Skyline's 911 Problem

Why some will not call 911

I was perhaps too brief in my January 2013 memo (21 months ago!) by sticking to what I could document about how we are overusing 911 services. The need for in-apartment consultation is not analogous to the inefficient physician house calls of our youth.

By Skyline offering no intermediate between first aid and lights-and-sirens, we are setting up problems for those who are reluctant to declare an emergency over something strange that isn’t getting better. Such residents would like to talk to someone knowledgeable first.

My mother was such a case at age 92, living independently in Horizon House, when she could not get to sleep because she felt strange. After several hours, she called the front desk and was connected with the night nursing supervisor.

My mother could not really explain what felt wrong and the nurse decided to come take a look. Arriving in three minutes, she soon suspected (correctly) a stroke and called 911, then called me in Phoenix.

I can guarantee you that my mother would never have called 911 and, had she lived here at Skyline under present management, she would have avoided phoning the front desk–knowing that they would automatically call 911 and subject her to the discomfort of transport and long hours in an emergency room. She would have waited until morning when, given how things progressed, she would have been unable to call anyone.

My mother had little experience with emergency rooms, merely a horror of causing people so much trouble (stopping traffic en route, etc.) over what could be flu or an upset stomach. Others of us may have additional reasons, valid or not, for hesitating.

My point is: we need to practice some preventative medicine for the emergency-wary by providing for an in-house consultation. And since there are always RNs on duty in the Terraces, there is really no excuse for not copying the procedures at Horizon House. Nursing supervisors, with more of a roving brief, would be a logical choice for occasional calls, day and night, and would be away from the Terraces for little longer than when taking a coffee break.

There has been a big push to treat stroke symptoms as an emergency, given the first-two-hours window of opportunity for the anticoagulant therapy. But fewer than half the stroke patients are going to have such classic signs as a weak arm or a numb leg. “Feeling funny” is all the others may be able to describe, yet they too need diagnosis and treatment in that two-hour window.

We are going to lose some of them if they cannot talk first to someone who can make the declare-an-emergency decision for them. That’s one of the services that CCRCs ought to be providing via the RNs already on staff. Do not confuse this need with such issues as a drop-in day clinic.

Horizon House, with twice our numbers, averages one such consultation call each day. This is not something that needs an additional FTE and budget line.

—W. H. Calvin
October 10, 2014  X2605, wcalvin@uw.edu

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The first memo:

Short of calling 911, what?

January 2013

The standing policy of Skyline on any urgent medical care is to call 911 and export the problem as quickly as possible.

One sees a similar attitude about helping up someone who has fallen; policy prohibits staff from assisting, even if the person does not appear to be injured.

“Just call 911” is a policy that makes residents wonder if PRCN’s unhelpful attitude isn’t taking corporate risk avoidance too far, and at the expense of residents.

The obvious improvement would be an ability to first call the in-house nurse in non-resuscitation cases. For four years, residents have been asking for a nurse to phone, one who can come to an apartment to assess the situation.

The perennial reply from executive directors is that “the law” or “regulations” make this difficult but that “We will study the situation.” For four years, residents have seen no improvements.

But this is not a problem where staff have to pioneer a better approach. Horizon House manages this quite well and has done so for decades.

The staff’s perennial excuse has caused growing skepticism among residents because advice on implementation and constraints has been only a phone call away or a walk down the street.

Yet there is no progress, year after year. “Not in our lifetime” is becoming the conventional ironic comment.

Is Skyline Overusing 911?

Skyline generates 48% more 911 “Aid Unit” (non-resuscitation) responses per person as does Horizon House. For Medic-level response, 160% more.

Presumably HH’s lower numbers are partly due to problems handled in-house by the HH nurse, ones that didn’t really need a 911 call, transport to a hospital, wasted resources, and a sleepless night.

The Horizon House Nurse Setup

The HH model is also attractive to many. Here are relevant snippets from current Horizon House handouts:

Advanced Registered Nurse Practitioners (ARNPs)-Medical Clinic: A reminder: we have an ARNP on duty in the Clinic, Monday-Friday, 8:30-4:00 pm. Our ARNPs collaborate closely with physicians from different medical clinics including Virginia Mason Internal Medicine, Swedish groups, and the University of Washington.

You are welcome to schedule an appointment with our ARNP if you are not feeling well or are unable to travel out to your primary care office. The ARNP will consult with your physician following your appointment.

The ARNPs are also available to make house-calls to your apartment. Residents may make three free after-hours requests per quarter; $50 per additional call.

www.horizonhouse.org/healthcare/medical-and-dental/.

Visits to apartments average about one per day. They are typically about falls, trouble breathing, chest pain, confusion and such.

If this is the type of in-house coverage that Tower residents want, they need to insist.

—W. H. Calvin
January 16, 2013, X2605, wcalvin@uw.edu

calls to 911	total	Aid	Medic	%Aid	census
Horizon House HH)	133	104	29	78%	680?
Skyline (SFH)	127	85	42	67%	376
Tower	76	63	13	83%	276
Terraces	51	22	29	43%	100
Kindred, 1334 Terry, only skilled nursing	45	11	34	25%
Park Shore	71	61	10	86%
Exeter House	54	39	16	72%

“Aid Unit” Responses (what in-house nurse consultation should reduce)

In 2013 there were 104 responses to Horizon House and 85 to Skyline (63 Tower plus 22 Terraces). But the Horizon House census is almost twice ours, so Skyline generates 48% more Aid-level calls per person as does Horizon House.

Medic-level responses (true emergencies; unconscious, resuscitation may be needed)

While true resuscitation-style emergencies are not the topic here, some limited insights can be gained from the comparison for Medic-level responses between HH and SFH. One sees that HH is calling in a Medic-level request far less often than does SFH.

HH had 29 Medic requests in 2013, while Tower+Terraces (with half the people) had 42 total. Per resident, SFH is calling in 160% more Medic-level cases than HH.

One obvious interpretation is that the HH nurse can make a better judgment call about declaring an emergency than whoever calls from SFH.

Qualifications to comparisons:

1.       HH census based on approximate number of units plus 25% dual occupancy. SFH census based on 2013 phone book count (Tower) and reported occupancy for Terraces (110 beds total).

2.      HH no longer offers Medicare A beds (typically post-op recovery; they formerly had 18 beds). However, skilled nursing beds are only a fraction of the total SFH census.

3.      The average age of HH residents is higher than at SFH.

4.      The 911 caller may be a nurse (good at distinguishing between Aid- and Medic-level urgency), a resident (apt to overstate severity), or the concierge (reporting second-hand; unable to answer the dispatcher’s questions, perhaps leading to Medic-level escalation).

5.      The low percentage of Aid-level requests from nurses (Kindred’s 25% and Terraces’ 43%) suggests that the nurses themselves are able to handle such Aid-level needs. No breakout attempted for HH.

(You too can access the Fire Department’s data base at data.seattle.gov. Welcome to “Big Data.”)

January 2013