Denying transport? What is involved?

medic417

medic417

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Yes another post was about similiar and I apologize for getting into a pissing war with another member. To help get this topic going in hopefully a civilized manner here is an expanded response to some points that were brought up.

Flight-LP said:
Telling someone no is not definitive education. It is an invitation to confrontation..............

I have found that most people who are truely by definition ignorant, respond well to appropriate education concerning utilization of resources and alternatives available. Those out to do nothing more than manipulate is a completely different story and yes, in that aspect, I do agree with you. The problem lies in perception. What you as a medic deems an emergency and what the pt. deems an emergency is usually 2 very different scenerios. Again, education comes into play here. A thorough MSE type assessment still needs to be performed and I question the ability of the average street medic to appropriately perform it. It must be performed with proficiency and understanding of the pathophysiology of disease and it must be done without bias. That alone will be a challenge for the medic working a 24 hour shift without sleep who is out on a 3 a.m. sniffle call.

It would be great in a perfect world, but thus far, the U.S. EMS world is far from perfect. We all know this.

Outside of ruthless manipulation and lies from some people, there are very few patients that call EMS who do not have a want or need for medical care. No they may not need a trauma center, or the cath lab, but they are requesting an intervention. Remember, sometimes YOU are all they have. Perhaps putting more focus on community health would benefit these folks? This is where education, combined with collaborative efforts, can really make a professional difference in this industry.

Despite it being "Emergency" Medical Services, sometimes we have to look beyond the meat and potatos of our profession. Sometimes you will be the medical practitioner, other times the social worker. Empathy and a passion for helping others should prevail, not a policy to prevent access to the only medical care some have. In my opinion, you are playing "judge and jury" and I really do not believe that a role that EMS sould participate in, nor do I believe that many are remotely qualified to do so.

If we had a VentMedic, Ridryder911, AK, or a few select others on every truck, those who can evaluate all of the variable and individual aspects of humanistic wants and needs, then maybe I could see it........................

Otherwise, NO!
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Telling no is the only thing some people understand. You will start off explaining why they do not need the ambulance and offer information for other types of services that they might benefit from. But sometimes you still have to say no and walk away. All of this after a complete exam by a compentent Paramedic.

Emergency is emergency. After explaining that their percieved emergency is not an emergency and where they can seek care again if they insist we have to say no. Many people despight your beliefs otherwise think they are entitled to an ambulance ride just because they want one. Wish I worked where you do and never got people that were that way.

We do not play judge and jury. We treat any problem they have that is needed. Sometimes that is all they need. Then we advise agin other places for follow up treatment. Yes many emergencies are not glamorous and if after the exam it is deemed ,whether for their mental, physical, or both , to be best to transport we transport. We actually still transport most patients that request. But we will say no w/o ignoring their problem, again see above.

Your right most people that call want medical care, that does not make it an emergency. See above paragraphs.

I agree many diploma mill medics and even some flight medics I have met regardless of where educated do not seem to be able to properly examine a patient so therefore they should not be allowed to deny transport. It seems as more and more flight services are springing up there is less and less difference in education between ground and flight EMS.

I agree if we all had people like Vent, Rid, AK on every ambulance this would be a mute point as it would have already have been implemented. In fact every service would be doing field treatment and denying transport when not needed.

I hope this expanded version of my answer helps you see my point, whether you agree or not. I hope that my experience and way of thinking will help EMS get out of their little comfort zone and find ways to improve patient care.

I apologize for my rude statements in previous topic.
 
Here are two posts from Rid that really intelligently go into some of the things required of EMS to provide proper patient care including denying transport.

" It is a myth that all patients have to be transported. What if the patient (supposed) wanted to be transported to the hospital to see other family members or has no complaints? There are several EMS services that have the right to refuse transport. I worked at one that the Supervisor had the authority to deny transport. This of course had to be cleared with the medical director on duty. Usually these were B.S. of thumb injuries or related non-emergency scenarios. Very few occurred but still occurred.

It is a common myth as well, that all patients have to be treated within the Emergency Department. EMTALA/COBRA does describe that all patients have to have a MSE performed. This can determine if there is life threatening injuries and if the patient can wait to be seen and be further evaluated and treated later. There are many times I have sent patients to their PCP for a later time after a physician seen them. Also payment can be demanded for prescriptions and services before the patient leaves, or they may not be offered or allowed to take them. Again, life threatening injuries are ruled out.

I instituted such policy in many ER's as many assume care is free. Uncaring that the ER is the highest level of red within a hospital and such costs prohibits other equipment, staffing and care to be delivered.

Most EMS does suggest that almost all patients be transported due to the potential liability. Until we start having more clear (no need for transport) protocols, we will continue to be used as a taxi service. This will be explored more as run volume and costs increase, staffing and staging is harder to meet the minimal demands. Some will take the risks. Of course there will be mistakes but I feel in the long run, there will also be the thought of requiring more educated Paramedics to be able to make these decisions and have such responsibilities. This will be judged in comparison to risks versus the offsets. Not enough units, personnel to potential liability for true non-emergency responses.

We can compare that one cannot transport one to a pharmacy to obtain medications, or a LEO to be able to provide transport to persons that need auto insurance or auto breaks down.

R/r 911"

"I believe both of you are emphasizing very valid points. The main problem is most medics do not who to call or what to do on many of those situations. Even more so, it is not limited just to EMS but in hospital as well.

For example the Grandma that calls at 0300 because she had ran out of her HTN medications, the simple isolated hand laceration that may require sutures but the patient is ambulatory, the new parents that is concerned about their newborn "choking" while nursing but is obviously in no distress.

These patient do not need nor should require EMS transport. The problem again is "if we don't who will and if something happens automatic litigation will follow".

With the new change and economic turmoil, EMS is going to have to start considering "out of the box and non-routine" procedures and protocols. It is just as dangerous to be transporting one of those patients and not have an available EMS unit to respond within reasonable time to a true AMI.

So how do we this? Unfortunately as bad as many would not like to see this brought back in wording again is education.
Education on multiple and various levels

Education not just to EMS personnel but to the physicians to write better protocols and to develop a wider & more broad to include contacting Social Services, Home Care, Hospice, etc.

Expanded education and truthfully formal education in medical care not just emergency care.

Administration needs to take off the blinders, introduce legislation and promotion for reimbursement to EMS for consultation and evaluation even for those that are not transported to offset time lost or costs for responses.

Better coalition between non emergency health care providers (hospice, home health, public health) and EMS. We all can learn off each other and respect each others responsibilities.

This is not just a pie in the sky thought, rather if we do not start; more than the patients will suffer. EMS systems can no longer exists on the "what if" factor as many are taking too many risks and gambling with poor responses and rushed care. As economical times become more harsh, we will see more abuse of the system and heaviness placed about. Rather ignoring and wishing it would go away, we need to deal with it and do it appropriately.

R/r 911"
 
This topic is reopened provided it remains civil.
 
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ffemt8978 said:
This topic is reopened provided it remains civil.
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Thank You.

Denying transport is not a responsibility to be taken lightly. I will transport if I have any doubts or my partner has any doubts. If anything including fear could be distracting patient from being able to allow a complete ALS exam we take them. But there are many patients that have minor injuries or illnesses with no other problems to be dealt with. We will treat the problem whether with meds or bandages and have patients family or friends take them to the doctor.

Even insurance including Medicaid and Medicare have guidelines that must be met for the transport to be paid. W/O fraud many patients do not meet the emergency qualifications they set so you are not getting paid. So by denying you are also lessening the stress on the person in the future as well.
 
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
 
medic417 said:
Thank You.

Denying transport is not a responsibility to be taken lightly. I will transport if I have any doubts or my partner has any doubts. If anything including fear could be distracting patient from being able to allow a complete ALS exam we take them. But there are many patients that have minor injuries or illnesses with no other problems to be dealt with. We will treat the problem whether with meds or bandages and have patients family or friends take them to the doctor.
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It appears from what I'm reading here is that your service has instituted such transport policy. Perhaps you could provide us a PDF of this policy so we can see the meat and potatoes of what you advocate? Or is that the policy I see above this post?
 
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karaya said:
It appears from what I'm reading here, is that your service has instituted such transport policy. Perhaps you could provide us a PDF of this policy so we can see the meat and potatoes of what you advocate? Or is that the policy I see above this post?
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Previous post in one from another service. I am not allowed to post my service per current policy. Trying to change that policy at this time.
 
Im not sure EMS in its present state should be denying anyone transportation. Im sure some systems are capable. I think those are few and far between.
 
CAOX3 said:
Im not sure EMS in its present state should be denying anyone transportation. Im sure some systems are capable. I think those are few and far between.
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I agree many diploma mill medics should not and really though they should not even be treating patients period.

Slowly we will eliminate those programs and then a true medical assessment will be performed and the Paramedic will have the option to deny if they do not need the ambulance. I am glad I have the option.
 
I agree with what has been said about educating the truly non-malicious EMS callers, as well as calling the BS for what it likely is from the blatant system abusers. What concerns me are the "aggressive" EMS providers, regardless of them being educated or otherwise and being capable of performing an appropriate assessment.

Example: Dispatched for general weakness. Family meets you and says they were at the doctors office today and later got a call back from grandmas doctor saying the labs show she has a UTI.
EMS: "Your grandma has a UTI? Yeah? You got a car right? You drove her to the doctors office earlier right? Why am I here?". The family may have no idea why grandma has "AMS" secondary to UTI.

I'm all for educating the family in that instance, regardless of transport or not. My concern lies with the medic/EMT's ability to appropriately inform pt:
#1) In a manner which the family will be able to comprehend and recognize the present "AMS" as associated with UTI, and not mistake it in the future for an AMS with a totally different etiology.
#2) In a way which the family will not get the impression they are now medically trained to recognize illnesses after getting a 5-10 minute briefing.
#3) The unintentional "intimidation" of the family (it's all their perception) that could make them hesitant to call 911 in the future for a loved one.

I'll go right out and contradict the above by saying I would like to have a company or even state policy regarding refusing transports that meet a strict criteria. However, after seeing some co-workers, as well as other employees from other services, I can understand why we are not allowed that priviledge yet. Hopefully we'll get there soon though! :)
 
AMS should be a disqualifier in the Deny policy, just like it is in field c-spine clearing protocols. If altered you can not be sure they are giving correct answers during your exam.

So good point vquintessence.
 
3) The unintentional "intimidation" of the family (it's all their perception) that could make them hesitant to call 911 in the future for a loved one.

This would be my biggest concern. Refusing transportation is a very slippery slope. It can have a multitude of consequences.

I will have to disagree with the AMS. Anyone with a change in mental status needs transportation.
 
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CAOX3 said:
3) The unintentional "intimidation" of the family (it's all their perception) that could make them hesitant to call 911 in the future for a loved one.

This would be my biggest concern. Refusing transportation is a very slippery slope. It can have a multitude of consequences.

I will have to disagree with the AMS. Anyone with a change in mental status needs transportation.
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Thats why I said AMS should be a disqualifer of the denial protocol.
 
Hi All:

Wow, a lot of good points, some of which I hadn't considered. One thing I would like to address is the issue of providers being less than objective. One of our roles is patient advocate. If you can't see the situation from the patient's viewpoint, and address the situation in the patient's best interest, then perhaps it's time for some re-training, or another assignment, or whatever. Point being that I think this is more a personnel issue than a policy issue.

Our service is considering a policy to allow medics to decline transport to patients who don't require an ambulance. I'd sure appreciate your participation there, too:
http://www.emtlife.com/showthread.php?t=11686

Thanks,
Mark B.
 
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