Thursday, April 09, 2015

NP in the ambulance?

Thanks to Neville Sarkari, long serving physician executive from Pensacola, Florida, for forwarding this editorial from the Los Angeles Times.

A proposal by Councilman Mitchell Englander could start reordering priorities at the LAFD by diverting the least-urgent medical calls to a team of just two people — a nurse practitioner and a paramedic. They would use an ambulance, but the goal would be to treat people who call with minor medical needs right there at the scene, rather than schlepping them to the hospital — thus saving millions of dollars each year on ambulance rides and hospital admittances. Nurse practitioners are able to do more than paramedics, including writing prescriptions and performing minor procedures.

Between calls, this nurse practitioner unit would reach out to "superusers" — people who call 911 more than 50 times a year — to help them find services and resources before they pick up the phone again.

I know that such proposal can be controversial, and I'm sure there would be logistical things to work through, but it seems really sensible and interesting.  Your thoughts?


@SteveHuffmanCIO said...

From Twitter:

Love the idea, however would unintended consequence = using 911 for more routine home based care?

Paul Levy said...

Good point, as in, "if you build it they will come," no?

@SteveHuffmanCIO said...

Right - If I can get an ambulance with an NP to take care of me quickly, why go to ER? Just call 911 and get home service! #bad

Richwlf said...

Lots of problems with this concept.
1. You can't look at a single visit and compare the costs. You need to factor in the downtime that you need to pay an NP who will wait between calls. You need to consider the cost and logistics of stocking the supplies and medication to treat minor fractures, close lacerations, perform rapid strep testing, drain abscesses, etc... These are the frequent minor emergencies that you might prevent from an ED visit.
2. Any problem that needs imaging, labs, consults, or more invasive procedures will still need to be transfered and this will simply add to the cost of the subsequent ED visit
3. Dispatch triage is far from perfect and unless one intends to send an NP on every call, many opportunities will be missed, and many responses with this team will not add value.
4. You will have built an attractive alternative to a PCP visit and further compromised a risk networks ability to control the care of the patient. Consider the added risk of inappropriate opioid spread, risk of medication error, etc...

In summary, perhaps a crowd pleasure but probably will end up a less value and more cost to the system.

Dave said...

This will sound like a bone headed specialist comment but here goes: unless and until PCP's, urgent care docs and ER docs start practicing evidence based medicine (I.e. No routine annual exams for healthy adults, no antibiotics for viral illnesses, adherence to screening recommendations of USPTF, etc) patients will continue to seek expensive care delivery systems. I don't forsee a substantial cost savings from mid level providers acting in the same manner.
Furthermore, any individual calling 911 50 times in a single year needs to see a psychiatrist, not an NP.

Anonymous said...

I find it is hard to change anything these days. Fire fighters and Paramedics will see this as a threat to their jobs and will oppose it. Fire Departments are only able to keep their volume up by trailing ambulances out to health calls. You could probably cut most departments in half if they were not going out on these health related calls. Also, isn't this a bit of nibbling at the edges of healthcare costs? Let's face it, with 10,000 people a day pouring into Medicare we had better get a handle on utilization and end of life care for that population or the whole system will collapse financially. There are some very difficult choices that need to be made if we are going to get serious about keeping costs down moving forward.

David Dolton ‏@DaveDolton said...

From Twitter:

I absolutely love this idea! ERs are filled with non-emergencies & debt. Make it $199 out of pocket, paid on the spot.

Anonymous said...

I can see the point of at least trying to solve a huge problem. I do agree that there are those who are going to abuse this, much like those who go to the ER for the flu. I do think that it would have to be pay based. Make it more expensive than going to urgent care, and they have to pay for ambulance ride. My guess is, people, once it has to be paid for, will use more common sense. Those who don't have the money for it, need to pay for part of their care in one way shape or form, rather than Medicaid/Medicare covering it. That would stop abuse there.

CJ said...

This is usually touted as Community Paramedic Service. It is actually NP service. Why not fund a house call service and find it some where besides EMS? Because EMS can get grants right now. When that changes, and it will, the next 'latest and greatest' model will come along. The only magic here is providing needed services to patients. The delivery model is almost beside the point. Important to point out that this is STILL not primary care.

Stafani said...

This is a no-brainer....I am always amazed at the sight of large fire department equipment sitting outside my building in response to a 911 call for 'persistent cough' or 'bad headache' or a 'fall' (all real events reported to me by concierge). Always thought it was a waste of taxpayer money and even more importantly, pulling a valuable resource in a low risk situation when a high risk need has to wait its turn.
This is a good first step to change the pattern..

Thomas said...

Like it. Triage in the field so to speak. May keep some of the frequent fliers out of the ED.

Anonymous said...

I love the earlier comment ending " perhaps a crowd pleasure but probably will end up a less value and more cost to the system" Seems like an experienced hospital administrator skilled at political infighting and stopping any change he opposes.

Lets consider the objections, shall we?

1) "need to look at the overall costs of supplies, etc " Is this actually a *problem* or just an issue to be examined in determining program viability? Listing 4+ minor procedures makes for a lengthy sentence as if these must be BIG costs, great trick of the trade.

2) "If the NP call isn't sufficient they still need to go to the ED, adding to the cost". Gotta love the one-sided math. Add on the extra costs, but don't mention the savings of ED trips that were avoided.

3) "dispatch might not send the NP team on all the opportunities to use them". Skilled rhetoric here! Because the program doesn't save as much money as possible in a perfect world, this is a "problem with the concept."

4) "Build alternative to the PCP visit". The crowner! We were talking about displacing visits in which the fire dept brings people to the ED, but somehow it is being compared to the PCP visit that wasn't happening in the first place!