What kind of emergencies most commonly occur during Telemedicine?

An emergency during telemedicine is a critical status during a telemedicine visit that threatens a life or limb.  The most common emergency during telemedicine is a psychiatric crisis where the patient has a reasonable probability they will commit suicide.  Remote monitoring emergencies may include new cardiac arrhythmias discovered during cardiac monitoring and extreme high blood pressure discovered on blood pressure monitoring. 

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9-1-1 Infrastructure Problems

Using 9-1-1 by itself for Telemedicine is unreliable
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When doctors call 911, they reach their local dispatcher, not the dispatcher for where the patient is located.

911 infrastructure is siloed by state.  Patients can be anywhere during an emergency but dispatchers can’t communicate across state lines.

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“Text to 911” is in less than 50% of PSAPs and concurrent voice calls go to different dispatchers

All Priority One 911 calls are answered before Priority Two 10-digit administration calls.  1-2% of PSAP zones change, close, or open every three months. Lists of PSAP admin phone numbers are hard to maintain for all patient geographies.

There are almost 6,000 PSAP 911 Dispatch Zones in the US.  Only the zone where the patient is located can dispatch first responders.

Hospital EMS can’t beat the 911 coverage of all patient locations and the 8 minute average response time.

 

Doctor's Duty

Our ethical responsibility is to act during an emergency.  For healthcare professionals the Duty to Protect and Warn Laws mandate activating emergency services for patients at risk of harming themselves and others. 

Patient Case
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“This is an emergency, hang up and call 911”

Our primary care telehealth practice has been seeing a patient for the past

year.   Late January she told her psychiatrist over telehealth she was going

to kill herself.  The psychiatrist said this was an emergency and told the

patient to “hang up and call 911” to receive in-patient care. They hung up and

the patient did not call 911.  A few days later she called her psychologist, said

she was going to kill herself by taking pills, and again was told to “hang up and call 911.”   The patient hung up.  The patient didn't call. 

 

On Tuesday afternoon the next week, she took a whole bottle of hydroxyzine pills and OTC pills. A few minutes later she called our telehealth practice in Little Falls, NJ, and told us she had “done something stupid.”  She is normally in Bergen county but this week she was in Toms River many hours south.  We have emergency telehealth protocols and were able to activate 911 in Toms River.  She became altered to the point she could not open the front door, so our providers coordinated with police and EMS to enter and identify the pills.  She made it to the emergency department and survived.  

 

The psychologist and psychiatrist had no idea what happened until we called them a few days later.  The psychiatrist does not track how many patients she asks to go to the ER or call 911 and does not follow up to find out what happened.  

 

Duty to warn and protect laws in the US

Which Staff have the Duty?

“Healthcare Providers, Mental Health Professionals including General Physicians, MD’s, Psychiatrists, Psychologists, Psychotherapists, Nurses, Social Workers, Marriage Counselors, data collectors, employees under supervision, and their secretaries, clerks, and stenographers.”

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Requirement To Report:
 

Example: Wisconsin s. 51.17, Stats Warning of dangerousness.
 

“(a) Any health care provider that reasonably believes an individual has a substantial probability of harm to himself or herself or to another person…

     1. Contacting a law enforcement officer regarding the individual and disclosing knowledge of potential evidence of a substantial probability of harm…

      2. Contacting the county department that the health care provider reasonably believes is responsible for approving the need for emergency detention of the individual”

Duty to Report Statutes by State

This information does not constitute legal advice and should not be relied upon as a substitute for seeking legal counsel.

Verbal and Written Hand-off Reduces Medical Error

Joint Commission recommends all hand-off procedures to have both written and verbal components for the critical hand-off information. 
 

“2. Standardize critical content to be communicated by the sender during a handoff – both verbally (preferably face to face) and in written form. Make sure to cover everything needed to safely care for the patient in a timely fashion. Standardize tools and methods (forms, templates, checklists, protocols, mnemonics, etc.) to communicate to receivers.

Patient Case
Verbal Only Hand-off: 9-1-1 Communication Error

"67 Lincoln Street vs 67 Lincoln Park"

A 911 call was placed multiple times and the address was verbally stated and

misinterpreted as street vs park.  First responders showed up to the wrong

address, no one was there, and they left as per standard EMS protocol.

On the fifth try they realized they were going to the wrong address.

If a doctor or clinic calls 911 or the police administrative number, the doctor’s address shows up on the dispatch screens, not the patient’s address.  If the doctor fails to explain that the address in the system is not the correct address, or the 911 dispatcher fails to further inform first responders that the forwarded address is not the correct address, first responders will go to the wrong address, not find any one, and leave.  If the doctor does not follow up, no one will ever show up.

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This information does not constitute legal advice and should not be relied upon as a substitute for seeking legal counsel.

 

Patient Behavior

Patients rarely call and are not as effective as a standard medical hand-off

1,981 articles reviewed on Patient Hesitancy and Pre-hospital Delay
 

  • Chest Pain patients wait an average of 3.5 hours to 7 days before seeking care

  • Psychiatric crisis patients rarely call 911 if their threat is real

  • Stroke patients wait an average of 1.5 hours to call 911 after symptoms have started and rarely call if they have a Transient Ischemic Attack. 

Patient Case

An 74 year old male calls your office because he is having epigastric and chest pains.  The after hours answering service gets you on the phone.  The patient says he usually has pain when he eats spicy foods, but this time it has lasted longer and feels more like a squeeze.  Antacids were not helping.  He has a history of CAD.  His niece insisted he call his doctor.  You ask him to call 911, the patient agrees, and you hang up. 

 

Thirty minutes later you called him back to see how things are going.  His niece picked up and said he did not call 911 because he was afraid of getting COVID at the hospital and did not want to go.  You talk to the patient again and activate Telemedicine 911.  He arrives in the ED and is shown to have an inferior wall MI. 

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When patients have chest pain, they hesitate to call 911 for an average of 3.5 hours.  Even if you tell the patient to call 911 and hang up, they still hesitate.  Telemedicine911 allows you to talk directly with 911 dispatchers and direct them to send your patients to cardiac centers with cath labs rather than the closest emergency room which may not be equipped. 

 

Time is heart muscle.  Your Telemedicine911 response gets the patient to the right facility without hesitation.  If the patient were in your office, you would coordinate 911, not your patient.  Take control of the situation

 

This same doctor has had 3 patients die in 2020 due to reluctance to call 911 and go to the hospital.

 

Faulty Protocols

Whenever a new client is interested in Telemedicine911, we ask them why.  We get the generic answers of “higher quality” and “better care,” but we also may learn of a bad patient case that prompted them to search for a better solution.  Please find  below common failures and examples of poor outcomes.  Hopefully this section will also prompt creation of better protocols before bad patient cases happen to you. 

Failure Type 1: List of EMS and 9-1-1 Administrative Phone Numbers and Fax
 

A large tele-primary care program created a database of emergency phone numbers covering all the addresses of their patients.  Some were 9-1-1 administrative 10-digit numbers and some were direct ambulance company numbers.  Providers and managers were given the excel sheet and directed to ask the patient their current address and call the corresponding number to the city or county.  Here are some things that happened;
 

1. When the doctor called the 9-1-1 admin number, the doctor’s address showed up on the screens. Some dispatches sent first responders to the address they receive as per 9-1-1 policy.
 

2. At times they called these numbers and were placed on on-hold while dispatchers handled real 9-1-1 dialed emergencies
 

3. At times they called the 9-1-1 dispatch and they no longer cover the area.  0-2% change, close, or open every 90 days.
 

4. At times the ambulance company was called and stated a 1 hour “transport time.”  Local ambulances are not always stationed with an average 8-12 min response time to all locations.  9-1-1 shuffles vendors to ensure coverage. 
 

5. At times an ambulance number was called for a suicidal agitated patient, and police do not arrive with EMTs. 
 

6. NJ 9-1-1 “The current NENA PSAP Directory contains information that was not provided by our office. Many New Jersey PSAP jurisdictions and contact numbers are not correct. None of the network transfer numbers appear in the directory as they can be dialed from anywhere and will not provide ANI/ALI information.”

Failure Type 2: Call the doctor's local 9-1-1 and request transfer
 

For emergencies a large national telehealth company had their doctors call 9-1-1 from their local phone and request the call be transferred to the 9-1-1 dispatch servicing the address where the patient was located. Here are some things that happened.

 

1. When the patient's address was in a different state, the dispatcher did not have the technology to transfer.
 

2. They had a patient in LA county when the doctor was located in Ventura county (2-hour drive).  The doctor’s call was first transferred to the wrong dispatch center, then transferred again and again, but did finally reach the location.  The process to 25 minutes. 
 

3. The doctor was rushing the emergency handoff.  The doctor’s address (not the patient's address) shows up on the 9-1-1 screens.  The dispatcher did not understand the request, said they could handle the case, and sent a unit to the doctor’s address on the screen.
 

4. A doctor called 9-1-1 and said she was calling on behalf of a patient in another area.  She needed to be transferred.  The police officer handling dispatch asked, “Are you the person who is having an emergency?”  “Where are you located now?” The officer stated it is not their policy to transfer or send units to people who did not call 9-1-1 themselves.  The officer instructed the doctor to have the patient call 9-1-1 themselves. 

Failure Type 3: Call the doctor's local 9-1-1 and request transfer
 

This method employs central staff to help providers coordinate telemedicine emergencies. Providers are given a phone number to call when there is an emergency for a staff member to help them.  Staff members range from administrators with knowledge of emergency services to outsourced call centers that aid in all telehealth operations.  Some of the reported failures include;

1. Doctors have reported wait times over 15 minutes for staff to pick up and help them.  Even if a call center is used as a backup, doctors should test pickup times for when they call. 
 

2. Handoff content changes 10-20% with each additional intermediate.  This is similar to playing the Broken Telephone Game.  When the doctor hands off the case to the administrative staff, who hands off the case to 9-1-1 dispatchers and EMS, information is left out or changed.