulance transport, the cost of providing ambulance service to non-acute patients is often not recovered, particularly given Medicaid reimbursement criteria for the medical necessity of ambulance transport.

A review of programs that are either in place or being evaluated reveals some variations on common solutions. These include an increased use of 911 screening tools combined with tiered response programs, issuance of taxi vouchers, and transportation of patients to facilities other than hospitals.

Call screening and tiered response

In December 2000, the Houston Fire Department implemented a squad program. In the busiest parts of the city, including the urban core, firefighter/paramedics were taken off the fire department ambulances and re-assigned to ALS quick-response vehicles such as Chevy Suburbans. Two ALS providers were assigned to each of these squads.

The ambulances were then staffed with two firefighters certified at the EMT-Basic level. When the 911 center receives calls that don't meet ALS criteria, these BLS ambulances are dispatched as a single resource. Single-unit BLS responses now account for 40% of the department's EMS calls.

If the 911 caller reports a sign or symptom that indicates an ALS response, the ALS squad is dispatched to assist the BLS ambulance. If the patient requires advanced care, one or both of the ALS providers will ride to the hospital on the ambulance and treat the patient. However, only about 35% of the calls responded to by the squad require the ALS provider to accompany the patient to the hospital, says Dr. David Persse, medical director for the Houston Fire Department.

“We have been able to develop a very high level of confidence that for certain call types, under certain circumstances, we will not need an ALS response,” he says. “Many of our callers have no critical illness but just need a ride to the hospital.”

The primary goal of the program has been to better use ALS resources by keeping them available in the community. The result has been dramatic: The city has witnessed a three-minute decrease in its response time to ALS calls, and because of the reduced response times, cardiac arrest resuscitations are up.

“We witnessed a 30% reduction in the number of cardiac arrest patients presenting in [pulseless electrical activity] or asystole,” says Persse, “and an equivalent increase in the number of patients presenting in shockable rhythms.” While the exact numbers are not yet available, anecdotal evidence suggests the save rate is up significantly.

The error rate on dispatching has been very low, with BLS ambulances calling for ALS assistance after initial dispatch approximately once out of every 200 calls. Of those cases, only one in 2,000 actually required ALS treatment of any type, and only one in 10,000 required critical ALS care, including the administration of life-saving medications, intubation or defibrillation.

The program has had other positive side effects. Paramedic attrition has been reduced significantly, and Persse says that “they love the program.” The squads are dispatched on working fires, where their two-person crews can provide the incident commander with an additional resource to set up a rapid-intervention team, rehab, EMS or other fireground duties. Finally, because the squads boast improved response times, the program has allowed the city to reduce fire engine responses to EMS calls by 28%.

The program isn't without problems. An unintended consequence is frustration felt by those firefighter/EMTs who staff the BLS ambulances on a 24-hour basis. “We rotate them between the ambulance and the fire apparatus in the station,” says Persse, “but we still recognize that there are legitimate frustrations for them.”

The city of St. Louis found a slightly different, but effective, approach to call screening. Recently retired EMS Chief Gary Ludwig, who currently serves as the vice chairman of the International Association of Fire Chiefs EMS Section, describes a call screening process that was implemented in 1998. Similar to those used Houston and other cities, incoming calls 911 calls were carefully screened by the communications center for ALS and BLS criteria.

If a caller was simply requesting transportation services but had no medical complaint, the call would be diverted to a non-emergency transportation dispatch center. The center, which is a private party contractor funded by the state Medicaid office, coordinates with about 15 existing Medicaid wheelchair, taxi and van services. A caller who needs a ride to the doctor's office, mental health facility, pharmacy or other such location would be provided with a ride covered by Medicaid.

According to Ludwig, this program, in coordination with a public education campaign, reduced the volume of EMS calls in 1998 from 80,000 to 65,000 in one year — almost a 20% reduction.

The programs in Houston and St. Louis have a common link. In both cases, everything hinges on the ability of the 911 communications center personnel to correctly match the caller's need with available resources. This requires a significant investment in training and an effective, ongoing quality assurance program in the communications center.

Taxi vouchers

The Phoenix Fire Department offers patients the option of using a taxi under certain circumstances rather than riding in an ambulance, but there's more to the program, and it all starts in the alarm room.

According to Capt./Paramedic Mark Faulkner, the Phoenix Fire Department only dispatches ambulances to EMS calls that meet alarm room criteria. For example, an ambulance will be dispatched on most, but not all, ALS calls or if one is the closest unit to the scene based on GPS data. Many times an engine company will be dispatched by itself with no ambulance. The engine company crew will assess the patient and determine what resource should be called to transport, if any.

At this point, the engine company can offer several options for the patient. Standing orders allow fire department personnel the option of recommending transportation by privately owned vehicle if the patient is comfortable with this option. Taxi vouchers can be given to patients who have no serious medical complaints but who need transportation to a doctor's office, pharmacy, clinic or other non-emergency room destination. Finally, the communications center also maintains a list of resources, including transportation services that can be called on to help customers when appropriate.

“Anyone who wants to be transported by ambulance will certainly receive that ambulance transport,” Faulkner says, “but we find that many times what they need is educated advice about where to seek transportation services so that they can access basic health care facilities.”

In Oregon, the Lakewood Fire Department recently began using taxi vouchers for patients under certain circumstances. Engine and medic crews can provide patients who have no serious medical complaints with a taxi voucher after consulting online medical control. Patients may use the voucher for transportation to a hospital, clinic, doctor's office, pharmacy or other reasonable destination. The taxi vouchers are funded by charities, local businesses and non-profit groups, including International Association of Fire Fighters Local 1488.

The Dallas Fire-Rescue Department takes a somewhat different approach. When a fire department EMS crew finds no medical justification for transporting a patient by ambulance, paramedics have the option of refusing transport. Crews carry brochures that describe private service options, including private ambulances, which a patient can call at his or her discretion. Firefighters are guided by local protocols that describe conditions under which transport is mandatory.

According to Capt. Greg Courson, the Dallas city charter states that fire department ambulances are intended for emergency use only, thereby giving the department authority to enact this policy. He says that this policy has been in place for over 30 years and has worked very well, reducing the number of transports by 7.3% in 2002, for a total of 8,083 calls. “If we had to transport everyone who calls, we would have to double our ambulance fleet,” Courson says.

Private partnerships

Las Vegas operates an impressive program to keep fire department ALS resources available in the community, according to Deputy Chief Ken Riddle, current IAFC EMS Section chair.

Ambulance service is provided in the city by both the Las Vegas Fire Department and a private franchise ambulance service. Calls for service are screened to identify the most appropriate level of response. Fire department ambulances will respond to ALS-indicated calls and assess the patient, but if it's determined that the patient isn't in critical condition or doesn't need immediate transport, then the private ambulance can be used for transport.

If the fire department responder finds no medical emergency or no likelihood of an emergency to develop after performing an assessment that includes vital signs, the fire department member will brief the patient thoroughly, leave a copy of the report and clear the scene prior to the arrival of the private ambulance. Patients are told when to expect the ambulance and advised to call 911 if their condition worsens. When asked about abandonment, Riddle says that “there is no abandonment if there is no emergency.”

As part of this program, fire department ambulances always respond to, and transport any patients from, trauma calls and motor vehicle accidents. “We were concerned about the safety of EMS providers operating on these scenes,” says Riddle, “and since the private service providers were not generally outfitted in personal protective equipment, we feel that fire department providers are better trained and prepared to handle hazardous scenes, especially when there is an extrication.”

The result of the Las Vegas plan is that the fire department transports only 9% of the total EMS calls, which means that department ambulances remain in service and are available to serve citizens when a true emergency exists. “Our guys love it,” says Riddle. “They are doing what they trained for and using their skills.”

Other facilities

Non-emergency calls aren't the only problem for fire departments that run ambulances. Many departments are reporting significant out-of-service times for their medic crews due to hospital diversions and a lack of beds in emergency departments.

In urban settings ambulance crews are routinely delayed while waiting for an emergency department bed to open up so that the patient can be transferred. In rural areas, ambulances that follow a mandate to transport all patients to full-service hospitals can find themselves away from their community for significant periods of time, all for a non-emergency patient transport.

Deputy Chief Bobby Wartgow from the Eastfork Fire and Paramedic District, Minden, Nev., can relate to this problem. The department serves a community located at the base of the Sierras near Tahoe and 20 miles from the closest full-service hospital in Carson City. The closest trauma center is 60 miles away in Reno. Transporting a patient removes an ambulance from the community for an extended period.

The community has two urgent care, non-admitting medical clinics of the type that have grown in prominence across the country over the past 20 years. Although these facilities were initially very limited in their capabilities, many have expanded to include on-site X-ray, lab and MRI services. In addition, staff training has been significantly enhanced for many of these facilities.

“These facilities have become an important part of the health care system,” says Wartgow. “They have been recognized as legitimate resources by the insurance industry, which is promoting their use for patients who do not need to be admitted to a primary hospital. And over time we have also come to recognize these facilities as capable of receiving, treating and releasing ambulance patients.”

According to Wartgow, the department will transport patients to these facilities “when we have a level of confidence they will be treated and released.” The facilities are equipped with radios and recorded phone lines, and they have become adept at receiving ambulance patients in a similar manner used by emergency departments.

“In many cases we consider one of these facilities to be the closest appropriate facility,” says Wartgow. Patients are still given an informed choice to be transported out of the area to a full-service hospital, but many prefer the convenience of the local option. Because the decision to recommend transportation to one of these facilities hinges on a paramedic's judgment, attention to training and quality assurance remain important considerations for the department.

Some concern has been raised about transporting patients to such facilities, as Medicare stipulates that reimbursement will only be made for patients transported to full-service hospitals and for patients who meet the standard of medical necessity for an ambulance.

But Wartgow notes that because many of the non-emergency patients who were transported 20 miles to the closest hospital didn't meet the medical necessity rule, the department was limited in its ability to collect fees anyway. If a patient is seen at an urgent care facility and the physician deems it necessary to transport that patient by ambulance to a full-service hospital, the medical necessity standard has been met and collection is virtually guaranteed.

Clearly, a number of alternatives to ambulance transport for non-acute patients can be found. None, however, seem to have taken root as a permanent solution to the problem for the fire service as a whole. For instance, the use of non — fire department vehicles for transporting patients requires at least some willingness to accept higher liability should a patient's condition deteriorate.

In the words of Faulkner from Phoenix: “We really haven't found any one plan that we are ready to implement.” Nevertheless, it's encouraging to know that the fire service, which always has been focused on solving problems, is taking bold steps to meet the growing demand for out-of-hospital routine medical care and transportation.

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Tony McDowell is a firefighter/paramedic with the Henrico County (Va.) Division of Fire.

Light-duty firefighters staff Phoenix pilot program

The Phoenix Fire Department is evaluating yet another alternative for transporting non-emergency patients.

This program involves a “service van” staffed by three firefighters who are limited to light-duty assignments. The service van operates out of a fire station and is staffed on the same 24-hour shift basis as other apparatus. The vehicle is dispatched to (or can be called for by on-scene units) for patients who need transportation to hospitals, urgent care centers or other destinations at the discretion of the company officer.

“The service van is for those customers whose needs we can meet without utilizing an ambulance,” says Capt./Paramedic Mark Faulkner. “In the past we were routinely transporting patients to emergency rooms to get a couple stitches or for runny noses. So the service van actually works better for us, and the hospitals seem to appreciate it also because it diverts non-emergency patients away from the emergency departments.”

Another plus is that the patient remains in the care of trained fire department personnel who can act immediately if the patient's condition changes. Patients must be ambulatory enough to ride in a sitting position in the van, as the light-duty personnel are generally restricted from lifting patients.

Of course, those light-duty employees themselves will need time to attend appointments with doctors, physical therapy or other needs related to their injury or illness. As a result, the department is evaluating the assignment of three such members to the service van to allow it to function should someone need time away from work.

Although the service van concept has been in operation for only a month, public reaction to the concept has been positive. The members who staff the van have enjoyed the opportunity, too. “It gives them the chance to continue working in the field on a 56-hour work week, and in the fire station, even though they are on light duty,” says Faulkner.