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Novel program in Houston reduces patient transports to EDs
By Keith Wesley, MD, FACEP, FAEMS & Karen Wesley, NREMT-P
Langabeer R, Gonzalez M, Alqusairi D, et al.
Telehealth-enabled emergency medical ser-
vices program reduces ambulance transport to
urban emergency departments. West J Emerg
Med. 2016; 17( 6):713–720.
Researchers in Houston wanted to measure the
ability of using a combination of telemedicine,
social service pathways and alternative means of
patient transportation for patients who didn’t
require an ED visit by ambulance. It was conducted by the Houston Fire Department and
termed the Emergency Telehealth and Navigation (ETHAN) program.
Eligible patients included those with primary care-related complaints. The most common categories were “abdominal pain,” “sick,”
“injury/wound” and “other pain.” Inclusion
criteria included the following: Able to have
full history and physical exam by paramedics
(non-emergent conditions); age > 3 months;
ability to communicate in English; normal vital
signs; absence of fever in chronically ill patients
or those over 65; ability to care for self; access
to private transportation; and access to pediatrician for pediatric patients.
Patients with chest pain, acute neurological changes, altered mental status or difficulty breathing, syncopal episode, suspected
non-accidental injury or neglect in pediatric
patients and minors with no legal guardian
on site were excluded.
Once identified, the patient was interviewed
via video by an emergency medicine physician
working in the Houston Emergency Center that provides regional telecommunication and dispatch for EMS. If the physician
and patient agreed that their condition was
non-emergent, the physician would pursue
one of three pathways.
The first was to provide a prepaid taxi ride
to the ED for conditions difficult to address
in a primary care office; the second was a
referral with taxi ride to a primary care physi-
cian appointment made by the emergency phy-
sician. The third pathway was non-transport
and delivery of aftercare instructions.
Over 12 months, EMS providers enrolled
5,570 patients to participate and compared
that to a control group of patients with similar
conditions who were not offered participation
in ETHAN. Eighteen percent of ETHAN
patients were transported to the ED vs. 74%
in the control group. Additionally, EMS cre ws
returned to service 44 minutes faster for the
ETHAN patients ( 39 vs. 84 minutes).
There was no difference in clinical outcomes
or patient satisfaction.
DOC WESLEY COMMENTS
The concept of mobile integrated healthcare
or community paramedicine (MIH-CP) has
been around for a few years. However, little has
been done to measure its impact on resource
utilization. A key concern many have regarding MIH-CP is the ability of EMS providers
to recognize and properly triage patients who
don’t require ambulance transport. ETHAN
addressed this by providing physician consultation using telemedicine to facilitate a reliable
patient interview and assessment.
This isn’t an expensive program, costing
$179 per ETHAN patient. When you consider that the average ED visit for primary
care-type complaints costs around $1,500, it’s
saving money. The authors note that a report
of the fiscal impact of this program is in the
works and I can’t wait to see it.
Unfortunately, these types of programs are
difficult to implement. This is particularly true
where private agencies provide services without
subsidies from their local municipality. EMS
is only compensated by insurers when patients
Although this compensation may be low,
it’s better than nothing. For programs like
ETHAN to succeed, insurers need to pay for
the telehealth services that EMS provides and
share some of the money they’re saving by not
transporting patients to the ED.
MEDIC WESLEY COMMENTS
Telehealth-enabled programs will succeed.
Although they’re costly to start up and annual
costs are high, EDs around the country are
overwhelmed with patients who don’t need
to be there.
The cynical side of me found this fact interesting: One-third of patients who met the
determination of non-emergent and had scheduled appointments for the next day in a clinic
failed to show. We see this often in the ED.
Why can’t the same ED physician assess via
telehealth to the ED triage desk, and then make
referrals to the appropriate care? Being ruled
by patient satisfaction scores and Emergency
Medical Treatment and Labor Act (EMTALA)
laws, hospitals have to take these patients. The
cost of healthcare rises when patients demand
services that could easily wait until clinic hours.
Programs like ETHAN are necessary and
need to be funded. Having the chance to be
evaluated by a physician and potentially being
treated without transport, is optimal for many
patients, especially the elderly or parents with
Although there are some no-brainers when
it comes to transport, the ED often sees people who just don’t know what else to do. Why
tie up an ED when these patients just want to
know if it’s ok to wait until tomorrow?
Time for a change. Uber Care. I like it. JEMS
Keith Wesley, MD, FACEP, FAEMS, is the med-
ical director for HealthEast Medical Transpor-
tation in St. Paul, Minn., and United EMS in
Wisconsin Rapids, Wis. He can be reached at
Karen Wesley, NREMT-P, is a paramedic and
educator for Mayo Clinic Medical Transport
and is the medic team leader for the Eau Claire
County (Wis.) Regional SWAT team. She can
be reached at email@example.com.