patient right to demand ambulance transport

[Shishkabob]

Here's one for you:

I have a level 1 trauma center an hour to my east, and a level 3 45 minutes to my south. Both are the same hospital, just separate campuses, meaning insurance works at both, medical records available at both.

I often have patients state they don't want to go to the one to the south because "They treated them wrong", but every single person I've asked to expand upon the "wrong" hasn't come up with a reason.




So... to re-iterate: Same hospital, different campuses. Why would it be wrong to go to the closer one, when insurance and patient info is no longer an issue, and the presenting condition is minor and non-chronic?

 

[the_negro_puppy]

Here's one for you:

I have a level 1 trauma center an hour to my east, and a level 3 45 minutes to my south. Both are the same hospital, just separate campuses, meaning insurance works at both, medical records available at both.

I often have patients state they don't want to go to the one to the south because "They treated them wrong", but every single person I've asked to expand upon the "wrong" hasn't come up with a reason.




So... to re-iterate: Same hospital, different campuses. Why would it be wrong to go to the closer one, when insurance and patient info is no longer an issue, and the presenting condition is minor and non-chronic?

Indeed I get this as well. Also like "My family member died there I want to go somewhere else" or "I heard that its a bad hospital" or "I heard the staff are bad there"

For us insurance is out of the equation as most people choose public hospitals which have no upfront cost. We do have private hospitals where if you have insurance you can be seen. Most people are happy to go to the closest hospital as its easier to get home/closer to home for them.

 

[Medicus]

Per my State's Dept of Health, we must transport the patient anywhere they want to go (and yes, when I mentioned crossing state lines, I was told anywhere they want to go). we get used as a cross town taxi all the time too.

If they call for the ambulance, taken em to the hospital of their choosing, unless you have an administrative support in writing saying you can deny them transport.

Not surprising that this is coming from the state where no one knows how to pump their own gas.

There is no way that is the complete story, and if it is, I would like to see documentation to support that. A patient who can tolerate a (presumably) longer transport across state lines to another hospital doesn't require an ambulance.

 

[usalsfyre]

Why does everyone seem to think "isn't immediately dying" is synonymous with "doesn't require an ambulance"?

What if I have a painful, angulated long bone or hip fracture likely to require surgery (and thus admission) but the facility that is in-network for my insurance provider is 25 minutes further away. I should have to do without pain management and position of comfort transport or be stuck with a higher/multiple bills?

 

[Medicus]

Why does everyone seem to think "isn't immediately dying" is synonymous with "doesn't require an ambulance"?

What if I have a painful, angulated long bone or hip fracture likely to require surgery (and thus admission) but the facility that is in-network for my insurance provider is 25 minutes further away. I should have to do without pain management and position of comfort transport or be stuck with a higher/multiple bills?

Why do you think that a long bone or hip fracture is not a medical emergency?

I just got out of the OR about 3 hours ago, but last time I checked, the femoral artery and vein run right through there (subtrochanteric hip fracture). Avascular necrosis is also a concern, particularly in femoral head ("hip") fractures. PEs are also common with hip fractures.

But hey, good idea!

 

[usalsfyre]

The huge majority of fractures are not time sensitive. Teching in the ED I put most fractures in plaster to be sent home. Further, I can't ever recall seeing a simple femoral head fracture with vascular comprimise.

Yet they are commonly very painful, so explain to me why they must be transported to the closest ED.

 

[Akulahawk]

Why does everyone seem to think "isn't immediately dying" is synonymous with "doesn't require an ambulance"?

What if I have a painful, angulated long bone or hip fracture likely to require surgery (and thus admission) but the facility that is in-network for my insurance provider is 25 minutes further away. I should have to do without pain management and position of comfort transport or be stuck with a higher/multiple bills?

That's where knowing what's "most appropriate" comes into play. We shouldn't ever be locked into one default destination for every patient. The point that I (and probably most here) was trying to make is that we have to consider the totality of the circumstances. For instance, if I can't provide you pain management for that angulated femoral fracture... that plays a part in which facility I take you to. If I can... again, that's another factor... Add-in local protocols that specify destinations for certain kinds of patients, and things can get really futzed up. Confused much? Oh... this subject most definitely can...

 

[usalsfyre]

That's where knowing what's "most appropriate" comes into play. We shouldn't ever be locked into one default destination for every patient. The point that I (and probably most here) was trying to make is that we have to consider the totality of the circumstances. For instance, if I can't provide you pain management for that angulated femoral fracture... that plays a part in which facility I take you to. If I can... again, that's another factor... Add-in local protocols that specify destinations for certain kinds of patients, and things can get really futzed up. Confused much? Oh... this subject most definitely can...

So what your saying is because some EMS systems are subpar, the patient gets to bear additional cost.

I agree there should be some sort of "reasonable limit", that's easily spelled out in policy. Simply saying the "closest facility that can handle your problem" is inappropriate and puts the system before the patient.

 

[Akulahawk]

The huge majority of fractures are not time sensitive. Teching in the ED I put most fractures in plaster to be sent home. Further, I can't ever recall seeing a simple femoral head fracture with vascular comprimise.

Yet they are commonly very painful, so explain to me why they must be transported to the closest ED.

They do happen...

"Femoral neck fractures often disrupt the blood supply to the head of the femur. The medial circumflex artery supplies most of the blood to the head and neck of the femur and is often torn in femoral neck fractures. In some cases, the blood supplied by the foveal artery may be the only blood received by the proximal fragment of the femoral head. If the blood vessels are ruptured, the fragment of bone may receive no blood and undergo avascular necrosis (AVN)." from http://emedicine.medscape.com/article/825363-overview#aw2aab6b2b4

 

[Medicus]

The huge majority of fractures are not time sensitive. Teching in the ED I put most fractures in plaster to be sent home. Further, I can't ever recall seeing a simple femoral head fracture with vascular comprimise.

Yet they are commonly very painful, so explain to me why they must be transported to the closest ED.

That's exactly it though- teching in the ED. You're doing it under an MD's orders who has assessed the patient and given the orders.

Also, it doesn't necessarily mean much that you don't "ever recall seeing a simple femoral head fracture with vascular comprimise"- you specifically would never see a femoral head fracture with vascular compromise because there would be no reason to tell you. Would you know what vascular compromise to the femoral head looked like if you saw it? There is a reason that patients with a hip fracture are supposed to receive AP films for three years after surgery- AVN can be insidious.

 

[Medicus]

Because the huge majority of fractures are not time sensitive? Yet they are commonly very painful...

How do you know? Do you have an MRI in your ambulance? How about a mobile x-ray? Ultrasound?

By the way, there is an entire cemetery at Mons that disagrees with you.

 

[abckidsmom]

That's exactly it though- teching in the ED. You're doing it under an MD's orders who has assessed the patient and given the orders.

Also, it doesn't necessarily mean much that you don't "ever recall seeing a simple femoral head fracture with vascular comprimise"- you specifically would never see a femoral head fracture with vascular compromise because there would be no reason to tell you. Would you know what vascular compromise to the femoral head looked like if you saw it? There is a reason that patients with a hip fracture are supposed to receive AP films for three years after surgery- AVN can be insidious.

I can't think of a single femoral head fracture I've ever seen go to the OR on the same day. 25 minutes wouldn't make a difference in the outcome, and if it got the patient to the facility they preferred, knew them, and was more convenient for their family and their pocketbook, how is that a problem?

 

[Aidey]

In my area we are required to transport if the patient/family requests it. We do have a protocol that allows for the non transport of known system abusers without a legitimate complaint. It is complicated, requires a doctor to agree and to my knowledge it never gets used.

Some info on our system. There are 5 local hospitals with ERs, one of them is a VA hospital. There are two companies that each run 2 of the other ERs. Each company runs one big hospital and one little one. All 4 of them use the same medical records system, which is also used by a couple of the local lab and imaging companies. All 4 ERs are in network for the local insurance companies. 2 of the hospitals are out of network to a certain insurance only if the patient gets admitted.

Our policy is that the patient is transported to the facility of their choice, or the closest appropriate facility if they are unable to choose. We are allowed to over rule patient choice, but only in select circumstances and up to a point.

When people pick a hospital that can't handle their condition we advise them that XYZ hospital is better for whatever reason, and I've yet to have someone refuse to go to the more appropriate hospital. If they do refuse we are supposed to call the more appropriate facility and have the patient speak with a doc. If they still refuse, we transport where they want to go and document the heck out of it.

I think the most common situation where a patient gets overruled is concerning the VA "ED". They can't do cardiac, there is not an RT there 24hrs, all radiology has to be sent out to be read, they don't have psych, etc. We can't even transport there without prior approval by the ER doc. So basically anyone who is actually sick goes to a different ER. The VA does have an arrangement where they will pay the bill if another hospital is more appropriate.

The other situation is when we are picking up at SNFs. The vast majority of the time the patient's hospital choice is preselected which is helpful, unless that hospital isn't the most appropriate. In those cases I tend to go to the other ER run by the same company as the selected ER. This usually only happens when we suspect cardiac or CVA.

 

[DesertMedic66]

If the patient wants to go to the hospital then they get to go. They have 3 hospitals in our response area that they get to choose from. We transport to 2 out of our area hospitals but a patient can not request those 2 hospitals. If they want a VA hospital they just get transported to a normal hospital. From there they can set up a BLS or ALS transfer to the VA hospital.

 

[medic417]

It is idiotic to transport every caller that requests transport. This leads to people learning to abuse the system. All progressive quality systems either have or will soon have a denial of transport guideline.

 

[JPINFV]

Denial of transport options!=rejecting reasonable requests?

 

[usalsfyre]

So I researched who you were and it appears I'm dealing with a med student or baby doc. Meaning you've most likely never actually practiced independently a day in your life. So, perhaps you might want to get that out of the way first, because there's probably clinicians who don't have MD behind their name that can run circles around you right now.

That's exactly it though- teching in the ED. You're doing it under an MD's orders who has assessed the patient and given the orders

It's impossible to take what you learn by working under someone else's direction and apply it to your own practice? Stop the presses, the whole medical education model is flawed! Not all docs require you to have a super secret physician decoder ring to teach you what their looking for.

Also, it doesn't necessarily mean much that you don't "ever recall seeing a simple femoral head fracture with vascular comprimise"- you specifically would never see a femoral head fracture with vascular compromise because there would be no reason to tell you.

Riiiiggghhhttt, I'm just the dumb tech right? There's NO reason I would EVER think to ask why's the patient being transferred in the middle of the night vs waiting till surgery comes in.

Would you know what vascular compromise to the femoral head looked like if you saw it? There is a reason that patients with a hip fracture are supposed to receive AP films for three years after surgery- AVN can be insidious.

You've neatly sidestepped the core question I asked earlier by calling into question my qualifications. Poor form. The question was...is there some reason this can't go the extra 20 minutes to my facility of choice rather than "the closest appropriate facility?

How do you know? Do you have an MRI in your ambulance? How about a mobile x-ray? Ultrasound?

Nope, neither does a good portion of medicine elsewhere in the world. Yet they manage to do just fine. This is a tired argument. You know as well as I do the majority of problems cam be diagnosed via physical exam, diagnostic imaging is usually used to confirm, and considerably overused at that.

By the way, there is an entire cemetery at Mons that disagrees with you.

Really. An entire cemetery that died solely of vascular compromise resulting from orthopedic injuries in say, the last 25 years? Wow...

Someone said on another thread a little humility goes a long way. This is true at all levels. If you approach practice like you've approached a few discussions I've seen on this forum, your staff is going to make you life a living hell.

 

[medic417]

Denial of transport options!=rejecting reasonable requests?

If patient has legitimate need of medical transport then they can be transported to a different facility that they want as long as it does not create a higher risk to the rest of the population because area will be uncovered or under covered for extended time. What is good for one is not always good for the greater number.

 

[Shishkabob]

When people pick a hospital that can't handle their condition we advise them that XYZ hospital is better for whatever reason, and I've yet to have someone refuse to go to the more appropriate hospital.

I've had on insist on an inappropriate facility while having an MI before. I was just happy I was able to convince them to go in the first place as that took 30 minutes to do.

Ended up being flown from the facility of their choice to a proper facility a short time after arrival.



Hopefully after seeing that bill, he'll listen to reason in the future.

If they do refuse we are supposed to call the more appropriate facility and have the patient speak with a doc.

Strangely, the doctors in my current system absolutely refuse to speak with a patient on the phone.

The other situation is when we are picking up at SNFs. The vast majority of the time the patient's hospital choice is preselected which is helpful, unless that hospital isn't the most appropriate. In those cases I tend to go to the other ER run by the same company as the selected ER. This usually only happens when we suspect cardiac or CVA.

Once had a fall patient where all indications pointed towards a head bleed. SNF wanted patient sent to a local hospital, who wouldn't be able to do anything. I instead went to a much more appropriate facility.

SNF complained. I explained reasoning to supervisors. Supervisors backed me up.

 

[DrParasite]

Not surprising that this is coming from the state where no one knows how to pump their own gas.

not doesn't know how to, is forbidden by state law from doing it. many of us do know how to do it, but our fuels costs are still cheaper than other states that pump their own gas.

There is no way that is the complete story, and if it is, I would like to see documentation to support that. A patient who can tolerate a (presumably) longer transport across state lines to another hospital doesn't require an ambulance.

(609) 633-7777 is the number for the DOH, call them and ask for Regulations and Enforcement/Legal division. That's what I did, and when I asked the question, that was what I was told. If you get a different answer, please let me know who you speak to, because I would love to hear the updated answer.