Distance to Hospital

Shishkabob

Shishkabob

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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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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.
 
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.
 
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.
 
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.
 
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.
 
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.
 
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.
Click to expand...

Is that true, or just a clever tactic?
 
46Young said:
Is that true, or just a clever tactic?
Click to expand...

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.
 
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.
 
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.
Click to expand...

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?
 
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.
 
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?
Click to expand...

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.
 
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.

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?
Click to expand...

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

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.
 
Smash said:
The overriding factor in any of these decisions is how close it is to knock-off.
Click to expand...


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

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.
 
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.
Click to expand...

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