How much money does the Baltimore city government spend on its emergency medical services (EMS) system, and how effective is the way these funds are allocated? What portion of the costs wasted on inefficient health care delivery can be circumvented to provide pre-hospital management care to a patient before he or she activates the EMS system in the first place?
A group of researchers and experts from the Hopkins School of Medicine, the Baltimore City Health Department and the Baltimore City Fire Department carried out a study to answer these questions for the major metropolitan area of Baltimore City.
The Baltimore City Fire Department provides an immense resource for citizens who need emergency medical assistance on an immediate basis. It operates 24 advanced life support transport units 24 hours a day, with four additional units during peak hours. In addition, during periods of high call demand, the fire department is able to add 12 advanced life support or basic life support units.
EMS overuse is a common issue in Baltimore City that creates a significant and sizable burden on an already taxed pre-hospital medical delivery system. EMS patients that are unnecessarily brought to emergency departments cost the hospital in terms of personnel and medical technology and equipment used to care for them.
Previous studies have shown that in-hospital case management techniques can decrease the resources devoted to patients who are considered frequent EMS users. However, these studies have had recruitment difficulties, small sample sizes and limited interventions.
Therefore, this group of researchers led by Michael L. Rinke from the Division of Quality and Safety in the Department of Pediatrics at the Hopkins School of Medicine sought to undertake a similar study with a unique pre-hospital case management intervention that focused on more intensive case manager involvement. They hypothesized that this, combined with improved recruitment, would decrease frequent EMS use in a major metropolitan area such as Baltimore City.
Throughout the study, 25 of the most frequent EMS users in a major metropolitan area were identified and 10 were enrolled in the intervention. They were given psychosocial and medical resources through weekly case management visits from a case manager at Baltimore HealthCare Access, a quasi-public agency of the Baltimore City Health Department, for five to 12 weeks between May and August 2008.
Overall, the case manager made 32 referrals to 22 separate agencies for these 10 patients. Over the course of the intervention, transport responses decreased 32 percent over predicted transported responses, and non-transport responses decreased 79 percent over predicted nontransport responses. Additionally, no adverse events due to decreased activation of EMS were noted by patient self-report after the intervention period.
Using cost calculations done by an independent firm and the Baltimore City Fire Department’s billing service, it was discovered that accounting for the case manger’s salary, the net savings to the health care system and to the fire department was $14,461 and $6,311 respectively.
According to the group of researchers, the most important factor that helped decrease the systemic burden for these high-frequency EMS users as well as the EMS department and hospitals is the involvement of a dedicated case manager helping to nagivate and coordinate the health care system for these individuals. It showed that these high-frequency EMS users had multiple unmet medical and psychosocial needs and required personalized interventions and referrals that were not being met by general EMS protocols.
“This program highlights the importance of simple interventions that can yield powerful results,” co-investigator Kathleen Westcoat, of Baltimore HealthCare Access, said in a press release published by the Hopkins Children’s Center. “For example making sure that a diabetic patient doesn’t run out of strips for the glucose monitor can prevent a frantic 911 call for a non-emergency.”
Further research in this area is needed in order to truly determine the burden frequent EMS users cause emergency departments within hospitals as well as other potential benefits that could be found from decreasing use of EMS by such patients. This study served as a pilot project that showed decreased EMS use resulted from minimal initial investment and resource allocation, and calls on other groups of healthcare officials to help contribute to improve healthcare and make healthcare spending less wasteful.
