Ambulances held hostage

[DrParasite]

Is there any need to prove this?

I mean, as long as no one questions it, no. When you are called into court, how do you "prove" that you didn't falsify your documentation, and didn't just dump the patient (who later died) in the waiting room?

I document who I turned the patient over and what location that occurred at. Not sure how an RN scribbling on the tablet would change anything.

my first paid job said if RN simply wants to scribble on the tablet, that's cool; if their signature wasn't legible, then fell to me to get and document the full spelling of their name. It is, after all, a legal document. not saying what I was told was right or wrong, just that's what we did. subsequent employers did not require receiving signatures

 

[Jim37F]

I’m not suggesting just dumping the patient in the waiting room and dipping out. But where is the burden of giving the charge or triage nurse handoff, them agreeing that the patient can sit out the waiting room, and then clearing?

The triage nurse simply refusing to accept the transfer of care on the grounds that you can't just say "I'm transferring care to you" anymore than any other random nurse in the ER you came across instead of the charge nurse or whoever is in charge of receiving the ambulances

 

[Tigger]

I mean, as long as no one questions it, no. When you are called into court, how do you "prove" that you didn't falsify your documentation, and didn't just dump the patient (who later died) in the waiting room?

my first paid job said if RN simply wants to scribble on the tablet, that's cool; if their signature wasn't legible, then fell to me to get and document the full spelling of their name. It is, after all, a legal document. not saying what I was told was right or wrong, just that's what we did. subsequent employers did not require receiving signatures

I document their full name, title, and signature. All of which could be falsified too, if you really want to play that game.

The triage nurse simply refusing to accept the transfer of care on the grounds that you can't just say "I'm transferring care to you" anymore than any other random nurse in the ER you came across instead of the charge nurse or whoever is in charge of receiving the ambulances

My point is that there really is no more burden on the hospital itself for putting a BLS patient in the waiting room than having them sit on the stretcher in the hallway. The patient is going to be seen in the ED one way or another, it makes no sense to make EMS babysit a patient that requires minimal if any more monitoring than what exists in the waiting room ("um hey nurse, this man's unresponsive.") Is EMS obligated to treat the patient if any sort of condition change occurs while in the ED? That seems like a nightmare for the ED too.

 

[MonkeyArrow]

This is fascinating. Just goes to show regional differences in EMS.

I’m not going to comment on the merits of holding the wall with a patient, but I can see the need for signatures to verify that the patient was appropriately handed over to whomever.

2 in hospital examples from recent memory. The first: a nurse transported a patient from the ER to an inpatient bed. The only catch was the unit was closed. Somehow, the room assignments got mixed up, but this nurse left a patient in an otherwise empty unit, and this wasn’t discovered for several hours. Luckily, the patient was not harmed. Now you may be asking very reasonable questions like “MonkeyArrow, how did this nurse not see that the unit was empty, and there weren’t any patients or any staff around? Shouldn’t this have been prevented if someone just used common sense?” Obviously, reliance on what I feel to be basic skills adults should possess is inadequate.

The second: a patient was transported back from CT to their ER room, and not hooked back up to cardiac monitoring. The nurse came in to find the patient in cardiac arrest. There was a large he-said-she-said of whether transport did or did not tell nursing that the patient was brought back and in what condition the patient was returned.

You or I may feel that a signature to confirm that the patient has been delivered to the right place and with their condition appropriately communicated (I.e. not in need of chest compressions) is elementary. However, from a systems perspective, there is always someone out there that will prove you wrong…

 

[Capital]

As the charge nurse at a busy level 2 trauma center, I can honestly state I've never held a crew longer than 15 minutes. We've been using our triage and fast track area for all EMS that isn't a trauma, MI, or critical patient. We funnel everyone there and have a designated paramedic that takes the report, and then a nurse and mid-level do the triage together. If the patient is stable they are moved back to a fast track chair and line/labs done. The patient goes back to the waiting room to wait for X-ray/CT etc. Once everything results they get the next designated bed in the back. That way my 50 beds in the back are not tied up while tests are being done, waiting for results. It's working pretty well. It also allows us to catch the more critically ill patient quickly because a paramedic, a nurse, and a PA or NP see them within minutes of arrival.

As for patient calls in hospital parking lots, that is a huge EMTLA violation for the hospital to not respond. We are federally required to cover 250 yards out from the hospital property in all directions. Now I have called EMS for a lift up the big hill in front of our ED with an OD (after I put in the IV, gave the narcan and I'm bagging). It should be illegal to put ER entrances on hills! My company responded and I caught **** forever about it

 

[EpiEMS]

The triage nurse simply refusing to accept the transfer of care on the grounds that you can't just say "I'm transferring care to you" anymore than any other random nurse in the ER you came across instead of the charge nurse or whoever is in charge of receiving the ambulances

Don’t think they can do that. They’re at the hospital. There are EMTALA obligations.

 

[Tigger]

You or I may feel that a signature to confirm that the patient has been delivered to the right place and with their condition appropriately communicated (I.e. not in need of chest compressions) is elementary. However, from a systems perspective, there is always someone out there that will prove you wrong…

I guess I don't see how a signature fixes any of these issue. Lazy people are also likely to be lazy about documentation and falsify or otherwise manipulate such procedures. Maybe it's different with Epic and RFID badges, but there's really nothing to stop people from falsifying these signatures.

I am not aware of any issues with abandonment in our system and lord knows we get plenty of feedback from the hospitals about what they want us to do differently.

 

[FiremanMike]

FWIW my usage of "signing off" had less to do with the physical act of getting a signature and more the act of giving report and turning the patient over. As long as I can tell a nurse/doc at the hospital "hey I brought you this patient complaining of this and my assessment showed that" and they say "sounds good" then I'll drop them in the gift shop if that's where they tell me to take them..

 

[NomadicMedic]

For those that don't require a signature. how do you "prove" that you transferred patient care to another provider, vs simply "just dumping the patient in the waiting room and dipping out"?

The hospital face sheet is how we do it. It's proof that the patient was registered. We don't leave a patient until they're registered.

 

[DrParasite]

The hospital face sheet is how we do it. It's proof that the patient was registered. We don't leave a patient until they're registered.

I had an issue where registration refused to print out a hospital face sheet for me, citing HIPAA... even better, the information on the face sheet was exactly the information that I just told her so she could type it into the computer... had to have the ER director call the registration director, who agreed that it wasn't a HIPAA violation.... good times

 

[NomadicMedic]

I had an issue where registration refused to print out a hospital face sheet for me, citing HIPAA... even better, the information on the face sheet was exactly the information that I just told her so she could type it into the computer... had to have the ER director call the registration director, who agreed that it wasn't a HIPAA violation.... good times

Most of our hospital systems have a method to assign the face sheet to our agency and we can access EPIC securely and get an it to attach to the PCR for billing. It has mostly eliminated lost paperwork.

 

[GMCmedic]

For those that don't require a signature. how do you "prove" that you transferred patient care to another provider, vs simply "just dumping the patient in the waiting room and dipping out"?

Around here, waiting room patients are registered.


ETA: all hospitals I've been too, track which service brought the patient in. Errors are made, but for the most part accurate. There is always something to trace it back.

 

[NomadicMedic]

Around here, waiting room patients are registered.

Same here.

 

[Tigger]

They are registered as agency specific EMS arrivals when we take them out front as well.

Every report I write needs an MRN documented as well.

Also of note, one of our receivings is out of staffed beds and has been for days. And now they’re closed to ambulance traffic which seems appropriate to me, no reason to take someone to a full hospital. Obviously not helpful if every hospital is full, but regionally we’re not used to hospitals being full for weeks at a time.

 

[NomadicMedic]

Another big issue is the “divert is a courtesy “ BS. If the hospital is saturated and there is no staff and no beds, don’t bring people there.

We frequently have hospitals on saturation divert and there are plenty of crews that will simply ignore that message and go there anyway. If you hold the wall for 3 hours, that’s you’re fault bro. Hospital x is 30 minutes away with no wait.

 

[CbrMonster]

Nope, I've done that too... I've also ran calls IN the hospital.

In most of those cases, EMS is used more as a transportation vehicle than a clinical provider, because most ER staff are not willing or able to leave the ER itself. Even if a visitor fell in a medsurg floor, EMS would be called to transport them down to the ER for eval, as the doctors and nurses couldn't/wouldn't treat them. in the parking lot, 9 times out of 10, hospital security would beat us to the parking lot and just walk the person to the ER.

well that's a relief


ok to me to run calls in the hospital i'd tell them to quite frankly piss off, with the exceptions of something like cct to another hospital. thats garbage, higher qualified people in there and they have gurneys they use to transport people to and from units.

This is actually very common. When I was new in EMS I worked inner city and there were two large hospitals in my zone whose parking lots we were regularly dispatched to for various reasons.

yeah we had a kaiser in my first in area that we frequented almost daily.

The best is when people call 911 from triage for transport to a different hospital because the wait is too long…

lol i cant count how many times i've had the call where someone called from the parking lot to transport to another hospital with a shorter wait time.

California has Nurse to patient ratios that are imbedded in law. 1 Nurse to 4 patients for the ED. So even if there are unoccupied beds in the ED, if they have maxed out the ratio you have to wait.

in fairness they can break there ratios and take more patients, worked in a california hospital and wtinessed it.

Why does that become an EMS problem? PWW make it quite clear that a patient’s percent at the hospital means the hospital has an obligation to follow their EMTALA requirements and cannot use EMS as a crutch.

And that epitomizes everything wrong with California, the only state that has such a law specific to hospital departments.

eh, i think in all fairness nurses should have a set ratio to patients, too many patients and you're gonna have more errors and their work loads get heavier everyday.



as someone else also mentioned ed's go down for saturation cause the other floors where they get admitted to are full, my wife currently still works in the ED and this generally is the issues, holding icu patients or the 8 5150's that sit in the er til it expires

 

[DrParasite]

Another big issue is the “divert is a courtesy “ BS. If the hospital is saturated and there is no staff and no beds, don’t bring people there

1) it is a courtesy. unless the hospital is experiencing an internal disaster, they are still accepting patients.
2) some hospitals won't go on divert, even though there are no beds in the ER. they might go on specialty divert, but not divert for the ER.
3) even if a hospital is on divert, the patient, can still request to be taken there.
4) some crews aren't told that a hospital is on divert until they walk in the door.
5) when all hospitals in the area are on divert, then none are on divert. where I used to work, we had two hospitals; when one went on divert, the other went on divert an hour later. when I was in upstate new york, we had 5 hospitals in the city... routinely they would all go on divert, and it would be a forced rotation, so even though they were full, they were still getting patients. after all, they need to go somewhere...

BTW, I'm not saying crews should make things harder for themselves by going to an overfull hospital. However, if the patient wants to go to a hospital, they have a right to choose their destination, even if it's busy. if the crews are told it's busy, they should advise the patient of such, but patients still have the right to choose their destination.

 

[Tigger]

1) it is a courtesy. unless the hospital is experiencing an internal disaster, they are still accepting patients.
2) some hospitals won't go on divert, even though there are no beds in the ER. they might go on specialty divert, but not divert for the ER.
3) even if a hospital is on divert, the patient, can still request to be taken there.
4) some crews aren't told that a hospital is on divert until they walk in the door.
5) when all hospitals in the area are on divert, then none are on divert. where I used to work, we had two hospitals; when one went on divert, the other went on divert an hour later. when I was in upstate new york, we had 5 hospitals in the city... routinely they would all go on divert, and it would be a forced rotation, so even though they were full, they were still getting patients. after all, they need to go somewhere...

BTW, I'm not saying crews should make things harder for themselves by going to an overfull hospital. However, if the patient wants to go to a hospital, they have a right to choose their destination, even if it's busy. if the crews are told it's busy, they should advise the patient of such, but patients still have the right to choose their destination.

We do not subscribe to the “if everyone is on divert then no one is on divert.” The system appoints a controller hospital when everyone is on divert to distribute patients in real time based on fractional capacity, staffing, and proximity to the call location. The crew calls the controller and they get an assignment. The patient can override this I suppose but I’m yet to have anyone insist on being taken to a full facility. non-voluntary psych and intoxicated patients are not afforded a choice at all.

 

[DrParasite]

We do not subscribe to the “if everyone is on divert then no one is on divert.” The system appoints a controller hospital when everyone is on divert to distribute patients in real time based on fractional capacity, staffing, and proximity to the call location. The crew calls the controller and they get an assignment. The patient can override this I suppose but I’m yet to have anyone insist on being taken to a full facility. non-voluntary psych and intoxicated patients are not afforded a choice at all.

not going to lie, I wish we had a system like where in any of the place I've worked. 3 different states, never had a system that did that. Makes a lot of sense, and I wonder why more systems don't do that. It would definitely help with wait times, especially when hospital capacity is updated in realtime

 

[CbrMonster]

Orange County, not sure if still the same for diversion was, call each hospital once you got diverted to the third furthest you could go to the original closest appropriate receiving.

I do like the idea of a controller, especially maybe someone working for the Lemsis that is not associated with any hospital to remove all bias and simply safety oriented.