Posted by: medicblog999 | September 29, 2009

The Frequent Customer!

Before I start, I havent forgotten about Jack and ECG Geek 6, thats coming tomorrow. It would have been tonight but I have been asked by Happy Medic to pitch in on a post discussion that he and CK from Life under the lights are currently having.

hello-againTo understand what is going on, click here to read CK`s post that started it off, then click here for The Happy Medics follow up. Once you have finished with them, Ill give my two penneth.

The topic of discussion is the ‘frequent flier’, or our ‘regulars’ as we like to call them.

I know for a fact that every ambulance service in every country has these people. The ones that you come to know very well. Sometimes you may actually grow to be fond of them, but mostly then can become a source of frustration when you realise that the only cover available in your area is you, and you are now stuck with someone who is in no need of emergency care instead of being available for those patients who truly need our services.

Happy Medic goes some of the way to address some of the issues, but he has requested the UK perspective, so I will give my thoughts on this subject. The text in Blue is HM`s:

These clients call 911 and use code words like “chest pain” and “seizure” and “difficulty breathing” to get their response bumped up to a priority dispatch. Then, when the crews arrive and find no life threat, they know the law and demand a transport to the ER, which they know we can not refuse.

It’s partly the same in my service. There will always be the ‘magic words’ which will get the Cat A response from us. I dont think there will ever be anyone either brave enough or stupid enough (pick you wording) to not act on a patient stating that they have chest pain or difficulty in breathing. The concept of the boy who cried wolf  has no place in EMS. You can pretty much cry wolf as long as you want, but as long as you dont become abusive to the paramedics that come to see you, you will always get an ambulance response. However, where we differ is what I have mentioned in the past, i.e. Respond not Convey. We do not have to take everyone to the Accident and Emergency Department. In fact we are actively encouraged to only take patients there who actually need their services. There are many other pathways and avenues open for us to move a patient through if we feel they are truly not emergent.

We have a number of tick boxes on our ‘Respond not Convey’ form, but the ones relevant to this discussion state the following.

  • The condition is such that a visit to an appropriate health professional should be sought e.g GP, Health Visitor, District Nurse.
  • The patient requires treatment at an accident and emergency department or walk in centre and has agreed to make their own way there
  • The patient requires assistance only

This opens up a wide choice of options for us to look into. The difficulty we have though is that we still have a problem in actually ‘refusing care’ at the point of patient contact. I have only done this once, and that story is here if you want to read it.

It goes without saying that we treat those who need it, right? So why can’t we be honest with those who don’t need it?

This goes straight to the heart of another point that HM makes later on in the post, that of the responsibility of the patient for their own healthcare. However, it goes to reason that if a patient is constantly phoning for help that they dont actually need, when you actually try and point out that their actions are putting others at risk, it just tends to go in one ear and out the other. They dont really care about anyone else, which is why they keep calling for themselves. There has been many times that I try and ‘educate’ the regular callers, only to realise that it has done no good what so ever.

There are also the sub category of regular callers who actually to have a condition which is feeding their apparent abuse of the system, that of the psychiatric patient who, even though we see them as wasting our time, have a genuine need for help, but there is no appropriate system for caring for them, so they just keep going around and around without receiving any definitive care (Psych ER anyone!)

Medical Directors need to be proactive in giving their systems tools to guide people out of the water slide that is defaulting to ALS to a hospital.

We are very fortunate that our Clinical team and Medical Director have gone a long way down this path already. Granted, a large proportion of this effort has been to try and keep the response times within targets, but with the end results of taking less patients to hospital. I cannot remember off the top of my head but Im sure that the last time I asked, my service is currently looking at about a 30% non conveyance rate (which encompasses telephone advice to make their own way to hospital, referral to a GP, advice from one of our clinical supervisors in the control room, or a referral from the crew). That already frees up a large amount of resources, but I am sure we could achieve so much more.

However, the big thing that is stopping American EMS in pursuing this pathway is the good old funding issue. If I am correct, the majority of income for EMS services comes direct from the insurance companies paying for the treatment and transport to the ER. If the patient isnt transported, there is a financial loss for that job. Imagine if one of the US EMS companies were achieving a 30% non conveyance rate – 30% less income into the service – 30% less staff??? Surely that is one of the biggest hurdles to over come before EMS can develop into its full potential in the USA.

The General Practitioner who was called and defaulted to a 911 response

Again, this is a problem over here too. But there have been occasions where a GP has passed a job through to the ambulance service without visiting the patient only to get a phone call from me 30 minutes later passing the patient back to him, now that I have ruled out all of the ‘magic words’ that were uttered over the phone first time round. It’s a completely different matter if the GP has visited though, but if the GP hasnt laid eyes on the patient, then I will be their eyes and ears and pass that information back to them to avoid a unneccesary A&E visit. I do however, understand that the GP is constrained by the limitations of telephone triage, and without seeing the patient, has to suspect worse case scenarios in some cases which does ultimately result in the big white van with the blue flashy lights turning up.

Gradually, the relationship that the Ambulance Service has with the GP profession is getting better. The GP’s are slowly realising the skills and abilities that we have and are slowly accepting that we are FAR more than just ambulance drivers now. I have many a GP in my patch who I feel that I can talk to as an equal in the community healthcare team (when discussing emergency medical conditions anyway), and this can only produce a more proactive and responsive healthcare solution over time.

Nothing in the laws says you can’t tell the truth. When people say “Sorry to bother you with this, but I didn’t know who to call” take the extra 5 minutes, grab a phone book and show them who to call, where to go and how to get help. Then do what the law requires. Be nice, be supportive, but be honest.

I certainly do this already, but there are many of my colleagues who do not. It’s a legacy from the ‘way we used to do things’. There has been so much change in my service in the short 9 years I have been in, that it must be quite staggering and frightening for some of the longer serving members of the team. They started their careers with the mantra of ‘everyone goes to hospital’ and then practiced that same thing for the next 10, 15, 20, 30 years. Now all of a sudden they are being asked to change their whole mindset. That just isnt going to happen. As long as everything is based on a clinical decision, there is no way to try and ensure that all paramedics refer patients on appropriately. What I assess as a ‘inapporpriate call’ may not be the same as what you do? All we can do is strive to do the best we can with the knowledge and awareness that there arent that many of us out there, and constantly ask ourselves if this patient really need to go to A&E, or is there another option?

No matter what we do over here in the UK. No matter what you guys do over there in the USA. There will always be the frequent flier. We may be able to do something in the future to care for them in a different way, but until we can do cardiac enzyme tests in the back of the ambulance to rule out cardiac chest pain, or have a mobile CT/MRI scanner to see if the patient is just drunk or has a head injury, or do blood gases to see if the patient is really that short of breath, then there will always be a proportion of patients who have to travel even though we are 99% sure there is absolutely nothing wrong with them.

Our systems are far from perfect. Hopefully when Happy Medic comes over in 8 weeks, he will see the best that we have, but will also hear from those amongst the ranks who maybe don’t have the same rosy outlook that I do. I cant pretend everything in the garden is always rosey, but there is one thing I know for sure, we are constantly looking for the next thing to improve things for our pre-hospital patients, even if that means not giving certain members of the community that taxi ride up to the hospital after all!



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Responses

  1. Thanks Mark, Champion!

  2. You guys have really taken off with this. It’s good stuff.

    I look to the British system as being a good answer to the US mess. If we had the options for different treatment pathways and alternative transport options that they do, we would be well on our way to improving our service.

    Notice I didn’t say “solving our problem” because I don’t know if a “frequent flier” is truly a problem… just someone who we can’t adequately help for whatever reason.

    Even if that reason is their own lazyness.

  3. Great post. It gives us all something to think about.
    I’m a huge fan of your blog.

    Keep up the good work.

    Cal
    (undertheredandblues.wordpress.com)


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