HONOLULU (KHON2) — Calls to 911 for medical help grow while on-time responses are on the decline due to the current heavy demand. Big changes are underway in how callers are serviced. Always Investigating looked into what patients can expect and what their rights are.

There are several ways in which the emergency medical system is trying to make response more timely and efficient: urgent care instead of the emergency room, social services for frequent callers and even possible rideshare or phone aid in the future.

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After a lull during the COVID lockdown, phones continue to ring off the hook now more than ever at the state’s 911 dispatch centers, with hundreds of medical emergencies a day and a slowing response trend — nearly one in five calls exceeded “response time standards” of 15 minutes in urban areas and 20 minutes in rural parts.

SOURCE: Department of Health’s Monthly number of 911 EMS responses in Hawaii (bars) and proportion within response time standard, 2012 through 8/2021

“It doesn’t necessarily tell one what’s going on in the system and how good the treatment is, or the EMS care,” explained Dr. Alvin Bronstein, the Hawaii Department of Health’s Emergency Medical Services chief, regarding the timeliness metric. “Because it really depends on outcomes, types of patient, the acuity of the patient, etc. So, it’s only one metric.”

SOURCE: DOH

Response times could be helped by some significant changes that just launched. Starting the first week of November, people might not get taken to an emergency room if they call 911 for medical help from West Oahu.

“It’s an emergency to the patient, but it’s not necessarily an emergency medically,” Bronstein said of some 911 calls. “But we want to get them the proper care.”

Instead, callers might get taken to what officials call an “alternative emergency care site.”

“If the patient is low acuity, meaning they’re not very sick or injured, and the paramedic feels they could go to an urgent care clinic and the patient is agreeable — the patient’s also part of this decision — we will take them to the Straub Clinic in Kapolei,” said Dr. James Ireland, chief of Honolulu Emergency Medical Services.

This is allowed by a 2019 law called Act 140. The City and County of Honolulu is eyeing expansion to East Oahu already, and probably windward next, Ireland added. State officials told KHON2 it will eventually expand to the neighboring islands.

“We also have that ambulance back in service in their area sooner,” Ireland said. “As you can imagine, if the Nanakuli ambulance goes all the way down to Pali Momi no lights and sirens and then drives back no lights and sirens, that community is without their ambulance for a little while. Whereas if they just go to Kapolei, a shorter trip, and then are back in service in their area, that’s better for everybody who needs 911 for the next call.”

Always Investigating wanted to know: What protects the patient, either from a faulty decision on a condition that could get worse quickly, or if you do not agree urgent care is better than the emergency room?

“We have a very strict triage guideline of only certain medical problems will qualify the patient,” Bronstein said. “And then there is a physician oversight to review that decision before the patient gets there. And then finally, if the patient says no, it’s no. If the patient wants to go to the ER, then that trumps everything, and we will meet their request.”

Some other 911 callers expecting a ride to an ER are now being met by a CORE — Crisis Outreach Response Engagement — crew instead, and as of a couple of weeks ago they are targeting frequent callers, such as the homeless, who do not need advanced life support ambulances.

“Some of the stories we’re hearing back from, like, the merchants for instances there may be a homeless person who spent literally like the last year in their storefront. CORE has been able to connect with them, address their medical issues, get them transported to an appropriate facility,” Ireland stated. “But also on the back end help them apply for benefits. And in one instance, it was a V.A. benefits the gentleman needed.”

EMS officials said, rest assured, a call will always be responded to, but how and by whom will continue to evolve.

“Other jurisdictions on the mainland in those situations are sometimes using ride sharing Lyft or Uber to go instead of the ambulance,” Ireland said. “And we are actually preliminarily exploring those options as well. Because again, if you have a minor sprain or a rash — or some people call because they’re hungry — those patients could definitely be serviced still, but not with an ambulance.”

There is also talk of tele-health style self-aid without ever leaving home.

“The introduction of a mid-level provider or a nurse call center is a possibility that we’ve been discussing,” Bronstein said. “It used to be the insurance payers, like Medicare, only paid if the patient was taken to hospital. So, this has been a big change in their outlook because they realize that there are other ways to meet the patient’s needs rather than the emergency department.”

For the past 30 years or so, a state agency under the Department of Health called Emergency Medical Services Advisory Committee (EMSAC) assumed the responsibility for the medical 911 service statewide. EMSAC contracts with the American Medical Response (AMR) on Maui and Kauai, the Big Island’s combined Fire & EMS department, as well as Honolulu’s EMS division. The state bills for all 911 runs and collects about half of what gets billed to insurers and patients directly. However, in July 2022, a big change is coming for Oahu.

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“Come July 1, the City and County of Honolulu will be on their own, so to speak, where they’re going to be in complete charge of the EMS system for City and County of Honolulu,” Bronstein said. “They will continue to get some state funding, but in on a decreasing scale, till finally they get very little state funding. That’ll be new, but we think it’s going to work just fine.”