Improving the Emergency Care System While Building Surge Capacity
Whether we’re talking about hospital beds or emergency ambulances, the first thought that comes to mind when surge capacity is discussed is the procurement of additional resources that can be pressed into service when there is a sudden uptick in demand. Yet no community is going to build extra hospital beds, buy extra ambulances or hire extra healthcare personnel to sit around and wait for a “big one” to occur. The way we’re going to handle surge needs is through redeployment of resources that serve nonemergent needs to handle emergent situations.
Most hospitals have the ability, within limits, to discharge patients early, cancel elective surgeries and make other operational changes to accommodate some level of surge. Law enforcement agencies can reassign staff to the street—detectives move back into uniform, school resource and traffic officers can be assigned to patrol areas of increased need. Fire services, often blessed with sufficient unstaffed reserve apparatus and with two-thirds or more of their workforces off duty at a time, can staff up and surge in the event of wildfire, earthquake or other major emergency.
In most communities, EMS agencies do not have this extra capacity. Peak-load staffing and tight economics (driven by transportation-based reimbursement and a crushing load of un- or underinsured patients) mean there are only enough ambulance vehicles and personnel to staff for the expected daily workload. Altering the standard of care (for example, not sending ambulances to particular categories of calls) comes with substantial concerns, both from community leaders and medical directors concerned about liability. But if EMS agencies embrace expanded roles, develop additional capacities and services, and provide additional training to their personnel, we too would have the ability to redirect medics employed in nonemergent roles to meet surge needs when required.
Removing Barriers to Proactivity
None of these ideas are particularly difficult to implement. None are terribly easy, either. Each has one or more barriers that must be overcome. Some of these are external to EMS, but many are within our reach to influence.
The biggest external barrier is the perverse economic incentives that exist in the system today. Reimbursement needs to be provided for services that involve other actions besides transportation to a hospital. Otherwise, we will continue to buy ambulances (even when we could do a lot with less-costly vehicles) and transport patients to EDs when less costly, more efficient destinations are more appropriate. This lies within the sphere of our federal healthcare agencies: the Department of Health and Human Services and the Centers for Medicare and Medicaid Services. If they want EMS to do its part, they must move to remove the financial disincentive to it.
Another barrier is EMTALA, at least the way it is structured today. EMTALA requires hospital emergency departments, but nobody else, to accept and at least “screen” all who present for care. Practically speaking, it requires free treatment of those who cannot pay. As we move toward some form of healthcare coverage for everyone, a new EMTALA is needed—one that requires others, like urgent care centers, primary care centers and other first-tier healthcare providers—to accommodate all who present. If we want people cared for by less-expensive providers in less-expensive facilities, the law needs to open the doors to those facilities.
A third barrier is presented by restrictive state-level scope of practice laws and regulations. In many states, the scope of practice is defined by a board or committee that has little if any input from EMS. Often, these regulatory boards are made up of members of other health professions, including some that perceive EMS as competition for jobs and services. The EMS scope of practice is often the most minutely specified of any allied health profession’s, delineating not only a pharmacopeia and invasive procedures but other minutia of prehospital EMS delivery—seemingly designed for the least common denominator of our community. If our federal policy-makers want EMS to help improve the emergency care system while building surge capacity, then federal action or incentives toward more permissive scopes of practice are needed.