Interesting, and transformative approach to an on-going struggle for many EMS systems.

You can view copies of the letter and the Buncombe County EMS and State of North Carolina Policy in the link.

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County to Mission: 'ER situation unsafe, unsustainable;' new ambulance wait time policy

By Mitchell Black

Asheville Citizen Times

November 13, 2023

https://www.citizen-times.com/story/news/local/2023/11/13/buncombe-may-change-mission-emergency-dept-patient-handoff-policy/71530048007/

ASHEVILLE – In the wake of increasing wait times for ambulance patients who are "parked" when arriving at the Mission Hospital Emergency Department while waiting for the hospital to accept them ― a patient and emergency services safety concern highlighted by the Citizen Times ― Buncombe County plans to implement a new handoff policy, according to a county letter to the hospital obtained by the newspaper.

The new policy allows county Emergency Medical Service workers to leave stable patients in the hospital staff’s care after the ambulance arrives, even if a bed is not ready for the patient.

County Manager Avril Pinder and Emergency Services Director Taylor Jones informed Mission Hospital Chief Operating Officer Wyatt Chocklett in a Nov. 3 letter that Buncombe would implement this policy by Dec. 15 unless the hospital makes substantial strides to fix the problem.

HCA Healthcare, a Nashville-based for-profit company, bought the Mission Health system in 2019 for $1.5 billion.

Wait times have grown significantly for Buncombe County ambulance patients arriving at the Mission Emergency Department in Asheville. Through the first three quarters of the year, 309 ambulance patients endured more than hourlong wait times at the Mission ED, according to data provided by Buncombe County EMS.

In 2018, four patients experienced more than hourlong wait times.

Mission Hospital spokesperson Nancy Lindell referred the Citizen Times to past statements regarding questions about the hospitals efforts to correct the long wait times. Lindell said in those statements that demand for emergency services is growing in WNC, that the hospital prioritizes patients based on acuity and pointed to Mission’s proposed freestanding emergency departments as a solution to relieving the burden on the emergency department.

In July the Citizen Times reported that hospital staff and local emergency service leaders pinned the lengthening wait times on an overtaxed emergency department and understaffed hospital patient care team, saying that the hospital does not have enough staff to quickly treat, admit and discharge patients.

Long wait times at the hospital has an immediate impact on the county’s emergency medical service response time, according to the letter.

The federal Centers for Medicaid and Medicare Services guidelines, in part say the "practice of 'parking' patients arriving via EMS, refusing to release EMS equipment or personnel, jeopardizes patient health and adversely impacts the ability of the EMS personnel to provide emergency response services to the rest of the community," the letter said. CMS guidance also notes that it is appropriate for paramedics tend to patients if hospital staff in the emergency department is overwhelmed.

“There is a direct correlation between the increase in BCEMS’s response times and the increasing handoff times at Mission,” Pinder said in the letter. “This is unfair to Buncombe’s community and puts unreasonable stress on BCEMS personnel who are already performing a stressful job. The current situation in the ER is unsafe and unsustainable.”

Buncombe County bills ambulance patients on a flat fee for the level of care provided and the distance the ambulance travels, which does not account for the time paramedics spend treating patients.

When paramedics spend time treating patients arriving at the emergency department, the amount the county charges the patient does not change. Pinder argued in the letter that this treatment “can be seen as Mission receiving a taxpayer subsidy.”

“If Buncombe is paying the EMS employees’ time and salary to pick up and transport patients, but instead they are providing care in the hospital, that is the subsidy,” she said in an email to the Citizen Times.

Lindell did not respond to a Nov. 9 Citizen Times question about Mission effectively receiving taxpayer support by press time.

Buncombe County’s policy will only apply to stable patients. The amount of time paramedics wait with patients depends on the number of EMS vehicles in service:

• If more than six vehicles are in service, and there are no upcoming needs, paramedics will wait 45 minutes.
• When fewer than six vehicles are in service and there are no upcoming needs, paramedics will wait with patients for 30 minutes.
• If there is one vehicle in service or there are “high upcoming needs” with fewer than three vehicles available, or there is a mass casualty event, paramedics will immediately hand off patients and return to service.

The policy also lays out the county’s process for communicating the handoff to the Emergency Department staff and finding a location for the patient before EMS staff departs.

Buncombe County’s new policy will be the second recent major change a local emergency service department has made to address growing wait times at Mission Hospital. McDowell County announced that it will suspend noncritical patient transfers from McDowell Hospital in Marion, to Mission. In a letter informing Chocklett of the change, McDowell emergency services noted several critical patients who waited extended periods once they arrived at the hospital.

The impending changes come on the heels of a letter the North Carolina Attorney General’s Office sent to Dogwood Health Trust, delivering notice that HCA violated the commitments it made as part of the 2019 agreement to purchase the Mission Health system. This letter specifically notes that HCA failed to comply with its emergency service-related commitments.

Dogwood, the nonprofit formed to receive the proceeds of the sale, has 40 days to work with HCA to fix the problems, otherwise the NCAG’s office can bring a lawsuit.

The North Carolina Department of Health and Human Services recently awarded Mission a Certificate of Need for a freestanding emergency department in West Asheville, which AdventHealth appealed.