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Have the Ambulances Stopped Coming?: Is it Real or Only Accounting?

Davidson, Steven J. MD, MBA

doi: 10.1097/01.EEM.0000334455.02685.75
LEADERSHIP OUTLOOK

Dr. Davidson is the chairman of the department of emergency medicine at Maimonides Medical Center, a professor of clinical emergency medicine at SUNY-Health Science Center in Brooklyn, NY, and a principal in Emerging Medical Concepts (www.emedconcepts.com), a medical leadership development and support consulting organization. He can be reached at davidson@pobox.com.

In April, we started our new electronic medical record system, and looking at a few months' experience and statistics from the first half of the year, the results have been gratifying.

The ambulances are still bringing patients to the Maimonides Medical Center ED, but for a week or so, it appeared as though we had many fewer ambulance patients in the first half of this year than in the same period last year although, total patient volume was up 1.6 percent and admissions were nearly constant. I still don't have all the answers, but I think our experience, particularly because it derives from our electronic medical record implementation, is instructive.

When Charlie Howe, our billing manager, brought the first six months of statistics to me — an unusual hand delivery — he called my attention to the drop in ambulance patients, particularly from April through June. When we drilled down on the data, it appeared as though something had happened to patient deliveries from the voluntary hospital ambulances and to a lesser degree from our volunteer community-based ambulances.

EMS in New York City, led by the Fire Department of New York, is an amalgam of the publicly operated fire department ambulances, voluntary hospital-based ambulance services dispatched through 9-1-1, and a web of community-based volunteer ambulances and proprietary ambulances dispatched through seven-digit telephone numbers. One of the larger and better organized of the volunteer ambulances in New York is the orthodox Jewish group, Hatzolah. Our hospital sees Hatzolah volunteers mostly from two nearby communities, though other Hatzolah volunteer organizations also bring us patients less regularly.

Other community-based volunteers, the Bravo and Bensonhurst Community Ambulance services, bring us patients, as do several nearby voluntary hospitals and our own hospital-based ambulance service. The ambulances dispatched through 9-1-1, whether FDNY or voluntary hospital-based, use the same ambulance call report while most of the volunteer ambulances and the proprietary ambulances use their own form for meeting state requirements.

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Was it Real?

In trying to find out what was happening to our ambulance drops, we asked whether there were really many fewer ambulance drops, was it merely accounting, or some of both? I didn't ask myself this question before I reported the apparent reduction in ambulance drops to our CEO. I reported it as a fact.

Stanley Brezenoff, Maimonides' CEO, is a long-time public servant. His past seven years at Maimonides have been one of his very few private sector employment experiences. A skilled administrator and troubleshooter, he has taught me about the emergency department's role in reaching out to the community.

His leadership has transformed Maimonides, and he has personally visited more than 150 community organizations to listen to them and learn from them what they needed from the hospital. Sometimes he brought me along. He has taken the message — the hospital's openness to the communities' needs —everywhere in Brooklyn (and beyond) that he's gone, the volunteer ambulance corps among them. He truly believes and teaches that our hospital belongs to the community: we who work there are merely stewards. He was concerned by the reported diminution in ambulance drops.

Until April 9, when we went live with our electronic medical record (see EMN, June 2002, p. 6), our ambulance triage nurse completed a triage form that went to the registration clerk along with the ambulance call report. Through check boxes and fill-in-the-blanks, the triage form captured the name of the ambulance company that brought the patient. The triage nurse enters the same information in the electronic medical record, but the information hadn't been made available to the registration clerk. We missed it. In all the work we did with the registration clerks around changes in workflow, we overlooked the registration clerks' usual process for getting the transporting ambulance information. They did not read the ambulance call report, but did read the ambulance nurse triage note.

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Finding the Answer

Between the time we discovered the deficit in ambulance transports and had determined its apparent genesis, we took advantage of the fact that our Maimonides' ambulances bring patients to our own ED. We undertook a one-day comparison of the registration system's data with our own ambulance department's call reports. Of 11 ambulance call reports showing Maimonides as the destination, only five were noted in the hospital registration system as Maimonides' ambulance transports. Four others were attributed to other ambulance operators and two weren't even recorded as ambulance drops, thus explaining our missing numbers.

The data seemed to suggest that ambulance drops had decreased, but the problem was systems-oriented

Looking further, I realized that in April, we might have experienced a true decrease in ambulance drops. To some extent, this can be explained through our early days of learning the ropes with our new electronic medical record, yet here it was July, and I was only just examining the quantitative data, something I'd neglected to do for too many months. I had spent time in April and May on the telephone with some of our volunteer ambulance providers. I'd listened to their concerns about the “computer system” and their frustration over waiting times at ambulance triage, potentially bad for patients and always bad for the volunteers who wanted to get back to work or family.

We're responding now by reconfiguring our clerk staffing to bring a registration clerk over to the ambulance triage location so that a clerk can enter the initial patient information while the nurse focuses on the patient and ambulance personnel. We've also changed the information available on the registration icon so that the registration clerk can see the nurse's selection of the ambulance provider. We're using the feature in HealthmaticsED, which opens a tool tips box to display means of arrival and the ambulance company's name.

Just like at your hospital, our lab calls us with “panic” values, which sometimes don't make sense in a given clinical scenario. What do you do? You build a safety net for the patient, and then repeat the test. Next time, I'll call the ambulance companies while rechecking the accounting before I call my CEO. Even though he always says that bad news can't wait, first I'll make sure it's news at all.

© 2002 Lippincott Williams & Wilkins, Inc.