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Routing

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Title:
Routing an alternative to the delivery of traditional "lights and sirens" emergency medical services
Creator:
Reissman, Stephan G
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English
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195 leaves : illustrations ; 28 cm

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Subjects / Keywords:
Government communication systems ( lcsh )
Emergency medical services ( lcsh )
Telephone -- Emergency reporting systems ( lcsh )
Emergency medical services ( fast )
Government communication systems ( fast )
Telephone -- Emergency reporting systems ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references (leaves 178-195).
General Note:
School of Public Affairs
Statement of Responsibility:
by Stephan G. Reissman.

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University of Colorado Denver
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Auraria Library
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51775140 ( OCLC )
ocm51775140
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LD1190.P86 2002d .R44 ( lcc )

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Full Text
ROUTING: AN ALTERNATIVE TO THE DELIVERY OF TRADITIONAL
LIGHTS AND SIRENS" EMERGENCY MEDICAL SERVICES
by
Stephan G. Reissman
B.S., New York University 1981
M.P.A., John Jay College of Criminal Justice 1993
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
Public Affairs
2001


2001 by Stephan G. Reissman
All rights reserved.
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This thesis for the Doctor of Philosophy in Public Affairs
Degree by
Stephan G. Reissman
Has been approved


Reissman, Stephan G. (Ph.D., Public Affairs)
Routing: An Alternative To The Delivery Of Traditional Lights And Sirens"
Emergency Medical Services
Thesis directed by Professor Richard Stillman.
ABSTRACT
Because of concerted public promotion and education, coupled with ease of
access, the telephone number, 911, has become both the publics emergency
services access point and the source for non-emergency information and
assistance. A large segment of the population that is looking to 911 and
Emergency Medical Services (911-EMS) agencies for medical assistance
actually require something less intensive than a lights-and-sirens emergency
response. However, most 911-EMS agencies do not have service options
other than that, and an emergency 'lights-and-sirens' ambulance response is
what usually occurs for most calls to 911.
In reality, many callers for 911-EMS could benefit from service options such
as telephone nurse advice, non-emergency transportation, or referral to other
available services (physician offices, social services, etc.) options that are
not typically provided by 911-EMS agencies.
This dissertation examines Routing," defined for purposes of this dissertation
as the various strategies now being used by a limited number of 911-EMS
agencies to provide a continuum of necessary services in addition to 'lights-
IV


and-sirens" response. The objective of Routing is to ensure that a person
that has an unscheduled medical need is routed* to the most appropriate
sources of care. This can range from a 911-EMS response to a nurse-
advisor facilitating arrangements for a clinic appointment. This is not to say
that patients with non-urgent conditions do not need medical care; rather,
they do not need emergency medical care.
As this is the first such study of 911-EMS Routing, the research conducted for
this dissertation required a qualitative research design using an exploratory
and descriptive case study approach to examine the findings.
The dissertation demonstrates that:
Routing has reduced the numbers of non-urgent calls responded to by
a number of 911-EMS agencies; thereby freeing the 911-EMS
agencies from responding to non-emergency calls and instead
increasing their ability to remain on stand-by for emergencies.
Most Patients/Callers were satisfied with being Routed;
Agencies that Route can have lower operations expenses than those
that do not Route, and
No callers died or had their conditions aggravated by being routed.
This abstract accurately represents the content of the candidates thesis. I
recommend its publication.
Signed
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DEDICATION
I dedicate this thesis to my wife Dori for her unfaltering understanding and
support while I was writing this and to my son Zachary for bringing joy and
wonder to my life. I cherish our times in Colorado and look forward to sharing
many more adventures in our future.
In addition this thesis is also dedicated to the Paramedics and EMTs I have
had the honor to work with over the years.


ACKNOWLEDGEMENT
I wish to express my sincere thanks to my thesis advisor, Franklin James,
who suddenly and unexpectedly died on July 4, 2001. Franklin was a
supportive and wonderful teacher who was instrumental in my growth and
development as a doctoral student.
I also wish to thank Richard Stillman who assumed the role of committee
chair upon Franklins passing. I appreciate his willingness to take on this
responsibility at such a critical point in the dissertation process.
Thanks and appreciation also go to my dissertation committee: Nancy
Shanks, William Atkinson, and Robert Gage for their encouragement,
understanding, and infinite patience with me during these past 6 years. Each
of you has contributed to the success of my doctoral studies in different ways.
I genuinely appreciate your commitment and time.


I would also like to thank my parents for their love and support, and for
instilling in me the importance of education and of service to the public, and to
my in-laws for their encouragement throughout this dissertation process.
Finally, I would like to extend a special thank-you to Joan Morrissey, my
editor. She has done a wonderful job of making my writing more coherent
and my arguments more cogent. I am indebted to her more than she knows.


CONTENTS
Figures.......................................................xv
Tables......................................................xvii
1. INTRODUCTION...............................................1
The Problem.................................................4
The Route of This Dissertation..............................6
2. LITERATURE REVIEW OF THE KEY FACTORS IN
911- EMERGENCY MEDICAL SERVICES DELIVERY....................9
The Traditional Provision of Emergency
Medical Services: Background and History..............10
Structure and Components of EMS Systems....................17
Types of 911-EMS Patient Care Providers....................18
Traditional 911-EMS Provision..............................19
Private Ambulance Services and
911-EMS Consolidators....................................23
Emergency Communications...................................25
Components of a 911-EMS Communications
System.................................................27
The Use of 311 as an Alternative
Non-Emergency Access Point.............................28
Priority Dispatch Systems..............................29
Phases of Emergency Response...............................30
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Pre-Arrival/ Dispatch.......................................32
911-EMS Deployment..........................................33
On-Scene Treatment..........................................34
Transport and Transfer of Care..............................35
Financial Aspects of 911-EMS Services..........................38
911-EMS Costs...............................................39
Funding for 911-EMS Delivery................................42
Fees for 911-EMS............................................46
Utilization of 911-EMS and EDs.................................47
Studies Examining Utilization of 911-EMS....................49
Studies Examining Utilization of EDs........................52
Telephone Triage / Nurse Advice Lines.......................57
A National Proposal to Include Routing
as Part of 911-EMS Delivery: The National
Highway Traffic Safety Administration (NHTSA)
and 911-EMS Delivery...........................................60
EMS Agenda for the Future...................................61
3. METHODOLOGY.....................................................66
Research Design................................................67
Validity....................................................68
Sources of Data.............................................69
Limitations.................................................70
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Sampling..................................................70
Expert Sources............................................71
Units of Analysis.........................................73
Impact Assessment Model...................................76
4. FINDINGS......................................................78
Examples 1 and 2: MCO Routing in Metropolitan Denver.........80
Managed Health Care.......................................81
Example 1: MCO Routing in Metropolitan Denver.............83
Example 2: Pathways/Access Management Routing in
Metropolitan Denver......................................103
Example 3: 911 Plus: St. Louis, MO..........................108
The Next Phase of 911 Plus...............................115
Effect of the Program....................................116
Example 4: Telephone Referral Project -
King County, Washington................................118
Phase I of the Telephone Referral Project in
King County, Washington..................................121
Phase II of the Telephone Referral Project in
King County, Washington..................................123
Example 5: Routing Included as Part of the
Restructure of a 911-EMS Delivery System:
Alameda County, California.................................130
911-EMS Delivery in Alameda County, California...........130
Status of the Plan.......................................136
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Impact Assessment Model........................................138
Step One Developing the Impact Assessment Model...........139
Step Two Developing the Impact Assessment Model...........141
Step Three Developing the Impact Assessment Model........142
Step Four Developing the Impact Assessment Model..........142
Step Five Developing the Impact Assessment Model..........142
Summary of Findings............................................143
5. DISCUSSION......................................................144
Significant Findings Benefits Yielded by Routing............147
Reduction in 911-EMS Non-Urgent Use.........................147
Freeing 911-EMS Units to be Available for
Life-Threatening Emergencies................................148
Reduction in Cost of Providing 911-EMS......................149
Patients That Don't Need to Tie Up 911-EMS
Agencies Still Receive Assistance Without
the Cavalry Coming to Their Door..........................151
Provide Alternatives to a Full 911-EMS Response
for Callers Who Need Advice or Direction
to Other Sources of Help...................................152
Maintain Equal Access to 911 for All Callers in an Area....154
Significant Findings Problems Caused by Routing..............155
Elimination of 911 as the Universal Emergency
Access Point When an MCO Directs its Members
to Call a Number Other Than 911.....................155
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Routing Can Delay Emergency Response to
an MCO Member in Need of Emergency
Care by Circumventing a Members Access
to the Local Public 911-EMS Agency............................158
Delay or Restriction of Access to
Emergency Care Due to Inappropriately
Designed Nurse Advice Lines..................................161
NHTSAs Expert Panel and 911-EMS Delivery........................163
Potential Effects of Routing on Overall Health
Care Utilization and Costs...................................167
Study Limitations.................................................168
Future Research Questions.........................................170
Does Routing Decrease Risk to Emergency
Crews and the General Public From Collisions?..........170
As More 911-EMS Agencies Move to Routing,
Do the Benefits of Routing Hold True?........................171
Would MCOs be Willing to Rely on an External
Public Agency, a 911-EMS Agency,
to Appropriately Route Their Members?........................171
What is the Effect on Other Agencies That Have
Received an Increase in Service Requests
Due to 911-EMS Routing?........................................172
What are the Potential Effects of Routing on
Overall Health Care Utilization and Costs......................172
Conclusion: What is The Appropriate Place
of Routing in the EMS System?................................173
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APPENDIX
A. ABBREVIATIONS USED IN THIS THESIS...........177
BIBLIOGRAPHY......................................179
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FIGURES
Figure 1. Major components of a 911-EMS system.....................12
Figure 2. Phases of emergency response.............................31
Figure 3. An example of a complete 911-EMS
response scenario......................................37
Figure 4. NHTSAs model of EMS responses...........................63
Figure 5. Agencies interviewed for this dissertation...............69
Figure 6. Expert sources interviewed for this dissertation.........72
Figure 7. The process involved in accessing a 911-EMS
response used by six of the seven MCO supported
nurse advice lines in metropolitan Denver..............91
Figure 8. Kaiser Permanentes PC Routing response..................97
Figure 9. Kaisers Pathways/Access Management
Program in metropolitan Denver........................106
Figure 10. The St. Louis 911 Plus system..........................111
Figure 11. Diagram depicting the concept behind
Phase II of the King County Telephone
Referral Project.................................................125
Figure 12. Proposed EMS System model for
Alameda County, CA....................................137
Figure 13. Scenario depicting the pitfalls of
911-EMS Circumvention................................160
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Figure 14. A scenario depicting a delay in access
to emergency care due to an inappropriately
designed nurse advice line.............................162

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TABLES
Table 1. 911-EMS agencies in Americas 200
most populous cities in 2000..............................21
Table 2. Expenses associated to a traditional 911-EMS
agency that provides 911-EMS for a city of 400,000........41
Table 3. Funding sources for 911-EMS delivery........................43
Table 4. Medicare standards for medical necessity
for ambulance services.....................................45
Table 5. ED Visits and EMS use in the
United States (1992 1999)................................48
Table 6. Studies evaluating 911-EMS utilization.......................50
Table 7. Studies of appropriate utilization of
emergency departments......................................53
Table 8. Examples of routing strategies examined
in Chapter 4 of this dissertation..........................75
Table 9. Examples of cities and regional areas
utilizing Routing Method(s) to direct callers to a
variety of non-emergency services beyond a
lights and sirens response...............................80
Table 10. Metropolitan Denver MCOs with
emergency care policies..................................85
Table 11. Routing via nurse advice lines by
seven metropolitan Denver MCOs...........................89
Table 12. Use of Kaiser Permanentes Nurse Advice
Line in metropolitan Denver in 1996......................93
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Table 13. Response times for reporting 911-EMS
agencies in metropolitan Denver..........................99
Table 14. Listing of low priority problems included in
the St. Louis 911 Plus dispatching protocol for
routing to other sources of services...................112
Table 15. Listing of call-types considered low priority
but may require physician assessment....................116
Table 16. Response to requests/response times
for 911-EMS in St. Louis from 1998 though 2000.........117
Table 17. 911-EMS utilization in King County,
Washington for 1999.....................................118
Table 18. The three categories of emergency response
in King County, Washingtons
Telephone Referral Project..............................120
Table 19. Interventions recommended the to
callers by TRP nurses during Phase II
of the King County TRP..................................126
Table 20. Reasons why eligible callers were not
transferred to the TRP Nurse Advice Line...............127
Table 21. Top five complaints filed by callers to the
King County, Washington TRP.............................129
Table 22. Effects of a Routing program on the
impact assessment model city (pop. 400,000).............140
Table 23. NHTSA-recommended routing
alternatives used by example cities
in this dissertation....................................153


CHAPTER 1
INTRODUCTION
Over the past 30 years, the delivery of emergency medical services (which
will be termed 911-EMS) has become a sophisticated means of rapidly
caring for the acutely ill and injured. Today, 911-EMS ambulances are literally
Mobile Intensive Care Units, providing out-of-hospital care- often in
unpredictable and volatile settings. Advances in technology and training
enable ambulance crews to render emergency treatment previously limited to
physicians in hospital emergency departments (EDs). 911-EMS agencies
transport as many as 14.6 million (of the more than 102 million patients seen
annually) in EDs across the nation (National Center for Health Care Statistics,
2001).
In an emergency situation, a delay of minutes can make the difference
between life and death. For example, when a person suffers a cardiac arrest
(meaning a cessation of breathing and heartbeat), they can survive no more
than 4-8 minutes without CPR followed soon thereafter by specialized
emergency medical care (rendered by 911-EMS or EDs) in order to have any
chance of survival. Similarly, a person that has stopped breathing as a result
of having a severe allergic reaction (known as Anaphylaxis) to shellfish also
has a life-threatening problem. That person needs a paramedic crew or ED
Care very quickly or death is imminent (Caroline 595-601).
Additionally, a delay of minutes can impact on a person's morbidity if severely
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injured or ill. Patients experiencing chest pain due to a heart attack can
receive in-field treatment by paramedics that will alleviate their pain, and
relieve dangerous cardiac rhythms. A patient in a motor vehicle accident can
suffer serve spinal trauma and paralysis if moved inappropriately. Again, 911-
EMS crews and first responder agencies are equipped and trained to handle
such situations (Caroline 320-328).
The principal access point for emergency medical services is primarily
through the telephone dialing of 911, the well-known emergency telephone
number. 911 has become the nation's primary point of access to police, fire
suppression and emergency medical services. While the public has come to
depend on access to a 911-EMS system that features rapid response and
sophisticated clinical care, many callers to 911 are only seeking advice
regarding available resources and do not want the cavalry to respond to their
door.
Studies estimate that only 10% 30% of calls to 911 are for life-threatening
emergencies. Additionally, studies show that from 25% 50% of the time,
people calling for 911-EMS have a non-urgent condition that does not require
a 911-EMS response. The remaining calls to 911 are for patients that do not
have life threatening emergencies but may need 911-EMS response or are
from people who simply did not know whom to call for help (Schuman, Wolfe
& Sepulveda; Gibson; Morris and Cross; Rademaker, Powell and Read;
Knickman, Smith and Berry; Brown and Sindelar). Historically, most 911-
EMS agencies have not developed alternate mechanisms to Route public
requests, other than dispatching 911-EMS crews to a scene (Stout 1994 83).
Experts in 911-EMS delivery have addressed potential solutions to this issue
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as part of a larger review of 911-EMS delivery. In 1996, the National Highway
Traffic Safety Administration (NHTSA)1 released The EMS Agenda for the
Future which was developed by a panel of experts in 911-EMS delivery to
outline the most important directions for future EMS development (National
Highway Traffic Safety Administration 1996 i).n The expert panel was the
result of a nationwide, multidisciplinary effort that pulled resources, advisors,
and reviewers from a wide variety of 911-EMS stakeholders. The EMS
Agenda for the Future has since been described within the EMS industry as a
blueprint for further development of 911-EMS delivery.
In the NHTSA document, the panel acknowledged that the care provided by
911-EMS agencies does not occur in a vacuum and that 911-EMS delivers
treatment as part of, or in combination with, systematic approaches intended
to attenuate morbidity and mortality.... They recommended that 911-EMS
agencies seek integration with other health care providers, organizations and
networks (10). The panel also explained ...911-EMS is unsophisticated in
terms of its ability to allocate appropriate resources to match the nature of
calls" (44), referring to the fact that few, if any 911-EMS agencies facilitate
access to actually needed services" beyond an emergency response.
In 1996-1997, NHTSA facilitated another expert panel attended by
stakeholders from EMS and managed health care communities. This panel
discussed the concept of multiple option decision points for 911-EMS
response, where 911-EMS agencies can influence patient care and
transportation issues through dispatching (911-EMS response vs. nurse
advice line); on-scene care and treatment (without patient transportation); and
1 The National Highway Traffic Safety Administration (NHTSA). formed in 1966, was the first federal agency involved
in the development of 911-EMS standards and continues to be active in the 911-EMS arena.
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transporting to various sources of care (EDs, physician offices, clinics, urgi-
centers). The panel concluded, in the Spring 1998 EMS and Managed Care
Bulletin, ...rather than offering a uniform response to all callers, the 911-EMS
system may create unique clinical pathways for each patient (National
Highway Traffic Safety Administration 1998). Both these Federal panels
acknowledged that there were options that 911 -EMS agencies could
incorporate into their delivery systems that went beyond the typical lights-
and-sirens approach to 911-EMS delivery.
The Problem
Because of concerted public promotion and education, coupled with ease of
access, the telephone number, 911, has become both the publics emergency
services access point and the source for non-emergency information and
assistance. A large segment of the population that is looking to 911 and 911-
EMS agencies for medical assistance actually require something less
intensive than a lights-and-sirens emergency response. However, most 911-
EMS agencies do not have service options other than that, and an emergency
lights-and-sirens ambulance response is what usually occurs for most calls.
911-EMS agencies typically do not deny response or transport to any patient
that requests these services. This happens even though many callers to 911
do not need the sophisticated and costly services of a 911-EMS agency, nor
do they need the specialized care of an ED. In reality, many callers for 911-
EMS could benefit from service options such as telephone nurse advice, non-
emergency transportation, or referral to other available services (physician
offices, social services, etc.) options that are not typically provided by 911-
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EMS agencies.
Additionally, limiting the delivery of 911-EMS to response-only efforts is not
the most effective use of health care dollars. For example, a patient may be
charged $53.00 for a non-urgent visit to a clinic or doctors office, while if that
same patient used 911-EMS and ED services, the charge would increase to
$411 dollars (Williams 642; Prewitt 1997). Hospitals and health care insurers
have introduced cost control mechanisms such as reducing the length of
hospital stays and shifting care to outpatient services. This dissertation
addresses methods that can reduce unnecessary use of health care services
and control costs through the use of alternatives to traditional 'light-and-
sirens 911-EMS delivery.
Finally, both the public and emergency responders are placed at unnecessary
risk due to emergency vehicles responding to calls that can, and should, be
handled by means that do not require such an immediate response. In many
areas, a 911-EMS response also includes a fire department first response
unit, and possibly the police. It is not unusual that as many as 8 or 9 rescue
personnel, in various emergency vehicles, rush simultaneously to a 911-EMS
call. This type of response, while necessary at times, puts responder and
civilians in jeopardy as the vehicles proceed lights-and-sirens through streets
(National Association of EMS Physicians). A person that needs advice rather
than immediate action does not warrant such a massive emergency
response. In addition, crews sent out to non-urgent calls are no longer
available for response to life-threatening emergencies.
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The Route of This Dissertation
This dissertation examines Routing, defined for purposes of this dissertation
as the various strategies now being used by a limited number of 911-EMS
agencies and Managed Care Organizations (MCOs) to provide a continuum
of necessary services in addition to lights-and-sirens response. The
objective of Routing is to ensure that a person that has an unscheduled
medical need is Routed to the most appropriate source(s) of care. This can
range from a 911-EMS response to a nurse-advisor facilitating arrangements
for a clinic appointment. This is not to say that patients with non-urgent
conditions do not need medical care; rather, they do not need emergency
medical care. The cost of care in an urgi-center or physicians office is far less
than the cost of 911-EMS response, transport, and eventual evaluation in an
ED.
This dissertation will examine the traditional response-only model of EMS
delivery as compared to various Routing methods used for 911-EMS Delivery.
To aid in this comparison, several cities and their respective 911-EMS
programs were examined and evaluated, they are: metropolitan Denver,
Colorado; St. Louis, MO; Alameda County, CA and King County, WA.
Specifically, this dissertation compares a traditional 911-EMS program with
other cities such as the 911-EMS program in metropolitan Denver, Colorado,
where the Routing alternatives are offered by private sector managed care
organizations (MCOs), and other U.S. cities (St. Louis, MO and King County,
WA), where public 911-EMS agencies have themselves developed Routing
alternatives that screen out non-emergent 911 calls.
This dissertation will show how the majority of Denvers citizens, as directed
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by their MCO, first contact access points other than 911, especially if they are
unsure of their condition or have a non-emergent situation. This is a different
approach than that used in St. Louis, MO or King County, WA, where the 911-
EMS programs have developed options such as telephone-based nurse
advice access, or non-emergency transportation for those patients who do not
need an ambulance, but do not have the means to get to non-urgent medical
care.
The purpose of examining these different approaches is to explain how 911-
EMS delivery and utilization has changed since its modest beginning in 1966
when the Department of Transportation (DOT) was established and EMS
systems were first implemented. This dissertation provides 911-EMS program
officials across the nation with information on the differing Routing
alternatives availableall providing varying levels of success. There are
problems caused by these Routing approaches as well as advantages. This
dissertation will reveal those pitfalls and benefits, thereby allowing new 911-
EMS programs as well as those programs seeking to restructure information
on how to best enhance their system's ability to provide effective and efficient
service to community members.
As this is the first such study of 911-EMS Routing, the research conducted for
this dissertation required a qualitative research design using an exploratory
and descriptive case study approach to examine the findings. An extensive
literature search was conducted as well as a series of multiple source
interviews that targeted key officials and were conducted via telephone or in-
person via semi-structured and open-ended lines of inquiry. This type of
inquiry required a snowball sampling technique to ensure an adequate
response from various public and private agency officials. In addition, media
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reports, scholarly research, and industry statistics were used as source
material and to develop models.
A limitation to this research is the limited availability of information that deals
with the delivery of public emergency medical services. While research has
and continues to be conducted on clinical care issues, administrative systems
issues have been neglected. One of the goals of this exploratory/descriptive
research is to present an initial examination into how an area impacts (and
will continue to impact) 911-EMS delivery. Another goal is to create an
increased awareness of the complexities involved in the delivery of this
essential public safety service.
This dissertation is presented in five chapters. After this introductory chapter,
Chapter 2 introduces key concepts in 911-EMS delivery, including the phases
of emergency response and financial aspects of 911-EMS. Chapter 2 also
provides a detailed examination of relevant background literature pertaining to
emergency medical services (911-EMS) delivery. Chapter 3 provides more
in-depth information on the methodology used for the research presented in
this dissertation, to include data collection and research design. Chapter 4
discusses the findings of this research. Finally, Chapter 5 discusses the
study implications and recommendations for further research.
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CHAPTER 2
LITERATURE REVIEW OF THE KEY FACTORS IN
911- EMERGENCY MEDICAL SERVICES DELIVERY
To understand how Routing impacts a 911-EMS system, it is necessary to
appreciate the background and history of the nations traditional 911-EMS
system as well as the key components that make up this complex system.
This chapter shows, through an extensive literature search, the key concepts
in 911-EMS delivery, including the phases of emergency response and
financial aspects of 911-EMS. It also summarizes recent research conducted
on the urgent and non-urgent utilization of both 911-EMS delivery systems
and EDs. This supports the problem posed in this dissertation, which is that
the telephone number, 911, has become both the publics emergency
services access point and the source for non-emergency information and
assistance.
Though there is a limited amount of research available, and this is the first
such study of 911-EMS Routing, the literature search conducted for this
dissertation supports the purpose of this dissertation, which is to examine the
traditional response-only model of EMS delivery as compared to various
911-EMS programs that are using Routing methods to increase efficiency and
to decrease non-emergent use of their emergency medical services. While
the literature review focuses on the more traditional methods of 911-EMS
delivery, there is also discussion of the innovations that have enabled the
implementation of the Routing Programs discussed in Chapter 4. These
include priority dispatching and nurse advice lines, both of which help 911-
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EMS agencies direct callers to the most appropriate source of care, rather
than a one-size-fits all response plan.
The Traditional" Provision of Emergency Medical Services:
Background and History
The provision of emergency medical services (EMS) in the United States has
advanced considerably since horse-drawn ambulances rolled out of hospitals
in Cincinnati and New York City just after the Civil War (Barkley 61-63).
Ambulance crews now provide more than just an ambulance ride to the
hospital. Delivery of 911-EMS has become a sophisticated means of rapidly
caring for the acutely ill and injured patient and Todays ambulances, staffed
by emergency medical technicians (EMTs) and paramedics (see page 26),
are literally Mobile Intensive Care Units, providing out-of-hospital emergency
care, automobile extrication and other rescue services, often in unpredictable
and volatile settings. Advances in technology enable crews to render
emergency care that previously was limited to hospital emergency
departments (ED).
For ease of discussion and to reduce confusion for those unaccustomed to
differentiating between 911-EMS agencies and EMS Systems, a 911-EMS
agency is a local agency- designated by local government to be the provider
of rapid response, on-scene emergency care, and ambulance transportall
of which is typically dispatched through 911. Today, fire departments, 911-
EMS departments, and private ambulance companies are the principal
agencies that provide these urban emergency medical services. Fire
protection and 911-EMS departments are usually government agencies.
Private ambulance companies can be contracted by municipalities to serve as
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the area's 911-EMS provider. Rural and suburban 911-EMS agencies often
add a volunteer component to the provider matrix (Fowler 32-34.) The 911-
EMS agency is the hub of the EMS System, which contains several other
organizations and components as shown in Figure 1.
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Figure 1. Major components of a 911-EMS system
(Source: Werner and Smith 649-653)
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911-EMS delivery, as is law enforcement and fire suppression, has become
an expected government-sponsored public safety service. Local government
typically provides these services. The mission of a public safety service is to
protect and preserve life, property, and natural resources (National
Telecommunications and Information Administration). Dr. Carl Post, noted
Professor of 911-EMS Management at New York Medical College, promotes
the delivery of 911-EMS as a natural extension of the public safety
function.... Sound public safety can facilitate good public health by increasing
the overall safety and...sense of well-being of the average citizen (58). The
National Highway Transportation Safety Agency's (NHTSA) publication, The
EMS Agenda for the Future," explained that 911-EMS represents the
intersection of public safety, public health and health care systems. A
combination of the principles and resources of each is employed by EMS
systems" (4).
911-EMS crews are structured into either a paramedic staffed Advanced Life
Support (ALS) ambulance or a Basic Life Support (BLS) ambulance.
Paramedic ambulances are mobile emergency rooms,' equipped with much
of the same equipment as an ED. Paramedic units receive medical
supervision (via radio or telephone) by a physician located at a hospital ED.
BLS crews provide care such as splinting, bandaging, and oxygen
administration. Additionally, first responder agencies, typically from fire
departments, serve a dual function of fire suppression and emergency
medical response. They respond in non-ambulance vehicles, may be either
ALS or BLS, and are designed to arrive ahead of the 911-EMS ambulance
(Pointer 98-104).
Government agencies have been involved in emergency care provision in
i
13


some form, since the Civil War. One of the first city ambulance programs in
the United States was established in New York City at Bellevue Hospital in
1869. Other hospitals in New York City and around the nation followed suit
and developed ambulance services. Early crews had little, if any medical
training. Overtime, physician interns were often assigned to staff
ambulances. During WWII, the interns were removed from ambulances and
reassigned to other in-hospital duty. After the war, interns were not returned
to the ambulance services (Mustalish and Post 3-4).
During the 1950s and 1960s, certain ambulance utilization trends emerged.
Urban hospital-based ambulance services gradually merged into more
centrally coordinated citywide services provided by fire departments or
organized as a separate agency, commonly known as a third service
program.2 In rural areas, volunteers and funeral homes provided ambulance
services. In addition, proprietary services provided routine transportation
services and in some areas, would contract with local government to provide
public ambulance services (Mustalish and Post 4; Giordano and Davidson
35).
Before 1966, ambulance services, were often staffed by minimally trained
personnel, who basically drove a sick or injured person to the hospital while
rendering little, if any patient care. This led to a study by the National
Academy of Sciences-National Research Council who in 1966 released a
report entitled Accidental Death and Disability: The Neglected Disease of
Modern Society. This document recommended many changes that were to
become the heart of Emergency Medical Services. The report helped to
2 The term third service' is used to indicate that the 911-EMS agency is a separate, unique third emergency
response agency apart from the police or fire departments, typically the two emergency services in a city.
14


inspire the National Highway Safety Act of 1966, which established the
Department of Transportation (DOT) as a cabinet level office and allocated
funding for training and establishing EMS systems. It also led to a
standardized curriculum for EMTs (Mustalish & Post 5).
Rousch and McDowell explained that Public Law 93-154 signed on November
16,1973 is known as the Emergency Medical Systems Act." This Act
confirmed that a governments role and responsibility in ensuring that EMS is
provided to the public. This law outlined the essential components of an EMS
system, of which a 911-EMS agency is the center and supported by the other
members of a network. The law also specified 15 essential components that
make up an EMS System: manpower, training, communications,
transportation, emergency facilities, critical care units, public safety agencies,
consumer participation, access to care, patient transfer, standardized record
keeping, public information and education, system review and evaluation,
disaster, and mutual aid. These components were required to be addressed
in order for a system to receive federal funding (11).
15


Among the specifications laid out by the Act was that an EMS System should:
have a centralized communications system;
utilize the universal emergency telephone number 911;
have direct communications links with other agencies in the EMS
System and other EMS Systems;
provide for effective utilization of all public safety agencies providing
emergency services in the service area;
provide care without inquiry as to ability to pay;
provide public education including how to access 911 -EMS;
be prepared to provide for 911 -EMS during disasters; and
establish mutual aid where beneficial (9-17)
A principal reason for the Act was to seed funding for state and local 911-
EMS programs and provide structure to EMS Systems and 911-EMS
providers. Though no longer in effect, the Act was responsible for setting the
stage for 911-EMS provision throughout the nation. The law was not,
however, specific as to which agency within a municipality was responsible
for actual service provision (Mustalish and Post 22 ). This led to 911-EMS
provision by fire departments, 911-EMS departments, hospitals, private
companies, police agencies, and volunteers.
16


Structure and Components of EMS Systems
Narad defines an EMS System as a complex interdependent public safety
network. The lead agency in an EMS System is the 911-EMS agency, which
may be municipally provided, contracted out, or a public-private partnership.
In addition, first responder agencies, such as a fire or police departments,
respond on-scene prior to the arrival of an 911-EMS unit. These organizations
render emergency medical response and treatment within a defined
jurisdiction (usually a city, county, or special district). In many areas, private
ambulance services are also involved in emergency and non-emergency
response, treatment, and transportation in a community. Private services are
often included in citywide disaster planning or are called in for situations
where the public emergency provider has more calls than it can handle. Other
agencies involved in the day-to-day operations of an EMS System include
police and fire departments, hospital EDs, and even local utilities (phone and
power companies).
Traditionally, the EMS System concept is designed to address urgent or
emergent health care needs. Routine, non-urgent medical transportation is
supposed to be handled by means other than the EMS System. This can
include public or private provided wheelchair van services or private, non-
emergency ambulances that are not dedicated to 911-EMS response, but
occasionally do respond to emergent situations (Stout 1994:83-84,96-97).
Figure 1, presented earlier, depicts an EMS System, with the 911-EMS
agency at the center, augmented by the other active agencies.
17


Types of 911-EMS Patient Care Providers
The four principal types of 911-EMS patient care providers are the Certified
First Responder, the Emergency Medical Technician (EMT), the intermediate
level EMT, and the Paramedic.
A Certified First Responder (CFR) provides care during the initial moments of
an emergency, prior to the arrival of an ambulance. A first responder is often
a firefighter, police officer, or another person who responds to incidents prior
to ambulance crews (Pointer 99).
An EMT renders 'basic life support, which can include administering airway
maintenance, CPR, treatment of hemorrhage and shock, and immobilizing
patients with multiple injuries for transport to the hospital. Based on DOT
guidelines, an EMT certification program requires a minimum of 110 training
hours. During the 1990s, many EMTs were trained to use an Automatic
External Defibrillator (AED) to shock the heart of patients in cardiac arrest.
These EMTs are categorized as EMT-Defibrillation, or EMT-D (Pointer 100).
An intermediate level care provider is called an EMT-Intermediate (EMT-I). An
EMT-I is able to perform the same skills as an EMT, plus defibrillate, start
intravenous lines and, depending upon state guidelines, administer certain
medications as well as intubate. An EMT-I performs many of the same
practical skills as a paramedic (see below), but may not have as extensive of
a knowledge base, and typically would not deliver as broad of an array of care
in the field as a paramedic (Pointer 101).
A paramedic, or EMT-P, receives an additional 750 to 1100 hours of
18


education and training above the basic EMT level. Paramedics have more
extensive assessment skills and a greater knowledge base than the other
911-EMS care providers, which permits them to treat a wide range of
emergent medical, cardiac, and traumatic problems. Paramedics provide
much of the same initial care as provided by physicians in the ED, such as
starting intravenous lines, administering cardiac and other medications,
interpreting EKGs, defibrillating patients, and performing endotracheal
intubation (Pointer 101).
All 911-EMS patient care providers are certified or licensed, and depending
upon each state, renew their credentials every 2 to 4 years via testing and/or
continuing education requirements. In addition, 911-EMS patient care
providers may receive certification by the National Registry of Emergency
Medical Technicians, a private organization that certifies all levels of 911-
EMS patient care providers based on a national standardized test and
continuing education requirement. Many states use or accept the National
Registrys standards and exams as a state testing and certification
mechanism (Caroline 8).
Traditional 911-EMS Provision
Throughout this dissertation, 911-EMS is defined as a government authorized
emergency medical services response agency. Fowler (32-34) writes that
this agency can either be a public agency (e.g., fire department or 911-EMS
Department); a private ambulance service contracted to be a municipal 911-
EMS provider; a public-private partnership (e.g., a fire department/ private
ambulance consortium); a hospital-based agency; a non-profit agency; or a
19


volunteer ambulance service (more prevalent in suburban and especially in
rural areas). 911-EMS can be operated as a city or county agency or as part
of a special district, such as a fire protection district. In most cities, 911-EMS
is accessed the same way as one would call for police or fire department
assistance, by dialing 911.
Table 1 shows the breakdown of 911-EMS Agencies in Americas 200 most
populous cities. In 2001, municipal agencies (fire departments or third
service 911-EMS) were the providers of 911 -EMS in 34% of the cities. In this
type of a system, the local government both finances and provides 911-EMS
activities. Additionally, in 94% of the 200 cities, fire departments provide first
response services. Private (or commercial) ambulance services, for-profit
companies contracted by local government, are the 911-EMS providers in
44.5% of these cities.3
The Public Utility Model is a variation on typical private ambulance provision.
In this method, the local government (in the form of a non-provider 911-EMS
oversight agency) determines the goals desired for the system and then puts
out a Request for Proposals (RFP) to procure services from commercial
providers. The selected provider is responsible for all ambulance care and
transportation, both emergency and non-emergency in the city or area. The
service agrees to perform within specified parameters and under local
government oversight. 911-EMS systems that are hospital-based make up
3% of 911-EMS providers. The remaining 1.5% of these cities provide 911-
EMS via police or volunteers (Cady and Lindberg).
3 While this table and most of the discussions in this dissertation are directed towards EMS delivery in Urban areas,
further research can evaluate applicability to suburban and rural areas.
20


Table 1. 911-EMS agencies in Americas 200 most populous cities in
2000
Type of .Service Percentage Number
Fire Department 39% 78
Third Service 911-EMS 12% 24
Private Ambulance* 44.5% 89
Hospital Based 3% 6
Police Department/Volunteer 1.5% 3
Includes Public Utility Models and Not-fbr-Profit
(Source: Cady, G. and D. Lind berg. 2001. *EMS in the United States: 2001 Survey of Providers in the 200 Most
Populous Cities, Journal of Emergency Medical Services, Feb.)
Oversight of a 911-EMS program is primarily a local function with state and
regional participation. Today, state 911-EMS offices are generally responsible
for educational standards and certification of 911-EMS providers, as well as
regulating, licensing and inspecting ambulance services. They are usually not
involved in daily operations (Spruill 37-38; Forbuss, Smith, and Wuertz 19-
20).
Local government typically decides on: the type of system in operation;
whether or not to contract the service out; the type of clinical standards and
protocols to be used by program medical directors; and the oversight
mechanisms used to monitor the service (20).
Braun, McCallion, and Fazackerly found that cities with populations between
400,000 and 1,000,000 provided an average of one ambulance for every
51,223 people, with an average response to the scene of the call of between
5.9 and 7.0 minutes. And these large city agencies average about 2.26 calls
21


per 10,000 people, per day, with an average ambulance unit responding to
3,900 calls per year.
Stout (1994 87)estimates that only 20-30% of 911 calls require paramedic
intervention. Pepe, Matsumoto, and Bass found that of 100,000 calls
examined in a large southwestern city, only 46,000 required transport. Of
these,15,000 needed ALS and 31,000 required BLS only.
Typically, 911-EMS crews respond to calls in an ambulance. The ambulance
is designed and equipped to carry more than one patient, but usually each
crew transports one patient per call. While transportation of a patient takes
place in an ambulance, ensuring the 911-EMS crew gets to the patient has
led to creative and innovative methods of response. 911-EMS agencies have
been known to respond via fly-car4, mopeds, bicycles, horses, or even on
foot, depending upon the situation or need (Lilja, Madsen and Overton 444-
445). In addition, first responder agencies might respond in fire engines, fire-
rescue vehicles, or police cars (Gunderson 29).
As discussed previously, 911-EMS crews are configured as ALS units or BLS
units. An ALS unit is designed to provide paramedic-level care and is
typically staffed by a crew of two paramedics or a combination of one
paramedic and one EMT. A BLS unit consists of an ambulance staffed with
emergency medical technicians.
4 A fly-car is a non-transporting emergency response vehicle (car, van, truck), usually staffed as a paramedic unit,
designed to intercept or provide back-up support to BLS ambulances.
22


Private Ambulance Services and
911-EMS Consolidators
Private ambulance services, for the most part, started as a secondary
business for funeral homes (Fowler 33). Over time, the private ambulance
sector has become a well-developed provider of emergency and non-
emergency services. Some operate as a contracted 911-EMS service, while
others provide purely non-emergency services, or a hybrid of the two. At the
time of the research conducted for this dissertation, there were 625
companies that were members of the American Ambulance Association, the
industry's trade organization. The organization lists approximately 25% to 33%
of all commercial ambulance services as members. Many of these companies
are small services that own only a few ambulances and may be operating in
urban, suburban, or rural areas (Leonard).
Private ambulances provide a mixture of emergency and non-urgent
transportation. It is possible to request an emergency ambulance response via
a private ambulance service through the companys own phone number
rather than through 911. Someone unfamiliar with local 911-EMS access
methods might do this, or a patient who has a particular hospital or non-
hospital destination they need to go to and the local 911-EMS unit cannot
transport there.
While there were many private ambulance services operating on a small
scale, prior to 1997, a few private ambulance services attempted to
consolidate the field. American Medical Response (AMR), MedTrans, and
Rural/Metro Corporation, were the three largest private services in the U.S.
Their strategy has been to purchase many smaller private ambulance
23


services throughout the country in order to combine service areas, purchasing
power, and market share. These companies are publicly traded, and have a
presence throughout the country (Laidlaw Purchasing...).
For example, in 1996, AMR had 11,000 employees, 1,800 ambulances and
operations in 27 states. In 1995, AMR's revenues totaled more than $625
million (American Medical Response 1995 Annual Report). In 1995,
MedTrans had 10,000 employees, 2,200 vehicles in 23 states, and a $600
million revenue (Laidlaw Purchasing..."). In 1993, Rural/ Metro ambulance
service operated in 16 states with $84 million in revenue. Rural/Metro is also
a provider of private fire-fighting services. Rural/Metro began in Scottsdale,
Arizona in 1948 as a privatized fire department, The Company is frequently
cited in privatization literature, including Reinventing Government, as a
positive and effective example of privatization (Osborne and Gaebler 224-
225).
In January 1997, MedTrans, the second largest consolidator, bought AMR,
the largest, for $1.14 billion. MedTrans is the medical transportation division
of Laidlaw, an international company that specializes in fleet-base business
such as school bus transportation and waste removal and management. The
MedTrans name was dropped in favor of AMRs name and logo and was
deemed the new name of the combined company. The merger gave the new
company 14% of the medical transportation business in the U.S. (Laidlaw
Purchasing...").
A large private service is able to handle a larger geographic area than a
smaller service with a limited area. In late 1998, Kaiser Permanente
contracted with AMR to have AMR provide all medical transportation services
24


i
for Kaiser members throughout the country (Austin and Svaldi).
In certain regions in the country, ambulance services have formed alliances
that permit them to compete with the larger private services by combining
their capabilities and coordinating care and transportation with certain health
care insurance payers. The services are able to maintain their individuality,
and provide local services, but combine to share resources if and when
necessary (Clemente).
Emergency Communications
In many communities, dialing the telephone number 911 is the principal
means to access emergency medical services. The National Emergency
Number Association (NENA) explains that 911 is the designated Universal
Emergency Number in wide use across the United States and provides the
public direct access to a Public Safety Answering Point (PSAP), which is
responsible for securing emergency assistance. The number sequence 911
was selected for two main reasons: it was easy to remember, and was a
unique number that had not been used as an area code or as any other code
within the telephone industry. The interest in the concept of 911 can be
attributed primarily to the recognition of characteristics of modem society, i.e.,
increased incidences of crimes, accidents, and medical emergencies,
inadequacy of emergency reporting methods, and the continued growth and
mobility of the population (National Emergency Number Association
Website).
In 1967, the Presidents Commission on Law Enforcement and Administration
25


of Justice, with the support of other federal government agencies and
officials, recommended the creation of a single universal number to report all
emergencies. The first 911 call was made in Halleyville, Alabama in February
1968. Today, 911 covers 85% of the population of the United States. Ninety
-five percent of that coverage is though enhanced 911 (E-911), where the
number and location of the phone used to make the call is transmitted to the
PSAP (National Emergency Number Association Website). The other 15%
use a seven-digit phone number or call the telephone operator to call for
emergency assistance.
Mayron, Long, and Ruiz studied the Minneapolis-St. Paul areas transition into
911, which was introduced in the Twin Cities in 1982. Prior to this transition,
there were over 100 different seven-digit telephone numbers used to access
emergency services in the area. Mayron, et al found 911 was a more efficient
means of activating 911-EMS than multiple seven-digit phone numbers.
Additionally, they found that when 911 is the emergency telephone number,
85% of the public knows it, compared to 36% to 47% of the public when the
telephone number is seven digits.
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Components of a 911-EMS Communications System
Rousch and Paris describe the components of a 911-EMS communications
system: Access Points, Communications/ Dispatch Centers, Dispatchers,
Dispatch to Ambulance Communications, Ambulance to Ambulance
Communications, and Ambulance to Hospital Communications (109-118).
Specifically, the two researchers explain that all 911-EMS systems require a
convenient and reliable Access Point to initiate a 911-EMS response by any
citizen in need This access point is typically accomplished by dialing 911.
Rousch and Paris maintain that a universal emergency number is desirable
because it permits rapid access to all emergency providers.... even in
unfamiliar territory, and that an ideal situation would include a dispatch
center for an entire 911-EMS region that would direct several adjoining
political subdivisions facilitate appropriate emergency response, and eliminate
confusion."
Both Rousch and Paris explain that the Communications/Dispatch Center or
PSAP must be capable of handling day-to-day operations as well as
infrequent but serious circumstances, such as disasters. Communications/
Dispatch Centers may be freestanding, serving only a 911-EMS agency, or
may be part of a multi-department center with police, fire, and 911-EMS
dispatching all from one location.
A 911-EMS Dispatcher establishes the urgency of the call and the nature of
the response including number of vehicles and knowledge of local geography
and available resources. A dispatcher also aids 911-EMS crews in the field by
providing information regarding location of the call, medical complaints,
27


hazards, and other pertinent information (Augustine 118-124). Computer
technology is used to aid dispatch center and call takers with programs that
will prioritize calls, help call takers give pre-arrival instructions, and coordinate
unit responses.
All 911-EMS Communications systems require the capability for Dispatch to
Ambulance, Ambulance to Ambulance, and Ambulance to Hospital
Communications. This enables the crew to receive the call from the
dispatcher, to communicate with each other while en-route or on the scene of
a call, and to communicate with an EO physician for further medical advice if
needed (Roush and Paris 113-116).
The Use of 311 as an Alternative Non-Emeraencv Access Point
Due to an increased use of 911 for non-emergency situations, Baltimore,
Dallas, and San Diego are among a few cities that have added an additional
access number for non-emergency situations. The new number, 311, is used
in Dallas for information about non-emergency city services. Promotions for
the use of the 311 number in Dallas stated if it doesnt involve police, fire, or
[911-]EMS, 311 is your call to City Hall. Any requests that might require an
emergency response are automatically shifted to a 911 dispatcher for
attention and prioritization (Nordberg 32-33; Furey 34-36).
In Baltimore and San Diego, the 311 number is used for non-urgent public
safety situations, reserving 911 for 'emergencies.' The use of the 311 number
conflicts with the philosophy that led to the development and use of 911. In
the Chapter 4, the St. Louis 'EMS Plus example demonstrates a city that
28


maintains a single 911 access point and filters non-urgent cases and
informational inquiries to other sources (Nordberg 32-33).
Priority Dispatch Systems
With more frequency, 911-EMS dispatch centers are using a form of what is
called a Priority Dispatch system. This system is designed to aid a 911-EMS
dispatcher in prioritizing incoming calls and for advising a caller on initial first
aid techniques prior to a 911-EMS crews arrival. Dr. Jeff Clawson, who
created the most used priority dispatch program in the country,5 dispelled
certain myths about emergency dispatching. Clawson explained that callers
to 911 often do not panic and are able to provide required information;
dispatchers can provide pre-arrival instructions to callers; and responding to
all calls with lights and sirens is not always required (125-146).
Curka, Pepe, Ginger, Sherrard, Ivy, and Zachariah also have examined the
effectiveness of a 911-EMS priority dispatch system. They found that
computer aided [911-]EMS priority dispatch system can safely and reliably
delineate a large percentage of [911-]EMS incidents that require only BLS
care, thus making paramedics available for more serious calls" (51). They
reported that an extremely small number of cases that could have used
paramedic care may not be detected, and the resulting effects of these calls
on patient outcome were negligible. They found that many important
operational, training, and cost-effective patient care benefits were realized
with this type of system (51). Their study did not look at excluding or Routing
patients from 911 response to other sources of services.
9 The Medical Priority Dispatching System (MPDS)
29


Recently, 911-EMS Priority Dispatch algorithms have taken into account non-
urgent calls to 911. Protocols have been developed that can identify when
callers do not need a 911-EMS response. An example of this can be found in
Chapter 4, the discussion about St. Louis 911-EMS Routing program.
Phases of Emergency Response
Fitch writes that a principle aim of 911-EMS is to minimize the time to
definitive care for victims of certain types of illness and injury.... [EMS
Systems] must consider how to minimize discovery and reporting times,
improve dispatch and crew alert functions, effectively utilize first responders,
reduce scene times, and transport to the appropriate facilities (602).
A synthesis of writings from Gunderson; Forbuss, Smith, and Wuertz; Werner
and Smith; and Fitch provide a comprehensive overview of the chain of
events that typically make up the 911-EMS response process. Figure 2
provides a simplified diagram of the phases of Emergency Response.
i
1
30


Figure 2. Phases of emergency response
31


Pre-Arrival/ Dispatch
A call to 911 is answered at a dispatch/ communications center, or the PSAP.
Typically two 911-EMS crews, one in an ambulance and a first responder
crew in other emergency vehicles, are dispatched simultaneously. The
dispatcher deploys the appropriate type of ambulance (ALS or BLS) and
coordinates the crews in the field as they respond, arrive on-scene, and as
they are enroute to the hospital. An often-cited standard for an 911-EMS
response is that 90% of the time, a 911-EMS crew should arrive on-scene in
a life-threatening emergency in 8 minutes or less from the time the call
reaches the PSAP. The first responder unit should get to the scene typically
in 3 to 4 minutes.
A call-receiving operator (CRO) is the person in a PSAP that receives most
911 calls. Most PSAPs are staffed with both CROs and dispatchers. CROs
secure the information necessary to deploy the appropriate level of 911-EMS
response to the right location. In many cities, CROs and dispatchers are
trained as emergency medical dispatchers (EMDs). EMDs are trained to ask
specific medical questions that are designed to determine acuity and to aid
the crews preparation during response. In addition, EMDs are trained to
provide pre-arrival instructions that direct callers on how to render first aid
while the response is en route.
The dispatcher is responsible for maintaining communication with the crews;
and directing the crews as they respond, while they are on-scene, and en
route to the hospital.
i
32


911-EMS Deployment
Depending upon 911-EMS agency policy, regional regulations, and
contractual arrangements, response units are deployed in either a one or two-
tiered response. Braun, et al writes that a provider may use an all ALS
response, called a single-tiered response; or a combination of ALS and BLS
response, called a dual-tiered response. There are three types of dual-tiered
responses typically found in mid-sized cities. In the first method, an ALS unit
is dispatched to all calls. If a callers condition is serious and that caller needs
paramedic care, the ALS unit will transport the patient to the hospital. If the
person is not in need of the higher level of care provided by paramedics, they
are transported by EMTs in a BLS unit. In the second method, a dispatcher
triages incoming calls and sends an ALS or BLS unit based on information
received. A patient can also be triaged on-scene, if necessary. In the third
method, two units respond, an ALS crew in a first response, non-ambulance
vehicle, and a BLS ambulance. Depending upon the condition of the patient,
the ALS crew may accompany the BLS crew to the hospital.
Gunderson writes that there are two general models for emergency
deployment, static and dynamic. Static deployment uses fixed locations to
position the ambulances in a set area, and except when on a call, the unit is
based at that location. The strategy is that dispatchers will send the units
closest to the emergency based upon the prearranged location of the
ambulances (29).
A static system does not account for variances in patterns of emergency calls.
Dynamic models are much more complex, looking at factors such as call
location, time of day, day of week, and time of year, to aid in developing a
33


response model to call patterns. 911-EMS vehicles in dynamic systems are
positioned to provide an optimum level of response based on changing call
patterns. The most common model is known as system status management.
There are also hybrids of static and dynamic modeling (Gunderson 29).
Some 911-EMS agencies use automatic vehicle locators (AVL) to aid in
dispatching. An AVL works via Global Positioning System (GPS) technology,
where transmitters, which are located in each ambulance, bounce a signal off
of a satellite. A dispatcher is able to track the location and status of ail
agency ambulances and can then dispatch the vehicle closest to the
emergency.
A popular measure of productivity of 911-EMS units is the Unit Hour
Utilization, or UH/U. The UH/U is a ratio that is equal to the total transports
divided by the total number of unit hours. A unit hour is each hour that a fully
staffed and equipped ambulance unit is on duty and available to respond to
calls" (American Ambulance Association 22). As a comparative measure, a
UH/U ratio close to one indicates that a unit is more productive than a unit
with a UH/U ratio closer to zero.
On-Scene Treatment
While care of an emergency patient often begins with pre-arrival instruction
from a dispatcher, the arrival of a first response unit stops the 'response
clock.' First responders, typically from local fire departments, provide on-
scene care before a 911-EMS crew arrives via ambulance. First responders
may be ALS or BLS level responders, depending upon local policy.
34


As discussed, responding 911-EMS crews are typically configured as either
an ALS or BLS ambulance. Paramedic ambulances are mobile emergency
rooms, equipped with much of the same equipment as an ED. Paramedic
units receive medical supervision (via radio or telephone) by a physician
located at a hospital emergency department.
Paramedics treat emergent and urgent patients on-scene with a combination
of standing orders and medical control orders. Standing orders consist of
treatments that can be carried out before contact with the physician is made.
Medical control orders are interventions that a physician authorizes the
paramedic to provide after radio consultation.
While there is a National Paramedic Curriculum that is typically followed by
states, each city or region uses their own treatment protocols. This variation is
based on the fact that local physician medical directors develop paramedic
protocols.
BLS crews are capable of providing the care necessary for many 911-EMS
responses. Many BLS units are equipped with AEDs (Automatic External
Defibrillators). Emergency medical technicians receive additional training to
use an AED to administer an electrical shock to patients who require it (based
on a computer program in the AED unit).
Transport and Transfer of Care
At the emergency department, the ambulance crew places the patient on a
hospital stretcher and officially transfers the patient over to ED staff, who then
35


takes over the care and control of the patient. The 911-EMS crew completes
a report for the patient, restocks and cleans the vehicle, and then returns into
service, available for the next call. Figure 3 provides a scenario as an
example of a complete 911 -EMS response.
The ED is a hospital unit designated to provide unscheduled outpatient
services to patients who need immediate medical care (GAO 2). The
American College of Emergency Physicians reports that as of 1996 there
were 32,000 ED Physicians and 75,000 ED nurses working in more than
5,000 EDs throughout the country. Federal Legislation (PL 99-272, also
known as EMTALA) mandates that all patients that present to an ED must be
assessed for severity of condition. Those with an emergency need must
receive treatment, regardless of their ability to pay for care (Zydlo 459-460).
The transport of an emergency patient depends upon a combination of the
patients condition and local policy. The choice of an ED can also be a
crucial decision. Critical trauma patients are usually transported to a trauma
center, bum patients are transported to bum centers, and so on.
36


Scenario. A 55-year-old accountant, who has health care
insurance from a 'fee-for-service indemnity insurer1 (such as
Blue Cross/ Blue Shield), experiences chest pain. A family
member dials 911 for help. The 911 dispatcher in the PSAP
dispatches a fire department first responder unit staffed with
paramedics as well as a paramedic ambulance from the 911-
EMS agency.
The first responder unit arrives on scene within 4
minutes of the phone call. They begin care, checking the
patient's pulse, blood pressure, and cardiogram, and begin
administering oxygen. The paramedics arrive within 7 minutes,
and continue gathering information about the patients history,
while they initiate an IV. Based on existing protocols and in
telephone consultation with an Emergency Room Physician,
they administer medication to help stabilize the patients
condition.
The patient is transported to the hospital without
incident, is diagnosed with a Myocardial Infarction (heart
attack), and admitted to the CCU. After discharge the patient
continues care directed by the family physician and the
patients cardiologist.
Figure 3. An example of a complete 911-EMS response scenario.
37


Financial Aspects of 911-EMS Services
Americans spent $1,035 trillion dollars on heath care in 1996 (HCFA, 1999).
This has been increasing steadily, up from almost $700 million in 1990 (an
increase of 148%) and almost $250 million in 1980 (an increase of 419%).
Torrens and Williams (1993) cite four main explanations for the increase.
First was the expansion of our supply of healthcare facilities and beds. This
began after WWII and was primarily due to the Hill-Burton Program that
improved access to healthcare throughout the nation. Second was an
increase in the number of physicians available throughout the U.S. and an
increase in demand for physicians (as well as subsidization of medical
schools). Third was the expansion of availability to health insurance
coverage. This expanded coverage came through private insurance offered
by employers as well as Medicare and Medicaid offered by Federal and State
governments. Fourth was the growth in medical science and healthcare
technology. Since WWII tremendous leaps have occurred in science and
technology that allow physicians to diagnose and treat illnesses and injuries
that could not have been done previously (422 423).
Estimates place the cost of emergency care (ED and 911-EMS) between $29
billion dollars and $36 billion dollars (Tyrance, Himmelstein and Woolhandler
1996, Rabin 1996, Skeen 1996, United States Senate. Special Hearing 103-
227). It is also estimated that the cost to provide 911-EMS in the U.S. is
estimated at $6.75 billion per year (National Highway Traffic Safety
Administration 1996 21).
38


Many EDs, often in urban area, have found themselves at times lacking the
financial resources to provide a full range of emergency services. This is due
in part to the high number of uninsured and Medicaid patients that use the ED
as their source of primary care. Hospitals collect little from these populations.
In an environment with mixed socio-economic classes, the hospitals can cost-
shift through billing patients with commercial insurance. In some urban areas
there is often not enough of a commercially insured population to make up the
difference in costs. These EDs rely on government and private grants and
subsidies to continue to maintain services.
Cost control mechanisms have been instituted to address the rising costs of
overall health care and ED care. Historically, MCOs have approached
controlling costs for health service by reducing the length of hospital stays
and shifting care to outpatient services. Routing by its design and mission
has the potential to assist the hospitals and health care providers control
unnecessary use and costs.
911-EMS Costs
Personnel expenses are the largest expense for a 911-EMS provider.
Although there are regional differences, one ALS ambulance can cost
$750,000 per year or more to operate on a 24-hour basis. This includes
personnel, equipment, vehicle, and support services. As discussed, a
medium-sized city provides, on average, one ambulance for every 51,000
people and responds to an average of 3,901 calls per ambulance per year
(Braun, et al.; Swor 77).
39


Table 2 demonstrates the actual year 2000 expenses of a 911-EMS agency
for an example city of 400,000 people and a call volume of 82,555 per year.
The 911-EMS agency provides only ALS (Paramedic) ambulances and first
response is provided by the fire department through BLS engines.
In this example, city personnel expenses make up 73% of the agencys
expenses, accounting for $8.7 million of the $11.9 million dollars in operating
expenses. The average cost per response is $144.25.
40


Table 2. Expenses associated to a traditional 911-EMS agency that
provides 911 -EMS for a city of 400,000
Responses 82,555
Number of Patient Transports 49,481
Average Daily Units 16.67
Personnel Expenses Total Per Response
Administrative $1,579,403 $19.13
Field Personnel $5,471,713 $66.28
Communications $375,183 $4.54
Benefits $1,299,602 $15.74
Total Personnel Expenses $8,725,901 $105.70
Other Expenses Total Per Response
Medical Director $150,000 $1.82
Supplies $596,866 $7.23
Fuel $170,027 $2.06
Vehicle Maintenance $661,801 $8.02
Insurance $179,000 $2.17
Depreciation $632,164 $7.66
Other $226,085 $2.74
Admin. Overhead $567,092 $6.87
Total Other Expenses $3,183,035 $38.56
Total Expenses $11,908,936 $144.25
Avg. Cost Per Response
41


I
Funding for 911-EMS Delivery
The federal government, believing that 911-EMS should be administered
through states, regions, and localities, provided seed money in the late 1960s
and early 1970s for demonstration projects to help get 911-EMS programs off
the ground. The majority of federal funding (except for Medicare and Medicaid
reimbursements) for 911-EMS ended in 1982. Most federal grants available
today are for special programs such as trauma research or the EMS for
Children Project (Swor 76-79; Mustalish and Post 7-12).
Most funding for 911-EMS comes from local and state sources, and insurance
payments. Typically, methods of funding 911-EMS include financing via
existing tax base (from a general fund), tax subsidies, fee for service (user
fees), and subscription fees. Funding might also come from vehicle
registration fees, drivers licenses, special tax districts, or local taxes (Fowler
32-33; Rousch and McDowell 15,16; Swor 79; Stout 214-216). Table 3
shows the typical funding sources for 911-EMS delivery.
i
i
I
i
42


Table 3. Funding sources for 911-EMS delivery
Category Funding Source
Fee-for-Service (User fees) Patients and their insurance companies, including MCOs, indemnity insurers, Medicare, Medicaid, and seif-pay
Tax Base Property taxes, special district funding
Subscription Private Citizens, Corporations, Communities/ Business Districts
Donations Private citizens, foundations, (primarily for Volunteer Services
Grants Foundations, Federal, State, and Local Government (very limited)
(Sources: Swon Mustalish and Post)
Fee-for-service billing (user fees) represents the major method of payment for
most (but not all) 911-EMS services. 911-EMS agencies typically bill patients
for services rendered. The payments come from several sources including
Medicare, Medicaid, private insurance, private paying patients, and Managed
Care Organizations (MCOs). For example, the total ambulance fees paid by
Medicare in 1993 was $1.5 billion, covering 3 million beneficiaries (Senate
Hearing, 1995 103-227), less than 1% of the Medicare Budget. In August
1996, The NHTSA estimated that the cost to provide 911-EMS in the United
States is $27 per capita, with total costs estimated at $6.75 billion per year
(National Highway Traffic Safety Administration 1996 21).
Insurers determine what they will pay for care using two principal methods, a
contracted rate or an examination of usual and customary charges in a
region. Medicare, for example, does not base payments on resource costs,
but charges. Ambulance companies are paid based on what they have
43


charged in the past and what other companies in the area charge (Senate
Hearings 103-227, 23).
Medicare approves payments for ambulance services only if the patient could
not be safely transported by other means. Table 4 outlines the nine situations
that presume that medical necessity has been met as specified in Section
2125 (2) (a) of the Medicare Carriers Manual.
44


Table 4. Medicare standards for medical necessity for ambulance
services
Medicare applies if the patient:
1. was transported in an emergency situation
(i.e. as a result of an accident, injury, or acute illness), or
2. needed to be restrained, or
3. was unconscious or in shock, or
4. required oxygen or other emergency treatment on the way to his/her
destination, or
5. had to remain immobile because of a fracture that had not been set
or the possibility of a fracture, or
6. sustained an acute stroke of myocardial infarction, or
7. was experiencing severe hemorrhage, or
8. was bed-confined before and after the ambulance trip, or
9. could be moved only by stretcher
(Source: Section 2125 (2) (a) Medicare Carriers Manual)
A December 1998 report issued by Medicare stated that Medicare paid as
much as $104 million for medically unnecessary ambulance trips. In spring
1999, Medicare began a negotiated rule-making process to develop a
national Medicare fee schedule for ambulance services to standardize fees
paid and reduce their payments for unnecessary utilization (HCFA
Announces..."; "National Medicare Fee Schedule..."). Additionally, the
negotiated rulemaking process has led to a call for even more stringent
definitions of when and how Medicare will approve ambulance use by a
Medicare patient.
This can lead to 911-EMS services relying more on non-emergency transport
45


services (wheelchair vans) to augment emergency ambulances, and to
improve dispatch and triage processes to ensure that a caller with non-urgent
medical needs receives the appropriate level of services for their condition.
These two activities are used effectively in the city of St. Louis, MO, and are
discussed in Chapter 4.
Fees for 911-EMS
Fees for 911-EMS vary by region, type of insurance provider, and type of
service provided (paramedic versus BLS). The average fee for BLS in the
200 most populous cities in the United States in the year 2000 was $272 per
transport. For ALS the average fee charged was $410 (Cady & Lindberg).
911-EMS agencies respond to all requests without consideration of ability to
pay. Often 911-EMS collects 60% or less of their bills (Darlin), although many
large urban 911-EMS agencies have a considerably lower rate (Atlanta, New
York City, Chicago). For example, the collection rates for 911-EMS agencies
in the Front Range of Colorado (Ft. Collins to Pueblo including all of the
Greater Denver Area) in 1995 were 63.29%, based on information from the
Colorado Department of Public Health and Environment. This collection rate
is also sometimes higher than hospital collection rates.
This rate may be due in part to a high number of uninsured patients, poor
data collection, and denials from insurance companies. Private non-
emergency transports typically have a high collection rate, often over 90%.
This is due to the fact that these calls typically are prescheduled, with
payment arranged in advance. Private services are proprietary and not under
obligation to respond to service requests, although Private services that are
46
l


contracted to provide 911-EMS services are obligated to respond to all
emergency requests.
Utilization of 911-EMS and EDs
In 1999, approximately 103 million people visited EDs throughout the United
States (National Center For Healthcare Statistics, 2001). As many as 14.6
million patients arrive at a hospital in 911-EMS ambulances. Estimates are
between 2.9% and 3.6% of the $1 trillion health care market are devoted to
emergency care (Tyrance, Himmelstein and Woolhandler, Rabin, Skeen,
Senate Medicare Hearings 103-227). Table 5 presents the number of ED
visits and 911-EMS transports in the United States from 1992 through 1999.
47


Table 5. ED visits and EMS use in the United States (1992 -1999)
Year ED Visits Change in ED Visits 911-EMS Transports
1999 102.8 million + 2.4 million 14.6 million
1998 100.4 million + 5.5 million 14.3 million
1997 94.9 million +4.6 million 13.5 million
1996 90.3 million - 6.1 million 12.8 million
1995 96.4 million + 3 million 13.7 million
1994 93.4 million + 3.1 million 13.3 million
1993 90.3 million + 500 Thousand 12.8 million
1992 89.8 million 12.8 million
Source: National Center for Health Care Statistics 1995-2001
With a focus on cost-savings and streamlining, some EDs have developed
walk-in urgi-centers, adjacent to the ED, designed to treat non-urgent patients
in a clinic setting. Other EDs refer non-urgent patients to other medical
settings after they have been evaluated. This decreases costs for care, does
not violate 'anti patient-dumping laws and may also fall within the guidelines
for reimbursement fostered by MCOs (Greene, J. 37-40). Unfortunately all
areas do not have the same access to alternative primary care sites.
48


Studies Examining Utilization of 911-EMS
While one might think that people reserve the use of 911-EMS or Emergency
Departments for life-threatening emergencies, this is often not the case.
People with conditions that could be handled outside of the emergency care
system often use these emergency services, which taxes the system and is
more costly than going to other sources of help. There have been several
studies that have looked at 911-EMS and ED utilization.
In the 1966 seminal study of the appropriateness of emergency services
utilization, Weinerman defined and studied acuity levels of patients presenting
to EDs. Acuity Level refers to the seriousness of the illness or injury and how
rapidly one requires medical intervention to minimize potential damage or
death sustained by not receiving timely medical care. Levels can be defined
as:
emergent: condition requires immediate medical attention; time delay
is potentially threatening to life or function;
urgent: condition requires medical attention within hours; there is
possible danger to the patient if medically unattended; and
non-urgent: condition does not require the resources of an emergency
department (ED); referral for routine medical care is sufficient.
While he found that the conditions of 58% of patients presenting to an ED
were non-urgent, 36% urgent, and 6% were emergent, he also warned that
patients are often unable to make these distinction of urgency and err in both
over and under-interpreting the gravity of symptoms."
Table 6 summarizes the major studies of 911-EMS utilization. A common
difficulty in each of these studies is that they do not use a standard term to
49


represent those patients that do not have emergent or urgent conditions. The
terms non-urgent, routine, inappropriate, mis-use and unnecessary are all
used. There is a difference between unnecessary and non-urgent. It is
possible that a patient with a non-urgent problem might need a BLS
ambulance for transport to the hospital. This is different than a 911-EMS call
that is unnecessary. All of the terms, however, do refer to patients that are
not classified as urgent or emergent and could receive medical care in non-
emergency department settings.
able 6. Studies evaluating 911-E MS utilization
Study \ i . , Study Year % Non- Urgent % Urgent and Emergent Term Used in Study Size
Schuman, Wolfe & Sepulveda 1977 35 65 Routine 133
Gibson 1977 31 69 Inappropriate 1,787
Morris & Cross 1980 52 48 Unnecessary 1,000
Rademaker, Powell, & Read 1981 42 58 Inappropriate 518
Knickman, Smith & Berry 1991 25 75 Unnecessary 896
Brown and Sindelar 1993 44 56 Misuse 145
Use of 911-EMS by patients with a non-urgent condition can be attributed to
multiple issues. A primary reason is the absence of adequate primary care
service utilization due to either health care access barriers or local culture.
Many in this group use the ED as their source of primary care. In this
situation, 911-EMS becomes a vehicle to transport non-urgent patients to the
emergency department (ED) and costs escalate to deliver routine primary
medical care (Government Accounting Office 4-5; Giordano and Davison 38;
Otto 363-364).
50


Another major issue is an individuals failure to recognize what constitutes a
medical emergency or medically urgent situation. As a public good, 911-EMS
responds to all requests for emergency assistance. Either the ill or injured
person or witnesses on the scene make the call to 911-EMS. The information
relayed to a 911 operator, therefore, depends on the level of acuity perceived
by the citizen-caller. These 911 calls may also be based on a citizens lack of
knowledge regarding emergencies and how to analyze the situation. Citizens
also often place calls to obtain guidance.
In addition, it can be difficult for the 911 operator to determine who the non-
urgent patients are. Stout observes that approximately 90% of calls for 911-
EMS are made by a family member or bystander and not the patient. A call
with a chief complaint of difficulty breathing may be for a patient experiencing
heart failure, a lung infection, an asthma attack, a severe allergic reaction, or
merely common cold symptoms. Each scenario would require a different
treatment protocol by a 911-EMS provider. Over the past few years, a
number of programs and algorithms, such as the Clawson Medical Priority
Dispatch System, have been developed to aid 911-EMS dispatchers and call-
takers in call triage. These programs typically do not deny a caller care,
rather, they are designed to recommend both the level and to prioritize
rapidity of response by the 911-EMS agency. More recent programs are
moving to developing algorithms that classify people as not requiring a 911-
EMS response (Otto 364-367), although the decision not to send a 911-EMS
response is a local policy decision (this is discussed in greater detail in
Chapter 4).
As Knickman, Smith and Berry and others have shown, those calling for 911-
51


EMS are often unable to determine the severity of their medical condition.
These researchers found that in 56% of the low priority cases they
researched, the person that called for an ambulance believed the patient was
going to die. In addition, Gifford, Franazak, and Gibson found that 73% of
patients interviewed felt they had an urgent/emergent condition while the
physician reviewers felt that only 39% fell into that category.6
Studies Examining Utilization of EDs
Emergency Departments have had similar findings when examining their non-
urgent population. A January 1993 report from the GAO entitled Emergency
Departments: Unevenly Affected by Growth and Change in Patient Use,
reported of the almost 100 million patients seen in an ED in 1990,43 million
could be classified as non-urgent. Across the various studies, the percentage
of non-urgent cases that arrived in the ED ranged from 12% to 55%. See
Table 7 for studies researching the utilization of EDs.
6 There is also a population of 911-EMS users who misuse the service, calling with the knowledge that they require
non-urgent, dinic level care. Induded among the reasons for this abuse is that the callers do not have a means to
get to medical care. Gatekeeping and managed care seeks to ensure these patients receive appropriate care
without needlessly using 911-EMS and EDs.
52


Table 7. Studies of appropriate utilization of emergency departments
Study Year Published % Non- Urgent % Urgent & Emergent Category of non-urgent Sample Size
Weinerman 1966 58 42 non-urgent 2,028
Jonas 1976 50 50 non-urgent 660
Gifford * 1980 33 67 Delayed 10,253
Buesching * 1985 12 88 Inappropriate 3,117
GAO 1993 43 57 Non urgent 689 hospitals A'
DHHS 1994 55 45 Non urgent 36,271
DHHS 1996 53 47 Non urgent 26,547
Derlet * 1995 18 82 Non emergency 176,074
Williams 1996 32 68 Non urgent 24,010
* Denotes Prospective Case Review. Ail others are based on retrospective review.
A Based on data gathered from survey of 689 hospitals and total patients seen)
The studies by Buesching et al.; Derlet et al.; and Gifford et al. all utilized
prospective case review. The results offered lower-end (12%, 18% and 33%,
respectively) rates of non-urgent cases. It is often difficult to classify an
emergency as the event is happening. Often a patients acuity is unclear until
many diagnostic tests are performed and interpreted.
Gill and Riley examined non-urgent use of EDs from a patient's perspective.
Their goal was to ...examine ED patients' perceptions of urgency, and to
53


determine whether patients with no regular source of medical care are more
likely to use the ED for problems they perceive as non-urgent. They found
that 82% of patients classified by the ED staff as non-urgent rated their
condition as urgent. For the respondents, the most common reason for
seeking care in the ED was expediency. They found ...patient-rated urgency
was not associated with having a regular source of care," concluding Simply
providing patients with a regular source of care is unlikely to have a significant
impact on non-urgent ED7 utilization without efforts to manage utilization and
ensure adequate access to primary care.
Another study, by Young, et al set out to characterize the reasons
ambulatory patients use hospital EDs for outpatient care and to determine the
proportion of ED patients who initially are assessed as having non-urgent
conditions, but subsequently are hospitalized. The researchers examined a
nationwide sample of visits in 56 EDs in a 24-hour period.
Young, et al concluded that most patients entering an ED in ambulatory
condition seek care in an ED because of worrisome symptoms or non-
financial barriers to care. They also found that most patients that were
initially classified as non-urgent were ultimately treated and discharged by the
ED. However, a small but disturbing percentage (5.5%) was admitted to the
hospital directly from the ED. If this proportion reflects the experience of EDs
nationwide, as many as 2 million non-urgent ED patients each year are
admitted to the hospital.
54


EMTALA. Triage, and Diversion of Emergency Patients Upon Arrival to
the ED. Upon arrival to an ED, patients are screened by a triage nurse or
emergency physician, and then categorized and treated in order of
seriousness. Federal legislation known as Emergency Medical Treatment and
Labor Act (EMTALA) which was passed as part of The Consolidated Omnibus
Budget Reconciliation Act of 1986 requires that all patients arriving at an ED
are screened and those in need receive stabilizing treatment by medical-
personnel. The law does not require the ED provide care unless the patient
has been determined to have an emergency medical condition.7
Hospitals with emergency departments that participate in the Medicare
program (most) have two basic obligations under EMTALA. First, they must
provide a medical screening examination to determine whether an emergency
medical condition exists. Second, where an emergency medical condition
exists, hospital must either provide treatment until the patient is stabilized, or
if they do not have the capability, transfer the patient to another hospital
according to EMTALA provisions. This care cannot be delayed by questions
about methods of payment or insurance coverage. Emergency departments
also must post signs that notify patients and visitors of their rights to be
examined and to receive treatment. EMTALA issues typically do not apply to
the provision of 911-EMS (Lazar, 1992).
Derlet, et al, in a 5-year study performed through the ED at the University of
California, Davis (UC-Davis) Medical Center found that patients arriving at an
ED with non-emergency (similar to non-urgent) conditions can be
7 The American College of Emergency Physicians (ACEP), in a 1988 position paper recommends that
all patients should receive an evaluation commensurate with needs. They recognize that an MCO
might desire to treat their member in a different surrounding. They also advocate that health plans that
utilize private ambulances should integrate them into the local 911-EMS system.
55


prospectively recognized and triaged out of an ED. These researchers also
reported that the integration of a referral network for non-urgent patients by
the ED to community clinics and primary care facilities aided the program.
In their study, the hospital was able to triage out 18% of the patients arriving
at their ED. While the study showed 0.4% triage errors, there were no
serious adverse outcomes. They reported a potential 5-year cost-avoidance
to the hospital of $3,696,735 for diverting 31,065 patients to non-ED facilities
or $150 per diversion. They could not predict actual savings, because they
did not know the payer mix of the triaged-out patients. They pointed out that
most of the studies with a 40% and above non-urgent rate are utilizing
retrospective review. They propose that real-time prospective review is far
more difficult than twenty-twenty hindsight.
Lowe, et al reviewed the guidelines used in the UC-Davis ED and used in
Deriets 1990 and 1992 studies. They concluded that Derlets guidelines may
not be appropriate as a universal template for patient triage. They also
commented that the UC-Davis EDs laudable relationships with area primary
care providers and clinic might not be possible in places that cannot support
such a primary care network.
The accuracy of triage systems have come under scrutiny. Brillman, et al
found that there was a great deal of variability among physicians, nurses,
and a computer program with regard to triage decisions. There are no
national standards for triage determinations among physicians. Other studies
(Gifford, Franaszek and Gibson; Foldes, Fischer, and Kaminsky), also noted
differences in perspective amongst physicians in determining triage priorities.
56


Gadomski, et al studied outcomes of children with managed care Medicaid
that had non-emergent conditions that were not authorized by their PCP to be
seen in a Pediatric Emergency Department. They concluded that diverting
children with non-emergent conditions to their PCPs was a safe short-term
practice. However, they also questioned the impacts of gate keeping, as they
found the diversions did not change the utilization patterns of the ED by most
of the children (or more likely their caregivers).
Telephone Triage / Nurse Advice Lines
Telephone triage lines, or nurse advice lines are not only for emergency
situations. They are seen in a variety of settings including physicians
practices, MCOs, hospitals and clinics, school and university health
programs, and call centers devoted to health information and education.
Wheeler writes that a decentralized health care system has resulted in the
increase in nurse advice lines as a means for patients to get assistance and
information (8). Richards writes that some nurse advice line services claim
they can divert more than half of the callers to less expensive treatments.
Currently there are hundreds of organized call centers devoted exclusively to
telephone health services and staffed by specially trained RNs (The WEBster:
Nursing and Telephone Triage).
Registered Nurses, via telephone, speak directly to patients, clients, or
consumers, assisting them in determining the urgency of care needed,
referring or scheduling appointments with physicians, and providing health
information and advice to the caller (The WEBster: Nursing and Telephone
Triage). Telephone triage/nurse advice services generally started in the
57


members in 1994, up from 400,000 one year earlier. Their nurses do not give
strict diagnoses or suggest specific treatments. Access estimates that it saves
the state of Tennessee up to $7.4 million dollars annually by through their
handling of 620,000 Medicaid clients. Oregon has saved approximately
$257,600 in ED costs by using a nurse advice line (Richards).
Access Health promotional literature explains that by using their system, a
person with lower back pain that could be handled by phone would cost 25%
less that an MCO office visit and would cost only 6% of what Medicaid would
charge for a similar ED visit.
Cost of a nurse advice line to an MCO or employer is approximately 50 cents
to 1 dollar per month per employee (Miller). Employee Managed Care of
Bellevue, Washington estimates that they can divert up to 8 of 10 callers from
going to an ED. Employee Managed Care had 1.5 million members in 1996,
up from 600,000 the year before. Nurseline, the nurse advice line division of
United Healthcare currently has 6 million enrollees. Health Decisions in
Golden, Colorado grew from 16,000 subscribers to 300,000 in 1995
(Richards).
Lowes writes of the Patients Advisory Nurse (PAN) Service used by Carle
Health Care in Champaign-Urbana Illinois since 1986. Receiving 12,000 to
14,000 calls per month, the service has received high satisfaction ratings from
its consumers, and has no suits alleging malpractice by the nurses.
Connolly writes about other nurse advice line centers. Employee Managed
Care Corporation in Seattle is staffed by 35 nurses and serves 1.2 million
members of MCOs with an expected growth to 3 to 5 million members. They
59


have been operating since 1983 and claimed that savings for the service
come out to 3 dollars for every dollar spent on the service.
Aetna's Informed Health Unit staffs nurses that assist with health care
questions, but do not issue prescriptions or make diagnoses." Access Health
offers both informational tapes and nurse consultation services for more than
one million members of their subscribing MCOs. It is interesting to note that
these services also specify that they are not an emergency service, and will
refer callers to their PCP if a triage nurse determines there may be an
emergency. They also do not call for an ambulance in an emergency
(Richards).
A National Proposal to Include Routing as Part of 911-EMS Delivery:
The National Highway Traffic Safety Administration (NHTSA)
and 911-EMS Delivery
The release of Accidental Death and Disability: The Neglected Disease of
Modern Society by the National Academy of Sciences-National Research
Council in 1966 attracted national attention toward the delivery of ambulance
services. The report explained that, in most cases, ambulances were
inappropriately designed, poorly equipped, and used by inadequately trained
personnel. Additionally, the report stated that more than half of the ambulance
services in the country were provided by morticians.
The Highway Safety Act of 1966 established the Department of
Transportation, who was given the authority to improve EMS delivery,
including the development of the initial EMT curriculum. As part of the DOT,
NHTSA is responsible for addressing issues related to Emergency Medical
60


Services delivery in the U.S. (Foens, 49-54)
While this literature review establishes that 911-EMS is primarily a service
delivered on the local government level, with support from state government,
NHTSA is one of the few federal agencies that continues to be involved with
911-EMS delivery. As stated in Chapter 1, NHTSA facilitated two major
initiatives that affect 911-EMS and Routing: an expert-driven 911-EMS
'Agenda for the Future, and a dialogue between experts in 911-EMS delivery
and MCOs. This discussion addresses these initiatives and how they affect
issues of Routing and 911-EMS delivery.
EMS Agenda for the Future
In 1996, NHTSA released their document titled the EMS Agenda for the
Future. It was the result of a nationwide, multidisciplinary effort, pulling expert
resources, advisors, and reviewers from a wide variety of 911-EMS
stakeholders. Its purpose was to "outline the most important directions for
future EMS development (i). The sections of the agenda titled Integration of
Health Services, and "Public Access [to 911- EMS] directly apply to Routing
issues. Discussion of these two topics follow.
Integration of Health Services. The EMS Agenda for the Future
acknowledges that care provided by 911-EMS does not occur in a vacuum
and that "911-EMS delivers treatment as part of, or in combination with,
systematic approaches intended to attenuate morbidity and mortality.... in
l


this document, the NHTSA panel recommends that 911-EMS agencies seek
to become integrated with other health care providers, organizations and
networks" (10)
The NHTSA panel points out that health care provider organizations and
networks (such as MCOs) must incorporate 911-EMS within their structures
to deliver quality health care. The panel warns that MCOs must not impede a
communitys immediate access to 911-EMS when a perceived emergency
exists (12). The use of Routing by 911-EMS agencies creates an
environment that integrates 911-EMS agencies into settings beyond
traditional public safety response.
Public Access to 911-EMS. In many places where a traditional 911-
EMS service is delivered, the services that a caller might need are not
available through the current 911-EMS services. NHTSA explains in the EMS
Agenda for the Future, ...presently 911-EMS is unsophisticated in terms of
its ability to allocate appropriate resources to match the nature of calls (44).
The example MCO and city agencies that are discussed in Chapter 4 have
addressed some of these issues through the use of Routing programs that
direct callers to a variety of non-emergency services beyond an ambulance
response. This is demonstrated in Figure 4, which proposes a range of
services that 911-EMS can either provide or facilitate for callers.
62



Example of Options Available to 911-EMS Agencies
1. Response by 911-EMS Emergency Response (lights and sirens)
2. Response by 911 -EMS Non Emergency Response
3. Referral to a Primary Health Care Provider/Network
4. Referral to a Social Service Agency
5. Referral or Provision of Non-emergency Medical Transportation
6. Medical Advice/ Information Resources
7. Response by Fire, Police, or Other Public Safety Services
Figure 4. NHTSAs model of EMS responses
(Source: EMS Agenda for the Future; 45)
63


NHTSA sponsored 911-EMS/MCO Roundtables. Additionally a series of
roundtable discussions hosted by NHTSA in 1996 through 1998 and attended
by key stakeholders from the EMS and Managed Health Care communities
discussed the concept of "multiple option decision points for 911-EMS
response" in which 911-EMS agencies can influence patient care and
transportation issues through dispatching (911-EMS response versus a nurse
advice line), on-scene care and treatment (without.patient transportation), and
transporting to various sources of care (EDs, Doctors Offices, Clinics, Urgi-
centers). Essentially, ...rather than offering a uniform response to all callers,
the 911-EMS system may create unique clinical pathways for each patient.
(National Highway Traffic Safety Administration, 1998)
The NHTSA expert panel identified principles that it believes will lead to
solutions beneficial to both 911-EMS delivery and health care insurers. These
include:
The public should have a clear understanding of what constitutes an
emergency and of the appropriate steps for accessing medical care in
emergency and non-emergency situations;
911-EMS, MCOs, and other community providers should explore
options for handling persons with non-emergency needs who access
911-EMS.
All communications centers that interact with the general public should
have carefully constructed protocols to identify and provide appropriate
services to callers;
Alternative communication centers, if engaged in call referral practices
should be connected to other community resources in a way that
allows for rapid and efficient call routing and ensures appropriate
response.
Any new triage tools that would allow 911-EMS personnel to route
patients away from the ED should be prospectively validated before
implementation;
64


911-EMS providers should use patient contact as an opportunity to
practice prevention interventions or promote prevention messages;
Destination options should include a comprehensive range of
community social services (2-3).
Chapter 4, presents through a discussion of case examples, Routing options,
advocated by the NHTSA panels, which create unique clinical pathways for a
person in need of 911-EMS services. While these changes can potentially
expand the role of 911-EMS agencies in a community, this thesis will
demonstrate that it is possible to provide Routing services without an increase
in expenses to the 911-EMS agencies that provide the additional service
options.
65


CHAPTER 3
METHODOLOGY
This thesis examines "Routing- how 911-EMS agencies can provide an
increased range of available services to the public beyond traditional
response-only service provision used by most 911-EMS agencies. The
objective of Routing is to ensure that a person that has an unscheduled
medical need and calls 911 for assistance is Routed to the most appropriate
source of care, ranging from a 911-EMS response and transport to an ED to a
clinic appointment.
The dissertation examines how traditional 911-EMS is delivered; what
Routing is; how 911-EMS agencies and/or other emergency care agencies
use Routing; and how Routing impacts the delivery of traditional 911-EMS.
The literature review in Chapter 2 examined traditional response-only
models of EMS delivery. This Methodology section describes the steps that
will permit an examination of the various Routing methods and their impact on
911-EMS delivery.
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Research Design
This dissertation employs an exploratory/descriptive case study format. Yin
writes that ...case studies are the preferred strategy when how and why
questions are being posed, when the investigator has little control over
events, and when the focus is on a contemporary phenomenon within some
real life context (1).
Hedrick, Bickman, and Rog write, The overall purpose of a descriptive
research is to provide a picture of a phenomenon as it naturally occurs...."
They go on to explain that exploratory research is a type of descriptive
research and "... is frequently used as the first in a series of studies on a
specific topic" and can also be used to ...identify the lines of inquiry that may
be productive to pursue in more focused follow-up studies" (44-45).
While there is a great deal of clinical research into emergency medical care,
there is limited research in the management of 911-EMS delivery. This is the
first such study that examines the phenomenon of Routing. The research
conducted for this dissertation fosters an examination of the conceptual
frameworks of Routing. It provides illustrative examples of Routing, a
phenomenon that has the potential to change the way 911-EMS is delivered
throughout the country.
i
t
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Validity
Ideally, a case study can be widely applied to other situations and provide
external validity; however, in an exploratory/descriptive study, Stake presents
the alternative of utilizing a case study that both demonstrates a phenomenon
and permits accessibility of information to the investigator (4).
Whenever research explores new territory, future investigation is required to
determine the extent that the initiating case study can be generalized. Across
the country, local and regional variances in 911-EMS delivery methods,
policy, ands legislation may require different responses by local 911-EMS
agencies.
Construct Validity is defined by Yin as "establishing correct operational
measures for the concepts being studied." He goes on to present three
tactics to increase construct validity; using multiple sources of evidence;
establishing a chain of evidence; and review by key informants (33). This
dissertation utilizes all three of Yins tactics. Multiple interviews of informants
from different organizations and corroborating secondary source data have
been obtained to satisfy Yins first tactic (multiple sources of evidence).
Reliability is also boosted by this multiple source method of information
gathering and corroboration. Further care has been taken to ensure precise
documentation and operational definitions throughout the research process.
68


Sources of Data
Yin writes that case studies rely on multiple information sources in order to
triangulate and corroborate the collected evidence (34). Information about
911-EMS agencies and their supporting EMS Systems were obtained by
interviews with 911-EMS providers and other agencies involved in emergency
care delivery. In addition, expert testimony was elicited from key industry
leaders, state departments of health, state 911-EMS associations, as well as
executives of the national private ambulance trade association. Source
documents were also obtained from the above entities. Figure 5 lists the
agencies that were interviewed during the course of this research.
Local 911-EMS Providers
Local Private Ambulance Services
Local Fire Departments
State Departments of Health
State EMS Associations
State Insurance Agencies
Managed Care Organizations (MCOs)
National Professional Associations:
American Ambulance Association (AAA)
American College of Emergency Physicians (ACEP)
American Hospital Association (AHA)
National Association of State EMS Directors (NASEMSD)
International Association of Fire Chiefs (IAFC)
National Highway Traffic Safety Administration (NHTSA)
National Association of EMS Physicians (NAEMSP)
American Association of Health Plans (AAHP)
Figure 5. Agencies interviewed for this dissertation.
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The research also includes articles from trade and scientific journals in
addition to local and national newspapers.
Limitations
Information was obtained from 911-EMS agencies and public organizations to
the extent that such information was publicly accessible, tracked and/or
available. This research was limited by the inability to obtain some
informationinformation that is not tracked by state or local EMS agencies
due to funding limitations or lack of higher directives (Budget Cuts,
Reorganization... 1-3). In general, MCOs and private ambulance services
have been reluctant to divulge certain operational and fiscal details, claiming
proprietary secrecy. However, to overcome this limitation, the findings of this
research rely on a combination of primary and secondary data, and an
accurate representation of the issues, policies and costs, as applied to
Routing.
Sampling
Interviews were accomplished via telephone or in-person. For this research,
this type of inquiry incorporated a loosely structured format. The interviews
followed a list of topics that were to be covered for each agency, but the
sequence of each topic presented varied with each interview. This permitted
the interviews to flow as freely as possible without interrupting the subject of
the interview. In addition, the interviewer permitted a free flow of conversation
in order to follow any leads that might be significant, but outside the original
topics.
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A snowball sampling technique was used in order to ensure an adequate
response and representation of policy from various public and private agency
officials. In this snowball sampling, initial contact with each agency was made
by an unscheduled cold-call. For each call, the interviewer introduced
himself and the reason for the call, inquiring if the contact would be able to
help or could refer the caller to a more appropriate source. As many agency
representatives were spoken with as was necessary until the desired issues
were addressed, ranging from 2 to 5 representatives. All agency
representatives were considered potential sources of information. Agency
personnel interviewed included claims representatives, nurses, paramedics,
911-EMS and Fire Department officers (lieutenants, captains, chiefs),
directors, physicians, MCO managers, executives, and program coordinators.
Participants consented to the use of the information gleaned from them.
The initial point of contact in each interview was only the source point to begin
the information gathering. After each interview, the subject was asked if there
was anyone else that the interviewer should speak with. The interview
process for each agency was considered complete when, the requisite
questions were answered and the key personnel referred to in the interview
process were reached. The goal was not to interview a set number of people.
Rather the goal was to obtain the most complete picture of each example of
Routing that was possible.
Expert Sources
Additionally, interviews with 911-EMS experts generated valuable information
and perspectives. The experts were asked about their viewpoint concerning
Routing and 911-EMS delivery and were invited to comment on the issue
71


based on their area of expertise. The experts were also asked to cite notable
Routing examples, several of which are examined in this dissertation. Figure
6 lists the experts interviewed and provides their occupation at the time of the
interviews.
James O. Page, J.D., Publisher of the Journal of Emergency Medical
Services (Jems) and leading 911-EMS systems designer
Jack Stout, 911-EMS Consultant and creator of System Status
Management
Tom Scott, 911-EMS Consultant and Researcher
Dr. Richard Narad, professor of health care management and 911-EMS
educator
Brenda Staffan, Marketing/Communications Director from the American
Ambulance Association
Don Jones J.D. MBA, Telephone Triage/ 911-EMS consultant
Jay Fitch, Ph.D., Fitch and Associates, 911-EMS Consultants
Rick Keller of Fitch and Associates 911-EMS consultants
Andrew Stem NYS 911-EMS Office
Jerry Overton, Director Richmond Ambulance Authority, Innovator in
Public Utility Model of 911-EMS delivery
Richard Bissel, Ph.D., University of Maryland and Baltimore County.
Professor of Emergency Health Services
Denis Meade, 911-EMS Educator, nationally known 911-EMS writer
Jane Howell, American College of Emergency Physicians
John Becknell, Editor in Chief, Journal of Emergency Medical Services
Figure 6. Expert sources interviewed for this dissertation
72


Units of Analysis
The unit of analysis in this dissertation is the Routing Program. The example
of each Agencys Routing Program discussed in findings will present one or
more of the different Routing methods cited by NHTSA in its EMS Agenda for
the Future."
As mentioned, the literature review in Chapter 2 examined traditional models
of 911-EMS delivery. In many places where a traditional 911-EMS service is
delivered, the services that a caller might need are not available through the
current 911-EMS services. As suggested by NHTSA, in its EMS Agenda for
the Future, Routing strategies 2 through 6 that direct callers to a variety of
non-emergency services beyond an ambulance response should be
considered for use by 911-EMS agencies to augment Strategies 1 and 7,
which are currently used by all 911-EMS agencies. The suggested strategies
are as follows:
1. Response by 911-EMS Emergency Response (lights and sirens)
2. Response by 911-EMS Non Emergency' Response
3. Referral to a Primary Health Care Provider/ Network
4. Referral to a Social Service Agency
5. Referral or Provision of Non-emergency Medical Transportation
6. Medical Advice/ Information Resources
7. Response by Fire, Police, or Other Public Safety Services
(Source: EMS Agenda for the Future, 45)
The discussions in the next two chapters provide illustrative examples that
demonstrate the various Routing methods discussed by NHTSA. How each
911-EMS agencies (and others) use Routing requires a descriptive review of
programs that are being developed and/or implemented throughout the
73


nation. The examples cited in the Chapter 4 are based on suggestions made
during the interviews with the 911-EMS industry leaders discussed earlier in
this chapter and include information as of December 2000. Each example in
Chapter 4 examines each 911-EMS provision before the Routing intervention
was used. Each example also includes discussions concerning the population
serviced, the service area, the 911-EMS call volume, the number of
ambulances provided, transport policies, and identifies other 911-EMS
providers in the EMS system (first responders, fires services, and private
ambulance services).
Each example continues with a discussion of the Routing method used and
concludes with a discussion of the impacts of Routing on the 911-EMS
agency after the Routing intervention(s) was implemented. Table 8 lists the
examples examined in Chapter 4.
74


Table 8. Examples of routing strategies examined in Chapter 4 of this
dissertation
Location Description
Metro Denver, CO MCO-Driven Routing: Managed Health Care organizations direct their members not to call 911 in all cases of unscheduled and unexpected illness. This includes a system in which their members receive emergency ambulance services from non-911-EMS organizations.
Metro Denver, CO Pathways/Access Management: Members of an MCO are directed to call a Private Ambulance Service instead of 911. They are routed to other forms of assistance if patient has a non-emergency situation that does not require a 911-EMS response.
Alameda County, CA 911-EMS System Restructure: This effort includes the NHTSA options for Routing built into the planning process
St. Louis, MO EMS Options Program. 911-EMS Agency adds Routing options to their previously traditional response program
King County, WA Telephone Referral Project uses Nurses to speak with certain categories of non-urgent callers to 911 to try to arrange for assistance other than a 911-EMS response.
75


Impact Assessment Model
Source data, previous research, and expert interviews are used to construct a
model that demonstrates the change in expenses that can come about as a
result of a 911-EMS agency instituting Routing into their day-to-day
operations.
For this model, the medium-sized city (population 400,000) discussed in
Chapter 2 will be used to demonstrate the change in 911-EMS expenses
generated by implementing a Routing program in that city. The model will
show the example citys actual current expenses and compare those
expenses to the estimated expenses that would be generated as a result of
implementing an assertive Routing program such as the one used in St.
Louis.
In one of the early studies of 911-EMS provision, Cretin discussed the
difficulties in developing models for 911-EMS service delivery explaining, u...
the modeling process requires that parameter values be estimated even when
the supporting data are scant. As long as the assumptions are explicit,
however, the purposes of the modeling process are still served (176). Cretin
elaborates, "Models are not intended to replicate real complex events exactly,
nor are they designed to make decisions. The results ... are intended to
better inform those who will make the decision after considering a variety of
factors including the models, their results, and the assumptions on which they
are based (176).
While EMS clinical studies have improved over the years, the limited amount
76


of data on operational issues leads to the use of some assumptions to
develop the model. The process involved in developing the model is better
defined in Chapter 4.
77


CHAPTER 4
FINDINGS
To review, a large segment of the population that is looking to 911 and 911-
EMS agencies for medical assistance actually require something less
intensive than a lights-and-sirens emergency response. However, most 911-
EMS agencies do not have service options other than that, and an emergency
lights-and-sirens ambulance response is what usually occurs for most calls.
In reality, many callers for 911-EMS could benefit from service options such
as telephone nurse advice, non-emergency transportation, or referral to other
available services (physician offices, social services, etc.) options that are
not typically provided by 911-EMS agencies.
This chapter examines the Routing strategies now being used by a limited
number of 911-EMS agencies to provide a continuum of necessary services
in addition to 'lights-and-sirens response. The objective of Routing is to
ensure that a person with an unscheduled medical need is Routed to the
most appropriate sources of care.
78


As recommended by the expert panel from the National Highway Traffic
Safety Administration (NHTSA), 911-EMS agencies should consider the
following Routing strategies:
1. Response by 911-EMS Emergency Response (lights and sirens)
2. Response by 911-EMS Non Emergency Response
3. Referral to a Primary Health Care Provider/Network
4. Referral to a Social Service Agency
5. Referral or Provision of Non-emergency Medical Transportation
6. Medical Advice/ Information Resources
7. Response by Fire, Police, or Other Public Safety Services
(Source: EMS Agenda for the Future, 45)
Currently Routing strategies 1 and 7 are used by all cities to provide
emergency response to people calling 911. This dissertation primarily
addresses Routing strategies 2 through 6, as they are in limited use
throughout the country. Interviews with industry experts and a general review
of EMS literature provided sources for notable examples of Routing strategies
2 through 6 in both cities and regional areas. These Routing strategies have,
to date, originated from public 911-EMS agencies, private ambulance
services, and managed health care organizations. Table 9 demonstrates, in
the cities and regional areas that were chosen for this dissertation, these
Routing methods.
This chapter then concludes with a Impact Assessment Model that examines
the changes in expenses realized by a 911-EMS agency in an example city of
400,000 after it initiates a Routing program similar to the program in St.
Louis.
79


Table 9. Examples of cities and regional areas utilizing Routing
Method(s) to direct callers to a variety of non-emergency services
beyond a lights and sirens response.
City Routing Method(s)
Denver, CO MCO Routing
Denver, CO Pathways/ Access Management
St. Louis, MO 911 Plus
King County, WA Telephone Referral Project
Alameda County, CA County-wide Restructure of 911-EMS Delivery System to Include Routing
Examples 1 and 2: MCO Routing in Metropolitan Denver
This section begins with a brief overview of managed health care, discusses
managed care in metropolitan Denver, and then leads in to the two examples
for that area. These two examples are discussed sequentially, and
demonstrate an evolution in the use of Routing by private sector MCOs in
metropolitan Denver. The first example, MCO Routing," is based on
research that took place in 1996 and 1997. The second metropolitan Denver
example, "Pathways/ Access Management, represents a policy change from
the first Routing strategy used in the area. Research for this second example
covers 1998 and carries to the present. These examples were chosen to best
demonstrate the evolution of private sector MCO policy changes. Both
strategies are used in other areas of the United States; therefore research
findings from this dissertation may be useful to policy makers in those areas.
80


Managed Health Care
Managed Health Care Organizations (MCOs) currently insure more than 135
million Americans8. Williams and Torrens write that the goal of an MCO is to
reduce health care expenditures while preserving continuity of quality care for
their enrollees. This is accomplished by coordinating member action, thereby
directing them to the most cost-effective source of medical care and other
health-related services.
Williams and Torrens further explain that historically, MCOs have achieved
lower costs for health services through the use of several strategies: reducing
the length of hospital stays, utilization review, shifting care to outpatient
services, creating an MCO network of care, and capitation (363).
A network of approved providers or health care organizations is created
when an MCO negotiates with hospitals and health care providers for reduced
fees. An MCO will exchange these reduced fees with a guaranteed patient
volume. With this contractual arrangement in mind, an MCO directs its
members to the most cost-effective in-network source of care whenever
possible.
Of these strategies, 'Utilization Review is the one tactic designed to reduce
inappropriate use of services. Typical methods of Utilization Review include
pre-admission approval for treatment, and mandatory second opinion
programs (Williams and Torrens 368). In an emergency, however, there is
typically is not time for a prior approval or second opinion.
* Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Point of Service (POS), and
Independent Practice Associations (IPAs) are the principle forms of MCOs.
81


911-EMS and ED use is usually patient-initiated and unscheduled, in contrast
to office visits and elective hospital admissions (Kongstvedt 147). A policy of
self-referral to EDs conflicts with the managed care philosophy, in that a
patient that is not managed by their MCO cannot have their costs and
location of care most efficiently directed.
MCOs believe that they lose control of both the care and cost of an ED visit
when members are permitted to go, unchecked, to an ED. Unlike 911-EMS
agencies, which are primarily treatment and transportation oriented, MCOs
have a greater variety of responses available to provide to a member
including: referral to a primary care doctors office, advising self-care, use of
network facilities/ providers, or calling for an ambulance. The problem is that
a person calling 911 is not automatically transported from the scene of an
emergency to an in-network MCO facility by the 911-EMS agency (Meador
and Low 416).
82


Example 1 MCO Routing in Metropolitan Denver
The metropolitan Denver area (or Greater Denver) is the 26th largest
metropolitan area in the nation. In 1996, when this phase of MCO Routing
was first explored for the purpose of this dissertation, metropolitan Denver
had fifteen 911-EMS agencies, a population of 1,856,755 and more than 40
MCOs.
Greater Denver contains approximately 50% of Colorado's population
(Denver Metropolitan Chamber of Commerce, 1997). Greater Denver also
has a greater-than-average managed care penetration (Murray 1995). Forty-
five and one-half percent of residents in metropolitan Denver are members of
a Health Maintenance Organization (HMO). This compares to 24.4% of the
state population and is more than twice the national level of 19.5 percent. In
addition, 18.5% of metropolitan Denver residents are members of PPOs. The
combination of HMO and a Preferred Provider Organization (PPO)
membership captures 64% of the metropolitan Denver population within
MCOs (AAHP 1995).
i
I
83


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