Registered nurse Ogechi Ukachu spoke into a telephone headset at the District’s 911 center, fielding an emergency call from a woman complaining about wrist pain.
Ukachu asked yes or no questions to determine the caller’s pain level, any blood loss and other symptoms that could pinpoint the extent of the injury.
After about a dozen answers, Ukachu determined the woman needed a trip to an urgent-care center — not a ride in a D.C. ambulance.
The call was a training exercise, but beginning Thursday morning, registered nurses such as Ukachu will process live calls in a program aimed at reducing the crush of non-emergency medical requests that swamp the 911 system in the District.
Instead of firefighters and ambulance crews at their doors, some callers will get a taxi or Lyft ride to take them to prompt medical appointments in their communities, all of which is arranged through the nurses who assess medical urgency in a system known as triaging.
Putting nurses in the call center is meant to extend efforts to reserve D.C. ambulances and medics for dire cases in a city where fire department officials say as many as 70 percent of the 911 medical runs they respond to involve patients with conditions that are not emergencies. The nurse triage program follows on the use of commercial ambulance services, starting in March 2016, to transport less-serious cases.
The city paid $1 million to launch the nurse program, which includes nurses’ salaries and a technology build-out, D.C. Fire Chief Gregory Dean said. The triage line will be staffed from 7 a.m. to 11 p.m. daily.
Initially, the nurses will field about 65 calls a day to gauge how well clinics and the transportation system handles the patient loads. The goal is to double that call load within six months and by 18 months be able to determine whether the program is a success, Dean said.
The city handled around 166,000 911 medical calls in 2017.
Operators at the 911 center will send callers who appear to have low-level medical issues to the triage line, where registered nurses will work through questions with them. For non-emergency requests, they will book an appointment with a medical provider near their neighborhood who can see the caller within two hours. They will also send a ride to take the caller to the medical center, to a pharmacy or back home, if that is what is needed, said Robert Holman, the fire department’s medical director.
Medicaid and Alliance will pay for Lyft rides for their members, and Yellow Cab will handle patients in wheelchairs and overflow if Lyft vehicles are not available, fire officials said. Callers with private insurance may have appointments booked but will need to provide their own transportation.
Because good transportation is key to the program, fire department officials worked with insurance providers who previously had paid only for trips scheduled at least three days in advance.
In the new system, “We expect most of them to be picked up within 30 minutes. Some will be picked as long as an hour after the call but no more than that,” Holman said. “Certainly there are people with bladder infections or painful sore throats who could not wait three days to see a provider.”
Over time, the system also may accustom residents to call medical centers or urgent-care centers rather than 911 for minor issues, Dean said.
Triage nurses will make appointments at 23 sites citywide, including neighborhood clinics and three urgent-care centers. These will include eight Unity Health Care clinics, Mary’s Center, Community of Hope, Family and Medical Services, Bread for the City, La Clinica del Pueblo and Whitman-Walker Health, Holman said.
Five nurses have been contracted through American Medical Response, the same private company the fire department pays to transport non-emergency patients.
“I think it’s probably going to be a very good thing because it will free up trained EMS people to do the things they were trained for, and they won’t have to deal with the more routine things that shouldn’t be handled through a 911 call,” said Randy Speck, chair of the Advisory Neighborhood Commission in Chevy Chase.
Speck said officials who presented the idea at a recent ANC meeting — one of several they attended — said only the “most routine problems” that “most people would absolutely agree do not require emergency care” would be funneled through the nurse line.
As long as it is implemented as such, Speck said, he is all for it.
Each non-emergency call is expected to last about 10 minutes. Overflow calls will be sent to call centers in Florida and Texas that will help make appointments and dispatch rides in the District, said Lisa Edmondson, an AMR clinical nurse manager. The nurses, who will have access to medical and personnel information for all Medicaid patients in their databases, will also follow up with patients the next day.
Edmondson said the company has run similar programs and their methods have been tested, but this is the first time the company has worked through the 911 system.
“We’re ready,” Edmondson said in an interview on the 911 floor Tuesday. “We’re just waiting for the first calls.”
City emergency responders said the 911 system relies too heavily on ambulance trips and emergency-room visits, meaning even callers who have minor problems wind up in an expensive medical setting and receive no steady stream of care from medical staff they know and who know them.
The setup results in the District’s most highly trained lifesavers being routinely dispatched by the fire department to treat minor fractures, headaches, sore throats and mosquito bites.
“There are many things as an organization that we have the capacity to do, but we don’t have the time [to do them] because of our EMS call volume, which is the busiest, by the size of our city, in the nation,” Dean said. If his department better manages call volume, it can create more time for on-duty training and inspecting new construction for fire safety.
The first agency in the country to add a nurse triage program to its 911 call center was the Richmond Ambulance Authority in 2004. But the Richmond program allowed callers to request an ambulance even after they were put through to speak to a trained nurse, regardless of diagnosis.
Impatient callers, tired of answering another round of questions, would often cut off the evaluation midway and say, “Just send an ambulance,” said Matt Zavadsky, the chief strategist for MedStar Mobile Healthcare in Fort Worth, Tex. Zavadsky also serves on the National Association of Emergency Medical Technicians.
The nurse triage program lasted about five years before Richmond shut it down.
Since then, other agencies have given nurses a try. But not many.
Just six jurisdictions in the United States offer nurse triage services in their 911 system: Fort Worth; King County, Wash.; Las Vegas; Louisville; Reno, Nev.; and Syosset, N.Y.
“This is still cutting-edge stuff,” said Zavadsky.
Seven years in, Zavadsky said, the community has completely changed its thinking around what calling 911 means.
“We now have people calling 911 and asking straight away to speak to the nurse,” he said. “They’re getting good advice and good outcomes.”
Zavadsky was one of several experts D.C. officials asked to advise on the District’s program. He told them to first improve the quality of their 911 response — fewer mistakes made in general means they are more likely to send the right people through to the on-call nurse.
“We’re not locked in. We’re looking to see if this works,” Dean said. “At the end of the day we are interested in patient outcomes and patient care. Is this the right step for this community?”