Distance to Hospital

[WolfmanHarris]

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.

 

[wyoskibum]

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.

 

[Chimpie]

Why?

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.

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.

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.

 

[the_negro_puppy]

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.

 

[abckidsmom]

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.

 

[Anjel]

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.

 

[usalsfyre]

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.

 

[wyoskibum]

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.

 

[Aidey]

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.

 

[MrBrown]

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

 

[JPINFV]

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?

 

[Shishkabob]

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.

 

[JPINFV]

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.

 

[BandageBrigade]

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.

 

[Shishkabob]

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.

 

[JPINFV]

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.

 

[JPINFV]

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?

 

[Shishkabob]

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.

 

[Aidey]

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.

 

[BandageBrigade]

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.