Dare County officials and hospital leaders review EMS interfacility transfer report, plan follow-up

Dare County commissioners, EMS leaders and hospital representatives discussed a consultant review of interfacility patient transfers and the operational, financial and personnel strains those transfers can cause.

The discussion, held during a Dare County Board of Commissioners meeting, centered on when ambulance transport is medically necessary, who pays when transports do not meet reimbursement protocols and how long-distance “long-haul” transfers affect 9-1-1 coverage and staff fatigue. County and EMS staff said they are partnering with the hospital to develop protocols and a return plan with costs for the board to consider.

The county presentation noted the partnership between the hospital and county goes back to 2002 and said both organizations are committed to process improvement in interfacility transfers. Commissioner John House (Commissioner House) commended staff for engaging outside EMS consultants referenced in the report and recounted past efforts to study transport options that were previously found financially infeasible.

Commissioner House said he reviewed the consultant findings and praised several recommendations while noting limits on feasibility. He also described past periods when only one ambulance was available in the county and said growth has increased demand. "There are times when we are posting a single unit through multiple districts," House said, and the county's geography complicates deployment.

County staff described a protocol used to determine medical necessity for ambulance transport and said transports that do not meet the protocol are not reimbursable. A county speaker said the question becomes "for the hospital ... what's the most cost effective way to do that? If they're gonna ask us to do it, then are they gonna be the payer of last resort?" The same speaker added the county is currently absorbing the cost of some nonreimbursable transports and said that practice is not sustainable given growth in both 9-1-1 calls and hospital patient volume.

Jenny (identified in the meeting as the operations officer for EMS) said the agency aims to move patients with life‑threatening conditions immediately, 24 hours a day, but that nonemergent transfers can sometimes be deferred to daylight hours. "If you have somebody that isn't in critical care ... then we can wait until the sun comes up so that we're not dodging the bears and having the staff out all night," Jenny said, adding that operations tracks every movement and that the agency spreads long hauls across multiple units to reduce fatigue.

Staff reported an increase in staffed units over recent years: nine years ago the county staffed eight units; that number has increased to 12, and the original staffing plan envisioned 13 units. Officials said seasonal peaks and major incidents still create periods of thin coverage and that long-distance transfers remove units from deployment areas.

Board members and staff raised morale and safety concerns tied to repeated long-haul trips and night operations. Jenny said the agency follows national standards for rest time and fatigue mitigation and that staff are encouraged to speak up if they feel unsafe. When asked about vehicle accidents related to driver fatigue during the present tenure of county leadership, a county speaker said none had been attributed solely to fatigue in the last nine years.

No formal board action was taken during the discussion. County staff said they would work with hospital partners to develop a proposed plan, including any cost implications, and return to the board with recommendations.

The conversation also referenced interviews in the consultant report in which EMS staff reported receiving inaccurate clinical information at times, a communication issue county leaders said the proposed protocols aim to address.