# Distance to Hospital



## Shishkabob (Apr 12, 2011)

I was talking with usalfyre last night about this.  At what point is a patients choice in hospital just unreasonable?   Mileage or driving time?  


Case in point.  In my county, we have a level 3 trauma center about 25-30 minutes to our south, a level 1 and level 2 nearly an hour to our east (one of which is our base hospital), and 2 level 1s an 1-1.5 hours to our west.   The level 1 to our east, and the level 3 to our south are affiliated, same exact hospital.

Now, obviously taking people to OUR hospital is a good thing, but that's not the question at hand, and neither is "being lazy".  And obviously, if a hospital has the ability that another does not, you go there (meaning a major trauma doesnt go to the level 3, a chest pain doesn't go to the level 3, etc etc)  Also, clearly the patient usually has a choice in their care.





But let's say you have a stubbed toe, or a stomach ache who wants to go to the hospital...  and want to go to one of the 50+ mile away ones, even though a closer hospital is just as capable.  At what point can / do you say that's unreasonable to a patient, if at all?


Why is it ok to go a long distance to one hospital, but say, not 2-3 hours to another?  What's the difference between driving 1 hour to our west, and 2 hours to our west?  4 hours away?  8?


Does your agency have a policy on such requests?  Or do you just recommend what you think is best, and go where the patient decides anyhow?


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## CANMAN (Apr 12, 2011)

We can transport to the second due hospital for the most part for a complaint such as you described. For me its a 12 mile trip vs. a 14 mile trip so its not a big deal. Priority 1's go to the closest hospital unless its a trauma, STEMI, etc. 

Once an EMS system starts to just transport patients where they would like to go you have created a huge problem of "where to draw the line." Your nice one day and go to the third due hospital and a week later Mr. Johnson is calling to be taken to his doctor's appointment at said hospital 50 miles away. Bad situation.


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## johnrsemt (Apr 12, 2011)

In Indianapolis where I used to work (911) it was we could take them anywhere in our county, or the next counties (touching our county):  we had 9 hospitals in the county including all 3 Level I's in the state:  and 3 Level II's.  The next counties had 8 hospitals, all Level III's, except one Cardiac Hospital, that had an ED,  but specifically for Cardiac emergencies.

  Here a Level III is 45 miles away and everything else is approx 90 miles; including 2 Level I's and 2 level II's.  

    We will transport to those,  and in certain cases a couple of other hospitals that are about 110-120 miles away.


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## palmer1121 (Apr 12, 2011)

We have a choice of 7 different local hospitals (less than an hour transport time), aeromedical transport, or long distance transport to specialty centers in atlanta.  Normally we transport to the hospital of patient choice if it is one of our 7 local hospitals.  Severe trauma patients either are transported by air or ground to the appropriate trauma center.  

We are pretty fortunate in having 3 hospitals with emergency cath capability within approx 30 min transport RLS, 2 stroke centers within the same, and a level 2 trauma center within the same.  

The only time this gets a little "hairy" is when patients request transport to a facility in atlanta.  Normally with a little explanation we can persuade the patient to go to an appropriate closer facility.  Normally the only time we would transport to atlanta is a pediatric or burn patient that needs a specialty center and we cant fly them.


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## Anjel (Apr 12, 2011)

If a patient is A&O x3 and wants to go to a hospital way out of the way. You can force them to go where you want. You can talk them into a closer but you can't force them.

My case was a 80yr old man. Open tib fib fracture after just causing a car accident. He wanted to go to lapeer where he lived 50miles away. When I could literally see our base hospital.

If we refused to take him there he said he would sit on the side of the rd and wait for someone who would.

I ultimately think its dispatchs call. If they want u to go or send someone else.


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## Medic2409 (Apr 12, 2011)

Our management told us to take them anywhere they want to go. :huh:


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## Aidey (Apr 12, 2011)

I usually just explain that it is very likely their insurance will not cover the mileage for the trip past the closest appropriate hospital, meaning they would be responsible for that cost along with whatever their co-pay is.


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## 46Young (Apr 12, 2011)

My EMS manual says 20 minutes past the closest appropriate if they're stable. that really helps us. It's a municipal 911 service, not a taxi service. If they argue to go further, I inform them that they did call 911, an emergency number, for emergency medical services. If they want to go 30 mins, an hour, two hours past the closest appropriate, then their condition, which they decided isn't time sensitive by way of their txp request, isn't emergent. Our resources are intended to serve the county, and also to remain reasonably close to their first due. I inform them that calling a private ambulance would be more appropriatew if they wish to travel so far.

In NYC, it's ten minutes past the closest appropriate, unless OLMC grants permission to go further.

If you work in a rural area, the service really needs a "closest appropriate" policy if the next hospital is an hour or more away. It's a taxpayer funded emergency service. In a rural area, units are already few and far between. If you're going a couple of hours away, other units may need to relocate towards your first due for coverage, which affects their response into their first due.


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## 46Young (Apr 12, 2011)

Aidey said:


> I usually just explain that it is very likely their insurance will not cover the mileage for the trip past the closest appropriate hospital, meaning they would be responsible for that cost along with whatever their co-pay is.



Is that true, or just a clever tactic?


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## Anjel (Apr 12, 2011)

46Young said:


> Is that true, or just a clever tactic?



Insurance Companies will think of anyway they can not to pay ambulance costs.

Here it's 10 bucks a mile. SOO 5 miles and 50 bucks. or 50 miles and 500 bucks. Which do you think they will have  a problem with.


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## abckidsmom (Apr 12, 2011)

Our rural system has a couple of hospitals that are about 45 minutes away, and a few more hospitals that are in the other direction, and about an hour away.  We have a closest appropriate policy and medics are forever refusing to transport to the farther away hospitals because of that.

I believe this is exceptionally poor customer service, because chosing for the patient which city they will be hospitalized in can be an expensive, devastating choice for them.  If they are in the hospital for an extended period, they will have to take on the risk and expense of an IFT to the "right" hospital, or their families will have to drive forever to see them, or not.

People who do not have support of their families in the hospital do not have as positive of outcomes as people whose families visit often.  

All for 15 minutes?  Half a unit hour?  It's worth it to provide good service to the patient, as long as that 15 minutes isn't detrimental, which I have not seen in many years.  

Either way we go, the trauma center is the furthest choice, and the further away trauma center is better, anyway, so I go with what the patient wants, or the closest facility.  The patient's request has a big chunk of the "appropriate" decision-making for me.


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## Anjel (Apr 12, 2011)

abckidsmom said:


> I believe this is exceptionally poor customer service, because chosing for the patient which city they will be hospitalized in can be an expensive, devastating choice for them.  If they are in the hospital for an extended period, they will have to take on the risk and expense of an IFT to the "right" hospital, or their families will have to drive forever to see them, or not.



I agree.

The old man with the open tib fib wanted to go the furthest away because his wife had just broken her hip and he had be taking care of her. And there is no way she could make the trip to where we are. Same with his kids. They had been married for 60 something years and he kept telling us that he loved her more now than before and he didn't know how he was gonna take care of her now. 

So you try telling an 80 something year old man crying that he cant take care of his wife that you refuse to take him closer to her. Really? Is that good patient care?


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## Veneficus (Apr 12, 2011)

*Sound clinical judgement*

Why would that not apply to the transport decision as well?

Just as much as the technical medical care given to a patient, social and economic factors are part of clinical decision making.


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## Chimpie (Apr 12, 2011)

Anjel1030 said:


> So you try telling an 80 something year old man crying that he cant take care of his wife that you refuse to take him closer to her. Really? Is that good patient care?



IMO... That's not patient care.  That's being sympathetic.  Okay..... _maybe_ you can look at it as causing mental anxiety having him far away from his wife.  But that's what IFTs are for.

An 80 y/o with an open tib fib needs to be taken to the closest appropriate facility.


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## Veneficus (Apr 12, 2011)

Chimpie said:


> An 80 y/o with an open tib fib needs to be taken to the closest appropriate facility.



Why?


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## Smash (Apr 12, 2011)

Linuss said:


> I was talking with usalfyre last night about this.  At what point is a patients choice in hospital just unreasonable?   Mileage or driving time?
> 
> 
> Case in point.  In my county, we have a level 3 trauma center about 25-30 minutes to our south, a level 1 and level 2 nearly an hour to our east (one of which is our base hospital), and 2 level 1s an 1-1.5 hours to our west.   The level 1 to our east, and the level 3 to our south are affiliated, same exact hospital.
> ...



The overriding factor in any of these decisions is how close it is to knock-off.


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## abckidsmom (Apr 12, 2011)

Chimpie said:


> IMO... That's not patient care.  That's being sympathetic.  Okay..... _maybe_ you can look at it as causing mental anxiety having him far away from his wife.  But that's what IFTs are for.
> 
> An 80 y/o with an open tib fib needs to be taken to the closest appropriate facility.



But how much difference is it really going to make if you add even 30 minutes to his transport time?  I get that there is increased risk, but he will also have a potential increase in complications of his hospital course if you add stress to the ordeal.


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## abckidsmom (Apr 12, 2011)

Smash said:


> The overriding factor in any of these decisions is how close it is to knock-off.




  That's been the deciding factor on whether the patient needs HEMS in so many calls I've listened to, also.


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## Anjel (Apr 12, 2011)

Chimpie said:


> IMO... That's not patient care.  That's being sympathetic.  Okay..... _maybe_ you can look at it as causing mental anxiety having him far away from his wife.  But that's what IFTs are for.
> 
> An 80 y/o with an open tib fib needs to be taken to the closest appropriate facility.



So do you force him to go to the closer? Against his will? Or call someone else to come get him? That sure would look good for your company.


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## HotelCo (Apr 12, 2011)

Anjel1030 said:


> So do you force him to go to the closer? Against his will? Or call someone else to come get him? That sure would look good for your company.



Or offer to call another service. FDs/3rd services around our area do that.


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## WolfmanHarris (Apr 12, 2011)

Our policy is set by the service in conjunction with the Ministry of Health (which handles dispatch) and is dictated by the Pt.'s triage level as per the Canadian Triage Acuity Scale (CTAS) as assigned by the attending Paramedic. 

Pt.'s designated a CTAS 1 (resus) go to the closest facility no matter what. 

CTAS 2 Pt.'s go to the closest facility in most cases; though they can be bypassed to PCI for STEMI, CVA bypass, dialysis bypass, Field Trauma Triage or in exceptional circumstances with a patch to a Base Hospital Physician. 

CTAS 3(urgent), 4(less urgent) and 5(non urgent) Pt.'s can go to hospitals within a 20 min difference in transport time, provided the hospital is not on time consideration.

I don't have a great link to a CTAS reference since mine is hard copy. Some information can be found here:
http://www.caep.ca/template.asp?id=b795164082374289bbd9c1c2bf4b8d32#support

There is talk that a new Prehospital Triage system will be coming down the pipe in the future as the CTAS system is an ED system that's been transplanted to the preshospital setting. This new system is coming down from the Canadian Association of Emergency Physicians in conjunction with the EMS Community.


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## wyoskibum (Apr 12, 2011)

*It's okay to say no.... Just be nice about it.*

If they are sick enough to call 911 and request ambulance transport, then they should go to the closest appropriate hospital.  In addition to the insurance question that has been raised, what about resource management.  Is okay to take an ambulance out of service an additional amount of time because the patient wants to go to another hospital?  I could possibly see it with a private company, but 911?

Let's not even bring up the frequent flyers/drug seekers who want to choose which hospital because hospital B will give them the sandwich and ativan and/or diluadid that they seek.


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## Chimpie (Apr 12, 2011)

Veneficus said:


> Why?





abckidsmom said:


> But how much difference is it really going to make if you add even 30 minutes to his transport time?  I get that there is increased risk, but he will also have a potential increase in complications of his hospital course if you add stress to the ordeal.





Anjel1030 said:


> So do you force him to go to the closer? Against his will? Or call someone else to come get him? That sure would look good for your company.



Yes.  wyoskibum nailed it.



wyoskibum said:


> If they are sick enough to call 911 and request ambulance transport, then they should go to the closest appropriate hospital.  In addition to the insurance question that has been raised, what about resource management.  Is okay to take an ambulance out of service an additional amount of time because the patient wants to go to another hospital?  I could possibly see it with a private company, but 911? ...



You're calling 911 because of an emergency.  You felt it was bad enough to tie up a 911 operator, ambulance and whoever else is responding.  Fine.  You get transported to the closest appropriate facility and handed over so the unit can be placed back in service as soon as possible.


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## the_negro_puppy (Apr 12, 2011)

It's a bit of a grey area. In my city we have 

4 large adult public hospitals,2 children's hospitals, and 4 large private hospitals all within about 30 mins or so (more in traffic).

Trauma patients, active chest pain etc obviously go to the closest appropriate facility, but other than that we try to take people where they want to go within reason.

But what is 'reasonable'

Driving past 4 different hospitals with a very low acuity patient when its 'knock off' time?

Taking low acuity patients past several hospitals to another because "They dont like the closer hospitals, or had a love one die (claimed killed by) in one of the closer hospitals?

Often to complicate matters we get regular updates on our pagers regarding hospital status: i.e diverting ambulances or hospitals reaching capacity. Then we have to explain to the patient why we have to go to a different hospital (diverting) when they have a medical file 3 feet thick at their 'usual' hospital.


I have found most people who are sick enough to require an ambulance are happy to go the the closest appropriate hospital.


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## abckidsmom (Apr 12, 2011)

Chimpie said:


> Yes.  wyoskibum nailed it.
> 
> 
> 
> You're calling 911 because of an emergency.  You felt it was bad enough to tie up a 911 operator, ambulance and whoever else is responding.  Fine.  You get transported to the closest appropriate facility and handed over so the unit can be placed back in service as soon as possible.



I am only going to "yeah, but" your posts one more time, there's no changing my mind or yours on the topic, but I will say this:  non-EMS people have a much much lower threshold for what constitutes an emergency.  I will put a qualifier on those people:  average, reasonably intelligent people are the ones I'm talking about.

Their threshold is lower, but they still needed help.  They really couldn't have handled their whatever without a sound mind helping them out.  If the different is under 30-45 minutes on the total turnaround, it's worth it to treat their preference with respect, IMO.

I understand the need to get the truck back in service, back serving the rest of the community, but when you are on a call, your patient is the one with the priority.  Not the better call down the street that you're "missing,"  not the potential call that you might miss later, etc.  If you can't make reasonable decisions in the patient's best interest because the system can't handle being down another unit hour, it's the system that needs help.


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## Anjel (Apr 12, 2011)

Ok so maybe it's different. 

But I work for a private company. That does 911. We have 6 cities we are contracted with. 

But we do a ton of IFT too. Sooooo why can't you call one of the transfer units and get them to take them.

I know you can't do it for every single patient. But there has to be exceptions.


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## usalsfyre (Apr 12, 2011)

I see Linuss and I are the only ones who work for a hospital-based service with out-lying 911 contracts. The situation here is considerably more complicated than it may seem from the outside. 

I'll take them wherever, within reason. I've found it's generally easier on everyone. If they cam be taken care of at a closer facility I might mention that (there's a couple of huge variables that are location specific, not worth explaining) but I generally don't argue or tell them I'm not taking them somewhere.


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## wyoskibum (Apr 12, 2011)

abckidsmom said:


> I understand the need to get the truck back in service, back serving the rest of the community, but when you are on a call, your patient is the one with the priority.  Not the better call down the street that you're "missing,"  not the potential call that you might miss later, etc.  If you can't make reasonable decisions in the patient's best interest because the system can't handle being down another unit hour, it's the system that needs help.



It's not about what calls you are missing.  It's not about the system.  It's about your duty to act.  EMS can be feast or famine.  You can be idle for hours on end or the :censored: can hit the fan.  While I have compassion for my patients and I have nothing but their best interest in mind.  My priority is to be efficient and be available to everyone that needs help.   So unless there is a valid reason not to, the patients go the closest appropriate facility.  

That also means getting your BUS back in service ASAP and becoming available quickly.


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## Aidey (Apr 12, 2011)

46Young said:


> Is that true, or just a clever tactic?



It does depend on the insurance company. For Medicare and Medicaid (at least my state's Medicaid) it is absolutely 100% true. There is some sort of exception if the hospital is less than 1 mile* further away from the closest appropriate facility. But they do specify they will not pay to take you to a hospital 10 miles further away just because. 

We usually don't have too much of a problem with people picking the furthest away hospital, but it does happen on occasion. 

The only 2 times I will really balk at it is when the closer hospital is more appropriate and when we are bypassing a not-busy hospital for one that is slammed purely based on patient choice**. You will never be able to convince me that taking the patient several miles further away to go to a hospital where they will be waiting for 2 hours just to see the doc is being an advocate for the patient. 



* I think it is one mile. 

** This excludes cases like "I'm having chest pain and I just had 5 stents placed at Hospital A." Even if Hospital A is further away and busier it is most appropriate. I'm more talking about "I tripped and my ankle hurts" and what not.


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## MrBrown (Apr 12, 2011)

You go where where take you, if you go to the hospital at all.


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## JPINFV (Apr 12, 2011)

Chimpie said:


> You're calling 911 because of an emergency.  You felt it was bad enough to tie up a 911 operator, ambulance and whoever else is responding.  Fine.  You get transported to the closest appropriate facility and handed over so the unit can be placed back in service as soon as possible.



How many people call 911 because 911 means ambulance? Shouldn't systems have a way to hand off calls to a third agency? How long should it take?

Using this logic, shouldn't anyone who presents to an emergency department be forced into any diagnostic and treatment decisions? After all, if they are taking up emergency department resources, why should they get a choice in their care?

What about the decrease in resources at the receiving hospital as they try to transfer the patient that you just took there to the correct (home) hospital? It is poetic justice, however, for an EMS crew to hold the wall a long time to wait for their previous patient to get transferred after refusing a reasonable bypass request. It's just unfortunate that 2 patients now have to suffer. 

If EMS is fighting for every piece of the health care dollar they can, does it make sense to waste health care dollars by transporting patients to hospitals outside of their home hospital? 

Shouldn't the call that's actually present take priority over the fabled bus of college cheerleaders crashing into the bus of hemophiliac nuns?


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## Shishkabob (Apr 12, 2011)

abckidsmom said:


> I am only going to "yeah, but" your posts one more time, there's no changing my mind or yours on the topic, but I will say this:  non-EMS people have a much much lower threshold for what constitutes an emergency.
> 
> Their threshold is lower, but they still needed help.  They really couldn't have handled their whatever without a sound mind helping them out.  If the different is under 30-45 minutes on the total turnaround, it's worth it to treat their preference with respect, IMO.



Ah, but if they want our help, is not going to where we recommend part of our help?  The vast majority of our patients don't know the difference between one hospital or the next.  Heck, one time I had a possible brain bleed coming out of a nursing home and the nurses wanted me to go to a certain hospital.  I instead went to another, since the first could not handle the patient.  They were mad, they threw a fit, they called my supervisor, and I won.  


I hate when they say "My doctor is at so-and-so".  Cool, good for you.  It's 4am, and your doctor is a GP, not an ER doc, therefore they wont see you when you get there, if at all.


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## JPINFV (Apr 12, 2011)

Linuss said:


> I hate when they say "My doctor is at so-and-so".  Cool, good for you.  It's 4am, and your doctor is a GP, not an ER doc, therefore they wont see you when you get there, if at all.



True, but if the patient has been hospitalized there in the past, then that hospital already has the patient's medical record. 

Also, if the patient does need to be hospitalized, then provided available space, it avoids a second transport, which facilitates emptying the ED. Emptying the ED means your patients gets transferred sooner. 

If the patient has private insurance, then it can make a world of difference in determining how much it costs the patient.


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## BandageBrigade (Apr 12, 2011)

The insurance is true for many insurance companys in most states. Including medicare/medicad. We do notify all those with no life threats of this. If they wish to continue to the further facility we have a form they sign which states that while we will still bill insurance they may be responsible for a portion of the bill. The key here is closest appropriate facility. Appropriate being the key word. bypassing a closer facility can be justified in most cases however. Such as specialty resource center, the patient has a specialist or established history at that center. Ive found that in most cases a good patient history, or even just asking the patient why he our she would like to go to the further facility will provide you with a justifiable reason to go there.


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## Shishkabob (Apr 12, 2011)

JPINFV said:


> True, but if the patient has been hospitalized there in the past, then that hospital already has the patient's medical record.



True, to an extent.  However as I said in the first post, the level 3 trauma to my south is of the same hospital system as the level 1 to my east.  Their info can be accessed at either hospital.  


I tell patients that fairly often when they bring up the "My info is at ____", and when I tell them it's also at the other hospital, they tend to be more willing to go to the closer one.


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## JPINFV (Apr 12, 2011)

BandageBrigade said:


> The insurance is true for many insurance companys in most states. Including medicare/medicad. We do notify all those with no life threats of this. If they wish to continue to the further facility we have a form they sign which states that while we will still bill insurance they may be responsible for a portion of the bill.


I was under the impression that you can't balance bill Medicare patients. 




> The key here is closest appropriate facility. Appropriate being the key word. bypassing a closer facility can be justified in most cases however. Such as specialty resource center, the patient has a specialist or established history at that center. Ive found that in most cases a good patient history, or even just asking the patient why he our she would like to go to the further facility will provide you with a justifiable reason to go there.


Strong work. 

Something I just thought of. Refusing a reasonable home hospital request is like sending a BLS ambulance on a CCT just because the BLS ambulance was closest and you always send the closest unit.


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## JPINFV (Apr 12, 2011)

Linuss said:


> True, to an extent.  However as I said in the first post, the level 3 trauma to my south is of the same hospital system as the level 1 to my east.  Their info can be accessed at either hospital.
> 
> 
> I tell patients that fairly often when they bring up the "My info is at ____", and when I tell them it's also at the other hospital, they tend to be more willing to go to the closer one.



Does the medical staff at one hospital have reciprocal privileges at the other hospital?


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## Shishkabob (Apr 12, 2011)

I would assume so seeing as it's the same hospital.



Even if not, the vast majority of the time in my experience, the patients doctor is for a specific problem unrelated to the 'emergency' that they called 911 for, and therefore not likely that the doctor would even know the patient went.


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## Aidey (Apr 12, 2011)

JPINFV said:


> True, but if the patient has been hospitalized there in the past, then that hospital already has the patient's medical record.
> 
> Also, if the patient does need to be hospitalized, then provided available space, it avoids a second transport, which facilitates emptying the ED. Emptying the ED means your patients gets transferred sooner.
> 
> If the patient has private insurance, then it can make a world of difference in determining how much it costs the patient.




The records justification only works in areas without computerized records. It doesn't matter what hospital I take you to here, they all use a universal system and can cross access any records. 

We are also very specifically not allowed to bypass an appropriate hospital with an open ER just because other parts of that hospital are closed (unless it is an L&D case that is going to bypass the ER and go straight to the floor). We have been expressly forbidden from doing that by both our MD and our management.


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## BandageBrigade (Apr 12, 2011)

JPINFV said:


> I was under the impression that you can't balance bill Medicare patient.



I guess I am unfamiliar with the term 'balance bill' 


I feel that refusing any reasonable request for taking a patient to a facility of their choosing is a disservice to the patient, that facility, as well as your service and yourself as a provider.


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## Aidey (Apr 12, 2011)

JPINFV said:


> I was under the impression that you can't balance bill Medicare patients.



I think it is allowed because the patient is deliberately doing something outside of their coverage. Like requesting a medication that isn't on the formulary, or demanding a more expensive test than the one the doctor says is indicated. 

Say you are 5 miles from the closest appropriate hospital, and 13 miles from the one the patient wants to go to. They get billed for the distance past the appropriate facility, so in this example 8 miles.


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## JPINFV (Apr 12, 2011)

Linuss said:


> Even if not, the vast majority of the time in my experience, the patients doctor is for a specific problem unrelated to the 'emergency' that they called 911 for, and therefore not likely that the doctor would even know the patient went.



Who's going to take care of the patient once the patient is admitted to the hospital? It surely isn't going to be the emergency physician.


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## usalsfyre (Apr 12, 2011)

JPINFV said:


> Does the medical staff at one hospital have reciprocal privileges at the other hospital?



Not to speak for Linuss, but I may be a little more familiar than he is. 

Yes and no, depending on if they want privileges at both places. There's also a fair number of independent (as in not tied to this particular system) and FM (apparently not allowed admitting privileges in that system) docs that don't have privileges anyway, so you get a hospitialist no matter what.


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## JPINFV (Apr 12, 2011)

BandageBrigade said:


> I guess I am unfamiliar with the term 'balance bill'


"Balance billing" is when a provider bills the patient for anything not covered by the insurance company. So if the bill is $500 and the insurance company only pays $300, then the provider can bill the patient for the remaining $200. This is different than deductibles and copays.


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## Shishkabob (Apr 12, 2011)

And it's not going to be their oncologist when they were involved in an MVC.


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## usalsfyre (Apr 12, 2011)

JPINFV said:


> Who's going to take care of the patient once the patient is admitted to the hospital? It surely isn't going to be the emergency physician.



All of that system's facilities have at least one staff internest.


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## BandageBrigade (Apr 12, 2011)

Ah. From aideys post i understand and that is my understanding as well, but I also know we cannot do it unless we explain it to the patient and they sign the form. I  do not know if that part is our company policy or statewide however.


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## BandageBrigade (Apr 12, 2011)

And we cannot balance bill for everything, just the amount of milage past the original facility


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## JPINFV (Apr 12, 2011)

Aidey said:


> We are also very specifically not allowed to bypass an appropriate hospital with an open ER just because other parts of that hospital are closed (unless it is an L&D case that is going to bypass the ER and go straight to the floor). We have been expressly forbidden from doing that by both our MD and our management.



This isn't about the hospital past the ED being full or not. This is about ED congestion. If the patient is going to be transferred out due to insurance or home hospital, the patient is going to be waiting in the ED until the transfer can be arraigned and the IFT ambulance accepts the patient. That's one less available bed in the ED for your future patients.


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## Aidey (Apr 13, 2011)

I guess this is where differences between specific areas comes into play. Due to the locations of our hospitals and ownership and capability levels we rarely ever do insurance based transfers. In fact I can not remember ever doing a single one, and I'm a hawk when it comes to PCS forms being filled out properly. Rarely we transfer patients due to MD request, which always seem to be surgery patients or our non open-heart surgery center sending out high risk MI patients. The vast majority of our transfers are because of lack of beds at the hospital the patient is already at.


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## 46Young (Apr 13, 2011)

Anjel1030 said:


> Insurance Companies will think of anyway they can not to pay ambulance costs.
> 
> Here it's 10 bucks a mile. SOO 5 miles and 50 bucks. or 50 miles and 500 bucks. Which do you think they will have  a problem with.



True, but I was really wondering if it was true so that I can inform a pt that they're on the hook for travelling farther, to use as a deterrent to being used as a taxi. It would be a tool to discourage lengthy transports.


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## MrBrown (Apr 13, 2011)

Outside Metropolitan Auckland there is often not a choice of transport destination as there is only one hospital.

Here in Metro we have a choice of five - ACH (Auckland City), North Shore, Starship (Paediatric), Middlemore (south) and West/Waitakere depending upon where you are.

Major trauma goes to Auckland or Middlemore if Middlemore is 10 minutes or more closer than Auckland (except paeds who go to Starship) and sometimes North Shore is bypassed for Auckland direct.

Patients do not have a choice of hospital i.e. they cannot say "I want to go here" because realistically there is generally only one facility and there would have to be extenuating circumstance to go somewhere specific if there was more than one choice of destination.

Billing here is through patient part charges, which is a flat rate for callout, with the remainder covered by bulk funding from the Ministry of Health and ACC.


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## 46Young (Apr 13, 2011)

abckidsmom said:


> Our rural system has a couple of hospitals that are about 45 minutes away, and a few more hospitals that are in the other direction, and about an hour away.  We have a closest appropriate policy and medics are forever refusing to transport to the farther away hospitals because of that.
> 
> I believe this is exceptionally poor customer service, because chosing for the patient which city they will be hospitalized in can be an expensive, devastating choice for them.  If they are in the hospital for an extended period, they will have to take on the risk and expense of an IFT to the "right" hospital, or their families will have to drive forever to see them, or not.
> 
> ...



I understand that bringing a pt to the hospital they want is good customer service. I'll generally take the pt where they want to go, as long as it is within reason. If their OB hospital is in DC or MD, I may take them there if I don't feel that delivery is imminent (I work in Northern VA for those that don't know). If their child is special needs, or had had a surgery further away, I'll always transport. We've transported to G'town from Annandale before during rush hour, because the pt was pleasant. Again, we have the twenty minute rule. From what you described, the next closest is only fifteen minutes. When they're asking to go an additional 30 minutes, an hour, or whatever, that's where I draw the line, unless they have a very good reason. I could care less about getting off on time. I do a lot of OT, so I'd welcome the extra time. It pays for a few days gas and dinner at the station.

I feel that if 911 is called, the situation is somewhat emergent, at least from the patient's point of view. If they want to go many miles past the closest appropriate, they must know at least subconsciously that their condition isn't that time sensitive, and that it isn't an emergency. Granted, they may not know that IFT services exist, but 911 emergency services aren't intended to taxi everyone wherever they want to go, which is oftentimes uncompensated or undercompensated. It's for emergent situations. 

For example, I used to routinely transport a pt that would call for an asthma attack. He would c/o dyspnea, get a free albuterol tx, txp past several hospitals to the one (literally) across the street from his job as a security guard, give a false name and demographics, and walk out of the ED as as soon as we transferred him to the hospital bed. Every day. Drove me nuts, but there was nothing we could do about it. There are the patients that make the rounds between all the hospitals after each gets tired of them. There were more than several occasions where the pt signs out AMA, calls 911 from outside the ED, and wants us to take them to another one.

Where do we draw the line on how far we transport? If I was driving near Philly, and got into an accident and broke my leg or something, I wouldn't expect the crew to take me to Virginia, even though they could make it in under three hours. What if it was my father-in-law? He's in his 80's. A broken hip or femur would have him laid up. He'd need rehab there, or an expensive IFT to get him near family. It would still be unreasonable to have 911 transport him close to family, either in Brooklyn, or VA, both several miles away. What's the cutoff, in your opinion (and others)?


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## MrBrown (Apr 13, 2011)

46Young said:


> Where do we draw the line on how far we transport? If I was driving near Philly, and got into an accident and broke my leg or something, I wouldn't expect the crew to take me to Virginia, even though they could make it in under three hours. What if it was my father-in-law? He's in his 80's. A broken hip or femur would have him laid up. He'd need rehab there, or an expensive IFT to get him near family. It would still be unreasonable to have 911 transport him close to family, either in Brooklyn, or VA, both several miles away. What's the cutoff, in your opinion (and others)?



Patients should go to the facility for the catchment area they are picked up in.  

If you have a choice of destination, patients should go to the facility appropriate for the problem they present with.  For example paediatric, cardiac or major trauma should go the facility best designated to treat that problem.

If somebody says "I want to go here" Brown would reply "OK, call this number for Ambulance Communications and arrange a private hire, you pay for it, bye!".

Should there be some extenuating circumstance then perhaps destination might be changed; for example patients with a long history at a particular facility should go there.  The only time Brown can think of destination was changed was an elderly man who did not like one particular hospital for cultural reasons so was probably just going to discharge himself if he was taken there.


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## JPINFV (Apr 13, 2011)

46Young said:


> What's the cutoff, in your opinion (and others)?



15 to 20 minutes outside your immediate service area. For example, the county I live in is basically divided between one service providing 911 transport service for the top half of the county and a separate service for the bottom half (paramedics are provided by the fire department and a handful of fire departments do their own transport). As such, any hospital inside that service area should be appropriate with an additional buffer zone around it. If you work in a very large regional system, then I can see limiting service area hospitals to, say, 30-40 minutes. However if you aren't being pulled out of the service area the limit should definitely be expanded. 

Any request outside of that is a "it depends." For example, LVAD patients go to their home hospital. Other exceptions along that line apply. System abusers should have their chart tagged and advised that they will go to the closest hospital 100% of the time unless a specialty hospital is needed. To me, this is no different than the emergency departments giving suspected seekers 1 dose of pain medication, advising them to seek care from a primary care physician, and then tagging the chart so that they can refuse future prescription.


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## 46Young (Apr 13, 2011)

JPINFV said:


> 15 to 20 minutes outside your immediate service area. For example, the county I live in is basically divided between one service providing 911 transport service for the top half of the county and a separate service for the bottom half (paramedics are provided by the fire department and a handful of fire departments do their own transport). As such, any hospital inside that service area should be appropriate with an additional buffer zone around it. If you work in a very large regional system, then I can see limiting service area hospitals to, say, 30-40 minutes. However if you aren't being pulled out of the service area the limit should definitely be expanded.
> 
> Any request outside of that is a "it depends." For example, LVAD patients go to their home hospital. Other exceptions along that line apply. System abusers should have their chart tagged and advised that they will go to the closest hospital 100% of the time unless a specialty hospital is needed. To me, this is no different than the emergency departments giving suspected seekers 1 dose of pain medication, advising them to seek care from a primary care physician, and then tagging the chart so that they can refuse future prescription.



I feel the same. Our LVAD's are placed at a hospital that's central to the county.

Back in the day, in NYC, I had a different outlook. We were only allowed to txp ten minutes past the closest appropriate. If it was longer, we needed OLMC permission. They would go through their thing with the pt, but the bottom line was, if the pt adamantly refused to go anywhere other than their destination choice, the OLMC would grant their request, since the pt would threaten to refuse tx/txp otherwise. We were instructed to have the pt sign the PCR saying that if their condition changed, that we were required to divert to the closest facility. We would let the pt know how to play OLMC by threatening  a refusal if we liked them, or if we wanted to go where they wanted. We liked going to other areas. Interestingly, the only pts who wanted to go clear across the city were pts who requested a hospital in the ghetto, such as Brookdale or Woodhull, for example. We had AVL, so we would drop them off, then have a blast running in the ghetto, and we wouldn't be able to make it out of there, unless we ran out of O2 or faked a mechanical issue or something. We liked seeing different neighborhoods from time to time.


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## 46Young (Apr 13, 2011)

MrBrown said:


> Patients should go to the facility for the catchment area they are picked up in.
> 
> If you have a choice of destination, patients should go to the facility appropriate for the problem they present with.  For example paediatric, cardiac or major trauma should go the facility best designated to treat that problem.
> 
> ...



Every place I've worked for has had the "transport everyone possible for billing purposes" policy, so turfing the pt to the privates, or suggesting alternatives to the ED via an ambulance was never an option. Never mind that many of these cases were uncompensated or undercompensated. There's also the threat of a lawsuit if we take them somewhere other than what they agree to. There's some protection if their condition is serious, and we txp to the closest appropriate, but still.....


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## MrBrown (Apr 13, 2011)

Ah America, the home of frivolous lawsuits! 

Lawyer:  You did not take my client to the hospital he asked to go to!
Brown:  In my professional clinical opinion as an Ambulance Officer it would be inappropriate to bypass the closest medical facility
Lawyer:  (to client) Why didn't you tell me he told you that? 

Is it common for the Ambulance Service over your way to be bulk funded for core capability or revenue dependant upon billing only?


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## 46Young (Apr 13, 2011)

MrBrown said:


> Ah America, the home of frivolous lawsuits!
> 
> Lawyer:  You did not take my client to the hospital he asked to go to!
> Brown:  In my professional clinical opinion as an Ambulance Officer it would be inappropriate to bypass the closest medical facility
> ...



There's too much money in TORT law. To expect any meaningful reform to take place is unrealistic.

Municipal systems are typically funded for core capability. To not bill at least the pt's insurance would be leaving money on the table so to speak. Hospitals and privates may have contracts with the local municipality, which covers their overhead. Some jurisdictions may keep any surplus, and others may let the EMS agency have it. 

In NYC, the hospitals are on their own financially, as far as I know. They use 911, which more often than not runs in the red, as advertisement for their hospital, for pt steering (a no-no, but it does happen), as training for the ones that also have an IFT division, and also as a means to attract employees. Pt steering, being a rolling billboard, and being in an affluent area or at least one where enough pts have commercial insurance, so that they realize that revenue instead of the city, is how they make out.


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## JPINFV (Apr 13, 2011)

MrBrown said:


> Ah America, the home of frivolous lawsuits!
> 
> Lawyer:  You did not take my client to the hospital he asked to go to!
> Brown:  In my professional clinical opinion as an Ambulance Officer it would be inappropriate to bypass the closest medical facility
> ...



Who's making arguments about lawsuits? In fact all I've been arguing is that the home hospital is best for the patient and best for the system as a whole in patients who actually have a home hospital.


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## Veneficus (Apr 13, 2011)

46Young said:


> What's the cutoff, in your opinion (and others)?



I think there needs to be some reasonable judgement involved. I wouldn't put a time or distance rule into effect because so many variables have to be taken into account.

If the patient is having a complication of surgery, I think the best thing to do is take that pt. to the hospital the surgery was at. It is best for the patient.

If the patient is unstable, probably best to go to the closest facility that can help with the specific pathology.

If it will benefit the patient to go closer to family then they should go there.

If your system is extraordinarily busy, it may be best on a given day to take them to the closest and let the hospital sort the rest out. 

I think the biggest issue in the case is recognizing what is best for the patient and doing it. 

If they need/want to go somewhere outrageously far to your district, call them a private. Wait on scene till the private shows and then be on your merry way.

Unless the patient is truly about to die any minute according to reasonable and rational clinical judgement, not "what if..." Why does the 911 service have to transport? (aside from the billing, but that is the depatment's interest not the patient)

It is probably not a good idea to take the indigent people to the most expensive private facility because it is close. It just creates problems down the pipe, and while it is easy for EMS providers to claim that isn't thier problem, they probably wouldn't like it done to them. The same with people who have specific hospitals for their insurance.

It is foolish to think that system intergrity plays no role at all, but it doesn't always cause a complete breakdown to go out of your way in the interest of the patient to some degree.

Basically do all that is reasonably possible to help the patient. Don't just always do what is best for the providers.


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## CAOX3 (Apr 13, 2011)

I take them where they want to go," my doctors at this hospital", "my cousins sisters brothers nieces's mother died at that hospital so I can't go there". If their not critical I'll take them where they want to go, where not going ob a road trip, within reason.


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## JPINFV (Apr 13, 2011)

Something else to think about. There's always that one hospital in your area that you wouldn't be caught dead in if you had the choice (anyone remember King Drew Medical Center?). Would you want to be on a gurney being told that you had to go to that medical center for no reason other than distance?


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## ZombieEMT (Apr 13, 2011)

In our department, we transport to the closest facility when the patient is not stable enough to make it to the hospital of their choice. When we have a stable patient, they make the choice. Other considerations are hospital specialties. Unless the patient is coding we take a trauma twenty minutes to the trauma center. However, our department is lucky. We have three hospitals which about the same distance to our department and the patient almost always chooses one of the three.


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## johnrsemt (Apr 14, 2011)

Sometimes it is due to what the patients insurance will pay:  if they are not critical; Insurance A will pay 90% of in network hospitals, and only 50% of out of network hospitals.    Even for the ED that can be $5,000 difference in out of pocket expense.


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## Bullets (Apr 15, 2011)

This is easy, pt says i want to go to some other place, my reply is "No, we have a level II trauma center, stroke center and cardiac center in town" Max transport form anywhere in my town is 5-7 minutes, and its the best hospital in the county. next closest is 15 which has a great L&D, then 2 20 minutes, one is scary, the other has a good L&D, and then one 30, which i would rather die then go to.

Is there anything they will do at other hospital that they cant do just as well at Generic University Medical Center?


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## usalsfyre (Apr 15, 2011)

Bullets said:


> Is there anything they will do at other hospital that they cant do just as well at Generic University Medical Center?



Be covered by a patient's insurance.

Be seen by a physician (after admission) with whom the patient has a prior relationship.

Not be seen by residents (not saying it's right, just saying it plays into people's decisions).


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## abckidsmom (Apr 15, 2011)

Bullets said:


> This is easy, pt says i want to go to some other place, my reply is "No, we have a level II trauma center, stroke center and cardiac center in town" Max transport form anywhere in my town is 5-7 minutes, and its the best hospital in the county. next closest is 15 which has a great L&D, then 2 20 minutes, one is scary, the other has a good L&D, and then one 30, which i would rather die then go to.
> 
> Is there anything they will do at other hospital that they cant do just as well at Generic University Medical Center?



And our crappiest hospital has the best urologist ever.  I am even willing to deal with riding herd on the nursing staff in order for my dad to see his urologist.

The patient's preference definitely comes into play when you are considering which facility is appropriate.


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## Bullets (Apr 15, 2011)

usalsfyre said:


> Be covered by a patient's insurance.
> 
> Be seen by a physician (after admission) with whom the patient has a prior relationship.
> 
> Not be seen by residents (not saying it's right, just saying it plays into people's decisions).



as a non billing agency, insurance rarely is mentioned on our calls for service

how often do you have to go to the hospital to be familiar with the various doctors there? if its an emergency, your GP wont be there for a while


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## JPINFV (Apr 15, 2011)

Bullets said:


> as a non billing agency, insurance rarely is mentioned on our calls for service


Just because you don't know what hospitals the patient's insurance covers doesn't mean that the patient doesn't know what hospitals his insurance covers.



> how often do you have to go to the hospital to be familiar with the various doctors there? if its an emergency, your GP wont be there for a while


You should go to a hospital with doctors that you are familiar with anytime you need intensive specialty care (e.g. LVADs), had recent major procedures or hospitalization, or when ever you expect you will need to be admitted. Sure, the PMD isn't going to be there when you arrive, but that doesn't mean that the PMD won't be the admitting physician for your patient. Most emergency medicine physicians do not have admission privileges.


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## Veneficus (Apr 15, 2011)

Bullets said:


> This is easy, pt says i want to go to some other place, my reply is "No, we have a level II trauma center, stroke center and cardiac center in town" Max transport form anywhere in my town is 5-7 minutes, and its the best hospital in the county. next closest is 15 which has a great L&D, then 2 20 minutes, one is scary, the other has a good L&D, and then one 30, which i would rather die then go to.
> 
> Is there anything they will do at other hospital that they cant do just as well at Generic University Medical Center?



Re operate.

Because the landmarks and anatomy are often totally unrecognizable, it really helps if the person who did it originally goes back, rather than a new person trying to figure it out as they go.

That applies to any surgical discipline, including OB/GYN.


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