Of ongoing concern to everyone involved in EMS is unnecessary use of ambulances. Depending on the definition, up to 52% of calls have been deemed "unnecessary." At best, surveys indicate that 15% of those requesting transport by ambulance services do not need it.
"It has been shown that unnecessary ambulance transports contribute to increased health care costs," noted Anthony Billittier, M.D., from the State University of New York at Buffalo. "In addition to the financial consequences, medically unnecessary transports limit the availability of ambulances and exposes both EMS personnel and the general public to unneeded risks (especially during red light and siren responses)." (See "A Multisite Survey of Factors Contributing to Medically Unnecessary Ambulance Transports," Academic Emergency Medicine, November 1996.)
Before plans can be made to lower this abuse, the characteristics of those using ambulances inappropriately must be found. In an attempt to address this issue, Billittier and colleagues looked at patients arriving at the emergency departments (EDs) of five hospitals in Buffalo and Syracuse, NY.
During a one-week period, all patients coming to one of the hospitals by ambulance was evaluated by an emergency physician. Transport was deemed to be necessary if the physician found that the patient was unable to ambulate; required or could have required out-of-hospital emergency care; required/could have required expedient transport to an ED; there was an immediate potential for harm to self or others; or transport was medically needed for some other reason. If one or more of the criteria were met, then the transport by ambulance was appropriate.
If patients were found to have been transported unnecessarily, they were surveyed and answers to a standard questionnaire were recorded. Friends or family members were interviewed if the patients could not answer for themselves.
A total of 626 patients were enrolled in the study. Of the 616 with gender identifications, there was roughly an even split between male and female. Using their conservative criteria, 11% of the transports were thought to be inappropriate.
"The relatively low percentage of patients in our study whose ambulance transportation was considered to be medically unnecessary may be explained, at least in part by our criteria," noted Billittier. "We included even the potential need for either out-of-hospital emergency care or expedited transport to an ED as justification for transport."
Of equal importance, however, was the fact that none of those patients whose ambulance ride was deemed unnecessary later died, went to a critical care unit or to the operating room. In fact, 88% were treated and released, and 11% were admitted to a regular floor hospital bed. This in an indication that judgments on medical condition were justified.
This study confirmed findings in others that indicate socioeconomic status and those who are beneficiaries of public health insurance plans are most likely to go to hospitals via inappropriate ambulance transport. Unemployment, household income less than $20,000 and no education following high school were common among this group.
Another important factor was the age of the patient. Most were younger than 40. There also is a very large repeater cohort in the study population as more than half indicated they had come to an ED by ambulance two or more times in the past. There was no attempt made to find out the necessity of previous visits.
Many of these (43%) stated that they perceived they had no other method available. The vast majority (just over eight out of 10) said they would be willing to use another form of transportation if it was available and 26% expected to be charged for the trip. It should be noted that one third said they would pay nothing, even if billed.
"These results suggest that the provision of non-emergency unscheduled transportation would be well accepted by this population," said Billittier. "The cost of operating these alternative systems is substantially less than the cost of operating an ambulance and transporting more than one person per vehicle may result in further savings."
The group found that 34% of those getting unnecessary transports had a private physician. However, only 22% of these attempted to get in touch with them prior to transport. The study's authors suggested that patients should be taught to recognize true emergency conditions and be encouraged to call their family doctor if these conditions are not present.
There also appears from the study's results a need to educate those around the patient in appropriate use of the ambulance. Interestingly, 77% of those patients who were transported unnecessarily had not called the ambulance themselves. Seventeen percent of all those surveyed said that someone other than their doctor had suggested calling the ambulance.
"Education about more selective ambulance use must be focused on those under 40 and with Medicaid insurance coverage," stressed Billittier. "Many patients who were transported unnecessarily by ambulance cite lack of alternatives as their primary reason for calling. Wheelchair vans, taxi cabs and private cars seem to be acceptable alternatives but it remains to be seen if they would be used if made available."
Kurt Ullman, a Firehouse® contributing editor, is a registered nurse and regional chairman of the volunteer Indiana Arson and Crime Association.
