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If a D.C. resident dials 911, they will no longer be promised an ambulance ride to the hospital. Individuals whose symptoms are determined to be minor or non-life-threatening will instead be put on the phone with a nurse.
The new policy, part of Washington’s “Right Care, Right Now” nurse triage line, aims to free up District resources — and hospital beds — for real emergencies.
D.C.’s Chief of Fire and Emergency Medical Services joins us to discuss.
Produced by Julie Depenbrock
- Gregory Dean Chief, Fire and Emergency Medical Services Department, District of Columbia
KOJO NNAMDIYou're tuned in to The Kojo Nnamdi Show on WAMU 88.5. Welcome. Later in the broadcast a former D.C. police officer joins us to discuss his latest crime novel. But first D.C. residents, who dial 911 will no longer necessarily get an ambulance ride to the hospital. Under a new policy rolled out last Friday, if an individual 911 caller's symptoms or injuries are determined to be minor, they will instead be put on the phone with a nurse.
KOJO NNAMDIThe new protocol is part of Washington's Right Care Right Now Nurse Triage Line, which aims to free up District resources and hospital beds for more serious emergencies. Joining me in studio is Gregory Dean. He is the Chief of the Fire and Emergency Medical Services Department of the District of Columbia. Chief Dean, thank you for joining us.
GREGORY DEANThank you.
NNAMDII'm wondering if you can lay out exactly how this new policy, which went into effect last Friday works. Someone calls 911, an ambulance arrives, and then what happens?
DEANWell, this program started in April of 2018, where you call 911 for a minor injury or illness and a nurse will assess you and determine if you're eligible to go to either self-care, take care of yourself or go to a clinic. And the idea behind this was one to connect patients with non-emergency conditions to more appropriate healthcare. And the other one is to preserve the department and hospital's emergency room resources so that we could take care of those patients that are in critical need.
DEANAnd so what we believe is since we started this program almost a year ago, that it is connecting. It's accomplished its goal. We are connecting lower acuity patients to more appropriate care. And our patients are getting to the nurse and getting transportation to the clinics in about 13 minutes. Ride is there. They are also being able to not go to the emergency room and sit for hours waiting to be seen.
DEANAnd we measure this by -- we call 100 percent of the patients back to see how they're doing and what their experience was as we make corrections. And then the second was how do we -- we were working on not impacting the emergency room and our resources. So this spring or actually last Friday we initiated another phase to this program, where when you call 911 and the nurse is not absolutely sure how to make a decision of a 911 caller, we'll send the fire truck.
DEANBut when the fire truck gets there, if they determine that your condition is eligible for the nurse triage line, they will call the nurse. The nurse will speak with you, but there's an additional piece of information that the nurse is now provided. That is that she will have the vitals for the patient to help make a better decision on what's the best care for the patient. And so that's the idea behind that.
NNAMDIChief Dean, before this new policy was implemented it was estimated that as many as 70 percent of 911 calls involved patients with non-life threatening emergencies. What effects are you hoping to see from this change in protocol?
DEANWell, we think that the care for patients has been good. I think we're accomplishing that goal is that we're starting to move patients. What we were unaware of and what we're learning is that we need to get more information to the nurse. And by having providers on scene and she's able to now determine, hey, I heard your conditions and I have your vitals. She's able to make a better decision on what is the right care right now for those patients.
NNAMDIAre there other cities that have put into practice a program like Right Care Right Now? What model is D.C. following?
DEANSo D.C. follows in a model where we probably have gone further than other cities. So they have Right Care Right Now, but it's not connected to 911. So they'll call a different number if they want to have something done. So here in the District, we have a long tradition of people calling 911 for primary care. And the idea is we're trying to separate that so that we can change that process right now. And what we hope is that by helping the nurse in her decision making it will make it easier for people to get the right care.
NNAMDIThe new system of assessment sounds like, well, a process. Is there a concern that this could keep units on a scene for too long and distract from other calls?
DEANWell, the units -- if the nurse wasn't there, the units would be on that scene anyway. The idea behind this now is if they qualify for going to a clinic, for Medicaid and Healthcare Life patients, they are provided transportation to the clinic. Usually they're in a clinic in about 37 minutes and they're provided transportation home. Currently if we take you to a hospital across town, you are there and you have to find your own way back home. So we're hoping that we are able to change the focus of dealing with primary care issues within your neighborhood within getting your primary care physician versus going to the emergency room.
NNAMDIHave you been hearing concerns from residents about this new policy? Is it possible after all that the EMS personnel, who show up on the scene could make an error in judgement?
DEANWell, it's always possible that people could make an error in judgement, but really we're benefiting, because not only is the primary care -- is the EMT and paramedic there, but now they're talking to a registered nurse, who is then being able to make that decision on all the information she has. So we're actually enriching the process for the patient, because this is really about patient care and patient safety.
NNAMDIOur guest is Gregory Dean. He is Chief of the Fire and Emergency Medical Services Department of the District of Columbia. We're talking about a new policy rolled out for people who call 911 in what turns out to be a non-emergency situation. Chief Dean, the nurse triage line, which launched last year, apparently has so far had a limited impact on the overall reduction of ambulance trips. Why is that?
DEANBecause the nurse needs additional information as they grow their sense of how it works. That's why we expanded the line to be 24 hours a day and additionally we are now having responders, when the nurse is unsure what she's hearing to reaffirm what is the appropriate care by providing vitals, the status of the patient, what the patient's condition looks like. So we think that this enhancement will benefit the residents even more and make everybody become even more comfortable with the idea primary care belongs in clinics. Emergency care belongs in the emergency room. Right now they're combined.
NNAMDIThere are people who call 911 a lot, a lot of them might not have primary care doctors or other access to care. Can you talk about that issue and how that affected emergency services?
DEANFor us, what we see is that people that go to the emergency room that do not have a primary care physician, they're still not getting treated for the underlining issues that drove them there in the first place. We believe that by you going to the clinics and having a primary care physician, they'll be able to not only treat you for what your immediate symptom is, but they'll be able to treat you for the underlining issues that are causing some of these challenges that we're seeing.
NNAMDILet's go to the phones. Here's Stephanie in Bloomington, North Carolina. Stephanie, you're on the air. Go ahead, please.
STEPHANIEHi. I'm actually in Washington D.C.
STEPHANIEMy phone number is from North Carolina.
STEPHANIEI'm a physician assistant and I do house calls. So I'm in people's homes and when I call 911 in D.C. now I get transferred to the nurse and I have to convince the nurse that my patient needs to go to the hospital. And I think if a provider is calling 911 and has deemed that their patient needs to go to the ER, then that should just be acceptable. And it's been frustrating, because it takes a long time to navigate through that whole thing and convince them.
NNAMDIConvince them of what?
STEPHANIEThat I believe that my patient needs to go to the hospital.
NNAMDIDo you ever have to --
STEPHANIEThey need an ambulance.
NNAMDIDo you have to convince them also that you are an in fact a provider?
STEPHANIEWell, no. I don't have to like provide my license number or anything, but they transfer me and the nurse wants me to explain and get into the details. And then I have to call the ER and tell them the same thing. So it's just like another hurdle.
NNAMDIChief Dean, is there a way of avoiding what seems to be maybe an unnecessary protocol?
DEANWell, I think when you call 911, you should expect that we're going to ask you basic questions to try to determine what is the right resource. And I can appreciate it that we're all in the same business, but if we're calling for assistance, we're trying to balance that with all the different types of resources we need to send. So I hear you and it sounds like you're having the same challenges at the hospital, because we're all in the same business of trying to triage and determine what the right resource is.
NNAMDIOkay. So is that something that adjustments can be made for in the system?
DEANSo I don't know that because -- and when I say I don't know that maybe I'm saying, "No" even in that when you call 911 to just say, "Send me resources." It's not what happens. You call 911, we are making a determination and we're going to explore what is the right resource we think should be sent based on the information you share.
NNAMDIOkay. Thank you very much for your call, Stephanie and good luck to you. Here now is Mary in Washington D.C. Mary, you're on the air. Go ahead, please.
MARYHi. Good morning and I love this show. Listen to it every day. Thank you so much. I just wanted to comment two things. A, I think what you're talking about in the District is disruption of the 911 model. And you're going through iterations of that disruption and I'm a whole hearted supporter of that.
MARYAnd then second, there was a comment a minute ago whereby I think you asked, you know, well what happens if the EMT makes a bad call. I have a personal experience, about a year and a half going on two years ago, I was having chest pains. I didn't know what was going on. I called 911. By the time the EMT showed up, I was fine. He checked my vitals everything was within normal range. But the EMT making an assessment they'd done and a couple of other factors decided, "I think it's a good idea that I take you in." And I thought, I was like, "Really?" He said, "I really think it's a good idea."
MARYSo he took me in to the hospital and as it turns out I had a 95 percent block left descending widow maker artery. And I had about one to two hours left of my life. I since reached out to your agency, sir, and I learned -- to thank the EMT. And I learned that you guys had been also making a concerted effort and training your EMTs in triage. So I would urge everybody in the District, listen, I'm alive, because of your organization and your agency.
MARYI am forever in you debt. And I think everybody in the District should know that transformation and disruption take some time. And these are iterations that you're talking about today. And these iterations are important and the fact that you're monitoring and measuring and soliciting feedback, that's part of the disruption process. So I'm all for it. Thank you so much.
NNAMDII'm glad you made that call, Mary. But, Chief Dean, in Mary's case the EMT was the individual, who made the decision. The way the system operates now, there would a nurse involved and even though the outcome would have hopefully have been the same for Mary, what's the relationship therefore between what the EMT does and what the nurse is able to do?
DEANWell, first, Mary, I'm glad you're with us. And I love your story and I'm glad to see that we actually took care of you. And that's really what it's all about. The EMT would only call the nurse if he thought the patient qualified to go to a clinic. Otherwise, the EMT is going to continue to provide medicine and take care of the patients. This program is only meant to free them up --
NNAMDIIn the case of non-emergencies.
DEAN-- sooner for real emergencies, okay. And Mary sounds like she had a real emergency going on at the time.
NNAMDIThe EMT said, "Mary's got a real emergency. I'm taking you to the hospital." It's my understanding that there are few people who have been responsible for a significant number of 911 calls, most of them turning out to be non-emergencies. For those people who have been so called like habitual 911 callers, how do you go about breaking that pattern and establishing a new one for them?
DEANSo we work collaboratively with behavioral health and with the health department on what we call our frequent callers, people that have called 911 more than 10 times. And we're looking to break that pattern by getting them the right help, so that they can get the right care that they need, which is different than what this program does. This program is for, you call and we send a resource. So we have a program called street calls. We have paramedics that work collaboratively with behavioral health, with the health department trying to get these patients into care and have them have a counselor to assist them in traversing the many systems that we have here in the District.
NNAMDIGot to take a short break. When we come back, we'll continue this conversation with Gregory Dean, Chief of the Fire and Emergency Medical Services Department for the District of Columbia. I'm Kojo Nnamdi.
NNAMDIWelcome back, we're talking with Gregory Dean, Chief of the Fire and Emergency Medical Services Department of the District of Columbia about the new nurse triage line in the District. And there are a lot of people who want to get in on this conversation. So allow me to let you do that. Here is Monica in Washington. Monica, your turn.
MONICAYes. Hello. Thank you for taking my call. One of the big concerns I have about this is that you have non-medical -- well, not non-medical personnel, but people who are not doctors who are making a decision about whether or not to take you to the emergency room, which might be in a situation where you are in a true emergency like having a heart attack and precious time might be wasted calling the nurse's line or also you're relying on the EMT's judgement rather than getting people to the hospital to a doctor to make that call.
NNAMDIWell, it would seem to be before the chief answers, Monica, that what you're saying is that if somebody calls 911 that the department's responsibility is to simply take that person to the emergency room without making any assessment whatsoever.
MONICANo, no. I'm not saying not to make any assessment whatsoever. The way that it has always been done is there is a brief assessment done, but then, you know, they do what do whatever they need to do to keep the person alive, but quickly transporting them to the emergency room. You know, as soon as the assessment -- the very quick assessment has been done. I'm just concerned that with this new policy there are a lot of extra steps that seem to be involved where you're contacting a nurse and everything wastes time in the precious moments where you really need care if it happens to be a heart attack.
NNAMDIOkay. Here's Chief Dean.
DEANSo the question you're asking is how to do we make the assessment. And, again, the only patients that we see that are eligible for the nurse triage line are those with minor injuries and minor illnesses. So you've called 911 and you've asked for us. And we have trained people that do medicine. And we want to make sure that we allow them to do medicine and for those that we think qualify for the nurse triage line, then they will confer with a registered nurse who will agree with that. But for any other reason that you call 911 and you are having an emergency we will continue to handle you the same way we do today. We will make an assessment. We will stabilize and we'll transport you to the appropriate emergency room.
NNAMDIThank you very much for you call, Monica. Here's Terry in Washington D.C. Terry, you're on the air. Go ahead, please.
TERRYYeah, thank you, Mr. Nnamdi and thank you for your service, Chief Dean. You know, I am an emergency physician, an ER doctor, and a practicing paramedic for many years. And I can't tell you how fantastic this program seems to us. Not only in terms of decompressing the system, but in terms of the residual effect in terms of burnout of first responders, EMTs, and paramedics, who spend the majority of their time responding to things where their skills are not needed.
TERRYMy big question is and a concern that all of us in the business have is, you know, what's going to happen when that one case comes up when somebody makes a bad decision and it ends up in a catastrophe and we know it's coming. I mean, we have catastrophes every day in the current system, but in the new system, how are you going to deal with that and do you have a good quality assurance program to deal with that set of circumstances?
DEANSo we continue to monitor each one of the calls we go on. So we call back and we talk to patients. We have CQI that are taken, consequential quality improvements. We're taking a look at how we're doing and looking at calls that turn the other way. The same risks you're talking about are the same risks we face today. We must continue to be diligent in keeping up with how we train our people, how we observe how well they deliver the service, and how we continue to educate them.
DEANThis actually helps and you talked about burnout. This actually helps also because we know that we're actually helping and taking care of people versus just showing up and taking them to the emergency room and leaving them there. This I believe is the direction that we should be headed so that not only the emergency responders, but those in the emergency room are actually able to do the jobs we train them for, which is emergency medicine not primary care medicine.
NNAMDIOkay. Thank you very much for your call. Catherine tweets, "Persons with rare conditions often speak with their physicians prior to making the 911 call. Is this new system going to respect that physical decision or will they have to go through a new protocol?"
DEANAgain, when you call 911, your call is triaged. All that information is used to help make that decision, but we still triage the patient to decide what is the appropriate care for the patient.
NNAMDIOkay. That was in the form of a tweet from Catherine. Here now is Michael in Alexandria, Virginia. Michael, your turn.
MICHAELHi. How are you doing? So I've been living in the District for about seven years now. And when I first moved here I worked in Dupont Circle, one of the restaurants. And any time an incident, you know, would come up if there was an emergency, 911 could never find us where we were located even though, you know, the address was very well-known. We could never be located.
NNAMDIWhen was the last time this happened, Michael?
MICHAELI haven't work in Dupont for the last couple of years, so like since 2014.
MICHAELAnd I had one other situation where my sister she suffers from epilepsy and I've had to call 911, you know, in several occasions for her. But because we know how the epilepsy behaves, we just need to have (unintelligible) they check for like injuries. Whenever we've called 911, they've almost forced us to take her to the hospital when she doesn't need to go.
NNAMDIOkay. Allow me to have the chief response. One is about your navigational system, what are you using? And two about the other issue.
DEANSo over the years we continue to update what we call the automatic (word?) locator as well as different things we're using for being able to find locations. Our firefighters, our EMTs, our paramedics, are all trained in learning their district. But at different times you get transferred out of your district so there might be challenges. We would hope that with modern technology they're able to find locations.
DEANSo, Michael, as you know seizure patients, again, while you're calling the idea is to keep them safe and move things away that they may bump into. And as long as it's not their first seizure our treatment at that moment is a little bit different. So I'm not sure. And I would be in a bad position to automatically say that your sister doesn't need to go to the ER room, because I don't know what they're seeing on scene. But traditionally if you are a patient that's had a number of seizures as long as your medication is good, as long as you are able to get back to that clarity zone, we can leave you based on the fact that somebody else will take you to be seen or talk to your physician. But, again, there is no exact science as to what's the right way. It's all based on what the provider sees and how the patient responds to the treatment.
NNAMDII want to make sure we address a few other things outside of the Right Care Right Now. Earlier this month you reported that the District had no backup ladder fire trucks if one goes out of service. Where does your reserve ladder fleet stand today?
DEANWe still have a challenge with reserve fleet. We have ordered ladders. We have three additional trucks coming into service toward the end of the summer -- first part of September. We will be putting a tower in service here in the next couple weeks. So we'll have four additional. But over the years, because of the call volume and everything else, we have not had a reserve fleet. So we are working very closely with the mayor, with the Council to create the apparatus we buy so that we can create a reserve fleet because apparatus has to go out of service for maintenance. They go out service because of accidents, different things. So you need to have that reserve fleet. We have not had that for a number of years. And we're seeing the impact to that today.
NNAMDIIndeed, Dave tweets, Have the chief explain how the failure of previous administrations to stick to the apparatus replacement schedule setup the current fleet problem. Ask him what needs to be done to prevent future mayors and councilmembers from making this often repeated mistake.
DEANSo the answer is that we're working very closely with the Council and the mayor to be able to procure enough apparatus so that we actually have a reserve fleet. By having that reserve fleet, that allows us to continue our purchase plan that we have in place for replacement of apparatus and allows us to be able to keep all our units in service. Traditionally we should have 16 trucks in service every day. By having a reserve fleet, you're allowed to be able to do that so that you can continue to provide the same level of service.
NNAMDIBack in September, a fire destroyed a senior housing complex in southeast Washington. There was some shock, because the fire alarm didn't work along with a host of other management issues. Who's responsible for inspections and why was this complex full of vulnerable elderly people in that situation?
DEANWell, who's responsible for the people in the building is, again, they rent it out. It's a low income property. They rented that out. The alarm system is the responsibility of the building owner to make sure and have the test. I think the last time we had inspected the building was in '17. The alarm system, and we were unable to make that determination, because of the condition of the building, as to whether it was working appropriately or not.
DEANBut what we do know is that the alarm was pulled, pulled by building maintenance and other people and the horns did not sound. So there was no notification to all the residents. And that's the idea behind that. So following that fire we went out and inspected all the alarm systems in high rise buildings especially residential to ensure that they were all working, because again, I think you're supposed to learn from these experiences to make sure we don't find ourselves back in that same position again.
NNAMDIThere's been an investigation. Do we know the cause of the fire?
DEANSo the fire investigators were unable to determine the cause, because of the amount of damage to the building.
NNAMDIFirefighting is a field historically dominated by men. Nearby in Fairfax County there have been reports of a deep culture of sexism in the department. One female firefighter committed suicide. Some point to harassment online in the days before she took her life. How would you describe the culture of the D.C. Fire and EMF and have there been similar complaints from women in your department?
DEANSo we've been fortunate in that there's been programs started that we started empowering women program. We have for the first time in years have promoted two females to battalion chief. This is a non-traditional profession and we believe as an organization that we're better if we have all the different people that work with us involved in all the different levels of this organization. So we've been working very closely with everyone to ensure that we represent the people we serve and we bring all those ideals in to make us much better. Again, it's an opportunity. We see it as that and we enjoy our opportunity to be as diverse as possible.
NNAMDITwo women battalion chiefs, are Queen Anunay and Kishia Clemencia.
NNAMDIAnd before we go, however, on this issue of gender, Ann called to say thanks to EMS, but she's hearing nurses referred to as she and EMTs referred to as male. Is that because the nurses predominantly female and the EMTs in your department predominantly male?
DEANThe large percentage of -- again, being a non-traditional profession has been male. We continue to incorporate. Actually, for me, the easiest -- I don't use "he" and "she". We use "EMTs". We use "firefighter". We use "paramedics". And we use "nurses". We have male nurses that actually work at our call center to review these calls also. So, again, without trying to decipher, I think it's more important that we look at whose there and that they're well trained to do the job.
NNAMDIGregory Dean is Chief of the Fire and Emergency Medical Services Department for the District of Columbia. Thank you for joining us.
NNAMDIGoing to take a break. When we come back, a former D.C. police officer joins us to discuss his latest crime novel. I'm Kojo Nnamdi.
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