But central Pennsylvania emergency medical providers are sounding an alarm, saying an accumulation of old and new problems threatens their ability to do what the community expects.
“Things are frayed close to the point of collapse,” says Jerry Schramm, the director of operations for Lancaster EMS. “It is teetering on the point of catastrophe where you may have 911 calls and there might not be an ambulance to respond.”
It has come to a head because of this: hospital emergency rooms in central Pennsylvania are regularly full. At such times, their staff can deal with only the sickest or most severely injured patients. Patients in non-life-threatening situations must wait, sometimes for many hours.
When that happens, hospitals put themselves on a status called “divert.” Divert doesn’t necessarily mean the hospital isn’t accepting ambulances. Rather, it typically amounts to a “request,” if the illness or injury isn’t life-threatening, to take the patient to a different hospital.
But that adds time and distance. Or the patient, who also has a say, might not want to be taken elsewhere. Or, as is often the case, the next closest hospital or hospitals may also be on divert.
Moreover, ambulance crews can’t simply drop off patients and be on their way. They must care for them until ER staff is ready to take over.
“We are actively treating patients on our stretchers in the emergency department,” says Bob Smith, a paramedic and operations chief for Susquehanna Township EMS in Dauphin County.
It causes major ripple effects, EMS providers say, that can hurt people having a heart attack or stroke or other emergency.
Smith’s company has a goal of being available for the next call within 20 minutes of delivering a patient to the hospital.
Now it commonly takes a 30 to 45 minutes or longer, according to Smith and multiple EMS responders in central Pennsylvania. Smith cited a recent instance where it took a Susquehanna Township unit an hour and 47 minutes to return to service.
The delays can interfere with tasks such as cleaning the ambulance, restocking supplies, completing documents and otherwise getting ready for the next call.
“We’re very lean in EMS. Anything that affects that efficiency, it really has ripple effects for the system,” says Steve Lyle, the executive director of the Emergency Health Services Federation, a non-profit that supports ambulance service in eight Harrisburg-region counties.
Most importantly, it means they might not be available for the next 911 call. In that case, another ambulance — usually from further away — must fill in. And while that ambulance is away, another company has to fill in. And so on, progressively adding distance and time.
Schramm describes a recent car crash on the Columbia Bridge spanning the Susquehanna River between Lancaster and York counties. He said an ambulance came from Paradise, about 20 miles away.
“It has become a vicious cycle. We are responding to calls that are way outside our service area,” Smith said.
Ambulance crews in the more populated parts of central Pennsylvania have a goal of arriving within about 10 minutes of someone calling 911.
In recent months, they say, it often takes double or triple that time. That can turn into an eternity for someone involved in a car crash, or having a heart attack or stroke or whose loved one is injured and possibly dying.
“At times it’s almost impossible to meet our mission,” Lyle says.
A delayed ambulance can impact whether someone lives or dies or how well they recover. During a heart attack, heart muscle dies by the minute, often until a blockage is cleared at the hospital. Dead heart muscle is gone forever. So minutes can mean the difference between a heart attack survivor returning to normal or having a permanently weak heart. Minutes are similarly critical with strokes and many illnesses and injuries.
“That additional five, seven, ten minutes could mean something for that patient’s outcome,” Lyle says.
More patients and staff shortages
On one level the situation is new. On another, it’s been building for 20 years or more.
According to Nathan Harig of Cumberland Goodwill EMS in Carlisle, the overcrowded ERs, which have come to a head during the last two months or so, are largely the result of a pair of “intertwined” issues: A shortage of health care workers, including hospital nurses, and COVID-19 patients who, since early summer, have been taking up many hospital beds and requiring a high level of care.
Harig points to another subtle contributor: Officially, a hospital has a certain number of beds. But its actual capacity equals the number it can presently staff. That number is often limited by the staffing shortage. It means a bed might not immediately be available for a new ER arrival. That forces patients to remain in the ER, where ER staff must care for them, preventing the staff from quickly turning to new patients.
“We in the EMS services are absorbing this,” Harig says.
Dr. Craig Skurcenski, UPMC’s vice president for emergency medicine in central Pennsylvania, says the situation described by EMS providers is accurate and should not be allowed to continue.
Deborah Berini, the CEO of Penn State Health Milton S. Hershey Medical Center, also acknowledged it, saying the drivers include “unprecedented volumes of patients over the past few months driven by a surge in COVID cases and patients who did not seek or had to delay routine and preventative care during the early stages of the pandemic.”
Skurcenki also agreed EMS crews shouldn’t have to care for patients inside the ER.
The role of EMS, he said, is “to adequately stabilize and transport those patients to an emergency department where the care can be given in the manner that it’s designed to be given … They are bringing us people who need our care, and we are there to assume that care.”
Skurcenski said the backed-up ERs reflect another trend: an increase in sicker patients, with more time-consuming needs, turning up not only in hospitals, but in settings that include urgent care centers and regular doctors’ offices.
Beyond that, staffing shortages at nursing homes and home health agencies are preventing people from being discharged from the hospital, restricting the supply of beds and creating log jams that extend to the ER and the ability to quickly deal with incoming patients, Berini said.
In the ER, staffs are able to quickly do an initial assessment to identify and deal with life-threatening situations, according to Skurcenski.
When it’s not life-threatening, patients often need various tests as part of a medical “work up,” Skurcenski says. That’s when things start to back up. Eventually, after test results are known, someone gets back to those patients to complete the evaluation and further care for him or her. Those are the patients who typically endure long waits, Skurcenski says.
He says UPMC is trying to speed things up with tactics such as getting doctors and physicians assistants involved earlier in the assessment process.
But additional solutions are needed, and will take longer to put in place. In fact, the present ER backlogs and delays are evidence of the need to “reinvent” emergency care, he says.
This will likely involve things such as faster discharge of patients with minor ailments, allowing them to wait at home for test results and receive further care the next day away from the ER, and using telemedicine to address more problems before they warrant an ER visit.
Many people in EMS also see a need for reinvention. In fact, they call it long overdue.
A crisis years in the making
In the early 2000s, EMS leaders and advocates, including state and local elected officials, began sounding alarms about problems, including stagnant reimbursements and funding and difficulty attracting young people to the occupation.
In 2018, Pennsylvania lawmakers established a 38-member commission to examine the situation, which they labeled a “crisis.”
In general, they concluded ambulance companies operate on a business model that couldn’t sustain a normal business. It had put many Pennsylvania ambulance companies out of business, with remaining companies struggling to survive.
One of the most telling signs of the neglect involves pay for ambulance workers.
According to Harig, central Pennsylvania companies that can afford it have recently bumped starting pay for EMTs to about $15 an hour. At smaller companies, especially rural ones, starting pay averages around $12.30 an hour, he says.
Even the best, most experienced EMTs in central Pennsylvania, earn $18-19 per hour, he says.
Starting pay for paramedics, who typically have at least 1,200 hours of training beyond the 150 or so hours required for EMTs, start at around $20 per hour and typically top out at about $27-28 in central Pennsylvania, according to Harig.
Harig considers it one of the most shocking and depressing things in health care that a newly-minted EMT earning $15 an hour may well wind up alone in the back of an ambulance presiding over a life-or-death situation.
On one hand, EMS has never relied on people focused on a high income, according to Harig and others. It tends to attract people who don’t want to be tied to a desk, who crave intensity and variety, and who want to know their work helps people in great need.
But the poor pay and benefits, and the pressure of the work, are making it hard to attract and retain workers, with young EMTs often choosing a new occupation within a year or so. Those who stay typically must work multiple jobs to sustain themselves and their families.
“EMS just doesn’t pay what it should pay their employees,” Smith said.
The 2018 report included a list of recommendations it said were needed to preserve reliable EMS service, including improving reimbursements and removing assorted barriers to getting paid.
Most haven’t been carried out and remain a problem, according to Lyle and others.
For example, EMS companies don’t get paid for situations such as when they’re called to the scene of fires or gas leaks but don’t end up transporting anyone. Often, the most they can hope for is a donation from the local municipality.
It’s often the same when they respond to medical emergencies but don’t take someone to the hospital. For example, they might get called to the home of a diabetic whose blood sugar has plummeted. They’ll give medication and aid to alleviate the problem. Or they’ll respond to a fall victim, helping the person off the floor, checking their vital signs and evaluating them for injury. In such instances, they’ll eliminate the need for ambulance transport and ER care, likely saving thousands of dollars for an insurance company or a patient. Yet most government programs and many health insurers won’t pay for it.
In some cases, they can bill the person directly, knowing the person will probably be surprised by the bill and may not have the money. Or, in some cases, an insurer will issue a check to the patient rather than the ambulance company, which is often a burden to collect.
Smith says community surveys show many people believe an ambulance dispatched by 911 is a public service fully funded by tax dollars. In reality, ambulance services receive few local tax dollars, relying largely on insurance reimbursements and their own fund-raising.
In fact, one of the great, unappreciated burdens, they say, involves “readiness costs”: The expenses of having responders on the clock at all times and buying and maintaining expensive vehicles and equipment. That includes “mobile intensive care units,” operated by many central Pennsylvania ambulance companies. Staffed with a paramedic, the units can provide much of the care available in an ER.
Asked about the top two or things needed to right the situation, Harig named eliminating reimbursement shortfalls and obstacles; ensuring a level of pay and benefits that will preserve EMS as a viable career; and providing a funding stream, perhaps by way of a local tax, to support EMS readiness.
Similar to the hospital officials, Lyle says additional tweaks involving how we deal with medical emergencies can help.
For example, he said ambulances often get called to situations that could be handled differently. These result from things like people not taking their medication correctly or not understanding how to manage their medical condition. Maybe there’s a way to help them without sending the same ambulance and crew that’s needed by people who may die if they don’t get the best and fasted care.
Beyond that, medical situations stemming from the aging population and problems such as obesity can be better addressed in ways that don’t entail an ambulance and the ER.
If these many problems aren’t addressed, Lyle warns, a badly needed ambulance might not arrive soon enough.
As it stands, he sees one cause for hope: the regular use of the word “divert” by emergency dispatchers, and the long ER waits for patients, is drawing attention. Major players such as UPMC and Penn State Health acknowledge the problem and the need for solutions. The state health department has likewise noticed, and has begun setting up meetings to better understand the problem and find solutions.
“I don’t see this as getting better without some interventions,” Lyle says.
Harig, however, sums up an ominous worry voiced by multiple EMS providers: “We’re doing all we can do absorb it. But unfortunately, that hides the issue.”
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