Community Paramedicine: 911 Alternative Destinations Are a Patient Safety Issue

Author Affiliation
Nick T. Sawyer, MD, MBA University of California, Davis, Department of Emergency Medicine, Sacramento, California;
California American College of Emergency Physicians Board of Directors
John D. Coburn, MD The Permanente Medical Group, South Sacramento Kaiser, Department of Emergency Medicine, Sacramento, California;
California American College of Emergency Physicians Board of Directors

Under-triage is a patient safety issue
Alternative destinations will disproportionately affect critically ill and vulnerable patient populations

Under-Triage is a Patient Safety Issue

As reported in the Annals of Emergency Medicine in 2014, studies have revealed under-triage by paramedics when not transporting patients to AD.7 The potential for under-triage is real if there is a failure of a community paramedic to recognize a real emergency when it exists. Further, identifying non-emergent patients based on their initial presentation is hazardous. In a study by Raven et al, 11% of patients with “primary care treatable” visits required immediate intervention, 12.5% were admitted, and 3.4% went directly to the operating room emergently.8

According to Morganti et al., “Nearly all studies published to date have found significant rates of under-triage by EMS Personnel…” These investigators identified 13 research studies examining the ability of paramedics and EMTs to determine the need for transport to the ED. These studies reveal EMS AD under-triage rates from 3% to 32%. They commented that the ability of EMS professionals to safely determine nonemergency patient “has not been clearly established.” Included in these studies was one study describing a cohort of under-triaged patients, who EMS professionals felt did not require transport to the ED for care, and who subsequently required admission to the hospital (18%), including a subset who required admission to the intensive care unit (6%). These problems were attributed to EMS professionals misusing study guidelines, undertraining in proper use of the guidelines, and improper or unclear instructions within the guidelines that could result in under-triage. These studies also revealed poor agreement between EMS professionals and emergency physicians about who required transport to the ED for care. Additional training is not likely to eliminate the problem of under-triage.

Alternative Destinations will Disproportionately Affect Critically Ill and Vulnerable Patient Populations

Patients who call 911 are more likely to be critically ill, elderly, and economically disadvantaged relying on public rather than private insurance.9 The patient population that arrives by ambulance does not reflect the general ED population. Whereas a proposed estimate of 13.7% of ambulance calls could be diverted to an urgent care center based on a Health Affairs study by Weinick et al., this study reviewed all ED visits rather than the population of patients who call 911.10 Rugar et al. analyzed ambulance transports and triage category and found less than 2% of patients arriving by ambulance had a triage category of less urgent or non urgent.11 Patients with a triage category of emergent were nine times more likely to arrive by ambulance, and with a triage category requiring immediate interventions, 50 times more likely to arrive by ambulance. This suggests a vast majority of ambulance transports are appropriate. The policy of diverting 911 patients away from EDs will not target low acuity visits. Studies suggest that it may target sick, vulnerable patients who already have limited access to care, and may further limit their access to specialty care. Even though EDs certainly have problems referring patients for specialty care, or achieving consultation during the ED visit, such referrals and consultations from ADs would most likely be even more difficult, if not impossible.

In conclusion, lowering healthcare costs for payers should not come at the expense of patient safety. Limiting access to high quality emergency and specialty care may show immediate cost savings to payers, but concerns remain over the longer term expense to patients and payers in terms of overall health outcomes. To date, the literature does not support paramedic-guided diversion of ambulance patients away from the ED to AD in terms of cost savings or equivalent health outcomes. As interest grows in CP programs, rigorous research methods should be applied to validate claims that CP is safe, improves quality and lowers healthcare costs.


Section Editor: Mark I. Langdorf, MD, MHPE

Full text available through open access at

Address for Correspondence: Nick T. Sawyer, MD, MBA, University of California, Davis, Department of Emergency Medicine, 4150 V Street PSSB Suite2100, Sacramento CA 95817. 2 / 2017; 18:219 – 221

Submission history: Revision received October 4, 2016; Accepted November 7, 2016

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.


1. Review of the evidence on the use of the emergency department by Medicaid patients and the evolving role of emergency medicine physicians. Available at:

2. ER visits continue to rise since Implementation of Affordable Care Act. Available at:

3. Dorner SC, Carmago CT, Schuur JT, et al. Access to in-network emergency physicians and emergency departments within federally qualified health plans in 2015. West J Emerg Med. 2016;17(1):18-21.

4. Singer AJ, Thode HC, Viccellio P, et al. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011;18:1324-9.

5. Kiser K, Shore K, Moulin A. Community paramedicine: a promising model for integrating emergency and primary care. 2013. Available at: Accessed Mar 7, 2014.

6. Hauswald M, Raynovich W, Brainard AH. Expanded emergency medicine services: the failure of an experimental community health program. Prehospital Emergency Care. 2005;9(2):250-3.

7. Morganti KG, Alpert A, Margolis G, et al. Should payment policy be changed to allow a wider range of EMS transport options?. Ann Emerg Med. ;63(5):615-26.e5.

8. Raven MC, Lowe RA, Maselli J, et al. Comparison of presenting complaint vs discharge diagnosis for Identifying “nonemergency” emergency department visits. JAMA. 2013;309(11):1145-53.

9. Squire BT, Tamayo A, Tamayo-Sarver JH. At-risk populations and the critically ill rely disproportionately on ambulance transport to emergency departments. Ann Emerg Med. ;56(4):341-7.

10. Weinick RM, Burns RM, Mehrotra A. Many emergency department visits could be managed at urgent care centers and retail clinics. Health Aff. 2010;29(9):1630-6.

11. Ruger JP, Richter CJ, Lewis LM. Clinical and economic factors associated with ambulance use to the emergency department. Acad Emerg Med. 2006;13:879-85.