A pilot study from McKinney Community Health Paramedicine program and BEST EMS

 *Adapted from a piece appearing in EMNews October 2010
Could Fire Based Advanced Practice Paramedic home visits decrease the frequent 911 calls/hospital readmissions in patients with stable chronic diseases; while also increasing In-Service time for fire apparatus?-----A pilot study from McKinney Community Health Paramedicine program and BEST EMS.

Liz Fagan MD, Hao Wang MD, Larry Bean MD, Dan Frey FF-APP, Brian Roether FF-APP, Chris Waller FF-APP, Fire Chief Danny Kistner, Operations Chief Tim Mock, EMS Chief Jason Hockett
With special thanks to:  Robert Leavitt FF-APP, JC Stinson FF-APP, McKinney City Manager Jason Gray, Sharon Malone MD, Tim Hartman MD, the Case Managements department, and The Entire McKinney Fire Department

Our goal is to enhance the health of the McKinney Community/Align with Institute for Healthcare Improvements Triple AIM, while providing a cost savings to the fire department, city of McKinney and local hospitals.  We hope to accomplish this by reducing non-emergent 911 calls while simultaneously reducing the need for 911 calls in the high utilizers group (HUG).  This should be reflected in unnecessary fire engine/fire truck calls and cost as they are disregarded when the squad takes the calls for them accompanying the MICU on medical 911 calls.

When patients with chronic disease in stable condition use fire-based emergency medical service (EMS) to transport to the Emergency Department (ED) for routine health care it is considered inappropriate ED utilization as determined by the New York University algorithm.  When 911 is called, an ambulance as well as a fire engine or truck is dispatched.  While treating this routine patient, the truck/engine is “Out Of Service”, and their service area has to be covered by either the neighboring district in the city or a neighboring city (mutual aid) for emergency calls. The ambulance charges from these patients who use EMS as a safety health care network result in an increased health care budget within the fire department. The aim of this study is to determine the effectiveness of CHP-APP home visits in minimizing the ambulance calls and hospital visits among these patients; while increasing in-service time for fire engines and trucks by having the squad disregard them on 911 calls.

Materials & Methods
Patients who had more than four “911” calls in the previous six months were enrolled in this study. After patients were discharged from the hospital, frequent home visits by fire-based advance practice paramedics were arranged in a step-wise manner as determined by individual evaluation of needs assessments.  Intensive and personalized plans of care were developed in conjunction with program medical directors (BEST EMS). Collegial coordination with hospital case management departments allowed maximal use of available community resources.  Patients were assigned to a category (Figure 1) which determined the frequency of their visits.  The patient’s general characteristics, number of 911 calls, number of ED visits/hospital re-admissions, number of fire engine calls disregarded, time of engine in-service time, and total CHP-APP home visits with time spent were collected. The outcome was measured for 180 days after enrollment to determine whether frequent home visits by CHP APP affected the number of 911 calls among these patients. Logistic regression analysis was performed to determine the potential independent risk factors that could affect the frequent 911 calls. Data were analyzed using STATA 12.0 statistical software.

From June 2013 till present, a total of 23 patients were enrolled in this study. The average age of the patient was 65.65±2.97 (95% CI 59.48-71.81). 65.22% (15/23) of patients were female. The average length of each CHP APP home visit was 44.57±7.95 min (95% CI 27.39-61.75 min). The total number of  911 calls before CHP APP  home visits was 9.14±2.88 times, and 5.17±1.91 times after CHP APP home visits (p=0.0412). Furthermore, the number of 911 calls after CHP APP visits for over 120 days were 0.8±0.5 times compared with those of before CHP APP visits (4.6±0.8 times, p= 0.0045). The odds ratio of the number of 911 calls 30 days after ED discharge among these patients was 1.82 (95% CI 0.66-4.98, p=0.24) by logistic regression analysis.  The average number of hospital admissions per patient pre-enrollment was 2.83 and 1.16 admissions after enrollment*.  The average number of ED visits/patient pre-enrollment was 8.67; which reduced to 2.16 after. There was a 59% reduction in hospital admissions and a 75% reduction in ED visits after enrollment in the program.  The Fire Engine/Truck was disregarded by the squad on 50% of the 911 medical calls during the pilot study.  This resulted in a more than an 8 hour Increase of In-Service Time for one engine during the 202 hours of the disregard pilot.

Frequent home visits by CHP APP after patients were enrolled in the McKinney Fire Department CHP program decreased the number of 911 calls, hospital readmissions, and ED visits, especially after 120 days. Among these patients, the potential risk identified that affected the frequent 911 calls was the number of calls within the first 30 days after discharge, though no statistical significant difference was reached due to the relatively small sample size. It is suggested that home visits by CHP APP should be emphasized heavily during the first month of patient discharge from the hospital.  The reduction in Fire Engine/Truck calls resulted in an increase in the In-Service time for the Fire Equipment.  The pilot has been determined to be a success, and will be continued with the addition of hospital case management referrals as well as CHF and COPD protocols starting 2014 (Figure 2)

“The Right Care at the Right Time, because it is the Right Thing to do”

*information only available from one of the two hospitals at time of submission.




BestEMS Figure2

Figure 1



Figure 2


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