Should an ED have its own ambulance service?
June 1, 1997
Should an ED have its own ambulance service?
Although it's not an option every ED can consider, there are clear advantages to owning and operating an ambulance service. Patient care is a key factor because ED physicians have direct input into prehospital protocols, including standing orders and the medications stocked on ambulances.
"We write their protocols and their standing orders, so if they don't carry something we want them to have, we can easily change that," says D. W. Pettigrew III, MD, FACEP, president of the Georgia College of Emergency Physicians and Medical Director of Athens Regional Medical Center's ED, which has operated an ambulance service for the past two decades. "That has made things very easy to work with them as opposed to other EMS services that bring patients into our hospital."
Having paramedics who are also hospital employees allows for a standard format for reports. "We tell our paramedics we want it short, simple, and to the point, instead of a rambling report that takes three minutes to give, when all they're asking is [whether] they can start an IV," says Pettigrew. Athens Regional's paramedics convey key information in a consistent order, including the patient's age, major problem, and their plan for intervention. "Then they tell the rest of the story, so as we listen to the story unfold, we know where we're headed," he says.
Major differences in paramedic reports can be problematic. "What we get from some other ambulance services is a long, rambling disjointed report with vital signs scattered through it somewhere," says Pettigrew. "It's not in a standard format, which makes it more difficult for us, since we can't see that patient, we are standing in front of another patient, [and] listening to the report on the radio."
The fact that the paramedics are hospital employees instead of fleeting visitors to the ED helps to build trust, he says. Between four and eight paramedics are stationed at the ED's dispatch department, so the staff is familiar with the entire crew. "It helps us maintain a real close relationship with them, and they with us. We know all of them by their first names, we know all about their kids and families, who's married and who's pregnant, and that really facilitates a team spirit," says Pettigrew.
Paramedics work in ED during peak times
As medical director for EMS services, Pettigrew does the QA reviews for the hospital's ambulance service and regularly attends meetings. "If they have questions about what I think, then I can let them know, and that really helps in ensuring the quality of the service we provide here," he says.
Staff interactions with the ED's own paramedics are markedly different from those of other agencies, he says. "It's really different from other services that just come in to drop off patients and refill their coffee cup and leave," says Pettigrew. If the ED is busy and paramedics are not out in the field, they assist with patient care, including performing CPR, maintaining an airway, and administering medications.
The practice has a dual purpose. "Assisting in the ED helps to build a team spirit and also provides an educational opportunity for them," he says. "They see different ways of doing certain things that they may not have seen before, so it's good training for them."
The situation is also cost-effective. "Because they can help us with staffing during the busy times, we don't have to call in extra nurses," says Pettigrew. "They help out in the moments of crisis with a bad trauma, or any kind of resuscitation, so we don't have to maintain that extra staffingthey can be our flex-up person." For some hospitals, that could mean eliminating a full-time nursing position, he says.
Although having a hospital-based ambulance service is clearly beneficial from a business standpoint, ethical issues such as respecting patient preference must be addressed. At Athens Regional, it is part of the EMS protocol to ask the patient which hospital they prefer. "The patient always needs to have a choice about where they want to go," says Pettigrew. "It's very important for the paramedics to say, Where would you like to go, ma’am?’ because the patient will not be satisfied otherwise."
The destination of ambulances should always be driven by protocol, not affiliation, says Michel A. Sucher, Vice President of Medical Affairs for Rural/Metro Corp. of Scotsdale, AZ. "Just because the hospital owns the ambulance, you can't automatically bring patients to it. If there is a more appropriate facility that's closer, or if the patient wants to go somewhere else, then the EMS ought to take them there, regardless of who owns the ambulance."
Patients still choose destination
However, the patient's choice needs to be appropriate for their condition and geographical location. "Patients need to understand the ramifications of their choice," says Pettigrew. "If they want to go to their own rural hospital and they're a trauma patient, that might not be appropriate. But if they have pneumonia and want to go to another hospital but are just too sick to get there on their own, that would be a reasonable request." In some cases, it would be acceptable for paramedics to override a patient's request, but such instances are rare, he says.
If the patient has no preference, the paramedics will generally bring patients to Athens Regional. "If the paramedics believe the patient would benefit by being brought to our hospital, they take them here," says Pettigrew. Bringing patients to their home hospital has definite benefits from the paramedics' point of view. "Restocking supplies is easier, because they know they can get anything they need right here," he says. "Also, they can come to a place where people know them and won't look at them with suspicion," says Pettigrew.
Trusting relationships help to ensure better outcomes for patients and also have a positive effect on ED patient volumes. "I know our EMTs trust us and they're happy to bring patients to our hospital, and that's what makes hospitals work," says Pettigrew. "It's also cost-effective for us to have a group of paramedics who believe in us and think the best care a patient is going to get is at our hospital."
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