ABSTRACT

On June 26th, mid-morning, a 47 year old male patient called into the 911 center with a complaint of being bitten by insects all over his body. Initially the caller wanted an ambulance to take him to the emergency room (ER), but he had advised the emergency medical dispatcher (EMD) that the rash and bites had been going on for a while. In Louisville, all medical 911 calls are triaged at the MetroSafe 911 center by a certified EMD using the Medical Priority Dispatch System™ (MPDS®) software, ProQA®. The end result of the EMD triage is an assigned (alphanumeric) determinant code that includes the chief complaint type, priority level, and a brief text description of the primary symptom or condition. After finding no symptoms or conditions requiring an emergency ambulance response, the EMD triaged the call to a determinant code of 02O02 - Stings/bites with no difficulty breathing or swallowing with symptoms present for ≥1 hour. In Louisville, this determinant code is eligible for transfer to an emergency communications nurse (ECN) for further evaluation as a potential non-ambulance case.

The ECN uses a nurse triage software program known as LowCode™, which provides protocols to manage these non-emergency 911 cases in a more efficient, clinically appropriate manner than past practice, which was to always send an ambulance on every medical 911 call, no matter what the problem was. The more serious medical cases continue to get an emergency ambulance response; but for the non-life-threatening cases, there exists a clinically sound process that assists the patient in obtaining the most appropriate medical care and transportation, which in many cases means directing the patient away from an emergency ambulance response—and the associated hospital emergency department visit—into an alternate treatment venue such as an urgent care clinic, primary care physician's office, or simply home-care with instructions and followup contact from an ECN. In some cases, our patients may get seen by a physician even sooner using these alternate facilities, which in turn helps ease the pressure on already overburdened emergency rooms. The nurse may also assist the patient in obtaining non-emergency transportation. A patient who is ambulatory will typically use transportation other than an ambulance. This practice has a further benefit: emergency ambulance crews are kept available to respond to the most critical, life-threatening cases.

In this particular case the ECN quickly established a rapport with the patient. The patient advised that he had had a rash and insect bites for some time and that he was itching all over, which made him feel miserable. The ECN used the LowCode™ insect bite protocol and found that, while there were no life-threatening symptoms, the patient's rash seems to have become infected. The insect bite protocol will navigate through a range of conditions ranging from potentially life threatening high acuity conditions—for example symptoms of shock, respiratory and airway compromise, anaphylaxis, multiple stings, bee and wasp stings—down to less urgent conditions such as a travel history, with mosquito bites, tick bites, head lice and other less urgent symptoms following insect bites. The LowCode™ software advised the nurse to choose a lower acuity response; the nurse was agreeable to the advice and scheduled the patient to be seen by a physician in the community the same day. The patient had no insurance, and the nurse felt that the patient's condition would not improve without a faceto- face consultation with a clinician. The ECN scheduled an appointment at a neighborhood primary care physician's office at a minimal charge to the patient. The ECN chose to send the patient to the office appointment in a public transport vehicle, and this alternative form of transport helped reduce the strain on the 911 system at the time.

This case illustrates how seamlessly the ECNS secondary Nurse Triage program works in Louisville, Kentucky. The patient received prompt, high quality, out of hospital care. And at the same time, the nurse scheduled a followup appointment for the patient, which could help to prevent future illness and another 911 call for emergency assistance. In addition, the use of a public transport vehicle instead of an ambulance further reduced the cost of this call to the community. During the follow-up callback the next day, the patient reported that the rash was clearing up and he felt much better. The patient was aware he had a future scheduled appointment booked and was very satisfied with the outcome.