Live From Expo 2023: Peter Antevy and Charlie Coyle on the Wall Time Problem

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Welcome to EMS Expo 2023, coming to you from EMS World Podcast booth here in beautiful New Orleans. We have so many incredible topics to discuss here this week. And with me now are two very familiar faces, good friends. Chief Charlie Coyle of Palm Beach County Fire EMS, and of course, the assistant, esteemed Dr. Peter Anteve. Gentlemen, thanks for coming back with us.

Hey, Mike, how are you, buddy? Thanks for having us on again.

Good to be here.

Hey, listen, guys, we always have some really good chats, for sure. And, you know, Dr. Anteve sent me a list of something that he thought was really important, and I think that it is really important across the country these days, and that is the issue of wool time. And so, for those that might not be familiar with that, I'm going to pass this over to Charlie right now to just give us a little heads up on what wall time means and the effects that it's having on the EMS systems across the nation these days.

Yeah, Mike, so essentially, wall time is just when you transport a patient to the hospital and your crews walk through the doors of the hospital and they sit there and the hospital maybe, maybe not. They acknowledge them and say, hey, what do you have? And then, boom, the nurse is gone, the paramedics are standing there with the patient, and you don't see the nurse again for 30 or 40 minutes, or the nurse comes back over and says, yeah, we'll get you a bed in the next 30 minutes. So essentially, wall time is you're physically in the hospital, but you haven't transferred the care over to the nursing staff for sure.

So, again, this is the kind of pay no mind type thing where, okay, we see you, but we're really busy here and we can't get to you. And like I said, this is pretty pervasive. I mean, we're seeing this all over the country, some places worse than others. And obviously, this is driven by demand and the amount of patients that these facilities are seeing and what they have upstairs. Peter, what are we doing or what can we do to combat this?

Well, first we have to recognize that the problem is not an EMS problem. It's a hospital problem, meaning that they. They don't have the personnel, meaning the nursing staff to actually staff the beds. So you may walk into an emergency department and see.

Four folks standing on the wall, but you have four empty beds and you say, well, why aren't we just going into the bed? Well, we don't have nurses for that. Then upstairs, if you take a walk upstairs, you'll see the same thing. You have a bunch of empty beds and then there's no nurses to staff those beds. And then, and Charlie mentioned this before we started talking, is that then the patients aren't being discharged fast enough so the whole throughput is not working. So we have to recognize that, yes, we're seeing a lot of patients in ems, but this is not an EMS problem and the hospital has to attribute resources to fix the problem.

All right, but. All right, I'm gonna play dabble's advocate. Now listen, I'm a medic, you know, I'm a chief and all that stuff. So listen, I'm pro us, but here's the story. This is a personnel problem. There's a personnel shortage, right? We have personnel issues. So what's the easy fix here?

Right?

You're saying, okay, well, you have to be able to move these patients. They don't have the resources, so what are they supposed to do?

Yeah, no, I think that they owe it to us to fix the problem. So there are ways of hiring more people, but those people cost more money. So I don't feel bad for the hospitals. They're making a lot of money, Mike, okay? They're just trying to save that extra dollar or two so that their pockets get bigger, they can hire. And they have hired our paramedics to work in the emergency department. Okay? But at the end of the day, in my opinion, what it really comes down to is that they're not actually trying to fix the problem. And instead they would look at us and just say, you know what, you're just going to stand there on the wall and that's something that we just cannot tolerate. So they have to spend more money, get more people, fix their processes upstairs and downstairs, and then if not, then they're going to suffer the consequences, which we can talk about later.

Well, this is basically a multi headed monster. Let's talk about that side. Because number one, right? Number one, you have a patient that's on the wall that isn't getting cared for. I mean, you still have providers with that patient, but they're not getting into this system. That's number one. Number two, we're losing those resources to answer other calls on the street. Right? And number three, which kind of gets probably buried is the perception that the patient and their family have right of, why am I not being treated here? What's going on? Right? And guess what? That always translates back to ems. It looks bad on us, right? So, Chief Charlie Coyle, who is always at the forefront of spearheading these incredible initiatives, what are we going to do about this issue?

So I can tell you a little bit specifically about what Palm beach county did. So what we did was, you know, in Covid, as much as I hate to even talk about COVID Covid really brought a lot of good things to light. What we learned was, you know, obviously everyone had to be gowned up for a while. These patients had to be in isolation rooms. So we understood there was going to be a backlog within during COVID However, as things started moving along during COVID and some of the restrictions kind of went down a little bit and everyone was able to lower their guard, we started finding out that these problems were continually consisting. So I would even challenge the group to say, did these problems truly exist before COVID And the answer is yes. Nobody was just measuring that. So what we did was we set up a crystal report, basically just a data mining tool to look at our hospital turnover times. And the crystal report is run every morning. It shows every one of our transports. It shows every time that. It shows each hospital, by the way, so all 20 hospitals in Palm beach county can see each other's data. And anytime that, you know, we have a unit there that's greater than 20 minutes, they get a little, you know, a little ding next to their name. If they're over 30 minutes, they get a little ding next to their name. If they get over over 45 minutes or over 60 minutes, essentially, that incident number gets put on the page, and we get the rescue number that transported the patient. And every single time that we looked at those cases specifically, it correlated exactly with what the crew was telling us. So the interesting part is, and this is where it gets a little bit contentious, is we started sending this to all of the hospital CEOs. We sent it to the county administrative staff, we send it to the East Nurses Forum, we send it to all the ER directors, and we send it to all the ER medical directors. As a matter of fact, we send it to all the EMS chiefs and the surrounding cities around Palm Beach County. So it's about 250 recipients every single day. And since 2020, we run this report daily. And I'll be honest with you, as long as I'm still in ems, and probably, if I go somewhere else, we're still gonna run the damn report because it's that important.

In other words, the way we like to say it in Jersey, you put their ass on blast is what you did. You're getting as many people on there to see they're not gonna like when their facility shows increased wall time.

It honestly is a healthy competition to make sure that we have availability to support the community. But, yes, I could second a little bit of what you said, Mike.

It's. All right.

Listen, how annoyed are the providers getting at this? This is frustrating, right? So listen, I told you, on a smaller scale, I deal with it in the Northeast.

But, like, we'll get calls from the provider like, okay, we're here 30 minutes. We're here 35 minutes. We're here 40 minutes. It gets to the point where the providers are really pissed, right? And then the chiefs get pissed, and you get to the point where you say, all right, well, enough is enough. Now you give them the last final. The final warning, and that's it. Right? I'm gonna leave this patient in the chair, and we're leaving. Now.

I would say we're within our rights to do that, but ethically and morally, are we doing the right thing? That's kind of like where we're walking a tightrope.

Yeah. I would say the term some people may think of is patient abandonment, and obviously, we never want to do that. But I think there's many steps that you would do before that. And my personal preference, Mike, would be to actually take the patient to another hospital before I would leave them there. Number one, what they're doing in places like the city that we're in today is that. And I spoke to some people about it just this morning, is that they actually leave a paramedic, a single paramedic, to, quote, unquote, babysit three patients who are sitting on the wall.

But it turns out that this city has to pay an outside ambulance company to actually cover the city at the cost of hundreds of dollars an hour because their medics are sitting on the wall for an hour or more. Right? So I think that.

I wouldn't just start leaving people in the hallway before I started doing things like Chief Coyle was mentioning. But I'm going to back up one step in that. You really have to make sure that you're getting the data right, and Charlie mentioned that. But you have to figure out a way to make sure that when you're looking at your data, it's accurate data. Like what is the exact time that you're transferring care to the, to the hospital. And then from that moment on, you know, I got here at 12 o' clock and I transferred care at 1 o'.

Clock.

So my wall time is exactly one hour. If someone gets in there at 12 o', clock, gets at 12:20, they transfer care. But then they went to speak to some nurses, they went to get a cup of coffee, and then they went available at 1 o'. Clock. Well, that's bad data. So just word to the wise, make sure that the data you're looking at is accurate.

Yeah, obviously, I mean, you know, certainly C suite folks, they don't like anecdotal. Right. On any. You have to have cold hard facts for them. You know, I think, Charlie, you had spoken about engaging C level executives and also establishing some rapport with the nursing staff. Right. Rather than being adversaries. Right. That never gets you anywhere. Right. You know, you have to kind of, you know, embrace their struggles.

Right.

Understand their struggles. We get it. They're working hard. It's not their fault they were put in that position. Right. But that's where now we start turning to the C level suite and we start saying, hey, what are you doing about this? Right. Where are we going with this? Because this has become a problem and it's a patient care issue. Patient care issue. So what are you going to do?

Yeah, well, I think you said something very important there, Mike.

Right.

Relationships. Right. So the same firefighters that can get frustrated from being on the wall for 45 minutes could also transport their aunt or their mother to that hospital and they want VIP royalty care. So you can't have your cake and eat it too sometimes. So you can't really just say, this hospital is no good. You know, you don't treat us right, you don't do this, but then all of a sudden your family member gets there and you're expecting the VIP treatment. So it really is a balancing relationship. And the CEOs, you know, to me, I gotta tell you, it's important to see them during blue skies as well. So you can't only go there when there's a problem. You gotta have that constant relationship with the CEOs, and they've gotta trust you. They gotta know when you send them data and you want to have a transparent conversation that you're not there to be adversary. And you want to say your hospital's no good and we're not going to transport to you anymore. The conversation could go there, but the conversation should never start there. So building that relationship is paramount for success because you never know what you're going to need from your hospital partners. It truly is a partnership for sure.

Listen, no executive wants to just hear from you during bad times, right? Because you just kind of lose their attention. Right? Then they know going with another problem. Right. You have to establish that rapport, like you say. But I think that outreach to those boots on the ground workers in the ED are really important to look, let them know, hey, listen, we know you're, we know you're struggling, right? But huddles, like I think you were talking about your EMS captains having those huddles in the morning to kind of everybody get on the same page, like, what are we going to deal with today? And are we, are we passing this information in real time? You know, what are some of those initiatives that you were talking about?

So again, during COVID you know, we were, I have nine EMS captains that work out on the streets in Palm Beach County Fire rescue every day. And essentially what we're doing is a huddle. A morning phone call was call from 8 to 8:30, and we reviewed the data from the day before. So we looked at which hospital struggled and the ones that were kind of, I guess you could say, on the naughty list. The EMS captain would go there, make sure they, you know, the nursing staff knows that that's the EMS captain working for the day, gives the phone number out to them to make sure that that staff has the phone number because there was a lot of travelers during that point and says, hey, listen, if you're struggling today, call us and let us know what can we do to make your job easier. However, yesterday's times are not going to be acceptable. So if you need us to kind of like move some patients around during the day and not come to your hospital, maybe we can help you with that. But the reality is we need to offload our patients and we're not going to have times like we had the day before.

I mean, you said a word there that I want to touch on. Travelers, traveling nurses. Right. And again, I'm not, it's not a stigma. I'm not saying that they're not familiar. It's not a home base for them.

Right.

So there's no real pride in ownership when you have travelers because they're just basically a mercenary hired gun. Right. Did you find that it was worse in situations where we had that type of dynamic going on that Was overrunning the ED's?

The answer is yes, we did. We did. But the one good news is the ER directors remain the same. So that's. Once you got that information brought to you again, the data, that is camera. So if you have the data in front of you, for me, I would either be with the ER director or, you know, the. The doctor that's in charge or the CEO, the EMS captains, the, you know, my boots on the street. I made sure they. They linked up with the charge nurse. So whoever that charge nurse was, they have to have a good relationship. If we need to elevate it after that, we did.

Peter, where do you come in as medical director for these agencies where you say, I gotta step in here and I gotta make a call to say, all right, this is just becoming too much of an issue.

So we have this good cop, bad cop dynamic.

I like it.

Normally, Shepke is the bad cop, I'm the good cop. Right.

He does notice, right?

Yeah, he knows. He knows. He knows. So in this particular case, I came up with an idea and I said, let's bring all the hospital CEOs onto a Zoom call, and then we're going to give them a talk on emtala. And I tell you what, there was smoke coming out of the computer screen. They were pissed. Why? Because they basically said, this guy just said that they're going to bring patients to our hospital and if we don't offload them, then we're going to talk to the patient. Because remember, we can't make the decision, the patient has to make that decision. But if we advise the patient and the patient says, yeah, you know what, I do want to go to the other hospital. And now we take that patient before a medical screening exam. That's an EMTALA violation on the hospital. So I played bad cop, they got upset, but now they took us seriously. So Charlie said, blue skies, we go visit, everyone shakes hands, we having cake. But then there's some times where you have to go in and just say, you lay down the law.

Well, you got to leverage. Right? I mean, the fact of the matter is, sometimes you only get their attention with some of these things that are really going to have negative outcomes.

Right.

Let's be honest. When you start talking about violations, when you start talking about emtala. Yeah. We start talking about JCO and things like that. These are real implications. Oh, now you got my attention. Right. And so.

Yeah, well, and so there's other things that other people who are probably listening to this have done. Number one is they'll have like actually like the pool chair is cots in their trucks, and then they'll just come and they'll open the cot, they'll leave the patient and they'll leave. The second thing is they'll charge the hospital back for the time. Right, because, because you're using my medic as an employee. So I'm gonna charge you on an hourly basis for that. So there are things that you can do. It's just that people just hope that tomorrow is gonna be a better day. But here's news flash for the next five years, this ain't going away. This is not a Covid thing. Like Charlie said earlier, this is a. We have the massive nursing shortage, we have a massive doctor shortage. By the way, you have a massive paramedic shortage. And so this is not miraculously going to go away. You have to fix the problem at your agency.

Charlie, have you seen improvements since you started to implement some of these initiatives?

Drastic improvements. Drastic improvements. And as a matter of fact, when I talk to the CEOs, whether it be in meeting or through phone call and sometimes even through text messages, they actually brag about their times. So it's almost like a business marketing tool for them to say, hey, listen, last month we were down to an 11 minute turnover and the previous months we were at 14 minute turnover. So we're doing so much better. Have you recognized our efforts? And you know, technically speaking, I don't even allow it to get to that because as soon as the times start to decrease, I'll shoot them a text and say, hey, listen, we really appreciate all the hard work you're doing. You're keeping our units in service, you're allowing us to support the community and we thank you for your efforts.

You've actually created a competitiveness to this amongst these facilities.

100%. Right? I mean, hospital CEOs, let's, let's say what it is, they're there for a reason, right? They sit behind there. Nobody can process numbers like they can. And they look at profit margins, right? So, you know, it's, it's, it is a business. It is a business. Now Fire rescue is also a business, but we have to support the community. Community in a different way. But it's impossible to support the community when you're stuck on the wall at a hospital. Really. It's not just looking at your hospital turnover times, you should be looking at your unit availability times because you should be in that 90 to 95th percentile where you have coverage in that zone that you're responding to. So that's very important to think about that. I know I never would have this would have never been a thing for me before COVID until we started getting gaps all throughout the county. So, you know, we're super blessed to have such great medical directors and to be able to, you know, have a conversation with hospital CEOs and do a zoom call. And honestly, you know, I wanted to say it earlier, but I didn't want to cut Dr. Antevi off. It was the first time, and I've known him for over 10 years, that someone said they did not like him. It was the coolest thing. They said he was a jerk. I'm like, Shepke and I were like, holy cow, did they say Peter Antevi's a jerk or high fiving over there?

Finally, do me a favor, get their names. I'm gonna have them on the podcast. That's what I need.

I sent him a Christmas card. I was like, you're right, he's a jerk. I hate this guy.

I need a Peter bashing podcast. It's. The time has come.

But because anyone that knows him, he's one of the sweetest and most kindest people you'll ever meet, and he's got a heart of gold. So, you know, they were just. He, he did. He had to put that, that, that medical director hat on that says, you know, we're gonna treat you like you're treating us. And right now, that's not that good.

It was a total Jedi mind trick. You just. Total Jedi mind trick.

Some people were crying.

I think it's unbelievable. Listen to me, guys. I always love having you two on. And, you know, this is a really important topic, and it's good because it kind of steers away from some of the things that we talk about clinically and from an operations perspective, this is something that has implications that are really far reaching, right from the personnel standpoint, from the patient standpoint, from the image standpoint, from the coverage standpoint, all of those types of things, and it can't be ignored. Like you say, Peter, this is not going away. This is not going away at all. And it's something that we're gonna have to learn to live with, and we're gonna have to adapt and overcome to get through it. But Charlie, as always, always driving it, you know, as far as the initiatives and things like that, really great stuff. And, you know, I would encourage the listeners and, you know, if you're in that spot, to take up Charlie's initiatives, because again, unless you have real cold, hard facts and strong data, you're not going to get buy in. You're just not. So, you know, again, I want to thank you guys for once again coming on and jiving with me. And we're going to, we're going to have you back tomorrow. We're going to actually talk about something else once Peter figures out what it was he wanted to talk about. But, gents, I do want to thank you for coming on. I want to thank you for all the things that you're doing down there and, you know, bring to the forefront some of these issues that we have and how we're going to get through them. So, Charlie and Peter, thanks again.

Thanks, Mike. Great to be here again.

Yeah, Mike, thank you once again. And again, it's such an honor to be a part of this EMS World experience and especially on your podcast. So thank you and we hope you have a great day.

Guys. Thank you and thank you for listening. Thanks for listening to EMS World Podcast live from New Orleans. We're having a great time here and we have some really, really great guests coming up. So make sure you tune in and we will talk to you real soon. I'm your host, Mike McCabe. Talk soon.

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