NFPA Journal

Last year, a driver for the ride-sharing service Uber went online to recount the harrowing details of transporting a young woman to a hospital in Chicago.

The call came from a nightclub. When the driver arrived, a bouncer for the club explained that the woman was intoxicated with drugs and alcohol and needed to be taken to the emergency room. The woman and a friend got into the car. “While en route, the girl vomited, stopped breathing, and was unresponsive to her friend,” the driver wrote on uberpeople.net, an online chat forum. “The other girl was losing it, screaming and crying, which only heightened the stress. I blew every red light to the hospital with flashers going and horn wailing. At the hospital, ER personnel crawled through my backseat area to extract and resuscitate the patient.”

Stories like these aren’t uncommon on the forum. There are posts about bloodied bar brawlers, women in labor, and men having chest pains, all seeking a trip to the hospital by way of an Uber—in many cases, when an ambulance would have been the better option.

As ride-sharing services like Uber and Lyft grow, people using them to get from point A to ER will inevitably increase, too. The practice might eventually be addressed by NFPA, as it develops a new guide to help EMS agencies move toward a community health care model.

Old practice, new twist

For those in EMS, it can be a troubling trend—but not exactly one they’re unaccustomed to.

People have been taking traditional taxi cabs to hospitals for decades. Working for Boston EMS, John Montes, now a public fire protection and emergency services specialist at NFPA, said he frequently responded to incidents where people had tried to make it to the ER in a cab. In those days, he said, taxi drivers’ rule of thumb was if the person could walk, they could get in the cab to go to the hospital—but it also meant that people who were ambulatory one moment could crash the next and require immediate emergency medical care.

Despite the risks, Montes thinks the practice is becoming even more common—especially with young people—in today’s so-called shared economy. Instead of a cabbie suddenly confronted with an unconscious passenger, it’s just as likely to be an Uber or Lyft driver, neither of whom are necessarily any better prepared than the cabbie to handle a potentially serious medical emergency. The public’s familiarity with ride-sharing technology and the corresponding user interfaces can heighten its appeal as a mode of emergency transport, Montes said, even in cases where people should be taking an ambulance. Over the last couple of years, news outlets have increasingly covered the practice of Ubering to the ER.

But it’s also prompting a public response from those in the fire and emergency medical services. In April, Mark Becraft, a veteran paramedic turned fire chief in Utah, condemned the practice in an interview with a local television news station. “It’s just unsafe,” he said. “I think Uber has its place. I just don’t think it’s in emergency medicine.” Becraft gave an example: Say someone is having a heart attack but they don’t know it. Ambulance personnel can figure that out, and instead of going to the ER, the patient can go straight to the catheterization lab—a timeline compression that is highly unlikely if a ride-sharing service is used.

According to Vincent Robbins, people experiencing cardiac events are just one group that has traditionally bypassed the EMS system to get to a hospital. Robbins, president and CEO of MONOC, New Jersey’s largest private, non-profit ambulance service, has over 45 years of experience in EMS. “They often downplay their condition to themselves,” he said of these patients, who are typically older adults. “They want to think it’s just indigestion. They don’t want to believe they’re having a heart attack.” Younger patients with conditions like asthma, who believe they’re able to manage symptoms themselves and don’t want to “bother” EMS providers, also do it, as do elderly people afraid of the cost of an ambulance, Robbins said. “Emergency department physicians will tell you there are a number of walk-ins who arrive without EMS intervention, which is what they really needed as precautionary treatment before getting to the hospital.”

With the obvious dangers of using ride sharing as a means of emergency transport, why would somebody risk it? From a patient’s perspective, the benefit of using Uber or Lyft over an ambulance starts with the comfort and familiarity of ordering one. “Ride sharing is incredibly user-friendly,” Montes said. “You can’t look on your phone and see where an ambulance is coming from, who’s driving, or how long it’ll take to get there. With these apps, you can.”

Beyond the convenience and transparency, ride sharing is significantly cheaper. Most ambulance rides cost between $800 and $1,200, according to Montes, while in most cases an Uber or Lyft ride will cost less than $50. A third benefit for the patient is a greater sense of control, especially when it comes to selecting a hospital to go to, a consideration reflected in the posts that appear on uberpeople.net. “Got a pregnant lady who was in labor who wanted to go to a hospital that was about 30 miles away from her house because she didn’t want to have her baby at the local hospital,” one driver wrote.

The community health care model may help EMS providers determine what kind of care is necessary in any given situation, and how quickly it should be delivered. Studies have found that as many as half of all ambulance transports to hospital emergency departments are inappropriate or unnecessary. Photograph: iStockPhoto

Officially, Uber doesn’t endorse the practice, but the company acknowledges it occurs. “We’re grateful our service has helped people get to where they’re going when they need it the most,” the company said in a statement sent to NFPA Journal. “However, 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 respond to a request for comment before the magazine’s deadline.

A role for ride sharing

Despite the concerns surrounding the practice, some EMS providers have started to explore a system where ride-sharing services are utilized for non-emergency medical transport. A number of shifts in the health care landscape over the last decade or so have allowed that to happen, according to Robbins.

First, there has been a significant increase in the number of urgent care facilities nationwide, which often provide low-level emergency medical care for injuries like a broken arm. EMS providers and health insurance companies realized that transporting patients who were experiencing non-life-threatening conditions to these facilities was both more sensible and cheaper than bringing them to hospitals. Once that started to happen, some providers began searching for an even lower-priority subset of patients who don’t require ambulances to get to urgent care. In many cases, that search led them to people who were known to repeatedly request ambulances unnecessarily—a common and significant drain on EMS resources.

“It became a kind of ‘aha’ moment,” Robbins said. “We realized we maybe didn’t have to take these people to urgent care centers. Maybe we could call someone else. And we could put our ambulance back in service to handle the life threats and the critical situations without having to put more ambulances on the road. It’s a way to manage the call volume and use of EMS resources.”

Robbins estimates that 15 to 25 percent of patients EMS providers encounter don’t require emergency medical transport and could in theory be transported to urgent care using a ride-sharing service. “It depends on the region, the market, the EMS system, but all combined, we could be talking somewhere between 15 to 25 percent of patients,” he said. For all dispatches, he guessed the figure to be between 7 and 18 percent.

Statistics show that, in many instances, trips involving patients being transported to an emergency department (ED) by EMS providers are unnecessary. A 2010 article in the Journal of Emergency Medical Services (JEMS) reported that in 2006, just over 24 percent of emergency department visits were classified as semi-urgent or non-urgent. According to the JEMS article, studies have also shown that 10 to 40 percent of EMS transports are “low-acuity transports” involving minor ailments like sprained ankles or people with flu-like symptoms. According to a literature review published in the journal Prehospital Emergency Care in 2013, articles from the United States, Canada, and the United Kingdom show that 30 to 50 percent of ambulance transports to the ED are inappropriate or unnecessary, which could translate to millions of unneeded rides. In 2009, for example, there were over 28 million EMS transports in the U.S., according to data from the National Highway Traffic Safety Administration.

Both Uber and Lyft have announced agreements with EMS companies to provide rides to patients, but that doesn’t mean the system is widely used, Robbins cautioned. Even his company, MONOC, doesn’t do it. “In my market, in New Jersey, I don’t think we’re going to see this happen for a really long time,” he said. “The reason is that in New Jersey, the advanced life support tier, the paramedic tier, of EMS is 100 percent fee for service. It’s not subsidized by taxes at any level—not from the town, not from the county, not from the state. So our source of revenue is only what we’re able to bill. We also happen to live in a state where the commercial insurance companies are not forward-thinking. They’re very much in lockstep with Medicare, and Medicare only pays if you transport … If I call Uber or Lyft to take a patient, that’s a response I’m not going to get paid for.”

In other areas, including those where insurance companies are willing to reimburse EMS providers for calls that don’t involve transport, Robbins foresees the practice becoming more common. The key to its success, he says, is a robust triage process to screen patients and determine the level of medical care they need. In Las Vegas, the city’s fire department recently launched a pilot program that uses a nurse to conduct those screenings. If the 911 operator thinks a health-related complaint might not require emergency medical transport, they transfer the call to a nurse who, with the help of computer protocol software, determines what’s best for the patient—a process that can end with ordering a Lyft to take the patient to an emergency department or an urgent care facility.

“I was a charge nurse in an emergency room who had to triage every single ambulance lining up at the door,” Melissa Giammarino, an R.N. who is part of the new Las Vegas program, told Hospitals and Health Networks magazine. “Each ambulance carrying someone who didn’t truly need emergency care took me away from other emergencies, from helping other nurses, and from dealing with other problems in the emergency department.”

NFPA’s codes and standards currently do not address the integration of ride-sharing services into EMS, but Montes said it could be incorporated into NFPA 451, Guide for Community Health Care Programs. Montes is the staff liaison for NFPA 451, which is expected to be open for public input early this year. NFPA 451 is the result of a growing push for community health care that incorporates EMS into the entire health care system—a practice generally referred to as community paramedicine—where EMTs and paramedics are employed to check in on community members after they’ve been discharged from the hospital to address their medical concerns, take vital signs, make sure they’re taking their medications, and other tasks that typically do not require a trip back to the hospital.

The model is meant to reduce readmissions to hospitals and missed appointments, which suck millions of dollars from the country’s health care system each year. It is also flexible and can address other public health issues such as behavioral health services and chronic substance abuse, depending on an assessment of the needs of the local community it serves.

Like Robbins, Montes recognizes the benefit ride-sharing services could offer not only to EMS providers but also the people they serve. “It could absolutely be a positive thing for EMS as it integrates itself further into the community health care system,” he said. “It could be a positive for the whole community.”

ANGELO VERZONI is staff writer for NFPA Journal. Top Photograph: iStockPhoto