Declining Transport

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MarkBaribeault

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Hi All:

Re: Declining Transport.

I’m a medic in Onslow County, North Carolina, the home of U. S. Marine Corps Base Camp Lejeune. We’re an all-ALS third-service system answering about 13,000 county-wide 9-1-1 calls annually (though the Base has its own system). We operate seven 24-hour trucks on 12-hour shifts, and we’re lucky enough to have a progressive management team who’re willing to push the envelope. We’re an NC Model System, and we do RSI, C-spine rule-out, adult IO, air transport to the cath lab, etc., all without physician consultation. (And yes, we have openings!) The point is that we’re not strangers to innovation, or to the occasional controversy.

We’re considering a policy that would allow our medics to decline transport to patients who don’t require an ambulance. Obviously, this would be permitted only after a thorough history and physical examination, and only with the concurrence of our medical control physician. Additionally, this policy probably won’t apply to patients who even mention certain “magic words,” like “chest pain,” “trouble breathing,” etc. As part of our research, we’d like to hear from other systems that have implemented or considered similar policies.

Admittedly, this practice would be a double-edged sword. On the one hand, it’s a huge liability exposure. If we evaluate a patient and decline to transport them to higher care, we’ve assumed a lot of the liability for any poor outcome. It also won’t help our public image a bit. However, we all know that almost half of our transports don’t require an ambulance; they could safely use medical facilities other than an Emergency Department, or transport methods other than an ALS ambulance. Given the current business environment of budget cutbacks, staff shortages, and abysmal reimbursements, this policy could improve our service to the folks who actually need an ambulance. We’re hoping it will also improve response times, reduce overtime and fuel costs, etc.

So, what do you think, is this a good idea or a bad one? Does your system allow medics to decline transport to patients who don’t require an ambulance? What procedure do you use, and how has it worked for you? Do you have any data on outcomes yet? What kinds of experiences have you had, both good and bad? Did you educate the public about the policy, and how? Have you had any feedback from patients, politicians, physicians, etc? Do you leave these patients with any transport alternative, such as a taxi voucher? Have you implemented any of the other N11 numbers (2-1-1, 5-1-1, etc.), and have they helped? Have you considered the situation where the patient requests transport to someplace other than the closest facility with no medical justification? Does that fit into this policy? How do you handle non-emergent institutional requests (i.e., calls from nursing homes, doctor’s offices, etc)? Did I miss anything? ;-)

We’d particularly like to see a copy of your policy, if possible. My contact information follows, and if you have any questions please post them here or call my cell. Be warned, however, that I work nights! There’s a fair chance you’ll have to leave a message. **CL EDIT: PLEASE CONTACT MEMBER VIA PM/EMAIL INSTEAD**

Thank you,
Mark Baribeault, Paramedic Sergeant
Onslow County Emergency Medical Services

 
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medic417 said:
I am a firm believer that we should say no more often.
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...but only if the providers can do an adequate medical assessment. I do not see 3 month wonders doing this.

If we do delay people into see a doctor or giving the a sense of security that they "have been checked out" may allow that minor symptom to become very serious thus extending hospital days and possibly an ICU stay. Some people are already putting off getting medical care and are coming in sicker thus, our higher level beds are full of illnesses that should have normally been treated by outpatient.

I am more for dropping a person off at a clinic or lower level of care than just leaving them on the sidewalk.
 
If a provider can't do a decent medical assessment as a patient advocate, isn't that a personnel issue rather than a policy matter though?

Re: delay. Certainly a consideration, but we can't be all things to all people. Given budgetary constraints just for starters, we need to start being a bit more careful how we use available resources. Hopefully we'll be able to work some alternative into this policy, such as a taxi voucher, etc. I, too, dislike the idea of just abandoning these folks, but I dislike the idea of having to respond cross-county to a true AMI even more.

Thanks,
Mark B.
 
MarkBaribeault said:
I read that thread with interest, but didn't see the policy. Thanks, I'll check it again...
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Here it is :


1. The decision to transport by EMS should generally be based upon medical necessity. If the pt.'s condition could be possibly compromise in delay in care, that person should be tx by EMS. Several factors should be carefully evaluated before a final decision is reached:

a. Age
b.Chief complaint including MOI or NOI
c. Immediate hx including the possibility of substance abuse
d.Associated symptoms
e.Past medical hx
f. Appearance
g. Level of consciousness
h. Vital signs
i. Appropriate physical exam

2. If after careful evaluation there is a decision not to tx by EMS, the situation should be explained in detail to the pt. and to any appropriate family member, guardian, nurse, or other legally responsible person. All area of the assessment specified above should be documented. A clear statement of the reasons for not tx the pt. should also be documented. The decision not to transport should be based on the consensus of all medics present. If there is no consensus then the pt. should be tx.

3. If the pt. decides not to be tx, and in the opinion of the medic tx is indicated, a complete explanation of all possible consequences should be given to the pt. and documented. The pt. signature should be witnesed by a neutral person if possible with the date and time indicated. This form is inadequate by itself; careful and complete documentation in the narrative report must be completed. The medic should asist the pt. with finding alternative tx.

4. Particular attention should be placed on pt's mental competency.

5. (More stuff concerning documentation)

6. If there is any doubt concerning whether or not the pt. should be tx., then that pt. should be tx. Alternative tx. is only indicated in cases where it is clear that the pt.'s health will not be jeopardized or where the competent pt. refuses tx. (Note: this means that even if we refuse a pt., we must still arrange alternative tx. if the pt. is stable enough to go that route. We have a private ambulance service that we would call that would take care of this patient for us. Using those guys help free up ALS units in the county.)

7. All adult pt. with atypical chest, upper abdominal, shoulder or upper back discomfort should be tx to the hospital for further evaluation.

8. All pt. who received aerosol treatment for any reason should be tx to the hospital. (Note: any patient that we give any sort of medicinal treatment to we tx. to the hospital).

9. All pt. under 18 and who has not been emancipated should be tx to the hospital unless a parent or responsible adult is present to assume responsibility.

10. Children less than or equal to six months of age, regardless of complaint or results of assessment, should be tx to the hospital. (Note: this indicates that if the parent refuses to let the infant be tx., they should sign a form releasing us from liability).

11. Families sometime call EMS for evaluation or tx of pt who are expected to die. They do not necessarily intend or desire that the pt be taken to the hospital. Pt. who are known to be terminally ill, and who have valid out of hospital DNR orders, do not need to be tx to the hospital if medical control agrees that the situation calls for comfort measures only. You are not required to tx. pt to the hospital if approved by medical control unless family requests further hospital management.

12. Hyperglycemic pt. with blood sugar equal to or greater than 400 should be evaluated by the hospital. They may go by POV if they are well-appearing with no other indication for tx and they have reliable tx. Transport all others.

13. Pt. with significantly abnormal vital signs must be tx for evaluation:
a. Adult with systolic BP <90 or > 220
b. Adult with diastolic BP <60 or >120
c. Adult with heart rate >110
d. Adult with respiratory rate >24
e. Anyone with air room O2 sats <93%
f. Pregnant pt with systolic BP >140 or diastolic >90
 
Right now a provider can do a decent medical assessment but only for the few things they have been trained for that present as an immediate emergency. Thus, that pesky education issue again. There are reasons why true physician extenders spend no less than 6 years in college and then may be limited in what they are allowed to determine.

Your AMI comment reminded me of this statement by Charles E. Truthan, D.O., FACOFP (FD-doctor) from an article he wrote a few years ago which I just recently linked again in an education thread on this forum.

As a Paramedic, I used to be able to diagnose a heart attack within 30 seconds of the patient telling me their symptoms. But as a Physician, I found it took me much longer. I had to listen to all of their symptoms, family history, learn what risk factors for heart disease they had, prior episodes, any difference between the current symptoms and prior symptoms. Then, I need to get a 12 lead EKG (and a prior one for comparison if available) plus plenty of labs and maybe even a chest x-ray. Yes, diagnosis was simpler as a Paramedic, I simply had no idea of how many other diagnoses there were. And do you know what else I’ve discovered? For a Paramedic it does not make any difference!
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Paramedics do look primarily for diseases that are immediately life threatening but don't realize there are other illnesses that can become serious within a few hours. Many even on this forum did not know of the importance of a fever and many still see it as a BS call across the board without looking further.

A person feeling generally ill may be blown off as having the flu but yet the Hb may be dropping from some unknow cause. But, the SpO2 monitor may still say 100% especiallly if the Hb is 7. To some, that is a clean bill of health and a BS call just based on no obvious findings that they can assess.

There is so much more to doing a thorough medical assessment than many realize. I listened to "BS commentaries" from various partners for over 30 years as I was advancing my own education and learning so much more than what is taught in a 700 hour Paramedic class. But for some, street smarts is the only education a good paramedic needs.

In the ED, we do listen to the extra commentaries and "judgements" from EMT(P)s who bring patients. We hear stereotypes and blatant discrimatory remarks just based on race, neighborhood and poverty level or in some cases the affluent "diseases". Sometimes the report is given with more of this information than assessment of the actual patient. Yes, how one lives can be a vital clue but that shouldn't be the entire assessment.

Few are aware of the cost that is spent on homeless people that live with chronic illnesses that are very real from years of living in this environment as well as drugs and alcohol related diseases. Many do view "chronic" as BS. The remarks I hear about the frequent flyers who have COPD make me cringe toward some who have little or no understanding of the disease but just that they are a nuisance because they call all the time for "shortness of breath". The SpO2 is saying "BS" because their "sat is fine". Of course, there is also the notion that all COPD is just one disease and it is just the same blanket treatment for all.

When the Paramedic education becomes more standardized to include classes that enable the provider to recognize other potentially life threatening illnesses and not just the obvious, the scope can expand to allow more to say no freely. Right now, for some minor trauma, maybe.
 
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VentMedic said:
...but only if the providers can do an adequate medical assessment. I do not see 3 month wonders doing this.

If we do delay people into see a doctor or giving the a sense of security that they "have been checked out" may allow that minor symptom to become very serious thus extending hospital days and possibly an ICU stay. Some people are already putting off getting medical care and are coming in sicker thus, our higher level beds are full of illnesses that should have normally been treated by outpatient.

I am more for dropping a person off at a clinic or lower level of care than just leaving them on the sidewalk.
Click to expand...


My mistake. I tend to post to short. Yes a proper exam by actually educated Paramedics is a must otherwise a service should transport all callers. The short pass the test courses would not qualify a Paramedic to be able to deny.

While I see your point I still feel we could educate them better by saying no to transport but giving them numbers to various other means of transport and addresses and numbers to clinics in the area.

I do respect that you will never agree with me on this completely until EMS makes giant strides towards real education.
 
many years ago I worked in a system that allowed the ALS providers to deny transport.

We very rarely used it, as it was quicker and easier to take the patient to the hospital. When it was used, it didn't really help the patient as no alternatives were provided.

Some people have no other recourse but the 911 system, both for chronic and short term illnesses. (aka flu) But if nothing is done for them it complicates itself then the pt becomes a life threatening emergency. (a preventable one at that)

I would suggest you look at wake county or other services that instead of denial of care, offer some curb side or more preventative interventions. It is my opinion that with the current economic trends and the forseable problems in healthcare funding, if you want to protect your service it will be with what you do offer, not what you don't.
 
Another factor to consider is the length of their shift.

We no longer allow our ED doctors to do 24s.

What about the Paramedic? How inclined are they going to be to do a thorough assessment after 20 hours or even want to do another transport?
 
VentMedic said:
Another factor to consider is the length of their shift.

We no longer allow our ED doctors to do 24s.

What about the Paramedic? How inclined are they going to be to do a thorough assessment after 20 hours or even want to do another transport?
Click to expand...

But in our system it takes less paperwork to transport than deny, so most actually transport. So that may not always be true Vent.

Now I agree a 24 busy service is idiotic, but many rural services you get to much sleep most 24 hour shifts, so a blanket stoppage of 24 is bad news as many providers drive in to work rural stations.
 
medic417 said:
I do respect that you will never agree with me on this completely until EMS makes giant strides towards real education.
Click to expand...

I would like to see EMS obtain the bare minimun for a solid educational foundation rather than a hodge podge system of advanced providers based on more recipes.

Since the Paramedic is probably the only licensed healthcare professional that does not require a degree (OR being the exception), that should be the priority for this profession. If we allow the 6 month Paramedic to have extended responsibilites, then we are justifying not advance education. Meanwhile, the other physican extenders are working collectively with the AHA (American Hospital Associations) and the AMA for solutions. They have spent years preparing for this time when they predicted the future would at sometime need their advanced training. EMS has still been sitting on its butt trying to break a world record for "certs".

EMS also comes up with their own protocols but don't always include alternatives in them that benefit the patients and the other members of the healthcare system. Again, EMS perceives itself to be different and doesn't also see itself in the bigger picture or with long term goals for the patients. Thus, just another band-aid approach. PAs and NPs are looking for the long haul and have geared their education and professional goals toward what may improve the system for patient care as their advocates in a botched health care system of the haves and have nots.
 
There will also have to be careful documentation and wording for your protocols for when they cross the boundaries of what is construed as "medical screening". Each state, as well as the Federal level, have regulations when you approach this area. This issue has already been dealt with by PAs, NPs and the triage sections of the ED. It can be a gray and complicated area.
 
Now Vent denying is so easy a caveman could do it.:rolleyes:

But your right there has to be checks and balances in place or some idiot will get you sued. Myself I do deny but if I have any doubts I transport. Our policy is both Medics must agree and document seperately why we said no. Honestly you do not deny many people. You still transport a lot of people that the emergency room has already released before you do paperwork and ambulance cleanup.

But it is nice when you can actually educate a person, help them contact the services they actually need, so they benefit long term not just for that few minutes. I have spent hours on scene assisting a patient get things in the works. So denying is not about taking the easy out.

It is said give a man a fish and they eat for a day. Teach a man to fish and they eat for a lifetime. Same applies in EMS.

So my advice to OP do not consider denying as an option unless you guys are highly educated Paramedics and are willing to take time to help the caller. Honestly you will find tranporting is the lazy mans way.
 
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For those of you who have college or institutional access, here is a good article from this month's Journal of Emergency Medicine.
While a no transport program benefits EMS, it still offers little to solving the patient's issues of transportation and access to medical care. Not all patients should be viewed as uneducated dead beats looking for a free ride. The other issue for EMS is how long do you want to spend on scene doing an adequate medical screening? Are there actually adequate alternative services in your area and what is the wait list for these services? Even for those insured by an HMO, it may take up to a month to get an appointment. (A diagnostic mammogram can take up to one year for the uninsured woman. Some areas have cut that wait done but by doing so, they eliminated access to the preventative routine exams for other women. Just tossed this in since some in EMS could careless about these issues.)

http://www.jem-journal.com/

http://www.jem-journal.com/current

EMS-Initiated Refusal of Transport: The Current State of Affairs

The objectives of this study were 1) to determine the number and characteristics of emergency medical services (EMS) agencies within the 200 largest US cities that sanction EMS-initiated refusal of transport; and 2) to determine the extent of no-cost alternative transport mechanisms among those agencies that allow EMS-initiated refusal of transport. EMS agencies located within the 200 largest US cities were contacted via telephone and surveyed as to whether their agency sanctioned EMS-initiated refusal of transport (EMS-IROT). Agencies with a policy were further questioned regarding its components and usage patterns. The telephone survey contacted 100% (200) of the target population. Currently, 7.0% (14) of EMS agencies have EMS-IROT protocols, with 64% (9) of those requiring direct medical oversight. Five (2.5%) of the 200 agencies sanctioned EMS-IROT without requiring online medical approval. Average annual call volume of the five agencies not requiring direct medical oversight was 70,800; their EMS-IROT protocols have been in existence a mean of 19.8 years. None of these agencies had a no-cost alternative transport mechanism. Three (1.5%) agencies terminated EMS-IROT protocols in the past. EMS-initiated refusal of transport continues to be a rare entity among US EMS agencies. Those that do not require direct medical oversight tend to have well-established programs, though no agency offered a formal no-cost alternative transport mechanism.
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Hi All:

I feel like I need to steer this back onto point. Certainly there's more than one valid view on the topic, and certainly there are many considerations involved. But my intent here was only to avoid re-inventing the wheel while developing this policy. To that end, I was looking for direction about the policy itself (thank you, Medic417), and perhaps pitfalls to avoid. Specific pitfalls, based on previous experience with similar policies.

I do not anticipate that any of our staff will be "blowing patients off" or otherwise acting in a less than honorable manner, while applying this or any other policy. Such folks tend to show their true colors regardless of the constraints put upon them, and they need to be dealt with by other means. I believe that the vast majority of us are in this to do the right thing by the patient. This time, next time, all the time, whether it's our first hour or our twentieth, whether the patient is 4 months old or 80, for both "sniffles" calls and full arrests.

Yes, a medic in the field can't perform the same assessment that a physician can in the hospital. That's rather the point, isn't it? But for the purposes of this discussion, I'll assume that the medic in the field knows this, i.e., knows the limitations of their education, skills, and equipment. This will also be a consideration in the assessment. I'll assume (there's that word again) that the medic is intelligent enough to look carefully at the results of their assessment, to look under other rocks for symptoms, to consider (at least some) differential diagnoses, and to make the best decision for the patient.

Ambulance transport is not always the best thing for them. Especially for the old and young, a bouncy ride in a strange vehicle can be terrifying. Then they'll be spending the next several hours in the ED, along with the disruption of their routine, etc., etc. Plus when the bill comes in... Anyway, my point is that we can (and should) be acting in the patient's best interest when we suggest they use other means of transport, or a different provider besides the ED.

Even if they have some atypical presentation of an occult disease process, that doesn't necessarily justify transport to the ED by ALS ambulance. We hope to be able to leave them with another option, be it by their own vehicle, or a taxi service, anything short of stranding them.

Thanks,
Mark B.
 
Do you mind if I ask a simple question?

Why would the county even be considering this? You stated that you run 7 trucks full time and respond to 13,000 a year. That equates out to 5 calls per truck, every 24 hours or 2.5 calls per 12 shift.

Seems to me that your system is far from being stressed out. So why not provide care to the citizens that want it?

I am all for denying care, in a system that is stressed to the limits and has lots of abuse.

This system seems far from that. That is why I am wondering why they are looking into it.
 
MarkBaribeault said:
Yes, a medic in the field can't perform the same assessment that a physician can in the hospital. That's rather the point, isn't it? But for the purposes of this discussion, I'll assume that the medic in the field knows this, i.e., knows the limitations of their education, skills, and equipment. This will also be a consideration in the assessment. I'll assume (there's that word again) that the medic is intelligent enough to look carefully at the results of their assessment, to look under other rocks for symptoms, to consider (at least some) differential diagnoses, and to make the best decision for the patient.
Click to expand...

I had hoped you wouldn't compare yourself to a doctor.

That would depend on how many diagnoses and differentials the paramedics know. It they are from a certificate program, their knowledge may be rather limited. Many may not even know what they don't know because of education limitations. Even a two year program does not offer enough knowledge in may cases which is why other healthcare professions are now at least a 4 year or even a Masters degree.

MarkBaribeault said:
Ambulance transport is not always the best thing for them. Especially for the old and young, a bouncy ride in a strange vehicle can be terrifying. Then they'll be spending the next several hours in the ED, along with the disruption of their routine, etc., etc. Plus when the bill comes in... Anyway, my point is that we can (and should) be acting in the patient's best interest when we suggest they use other means of transport, or a different provider besides the ED.
Click to expand...

I hope you are not going to make your point by using those arguments. As I already stated, it may take weeks and months, not hours, for an appointment with a physician at another alternative site.

The very old and the very young are the two groups that are trusting and will be the ones that often get over looked in the healthcare system. I really do not see it as a wise decision if you deny transport to a child or even an elderly person if they made the call for help.

You also should not mention money as a reason NOT to transport regardless of your well meaning intentions. It may come across as discrimination or the wallet biopsy.

Definitely find alternative solutions if you want to help the healthcare situtation in your area and not become part of the problem by further lengthing the time it takes for these patients to get adequate care.
 
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reaper said:
So why not provide care to the citizens that want it?

I am all for denying care, in a system that is stressed to the limits and has lots of abuse.

This system seems far from that. That is why I am wondering why they are looking into it.
Click to expand...

Reaper while I can not respond for the OP in our case we do it to educate the public. Honestly in a busy system it would add more work to it. You are on scene longer. You have more paperwork. So denying is not a convience to the crew, its actually more work.

Myself I prefer to do the more work and educate rather than allow the abuse or even if its the first call ever educate to what is really an emergency. This in the long run benefits the caller and the system.
 
medic417 said:
Myself I prefer to do the more work and educate rather than allow the abuse or even if its the first call ever educate to what is really an emergency. This in the long run benefits the caller and the system.
Click to expand...

You can educate only to a certain extent. You are not Social Services and can not sign them up for the assistance they may need. Some must make it to the ED for a need of these services to be recognized and the patient is then entered into the "system". Unless your agency has a direct link that can summon a home consult or follow up, there may be little you can do and it may actually prevent them from jumping through those initial hurdles of getting into the right care program.
 
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