88 Implementation of a Nurse Practitioner Response Unit in an Urban EMS System

The Los Angeles Fire Department (LAFD) is the sole provider of 911-EMS response for the City of Los Angeles, and in recent years has experienced a disproportionate increase in 911 use by patients with low acuity medical complaints and 911 frequent users. In January 2016, LAFD launched a Nurse Practitioner Response Unit (NPRU) - a specialized ambulance run by a licensed nurse practitioner (NP) and a firefighter/paramedic with the mission of treating and releasing patients on scene, and providing linkage to further care. This study describes the first three months experience of this new model of prehospital care delivery. This was a retrospective review of LAFD electronic health records and prospectively collected patient survey results from NPRU incidents occurring from January - March 2016. The NPRU serves a single 28 square mile battalion in the South Los Angeles area. Low-acuity 911 callers were selected by the NPRU by monitoring dispatch radio traffic during the hours of 8am - 6pm, Monday - Thursday. Also, housed (ie, non-homeless) 911 frequent users living in South Los Angeles were identified from LAFD health records, and consented for scheduled visits, NP assessment and referral to resources. Summary descriptive statistics were collected regarding patient volume, time in service, provider impressions and treatments provided. Patient satisfaction and linkage to primary care was assessed through standardized telephone survey instruments at 24 hours, 7 days and 30 days after each incident. The NPRU unit was linked to 256 unique patient incidents over 46 operational days (mean 5.6 incidents per day, median 5, IQR 4-7, Range 1-12). Of the 256 incidents, 41 cases were cancellations; in 26 cases no patient was found; in 4 cases the patient refused EMS care outright; and in 3 cases the patient was otherwise ineligible for NPRU care, leaving 182 incidents for evaluation (71.1%). Of these 182 incidents, 172 (94.5%) were low-acuity 911 callers (Mobile Urgent Care), and 10 (5.5%) were scheduled visits with LAFD 911-frequent users. A total of 89 (51.7%) low-acuity patients were treated and released on scene, of which none reported having used a 911 ambulance in the follow-up period to date. Two individuals reported visiting an emergency department within a week of their NPRU care for refill of pain medications, and no low-acuity patients reported requiring hospitalization. In the 32 patients surveyed, 100% agreed that NPRU personnel treated them with courtesy and respect, and rated their overall quality of care as very good or excellent. Ten 911-frequent users were seen by the NRPU and they received a comprehensive assessment and were referred for further resources, of which 50% showed decreased EMS utilization over the next 30 days. The LAFD Nurse Practitioner Response Unit offers low-acuity 911-callers an alternative to costly EMS transport and ED care, and preliminary results support its feasibility, efficacy and patient satisfaction. Further studies are needed to confirm these findings and assess cost effectiveness of this new model of care delivery.