By Daniel Beekman
The Seattle Times

SEATTLE — A Seattle woman’s nightmarish ambulance wait in the days before her death might have played out differently in another community, because U.S. cities have set up their 911 systems and nurse lines in various ways.

Many cities, like Seattle, have added 911 nurse lines in recent years to divert low-level patients away from crowded hospitals. But some have equipped their systems with more protections against extreme delays, like the 10 hours a woman named Pamela Hogan waited for a nurse-ordered ambulance in 2022.

| EARLIER: 10-hour ambulance delay puts Seattle’s 911 call triage under scrutiny

It’s not clear that Hogan’s wait is what caused her death, but her estate is suing and her ordeal is raising questions about the city’s 911 medical system.

As Seattle leaders like new Mayor Katie Wilson deal with scrutiny over Hogan’s case and as additional communities consider adding 911 nurse lines, they may be able to learn from choices by policymakers elsewhere.

The Seattle Fire Department and its ambulance contractor, American Medical Response, say they’re generally guiding 911 patients to appropriate care. They declined to comment on Hogan’s case and a Seattle Times investigation.

But in Washington, D.C., as well as closer to home in Washington state and in other places, there are examples of more cautious approaches, say independent experts, including emergency response leaders and health care watchdogs.

“When we call our local Fire Department, we don’t expect to be passed off to a multibillion-dollar corporation without public oversight or transparency,” said Emily Brice, co-executive director of Northwest Health Law Advocates.

In Seattle

Seattle’s Nurse Navigation program went live in 2022 and is operated by the parent company of the city’s for-profit ambulance contractor, AMR.

When someone phones 911 with a low-level medical problem, Fire Department dispatchers can now route the call to a nurse. The nurse can try to resolve the problem with options like telemedicine or an Uber ride to a clinic.

Or the nurse can order an ambulance from the company’s dispatch office.

| Nurse Navigation Program

AMR was already providing ambulances for Seattle, but the nurse line was new. Before it launched, AMR was racking up financial penalties for violating the city’s contractual time standards, which said ambulances had to arrive within an hour.

Seattle and AMR officials promised the nurse line would relieve pressure on ambulance crews and thereby reduce delays to patients with more serious needs. They didn’t publicize some important details, however.

AMR’s nurses are located at a call center in Texas. They order ambulances for most patients they triage: more than 4,600 last year. And Seattle officials have excluded the nurse-ordered ambulances from the city’s time standards, giving the company more operational flexibility and shielding it from late penalties, experts say.

Patients like Hogan can’t update the nurse line directly as their conditions evolve, their AMR ambulances aren’t subject to contractual penalties for delays and the Fire Department doesn’t document how long the rides end up taking.

Those details and staffing issues may help explain why Hogan waited so long on a busy night, despite a nurse recommending she get care within four hours and despite Hogan calling 911 back multiple times, some experts said.

“If you don’t track it, you don’t know what’s happening,” added Cheryl Kauffman, who owns the health care consulting service Seattle Patient Advocates, describing the city’s setup as “a perfect recipe for poor outcomes.”

In other cities

Nurse lines and 911 systems vary from place to place. For example, Spokane uses AMR and exempts nurse-ordered ambulances from strict time limits, like Seattle does. But Vancouver, Wash., also uses AMR and doesn’t do that.

When the nurses order ambulances for Vancouver patients, the city’s time standards apply, the wait times are tracked and AMR can be penalized for delays, said Michelle Bresee, an emergency medical services analyst at the city.

“They’re still a person waiting for service and we want to make sure that person gets a response in a reasonable amount of time,” Bresee said.

Washington, D.C., also maintains ambulance wait standards and reporting, directing nurses to bounce patients back to 911 for ambulance dispatching.

“We want every call to have the same response standards,” said David Vitberg, the district’s Fire Department medical director and the lead editor of a textbook on emergency care and transportation. “There’s an inherent risk in not holding (ambulance) units to some sort of response time metric.”

D.C. requires AMR’s parent company to embed a nurse in the district’s 911 center, integrate its computer system with the district’s and check medical histories to help triage patients. Seattle’s contract lacks those guardrails.

In Fort Worth, Texas, the 911 agency maintained time standards for nurse-ordered ambulances and built its nurse line in-house to guard against potential communication gaps, said former administrator Matt Zavadsky, who set up that system. Seattle couldn’t afford to do that, the Fire Department said.

Fort Worth automatically upgraded its responses based on triggers like repeated callbacks or unexpected ambulance delays, sometimes routing a patient back to a nurse or sending a paramedic to check on them, said Zavadsky, now a nationally recognized consultant on emergency medical systems. Seattle’s system has no such automatic triggers, the Fire Department said.

There are other considerations, said Conrad Fivaz, medical director for Priority Solutions, another nurse-line vendor that operates internationally.

Priority Solutions only works with 911 agencies that employ nurses in-house, integrate their computer systems and are accredited by the International Academy of Emergency Dispatch, Fivaz said. Seattle doesn’t tick those boxes, he said.

Priority Solutions also only works with registered nurses, Fivaz added, whereas AMR has used less-qualified nurses for some patients. Josephine Ensign, professor emeritus at the University of Washington School of Nursing, said she believes nurses assigned to triage vulnerable 911 patients should hold Bachelor of Science degrees in nursing with training in public and community health.

“You have to put things in place to mitigate the risk,” Fivaz said.

What’s next

Ken Miller worked with AMR to launch a nurse line when he served as medical director for the 911 system in Santa Clara County, Calif.

His system agreed to a contract like Seattle’s, exempting nurse-ordered ambulances from time standards, said Miller, who’s since left the county.

But Miller was “never satisfied I had enough transparency,” he said, describing what happened to Hogan in Seattle as his “nightmare” scenario.

“This goes beyond Seattle,” as cities across the U.S. continue experimenting with nurse triage lines to reduce strain on 911 systems, said Miller, who has served on the National Emergency Medical Systems Advisory Council.

A nurse-ordered ambulance should at least be required to reach a patient within whatever period the patient’s nurse recommends, some experts said.

“If your own staff say the patient needs care within this time frame, you should provide that,” said Amber Sabbatini, an associate professor of emergency medicine at the University of Washington who researches health care systems.

Seattle just missed a potential opportunity to secure more accountability, because officials signed a new, five-year contract with AMR in September and chose to continue exempting nurse-ordered ambulances from oversight.

But with a new mayor, city attorney and two new City Council members, it’s possible Seattle leaders will revisit the matter.

Kevin Mackey, medical director for the Sacramento Fire Department, said Seattle’s 911 system enjoys a stellar reputation; its Medic One program broke ground decades ago by training firefighters as paramedics. Yet he agreed with other experts that Hogan’s case and Seattle’s guidelines are worthy of review.

“The public expectation should not and cannot be perfection,” Mackey said. “But it also should not and cannot be that people are going to die.”

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