Figure 1: Trends in EMS Arrival and Admissions Versus Walk-in ED Patients

COVID-19 won’t go away. As the pandemic peters out, one of the relationships you may want to build—or recover—will be with the EMS services surrounding your emergency department. Why? Here are few reasons.

EMS arrivals are increasing in 2021, on a new trajectory over the last five years, with continued high acuity.

• At least 70 percent of hospital inpatients are processed in through the emergency department; the majority of those admissions arrive by EMS.
• For medical centers that specialize in trauma, burns, acute cardiac intervention, and comprehensive stroke care, patients brought in by EMS represent the majority of patients who are served by those specialty programs.
• EMS is building novel out-of-hospital programs for mental health and substance abuse patients in many communities.
• EMS and the emergency department have overlapping responsibilities for multiple-casualty incident preparedness.
• Both the emergency department and the EMS system will be undergoing profound design changes post-pandemic. New designs will focus on improvements in patient and staff safety, flexibility, and cleanliness.

The 2020 Emergency Department Benchmarking Alliance (EDBA) survey gathered performance measures from more than 1,300 participating emergency departments. Specifically, the survey asked member emergency departments to report metrics related to their interactions with EMS. This survey has a 14-year trend line demonstrating that a very consistent percentage of ED patients arrive by ambulance. A large percentage of those patients will receive diagnostic testing in the emergency department, initial treatment, and then admission to an inpatient hospitalization (see Figure 1). EMS patients are admitted in about 40 percent of cases. Patients arriving by other means have a much lower admission rate, approximately 13 percent.

The pandemic resulted in a transient reduction in patients arriving in the nation’s emergency departments; however, the ones arriving remain high-acuity and slightly more likely to arrive by ambulance.

EMS arrival rates vary by type of emergency department (see Table 1). They are higher at emergency departments with higher volumes and by far greatest in emergency departments serving adults, where one-quarter of patients arrive via ambulance. Ambulance arrival rates average around 12 percent in lower-volume emergency departments and about 9 percent in emergency departments that serve only pediatric patients.

Repairing a Strained Partnership

Although EMS and emergency departments have traditionally maintained strong partnerships, the last two years have presented massive challenges to those relationships.¹ Many emergency departments shut their doors to EMS personnel.² As a result, communication during the transition of patient care was less complete, and EMS personnel were left outside to produce patient care reports, decontaminate personnel, clean and resupply their rigs—all without being able to enjoy simple biological functions like emptying their bladders or getting a refreshment after an exhausting run.

Table 1: EMS Arrival and Admissions in 2019

Recent months have demonstrated that boarded inpatients crowd out those who are just arriving, creating “ambulance patient offload delays” (a new term to describe EMS personnel who are holding the wall). A result of this is that EMS agencies are literally “out of ambulances” to respond to the next set of medical or trauma emergencies occurring in the community. In many metro areas, these situations boiled into very tenuous relationships with fire and EMS staff, and the potential for poor patient outcomes blossomed into finger-pointing and malpractice allegations against all parties.

Emergency physicians and EMS directors must develop regional models of care that match local needs to the appropriate use of ambulances and emergency departments. This presents a timely opportunity to address these aspects of the 911 system. It may also represent an ideal time to plan for how to care for patients with mental health and substance abuse issues outside of the traditional law enforcement–EMS–emergency department pathway.^3–6

Localities should also develop new systems for multiple-casualty incident management, as recent active-shooter events across the country have had transport of patients managed outside of the EMS. During some of those incidents, EMS has been stationed at the entrances to the hospitals to help receive, triage, and move patients into the hospital.^7–9

Emergency physicians should plan for a variety of care models useful to patients in need of mobile services, whether they are scheduled or unscheduled. When we apply the Triple Aim to emergency care, effective patient care will be provided at the right place, at the right time, with the right equipment and personnel, at the right price, and, of course, for the appropriate value. Plus-circle

References

1. Augustine JJ. New out-of-hospital care models could affect your emergency department. ACEP Now. 2019;38(5):19.
2. Krouse S. Coronavirus crisis makes ambulances rethink hospital trips. Wall Street Journal. April 3, 2020.
3. Russell T, Doom A. Dallas works to avoid sending people in crisis to emergency rooms or jails. Pew Trust website. Accessed Oct. 18, 2021.
4. Leseman M. Mental health first responders coming to Anchorage in 2021. Alaska’s News Source website. Accessed Oct. 18, 2021.
5. Waters R. Enlisting mental health workers, not cops, in mobile crisis response. Health Aff (Millwood). 2021;40(6):864-869
6. Whelan R. Resolve Crisis Services provides phone and mobile mental-health support to 1.2 million people in Pittsburgh and surrounding areas, handling hundreds of calls a day. Wall Street Journal. June 27, 2021.
7. FEMA. 1 October After-Action Report. Aug. 24, 2018.
8. Jacobs LM, Wade D, McSwain NE, et al. Hartford consensus: a call to action for THREAT, a medical disaster preparedness concept. J Am Coll Surg. 2014;218(3):467-475.
9. Aurora Century 16 Theater Shooting: After Action Report for the City of Aurora. City of Aurora website. Accessed Oct. 18, 2021.