Patient Flow E-Newsletter
Volume 4, Issue 4
October/November 2007
Special Focus Issue-Integrating Pre-hospital and Hospital Care

Perspectives
Seeing the Glass Half Full: ED-EMS Partnerships Achieve Success in Emergent Care

When I open a newspaper these days, there is undoubtedly some article detailing the shortcomings of our medical system. It feels like we are constantly being bombarded with stories highlighting our problems and failures, and from the sounds of things it would seem that Americans are getting some pretty lousy medical care. And at many institutions and at various times, that's undoubtedly true.

But after 25 years working as an emergency medicine professional in Atlanta, Georgia and Dayton, Ohio, both as a physician in the emergency department (ED) and in the field as an emergency medical technician, I look at things from a different perspective. When it comes to emergency care, I believe that all of us can proudly and sincerely say that our medical system provides some of the best care in the world to those who need it when they need it most. Sure, there are plenty of areas where we need to improve, but the fact of the matter is that our emergent care system is really a story of remarkable success.

Consider this: 30 years ago we were regularly burying 50-year-old men from cardiac arrest. These were men who died in their prime simply because there was no system in place to help them quickly, and a poor system for identifying the risk factors for sudden cardiac death. Because of significant developments in the health care system, often led by emergency providers, we have reduced sudden cardiac death dramatically, rates of cardiac arrest are markedly lower, and patients at risk now routinely survive to lead healthy lives. Trauma and burn prevention programs have also yielded stunning reductions in premature death. If these are not positive signs of success, then I don't know what is. We need to take a step back from assessments of our problems every once in a while and recognize the successes of our emergency system in keeping people alive and preventing premature death.

One of the most important developments in emergency care is the emergency medical service (EMS) system. As the providers of life-saving pre-hospital care, EMS has become a frontline medical resource and a vital extension of our hospital emergency departments. EMS also provides the important transportation link for inter-hospital transfers, discharged patients and the growing nursing home population.

By the numbers, we see that up to 20 percent of all patients arriving in EDs arrive via EMS. Of those, about 40 percent get admitted. This represents a significant pathway for admitted patients to hospitals and further demonstrates what an important access point EMS is for patients who are typically the sickest or worst injured. In short, EMS provides critical access to patients and to great care.

Of course, after nearly three decades in providing emergency care and still actively working as an EMT, I have certainly experienced the darker sides of things. From ED diversions and chronic rerouting, to controversial off-loading delays, I have seen it all from both sides. This has allowed me the opportunity over the years to work with a number of different emergency medical systems. We've worked together to identify what works best and find solutions to common problems.

I cannot stress enough that successful emergency care depends on a smooth collaboration between the pre-hospital and the hospital environment. It is vital that hospitals and EMS maintain strong and consistent communications that focus on what is best for safe and effective patient care. When this cooperation does not occur, when the patient's care is not kept at the center of all discussions, or when resources are not made available or are misused, problems arise that negatively impact the quality of pre-hospital care, including delays, crowding and the flow issues that are all too familiar.

I think effective antidotes to these types of problems are "regional accountable systems" that arise from collaboration between ED and EMS leaders. These ensure that a region's available emergency services are staffed and utilized appropriately and collaboratively - from the phones and computers to the dispatch centers and vehicles. This type of system distributes patients to an appropriate and open emergency department, which helps hospitals avoid inappropriate diversions and rerouting.

In Dayton we collaborated on a system called CareNow, which helps people avoid using emergency services unnecessarily by providing constant access to needed information. We brought together EMS providers, ED leaders, 911 directors, physicians, payers and other medical stakeholders to determine how we could cooperate to provide unscheduled care needs, many of which lead people to the ED.

Through CareNow, patients had phone or computer access to a system that allowed them to receive advice on the correct care for non-trauma related issues and linked regional medical resources. For example, if a person has a consistent headache and is worried, he or she can call the system and be routed to their primary care physician for advice. This significantly helped the system eliminate unnecessary ED visits and freed up EMS resources - and it increased cooperation among health care professionals from different sectors.

That's what we need to do more often - communicate effectively, share best practices, and recognize the successes we have achieved in providing emergency medical care in our communities. When we keep the patient at the center of the discussion, focus on what we all do well, and get creative about solving problems as an ED-EMS partnership, we will continue to improve the quality of care we provide to patients, and provide the service our communities need.

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Jim Augustine, MD, FACEP
Medical Director, Atlanta Fire Department
Clinical Faculty, Department of Emergency Medicine, Emory University