Paramedics to decide who is transported to the hospital

Ambulance companies reinstitute “assess and refer” policy to reduce the number of non-emergency patients being taken to local hospitals

TULARE COUNTY – Sierra View Medical Center’s Sept. 4 announcement it had reached capacity prompted Tulare County ambulances to reinstitute a policy not seen since the height of COVID-related hospitalizations in December and January.

There were 30 COVID-confirmed ICU patients in Tulare County on Sept. 5, the highest since the pandemic began in March 2020. The day before, Tulare County instituted an “assess and refer” order for all ambulance providers, according to Dan Lynch, director of the Central California Emergency Medical Services Agency (CCEMSA). Lynch said hospitals in all four counties overseen by CCEMSA (Tulare, Kings, Fresno and Madera) have had to transfer patients to other areas of the state due to the lack of staffed beds in the south Valley.

“We are hoping and praying this was the peak,” Lynch said. “We have lost our hospital capacity to COVID.”

Under normal circumstances, EMS crews cannot refuse someone medical transport to a hospital if they request it, even if it is not recommended by the crew. The “assess and refer” policy states emergency medical technicians (EMTs) and paramedics will evaluate patients at the scene and determine if they require emergency transport to a hospital. If their condition is deemed a non-emergency, patients will be advised to seek care at an urgent care facility, contact their primary care physician or taken advantage of telehealth appointments offered by most insurance carriers. The idea is to reduce the number of non-emergency patients being taken to the hospital and keep as many ambulances on the road as possible.

“A lot of people either forget or are unaware there are telehealth options available to them,” Lynch said.

Under the assess and refer policy, the decision to transport a patient to a local hospital will be determined by EMTs or paramedics based on their heart rate, blood pressure, breaths per minute, oxygen levels, and if they appear to be comatose.

The assess and refer policy was implemented for the first time ever on Dec. 21, 2020, when COVID-confirmed ICU patients reached a then-record 24 and climbed to 29 by Jan. 10, 2021. It was lifted in February after the number of COVID-confirmed ICU patients steadily dropped until June, the lowest point since the pandemic began.

An assess and refer order is now in effect in Tulare, Kings, Madera, Fresno and Kern counties, Lynch said.

Lynch said if the number of hospitalizations don’t start to fall soon, the situation will be exasperated by the coming flu season. Beginning in October, the flu season overwhelms the EMS system, even before COVID, and this flu season could be more dire as the delta variant flares up across the country.

“The situation now is more critical than in December and January,” Lynch said. “The EMS system is already being hit hard.”

One of the ambulance providers, Dinuba Fire Department, made it clear in a Sept. 8 Facebook post the rise in COVID cases was stretching the resources of both hospitals and ambulance providers.

“Hospitals are operating at disaster levels and there is limited patient bed capacity available,” Fire Chief Jordan Webster stated in the post. “Most of our hospital emergency departments are holding ICU patients, which requires significant emergency department space and resources that are no longer available to the emergency department.”

Webster said Dinuba Fire staffs three advanced life support ambulances which cover 400 square miles of northern Tulare County. He said the new assess and refer policy will allow the EMS system to reduce hospital admissions and keep more ambulances en route to calls.

As president of the county’s largest ambulance provider, Paul Main said American Ambulance in Visalia is seeing call volumes 15% to 20% higher than normal and the COVID patients have more severe symptoms. The severity of the delta variant, coupled with hospitals reaching capacity, has created a backlog at local emergency departments. Main said many of his crews are stuck waiting in the hallways of hospitals monitoring patients waiting to be handed off to ED nurses and physicians. Known as “wall time,” Main said crews have been waiting an average of 90 minutes, and in extreme cases several hours, at the hospital before they can head back out to respond to calls.

“The current situation seems more severe to us [than the winter surge],” Main said.

Main has started stationing a paramedic crew, comprised of a paramedic and either one or two EMTs, at the hospital so that incoming ambulance crews can hand off their patients and return to the road, some of them from as far as Kings and Fresno counties. In some cases, an EMT will leave wall support and go back out with another paramedic, other times there are no crews stationed at the hospitals. Last week was the first full week of the “wall support” crews and it seems to be working as wait times have been cut from an average of 90 minutes down to 60 minutes. Other providers, such as Exeter Ambulance, Lifestar in Tulare and Imperial in Porterville, are also posting paramedics at the hospital to assist in the effort.

“The providers are all working together and as innovatively as possible to make our system work,” Main said. “We are doing everything to make modifications to make sure ambulances are available.”

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