Saturday, September 14, 2002

Have the ambulances stopped coming? Is it real or only accounting?

As I sit down to write this column in early July, I’ve been pondering our first six-month results. You’ll recall that a few months ago I wrote about our electronic medical record startup in April and with a few months of experience and the statistics from the first half of this year—well suffice it to say this column nearly wrote itself.

Yes, 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% and admissions were nearly constant. So while I still don’t have all the answers as I write, I think our experience—particularly because it derives from our electronic medical record (EMR) 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 off in ambulance patients, particularly for April-June. When we drilled down on the data that day it appeared as though something had happened to patient deliveries (“ambulance drops”) 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 (FDNY), is an amalgam of the publicly operated fire department ambulances, voluntary hospital based ambulance services also 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 NY 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, Bravo and Bensonhurst Community Ambulance service 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 (ACR) while most of the volunteer ambulances and the proprietary ambulances use their own form for meeting state requirements.

In trying to find out what was happening to our “ambulance drops”—we asked, “Were there really many fewer ambulance drops, was it merely accounting or some of both?”

Well 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—uh oh.

Stanley Brezenoff, Maimonides’ CEO is a long-time public servant. His past seven years at Maimonides has 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 even as 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 has brought me along. He has brought the message of the hospital’s openness to the communities’ needs everywhere in Brooklyn (and beyond) where 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) our ambulance triage nurse completed a triage form that went to the registration clerk along with the ACR. The triage form captured through check boxes and write-ins the name of the ambulance company that had brought the patient. The triage nurse enters the same information in the EMR, 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 ACR; they did read the ambulance nurse triage note.

Well, between the time we discovered the deficit in ambulance transports and had drilled down to its apparent genesis we took advantage of the fact that our Maimonides’ ambulances bring patients to our own ED. So we undertook a one-day comparison of the registration system’s data with our own ambulance department’s ACRs. Whew! Of 11 ACRs 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.

Looking further I realized that in April, we might have experienced a true decrease in ambulance drops. To some extent this is explicable through our early days of learning the ropes with our new EMR, yet, here it was July and I was only just examining the quantitative data—I’d neglected to do so 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. Using the feature in HealthmaticsED™ which when “mousing over” the icon—a “tooltip” box opens on the screen displaying text, which now includes 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 the given situation. 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.