When Pamela Hogan phoned 911 from her Seattle apartment, she was suffering from knee pain so intense she couldn’t stand up. She had been trapped in her bed all day, unable to eat, drink or get to the bathroom. Worried and alone, Hogan thought an ambulance would come quickly and take her to the hospital.
She was mistaken.
Seattle no longer is capping ambulance wait times for certain 911 patients, tracking those waits or penalizing its ambulance contractor when they run long.
So the 71-year-old, a retired executive assistant who loved cooking casseroles, watching “Judge Judy” and listening to The Pointer Sisters, waited one hour for a nurse-ordered ambulance, according to call recordings and court documents.
Two hours. Three hours. Four hours, phoning 911 back several times and telling the Fire Department about a heart condition. Ten hours.
By the time an ambulance arrived at Hogan’s building, it was the middle of the night and she wasn’t answering her phone. The ambulance left without her.
Weeks later, her body was found decomposing on the floor of her bedroom.
It’s not clear Hogan’s wait is what killed her, but her estate has sued and her experience raises questions about Seattle’s relationship with its for-profit ambulance contractor, American Medical Response, which also provides the city’s 911 nurse line.
“More checks and balances and accountability need to happen,” said Josephine Ensign, a professor emeritus at the University of Washington School of Nursing who called Hogan’s case concerning and upsetting. “Seattle can do better.”
Seattle and AMR have denied the lawsuit’s wrongful death allegations and say the nurse line is generally working as intended. They say it’s reducing strain on hospitals and ambulances by diverting low-level patients to more appropriate care.
But most Seattle callers triaged by the nurse line are still being sent to hospitals in AMR ambulances, rather than being diverted, program data reveals. And officials have exempted those nurse-ordered rides, like Hogan’s, from city standards that normally require the company’s ambulances to arrive on time.
It’s possible that Hogan’s experience was an aberration. But the city stopped tracking ambulance waits like hers in 2022, so officials have no way to know. [...]
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Hogan’s wait started when she dialed 911 on the afternoon of April 8, 2022.“I’ve got really bad knees because of rheumatoid arthritis and there is damage to them as well, and I’ve gotten to the point where I can’t get up,” she told the Fire Department dispatcher who answered, according to a recording of the call obtained through a public records request. “I’d like to go to the ER and have them look at my knees.”
Hogan had used 911 for emergencies before, assuming this time would be the same. Instead, her call was transferred to the nurse line operated by AMR’s parent company, Global Medical Response, from a call center outside Dallas.
“I’m going to bring the nurse on the line here and let them kind of help figure out the best course of action,” the Fire Department dispatcher said.
Hogan told the nurse she had been stuck in bed all day and had completely filled an adult diaper, according to a recording disclosed by AMR in the Hogan litigation. She described her pain intensity as 10 out of 10.
“I will get someone out to you,” the nurse said. “To get you to the hospital.”
Then the nurse ordered an ambulance, recommending care within four hours, according to another recording disclosed in the Hogan litigation. An AMR dispatcher in Seattle said it would take three to four.
Neither of them told Hogan, who was no longer on the phone.
Strained system
In the years before Hogan’s emergency, the Seattle Fire Department and AMR were dealing with a mounting number of 911 calls from patients with low-level needs, said Michael Sayre, the Fire Department’s medical director.
Few 911 patients receive lifesaving interventions and most emergency room visits are for nonemergency issues, national research has shown. People sometimes dial 911 not because they’re in imminent danger but because they’re not sure whether they’re sick or not, Sayre said.
These patients put pressure on the Fire Department’s dispatchers, who work long, grueling shifts. Such calls often involve homeless people or other patients without regular doctors, noted Ensign, whose decades of Seattle-based work has focused on health and social inequities.
“They don’t know what else to do, so they call 911,” Sayre said.
For acute 911 calls, the Fire Department sends its own highly trained crews. They can transport patients in red Medic One ambulances or hand the patients off to AMR emergency medical technicians in white ambulances.
For less-acute calls, the department may simply send AMR. One way or another, the company handles most of Seattle’s ambulance responses, approximately 50,000 annually. [...]
New program
Like other cities that use ambulance contractors for 911 callers, Seattle allows AMR to bill patients. In return, the company must meet standards for patient care: For years, its ambulances were supposed to arrive within 11½ minutes for more-urgent calls and one hour for less-urgent calls, at least 90% of the time.
But in the wake of the COVID pandemic, AMR was struggling with ambulance staffing in Seattle, arriving late for many of its 911 patients and paying a price, Fire Department records show. The city assessed the company almost $1.4 million in contract penalties for ambulance delays in 2021.
Enter the Nurse Navigation program, which Seattle and AMR leaders said would relieve that strain and improve ambulance response times in the city by diverting low-level callers to cheaper, better solutions. When it launched with fanfare in February 2022, then-Mayor Bruce Harrell called it “a strong example” of how to make a system “more efficient and ensure better care at the same time.”
The idea wasn’t new: King County had been using a 911 nurse line on a smaller scale for years, and cities across the world were experimenting. When implemented well, these programs can deliver real benefits, many experts say.
Seattle preferred not to hire its own nurses, said Sayre, the medical director, citing the costs involved. So the Fire Department turned to AMR, which agreed to triage the city’s callers almost for free. AMR had launched Nurse Navigation in Washington, D.C., in 2018 and had been attracting positive attention. [...]
Requirements removed
Before Nurse Navigation, patients like Hogan could expect assistance in under an hour. That changed in 2022 with an amendment to AMR’s contract that gave nurse-ordered ambulances a reprieve from any response-time standards.
Seattle and AMR officials say this made sense, because the nurse line is allowing ambulances to prioritize critical patients over stable ones. The company is no longer incurring late penalties for its Seattle responses still subject to time standards, a representative said, citing the nurse line and better recruiting.
But the city removed a significant guardrail when it removed standards for an entire category of ambulance rides, experts contend. Last year, more than 4,600 rides ordered were completely exempt from time standards and contractual penalties.
“Your community’s leaders may think 10-hour waits are OK,” said Matt Zavadsky, a nationally recognized health care administrator who managed a 911 system and helped start a nurse line in Fort Worth. “If your community’s leaders are not OK with that, you need a contract that prevents that.”
Instead, Seattle has left itself in the dark. Response times for nurse-ordered ambulances are excluded from AMR’s monthly reports to the Fire Department, so the city doesn’t know how long patients like Hogan are waiting.
by Daniel Beekman, Seattle Times | Read more:
Image: Jennifer Luxton / The Seattle Times
