EMS vs Ride-Share: How Should Patients Get to the ED?

Michael T. Hilton, MD, MPH

Disclosures

August 01, 2018

It's 5:00 PM, rush hour in the city. Downtown sidewalks are filled with the ebb and flow of pedestrians passing the stagnant rivers of cars. The office is closing down; lights are going out. Your coworkers say goodbye. Time to head home.

On your way out, something catches your eye. Your boss's door is closed and the lights are still on. He should have left by now. You knock; with no answer, you open the door. He is sweaty, pale, and breathing fast. He doesn't look well; he needs help. You call 911. He seems to be getting worse with each question the 911 operator asks. Three minutes pass; it feels like an eternity, why so many questions? Finally, the ambulance dispatcher is on the line.

"How soon until the ambulance gets here?"

"As soon as we have a unit available sir, we will assign the call. In the meantime, stay on the line with me. Ask him if he has any medication for his breathing."

"In the meantime?" How long is this meantime? Checking your phone, the nearest ride-sharing car is 3 minutes away and you'll be at the hospital in 20 minutes! "How much longer?"

"As soon as we have a unit available, sir, as I have explained. In the meantime..."

Traditionally, emergency medical services (EMS) has been the primary means for transporting ill or injured persons to an emergency department (ED). Since 1968, the phone number 911 has provided access to fire and police emergency services.[1] As EMS systems developed during the 1970s and until the present time, 911 has been the primary access point for EMS.[2]

When EMS providers arrive, they perform a medical assessment, deliver emergency medical treatment to stabilize identified emergency conditions, and then safely transport the patient to an appropriate ED that can best manage the patient's condition. In some cases, this may be located at the nearest hospital. In other cases, such as for trauma, stroke, myocardial infarction, or pediatric or obstetric patients, this may be located at a more distant hospital that has specialty services for the patient's condition.[3,4,5,6,7,8]

For some conditions, this package of assessment, treatment, and transport to an appropriate destination provides morbidity and mortality benefits to patients.[9,10,11,12,13] For other conditions, it offers more rapid treatment of pain and can prevent further injury during transport to the hospital, such as by immobilizing an injured extremity.[14] This kind of care takes time, however.

Does Rapid Transport Make a Difference?

EMS doesn't necessarily arrive quickly, place a patient on a stretcher, and speed to the nearest hospital with lights flashing and sirens blaring. The EMS of 2018 isn't the EMS of the 1970s. Lights and sirens are not necessary for most ambulance responses. This transport mode with lights and sirens places EMS providers, patients, and the general public at risk for injury or death from motor vehicle crashes and only saves an average of 1.7 to 3.6 minutes, with no known morbidity or mortality benefit.[15,16,17]

A few possible exceptions to the importance of very rapid transport to an ED exist for patients with penetrating trauma and in rural settings. A delayed ambulance response or prolonged scene time may cause increased morbidity and mortality in cases of trauma in rural areas.[18,19,20,21,22,23] However, many studies find no association between EMS time intervals and mortality in trauma or in other conditions.[17,24,25,26,27,28,29,30] Some of this discrepancy may be related to differences of the effect of time on patients with penetrating trauma, who may be a unique subset requiring rapid transport to the ED.[23,31]

Arising from the need for rapid transport for patients with penetrating trauma, Philadelphia police now transport victims of penetrating trauma, bypassing EMS.[32] Police sometimes also transport patients with blunt trauma, without a known increase in mortality. The mortality of patients with penetrating trauma transported by police is similar to the mortality of those patients transported by EMS.[33,34,35,36] There is also evidence that, compared with EMS transport, private vehicle transport of trauma patients may lead to lower mortality in patients with penetrating trauma.[37,38,39,40] However, penetrating trauma is only one subset of all EMS responses.

Emergency Medical Dispatching Algorithms Improve Efficiency

To guide decision-making as to which calls for help require a lights-and-sirens response, emergency medical dispatching algorithms have been developed and EMS dispatchers are trained in emergency medical dispatching (EMD).[41,42,43,44,45] Thus, ambulances may take longer to respond to lower-acuity calls because they aren't using lights and sirens, but this can lead to the incorrect assumption that ambulances don't respond quickly to higher-acuity calls for help.

In order for these EMD systems to work, the dispatchers must ask many questions to gather the necessary input data.[46,47] High-acuity calls are rapidly identified by the first few questions, and ambulances are dispatched quickly. The dispatcher, however, will continue to ask questions to obtain more information that may be helpful for EMS providers. The dispatcher also will provide first-aid instructions over the phone.

For lower-acuity calls, even more questions are asked before an ambulance is assigned. This is to further differentiate the priority of the call, and it allows for a more nuanced determination. The impression to the caller may be that all calls to 911 will lead to many questions without help being sent as soon as possible.

EMS services are also mostly overburdened. In the largest cities and in rural areas, call volume for EMS assistance has steadily increased, without a commensurate increase in ambulances, funding, or EMS personnel.[48,49,50,51,52,53,54,55] Because the EMS system in some cities is overtaxed, the transport of patients by police and firemen has become the standard. Through EMD algorithms and dispatch call priority systems, lower-acuity calls may have a delayed response or be held until units are available. Higher-priority calls will receive a faster response. If someone calls 911 for a lower-acuity issue, such as abdominal pain, and receives a delayed response, the caller may assume that EMS delays responses for all calls for help, including higher-acuity calls.

Unexpected Costs Further Complicate Use of EMS

The public also may assume that an EMS response is free or fully tax-supported, such as with a police response. In many jurisdictions, EMS is not tax-supported. In others, it is only partially tax-supported.[56,57] The cost of operating an EMS service is high, and the revenue margins are thin.[58,59] Most services barely break even. EMS is a medical service and usually needs to bill to remain operable. Some volunteer services and municipalities operate on a subscription basis and do not bill subscribers.[60,61,62,63]

The costs of operating an EMS service are higher than what Medicare, Medicaid, and/or insurance pays, in part because the Centers for Medicare & Medicaid Services (CMS) view EMS primarily as a transport service, with fee scheduling based primarily on distance.[64,65] Aso, CMS only pays for EMS transport that they determine to be medically necessary. Thus, many EMS services need to balance-bill.[66,67]

For uninsured patients, the entire bill will be sent to the patient. EMS transport for uninsured patients or when the EMS transport is determined not to be medically necessary may cost $300 to over $1000.[58,61,68] Patients may be surprised to see a considerable out-of-pocket expense when expecting a free or covered service.[69]

These are all barriers to calling for EMS.[70] Because of them, people may look for alternative means to get to the ED during a medical emergency.

Is Ride-sharing a Viable Substitute for EMS Transport?

One alternative may be to use a ride-sharing service. These services have become popular.[71,72,73] In many areas not well served by traditional curb-hailing taxi or call-for-hire livery services, peer-to-peer ride-sharing has filled a niche.[74] Even in New York City, with its ubiquitous classic yellow taxis, ride-sharing has been gaining ground.[75,76,77,78,79,80] It has even been thought to be a cause both of increased traffic and taxi driver suicides in New York City.[77,81,82,83,84] The public is becoming comfortable using these services, and recognizes them for their ease of use, fast response, and reasonable cost—exactly opposite what is often the public perception of the local EMS.

Ride-sharing services may be an appropriate transportation method for some medical problems. Primary care providers are partnering with ride-sharing services to provide transportation to routine medical visits, and the medical literature on ride-sharing services focuses upon improving access to primary care.[85,86] For emergencies, EMS may provide a morbidity or mortality benefit and works within the regional systems of specialty care to provide the most efficient route to the right care, at the right time, and at the right place. No data exist on the mortality or morbidity advantage during medical emergencies for ride-sharing transport to the ED versus private vehicle or EMS transport.

Nonetheless, people may be using ride-sharing services for medical emergencies. The popular press and blogosphere has discussed how ride-sharing services have been associated with lower EMS utilization in urban settings.[87,88,89,90,91,92] However, all of these reports are based on a single unpublished economic study that has not been peer-reviewed.[93] This study has many limitations to its conclusion that ride-sharing causes a decline in EMS utilization. At most, it only identifies a correlation, with no determination of causation.[93,94]

The National Fire Prevention Association (NFPA) magazine published an introduction to the idea of ride-sharing for emergency medical conditions.[95] Uber provided this statement to the NFPA: "It's important to note that Uber is not a substitute for law enforcement or medical professionals. In the event of any medical emergency, we encourage people to call 911." Lyft did not comment in time for the publication of the article.

For an article published in Slate,[96] a Lyft representative stated: "When it comes to medical emergencies, Lyft should not be used as a substitute for emergency transportation. People should be calling 911." An Uber representative commented, "Uber is not a substitute for law enforcement or medical professionals. In the event of any medical emergency, we always encourage people to call 911." From a ride-sharing vehicle driver's perspective, transporting an ill passenger is not desirable because of perceived legal liability and biohazard contamination risks.[76,97]

In most cases, patients should call 911 for medical emergencies. For lower-acuity urgent medical issues, ride-sharing may be appropriate and is probably safer than driving oneself to the ED. Indeed, many of these urgent issues are probably better managed at an urgent care or primary care medical office, and ride-sharing is an appropriate transportation to these healthcare providers.

Ultimately, EMS systems can learn from ride-sharing services. The use of ride-sharing apps has led the public to expect ease of use, incorporation of GPS, access via an app, value, and low cost. EMS services and 911 dispatch centers need to meet the public's expectations.

In addition, the public needs to be better informed. EMS systems should teach the public about EMS, the EMD process, which medical emergencies require EMS, and which medical issues can be managed at urgent care or a primary care medical office.

Ride-sharing as an alternative to EMS is unlikely to replace EMS, but the public's consideration of using ride-sharing for transportation to an ED for a medical emergency highlights some of the areas in the EMS system that need improvement.

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