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Service Delivery Innovation Profile

Emergency Medical Technicians Use Checklist To Identify Intoxicated Individuals who Can Safely Go to Detoxification Facility Rather Than Emergency Department


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Snapshot

Summary

Trained emergency medical technicians in and around Colorado Springs and El Paso County, CO, use a checklist to evaluate intoxicated individuals to determine if they need to go to the emergency department or can safely be transported directly to a county detoxification facility. The program has allowed for the safe transfer of a meaningful proportion of these individuals to the detoxification facility, thus avoiding expensive, unnecessary visits to crowded, resource-constrained emergency departments.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the proportion and number of intoxicated individuals transported directly to the detoxification facility rather than the ED, along with information on unplanned transfers among those transported to the detoxification facility.
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Developing Organizations

American Medical Response, Inc.
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Use By Other Organizations

The city of Denver has a somewhat similar program in which EMS personnel patrol the downtown area in a vehicle, looking for intoxicated individuals who could benefit from transport to a detoxification facility.

Date First Implemented

2003
The initial trial ran from December 2003 to December 2005 with one local detoxification facility; the program remains in place today, in partnership with a different facility.begin pp

Patient Population

Vulnerable Populations > Substance abusersend pp

Problem Addressed

Many intoxicated individuals served by emergency medical service (EMS) providers do not have medical needs that require emergency department (ED) care. Yet many EMS systems lack the resources (including linkages with other community-based programs) to offer destinations other than EDs to these patients. This practice exacts a significant toll on ED resources.
  • Routine transport to ED for all intoxicated individuals: Most EMS systems lack the resources (including linkages with other community-based resources) to offer destinations other than EDs to intoxicated individuals who do not require immediate medical attention. As a result, they transport these individuals to local EDs for "medical clearance." For example, before implementation of this program, EMS personnel throughout the greater Colorado Springs metropolitan area routinely followed this practice.1
  • Exacting substantial toll on EDs: The routine transfer of all inebriated individuals to EDs exacts a meaningful toll on their staff and resources.1 At the national level, individuals with uncomplicated alcohol intoxication account for 0.6 percent of ED visits, at a cost of roughly $900 million annually.2 These individuals also tend to be frequent ED visitors, consuming a disproportionate share of resources.3,4 In the Colorado Springs and El Paso County, CO, area, intoxicated individuals accounted for roughly 1 percent of ED volume before implementation of this program. One hospital system with two EDs handled roughly three-quarters of these patients, who often lined the hallways, took up valuable bed space, or became a distraction to ED staff and other patients (e.g., because of their erratic behavior). ED staff and physicians at the other hospital system (which has one ED) also periodically complained about these patients.

What They Did

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Description of the Innovative Activity

Specially trained emergency medical technicians (EMTs) in and around Colorado Springs and El Paso County, CO, use a checklist to evaluate intoxicated individuals to determine if they need ED care or can safely be transported directly to a county detoxification facility. Key program elements are detailed below:
  • Trained EMTs called to scene: Whenever a 911 call comes in about a person who appears to be intoxicated, paramedics go to the scene, as do the police department and in some cases (within Colorado Springs city limits) the fire department. After arriving, the paramedics conduct a preliminary evaluation as to whether the individual might qualify for direct transport to the detoxification facility. If so, they call in specially trained EMTs to conduct a more thorough evaluation using a checklist (as described in the bullet below). These EMTs routinely patrol the area in a multipurpose vehicle capable of safely transporting intoxicated individuals.
  • Assessment via checklist: The current checklist consists of 10 questions that screen for age (only those 18 or older qualify), ability to cooperate with the examination, mental capacity, injury or medical problems, blood pressure, heart rate, ability to walk, and whether the individual takes Coumadin (a blood thinner that can react with alcohol). Only patients for whom the answer is no to all of the following questions qualify for consideration:
    • Is the patient younger than 18?
    • Is the patient unable to cooperate with the examination?
    • Does the patient appear to lack the mental capacity to make decisions?
    • Has the patient experienced a significant mechanism of injury?
    • Does the patient have a medical problem, complaint, or injury that needs to be evaluated in the ED?
    • Is the patient on Coumadin?
    • Does the patient have a systolic blood pressure greater than 190 mmHg?
    • Does the patient have a diastolic blood pressure greater than 110 mmHg?
    • Does the patient have a persistent heart rate greater than 140 beats per minute?
    • Is the patient unable to walk?
  • EMT-led decision: The specially trained EMT makes the final decision as to where the patient should go, typically to the ED or detoxification facility, as outlined below:
    • ED for virtually all at-risk individuals: If the answer to any of the 10 questions is "yes," the EMT almost always concludes that the patient needs to be transported directly to the ED, in which case the standard EMS crew transports the person in an ambulance. The protocol allows the EMT to review the case by telephone with a medical control physician at the hospital ED to decide if the algorithm should be overridden and the patient sent to the detoxification facility anyway. In reality, however, this option is almost never used.
    • Detoxification facility for most low-risk individuals: If the answer to all screening questions is “no,” the EMT will almost always decide to transport the patient to the county detoxification facility. In these cases, the EMT also completes a “detox patient care report” that summarizes the patient’s condition for staff at the facility. In rare instances, the individual might be left where he or she is, provided it is a safe environment protected from the elements (such as a home). Occasionally, the police might take the individual into custody, or arrangements will be made to have a friend or family member pick up the person.

Context of the Innovation

American Medical Response, Inc. is one of the nation’s largest private medical transportation companies, with nearly 17,000 paramedics, EMTs, nurses, doctors, and support staff who provide emergency and nonemergency transports in more than 2,100 communities across the nation. In the 5-county region that includes Colorado Springs and El Paso County, the company employs 250 paramedics and EMTs who currently handle approximately 60,000 calls each year. (At the time this program began in 2003, annual call volume totaled roughly 40,000.) As noted earlier, situations involving intoxicated individuals account for a small but meaningful proportion of these calls.

The impetus for this program came from the local medical director of American Medical Response and from physicians and staff at local EDs who had become concerned about the substantial toll that intoxicated patients were taking on ED resources (as described earlier). The local medical director convened a group of people that included EMS providers and representatives from the two hospital systems and the local detoxification facility (a nonprofit organization known as Lighthouse). This group was charged with finding an alternative way to identify and address intoxicated patients who do not require medical attention. (Lighthouse closed in 2009 and a new facility now participates in the program; the Planning and Development Process section below provides more details on this transition.)

Did It Work?

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Results

The program has allowed for the safe transfer of a meaningful proportion of intoxicated individuals to the detoxification facility, thus avoiding expensive, unnecessary visits to crowded, resource-constrained EDs.
  • Many avoided ED visits: During the initial trial (December 2003 to December 2005), nearly 1 in 5 intoxicated individuals (138 out of 718) were transferred directly to the detoxification facility, with the remainder (580 individuals, or 80.8 percent) sent to the ED.1 Since that time, use of the checklist has expanded greatly. As of December 2012, EMTs transfer between 100 and 150 patients a month directly to the detoxification facility. In the absence of this program, virtually all of these individuals would have been sent to local, often overcrowded EDs.
  • Virtually all those needing ED care getting it: Only 2.9 percent of those sent to the detoxification facility in the first 2 years of the program experienced a medical condition that led to an unplanned transfer from the detoxification facility to the ED during the 12 hours after their arrival. None of these patients died or experienced any serious medical complications. Internal retrospective analysis found that 99 percent of intoxicated individuals who needed to go to the ED went there. In other words, only 1 percent of patients who actually required immediate ED care ended up being sent to the detoxification facility; this figure is known as the program's "under-triage" rate, which needs to be kept as low as possible to promote high-quality care and avoid legal liability.1
  • Potential opportunity for more direct transfers: During the first 2 years of the program, only 42 percent of the 580 individuals brought to the ED needed to be there. In other words, 58 percent could have theoretically gone to the detoxification facility but instead were transported to the ED. (The 58-percent figure is known as the “over-triage” rate, since it represents people triaged to the ED who safely could have gone elsewhere.) A high over-triage rate is to be expected with this type of program, which needs to "cast a wide net" to be sure that those who require ED care receive it. However, there may be an opportunity for program leaders to reduce the over-triage rate without meaningfully increasing the risk of under-triage. The American College of Surgeons Committee on Trauma recommends creation of a system that produces a lower over-triage rate (between 25 and 50 percent), suggesting the potential to safely increase the number of direct transfers to the detoxification facility in El Paso County and Colorado Springs.1

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the proportion and number of intoxicated individuals transported directly to the detoxification facility rather than the ED, along with information on unplanned transfers among those transported to the detoxification facility.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Developing initial checklist: The workgroup of local EMS officials, ED physicians and nurses, and Lighthouse detoxification facility staff developed and approved the initial checklist, which was based primarily on existing requirements of the detoxification facility related to transfer and acceptance of inebriated patients from the three local EDs. The checklist comprised 29 items, reflecting Lighthouse’s lengthy list of requirements.
  • Training paramedics and EMTs: Paramedics are the most extensively trained individuals within an EMS system. For the first few years of this program, paramedics used an earlier version of the checklist to determine whether a patient was eligible for direct transport to the detoxification center. These paramedics received roughly an hour of training specific to the checklist, with an experienced paramedic walking them through each question. This training supplemented the 8 hours of indepth training that all newly hired paramedics receive, which emphasizes how to evaluate mental status and associated medical/legal issues. In recent years, the medical director and other leaders at American Medical Response decided to have specially trained EMTs complete the same educational training program, and now these "detox EMTs" make the final determination as to whether an inebriate qualifies to go directly to the detoxification center or should be transported to an ED.
  • Collecting followup forms for program evaluation: For the first 2 years, the medical director received followup reports from Lighthouse about patients transported directly to the detoxification facility. He used this information to ensure that patients with unmet medical needs were not being sent to the facility rather than the ED. However, administrative hassles and resource constraints led to the abandonment of this practice.
  • Holding monthly assessment meetings: For the first several years of the program (extending beyond the initial 2-year study period), the workgroup met on a monthly basis to assess how the program was working for the local hospitals and the detoxification facility.
  • Transitioning to new facility: The program was temporarily suspended after Lighthouse closed in 2009. Later that year, the El Paso County Sheriff’s Office opened a new detoxification facility with more beds than at Lighthouse. The medical director convened a new workgroup made up of EMS personnel and representatives from local EDs and the new facility to develop and approve a new checklist. Because the county facility had fewer restrictions and mandates than Lighthouse, the new checklist contained only the 10 questions described earlier.
  • Training on new checklist: Paramedics received training on the new checklist during regularly scheduled “refresher” sessions, while the detox EMTs received approximately 90 minutes of training on it during a special training session. 

Resources Used and Skills Needed

  • Staffing: Four EMTs are currently trained to conduct assessments using the checklist, two of whom represent new full-time hires for this program. (The other two already worked for American Medical Response and also spend time on other duties.) Using EMTs reduces the burden on more experienced, higher paid paramedics, allowing them to respond to other calls rather than spending time transporting intoxicated individuals.
  • Costs: Program costs include salaries and benefits for the two newly hired EMTs, along with the costs of modifying an existing van (previously used to transport those in wheelchairs) for use with intoxicated individuals. Modifications included installing a steel cage to protect the driver and outside locks. A new van would cost between $30,000 and $40,000.
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Funding Sources

American Medical Response, Inc.
The program is funded internally by American Medical Response, Inc.end fs

Tools and Other Resources

The original checklist (used with the first detoxification center) can be found in the article listed in the References section.

Adoption Considerations

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Getting Started with This Innovation

  • Evaluate need for program: Some communities (e.g., large urban areas) likely need this type of program, although others (e.g., many suburban and rural areas) do not have enough of a problem with intoxicated individuals consuming ED resources to justify the investment. Consequently, the first step should be an analysis to determine the extent of the problem at the local level, with EMS providers and ED physicians and nurses participating in this exercise.
  • Partner with local detoxification facility: The program will not work in the absence of a local detoxification facility with adequate resources to handle an influx of patients.
  • Bring together key stakeholders: Representatives from local hospitals, EDs, detoxification facilities, mental health agencies, and EMS providers should come together to discuss needed protocols, checklist questions, and monitoring systems to ensure that the program correctly identifies those who can safely bypass the ED.
  • Leverage existing resources: The two checklists used as part of this program may be a useful starting point for local stakeholders interested in adopting this approach.

Sustaining This Innovation

  • Continue to monitor program impact: If possible, program leaders should continue to monitor the program’s impact by collecting followup information on at least 20 percent of those sent directly to the detoxification facility. This step will help to ensure that the under-triage rate remains low, with few if any individuals in need of ED care not getting it. (The leader of this program hopes to secure funding to allow for additional monitoring and evaluation; as noted earlier, he received followup information on those transported to the detoxification facility for only the first 2 years of the initiative.)
  • Tweak checklist over time: As noted, any checklist will tend to err on the side of over-triage, thus ensuring that those who require medical care get to the ED. However, there may be opportunities to make minor changes to enhance the checklist's ability to detect those who can safely be transported to the detoxification facility. For example, analysis of the initial checklist found that the inability to walk with minimal assistance was the most common reason that patients ended up being sent to the ED. Yet for many intoxicated individuals, the inability to walk is a direct, temporary result of their inebriation, and hence does not require medical intervention. Going forward, program leaders hope to analyze this issue further and possibly expand the checklist to enable EMTs to identify a subset of individuals with ambulation problems who might safely be sent to the detoxification facility.
  • Provide refresher training: EMTs or paramedics likely need periodic courses on how to use the checklist, particularly after any changes are made.

Spreading This Innovation

Some members of the American College of Emergency Physicians and others outside the organization have taken enhanced interest in the development and standardization of community "sobering centers", while also displaying interest in further testing and study of prehospital detoxification center patient evaluation criteria.

Use By Other Organizations

The city of Denver has a somewhat similar program in which EMS personnel patrol the downtown area in a vehicle, looking for intoxicated individuals who could benefit from transport to a detoxification facility.

More Information

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Contact the Innovator

David W. Ross, DO
Medical Director
American Medical Response, Inc.
2370 North Powers Blvd.
Colorado Springs, CO 80915
(719) 494-7810
E-mail: drdr0682@aol.com

Innovator Disclosures

Dr. Ross reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Ross DW, Schullek JR, Homan MB. EMS triage and transport of intoxicated individuals to a detoxification facility instead of an emergency department. Ann Emerg Med. 2013;61(2):175-84. [PubMed]

Footnotes

1 Ross DW, Schullek JR, Homan MB. EMS triage and transport of intoxicated individuals to a detoxification facility instead of an emergency department. Ann Emerg Med. 2013;61(2):175-84. [PubMed]
2 Pletcher MJ, Maselli J, Gonzales R. Uncomplicated alcohol intoxication in the emergency department: an analysis of the National Hospital Ambulatory Medical Care Survey. Am J Med. 2004;117:863-7. [PubMed]
3 Thornquist L, Biros M, Olander R, et al. Health care utilization of chronic inebriates. Acad Emerg Med. 2002;9:300-8. [PubMed]
4 Larimer ME, Malone DK, Garner MD, et al. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA. 2009;301:1349-57. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 13, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 11, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

David W. Ross, DO
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