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.
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)?
