The Los Angeles Fire Department (LAFD) created an advanced provider response unit (APRU) pilot program to help people who call into 911 but do not require ED care.

The goal was to make better and more efficient use of ambulance and emergency medical treatment resources, and a pilot study shows that the program works. Among patients in one service area that had frequent, low-acuity 911 calls, the APRU response led to a 66.7% decrease in use of emergency medical services.1

The number of calls LAFD fields from low-acuity patients has increased sharply, says Stephen G. Sanko, MD, LAFD assistant medical director and assistant professor of clinical emergency medicine at the University of Southern California.

“In recent years, we’ve seen accelerated use of 911 in the city of Los Angeles, among particular demographics and certain parts of the city,” Sanko says.

The LAFD is the biggest provider of acute, unscheduled care in Los Angeles. More than 1,200 firefighter paramedics make 420,000 EMS visits each year.

The 911 calls began to increase in the years before the Affordable Care Act was implemented, rising by 3% to 8% each year. From 2012 to 2016, the volume rose more than 20%, he adds.

“At the same time, our fire department and EMS bureau were not receiving 8% more in funds, hiring more EMTs or paramedics, or purchasing more ambulances,” Sanko says. “We had to be more creative and efficient in how we did business in meeting this increasing need of people calling emergencies.”

Their solution began with implementing a new and better 911 system for the city. The system is more efficient and provides flexibility, allowing the LAFD to adapt it to the city’s needs, including allowing the city to begin its mobile integrated healthcare program.

“We detected that our growth was focused in a few areas: three of our 14 battalions accounted for over 50% of our growth from 2012 to 2016,” Sanko says. “This included low-acuity calls for help where patients were transported by ambulance with few or no interventions, and they were discharged from the hospital with few or no interventions.”

Firefighter paramedics also handled increasing cases of mental health exacerbation, issues related to substance use disorders, and minor trauma, he adds.

LAFD officials heard of a prehospital, nurse practitioner model in Arizona, and they visited the program to see if it could apply to the LA community. “We decided, with some adjustments, that was something we could implement here,” Sanko explains. “We planned and then launched our first unit in 2015.”

The process starts with when someone calls 911. The telecommunicator goes through descriptions and gives the case a dispatch code.

“For every dispatch code, there is an assigned algorithm of resources, including advanced practice providers,” Sanko says. “Based on historic data, we know some of the dispatch codes that would benefit from an advanced practice provider on scene, so the NPRU is dispatched.” When the APRU arrives, they can evaluate the patient, treat in place, and transport if necessary, he adds.

The mobile team also can self-refer to 911 calls: “Our APRUs are listening to radio traffic and looking to cherry-pick calls where they feel their services would be helpful,” Sanko says.

The mobile advanced practice program started with the city funding one APRU for the area with the greatest increase in 911 calls. The program was linked to 1,038 calls between January 2016 and July 2017. Of these, 812 people received the mobile help, Sanko says.

Diverting that many low-acuity calls away from the ED results in cost savings. Although this has not yet been calculated, Sanko estimates that each person who is taken by ambulance to the ED for treatment and does not require an ED or hospital setting accrues expenses of around $1,100 to $2,500, on average.

“If we are able to treat and release or navigate, it represents potential savings in time and money for patients and payers, and it’s more efficient care,” Sanko says.

Based on the early success, the LAFD decided to expand the program to five APRUs, funded through private-public partnerships with other health systems, he explains. “The hospital systems recognized the benefits of improved efficiency of 911,” Sanko says.

The APRU uses a converted ambulance, containing a refrigerator and medication. It contains point-of-care technology and brings a nurse practitioner with ED experience together with firefighter paramedics to provide mobile urgent care.

“It is treat-in-place,” Sanko says. “Every patient is offered a trip to the ED; however, they also can be seen by the nurse practitioner to receive treatment in place.”

The APRU team can treat patients and leave them in their homes, or they can refer patients to a primary care provider or other resources. The team also takes patients to alternative destinations, such as a mental health urgent care facility, he adds.

“If they’re intoxicated from alcohol and meet certain criteria, we transport them to a sobering center,” Sanko explains.

Emergency services and local hospitals have used a lot of resources transporting intoxicated patients to EDs. These patients need help, but their conditions usually are not emergencies, and taking care of them prevents paramedics from responding to true medical emergencies. The solution of using the APRU to evaluate intoxicated patients and refer those who meet criteria to a sobering center has worked well, Sanko says.

“We have been able to clear more than 1,100 patients to go to the sobering center, and this has freed up around 10,000 hours of local emergency department bed time,” he explains. “This, in turn, has helped to decrease the wall time for our paramedics.”

Wall time is when a paramedic transports a patient to the hospital ED, but there are no beds available for that patient. The paramedic has to wait at the hospital, sometimes for hours, until an ED bed is available.

“Meantime, the hospital is riding the wall — not available in its district to respond to the next critical call — and this has marked effects for emergency medicine and 911,” Sanko says.


  1. Sanko S, Kashani S, Ito T, et al. Advanced practice providers in the field: Implementation of the Los Angeles Fire Department advanced provider response unit. Prehosp Emerg Care 2019:1-14. doi: 10.1080/10903127.2019.1666199. [Epub ahead of print].