Law That Says You Can Not Deny Transport in the USA

[medic417]

On another topic this came up. I have researched for years and have found no law that says you can not deny transport to a patient that is non emergent, that has no need of an ambulance. From early in my education as a first responder I was told the law says you must transport yet no law was or has been provided. In Texas I actually even called the state about it and was told no you do not have to transport all that request, the only requirement was that your medical director establish a protocol for denying transport.

So please provide me your state law or federal law with link to confirm that says you must transport all that request transport. Not your protocol but the law.

Thanks in advance.

And its not abandonment as they did not need further care.

"Abandonment is sometimes defined as the unilateral termination of the provider/patient relationship at a time when continuing care is still needed. It is a form of negligence that involves termination of care without the patient’s consent. To prove abandonment, a plaintiff must show that a patient needs care — that a medical provider has entered into a relationship to provide care to that patient, and then either stops providing care or transfers care to a person of lesser training when the patient needs the higher level of training. "

http://www.jems.com/news_and_articles/columns/Maggiore/Patient_Abandonment.html

 

[emtfarva]

On another topic this came up. I have researched for years and have found no law that says you can not deny transport to a patient that is non emergent, that has no need of an ambulance. From early in my education as a first responder I was told the law says you must transport yet no law was or has been provided. In Texas I actually even called the state about it and was told no you do not have to transport all that request, the only requirement was that your medical director establish a protocol for denying transport.

So please provide me your state law or federal law with link to confirm that says you must transport all that request transport. Not your protocol but the law.

Thanks in advance.

And its not abandonment as they did not need further care.

"Abandonment is sometimes defined as the unilateral termination of the provider/patient relationship at a time when continuing care is still needed. It is a form of negligence that involves termination of care without the patient’s consent. To prove abandonment, a plaintiff must show that a patient needs care — that a medical provider has entered into a relationship to provide care to that patient, and then either stops providing care or transfers care to a person of lesser training when the patient needs the higher level of training. "

http://www.jems.com/news_and_articles/columns/Maggiore/Patient_Abandonment.html

I answer your question with a question, What about the Americans in labor act laws? have you looked at those?

 

[ffemt8978]

EMTALA covers medical emergencies, not the person with no medical necessity for wanting to go to the hospital.

 

[medic417]

I answer your question with a question, What about the Americans in labor act laws? have you looked at those?

If they are in labor they have medical need. So not applicable. My question is denying transport to those with no need.

 

[emtfarva]

EMTALA covers medical emergencies, not the person with no medical necessity for wanting to go to the hospital.

But, in the other thread you said that you responded to the call. I always thought if someone thinks it is an emergency than it is. In the case you stated I would think that the mother thought it to be an emergency, right?

 

[Summit]

I believe the legal question was always one of liability. Most EMT-Bs and many would argue many Paramedics don't have the education or the tools to make a determination of whether a patient doesn't deserves transport, certainly at least when it comes to being able to defend that decision in a civil court case. And liability is what it comes down to for the most part (for the company and their MD more than the field provider).

I think that's a major argument put forth by many on this site for higher education standards for EMS. Refusal (along with treatment) becomes more sensible with understanding and knowledge. Other medical professionals might also respect such judgment (the ED). And then those medical professionals are not burdened with making the same decision twice (less frivolous ED traffic) and the whole system benefits (less cost and load). With the education, capability, and respect of the medical community would also come the flexibility to resist tort challenge.

 

[medic417]

I believe the legal question was always one of liability. Most EMT-Bs and many would argue many Paramedics don't have the education or the tools to make a determination of whether a patient doesn't deserves transport, certainly at least when it comes to being able to defend that decision in a civil court case. And liability is what it comes down to for the most part (for the company and their MD more than the field provider).

I think that's a major argument put forth by many on this site for higher education standards for EMS. Refusal (along with treatment) becomes more sensible with understanding and knowledge. Other medical professionals might also respect such judgment (the ED). And then those medical professionals are not burdened with making the same decision twice (less frivolous ED traffic) and the whole system benefits (less cost and load). With the education, capability, and respect of the medical community would also come the flexibility to resist tort challenge.

Yes for it to become standards of care to deny those that have non emergent problems education will need to improve.

And liablity will always be an issue. But what if any law says we can not deny transport to those that do not need an ambulance.

 

[Flight-LP]

True, no such law exists per se, however show me a medical director who is willing to take on that liability and I'll show you some great oceanfront property in Arizona..............

I have only ever experienced 1 time where we could look a patient in the eyes and say "no"; that was during Rita in '05.

Todays society is not one that accepts "no" very well. Outside of the blatant liability issue, you also run into safety issues, specifically your personal safety. Eventually your going to say "no" to the wrong person and either you get your a$$ beat or a negative outcome occures and someone starts hunting you down. EMS has a LONG way to go before it can make a MSE decision that is now only entrusted to physicians and mid-levels. There are enough proficiency issues with treating the obvious ill and injured. How can you remotely expect to differentiate the not so obvious ones.

Take for instance the 3 a.m. "I've got a cough, sore throat, fever, and congestion for 3 weeks and it won't go away" call. Just off of that complaint, would you transport? why or why not? What is their issue? Is the common cold? Flu? Sinusitis? Bronchitis? Pharyngitis? Strep A? Strep F? Pneumonia? Upper Respiratory Infection? Rhinitis? Do you know the differentiation between them?

Seems to be a simple ENT issue, doesn't need an ambulance now does it?












































































What if turned out to be pertussis, epiglottitis, or a frontal sinusitis that lead to sepsis because your patient didn't get the IV antibiotics they needed? Are YOU really PREPARED to make that call without having the needed resources to identify and differentiate????

Take them to the hospital...................

 

[medic417]

True, no such law exists per se, however show me a medical director who is willing to take on that liability and I'll show you some great oceanfront property in Arizona..............
...................

Actually there are numerous systems nationwide that have right to deny policys. My service allows denial. Yes you still take most but at least you can educate the public of what constitutes an emergency by saying no when not an emergency.

Here is a partial example of one that discusses denial or transport as well as patient refusal

CANCELLED CALLS PROTOCOL

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]

But, in the other thread you said that you responded to the call. I always thought if someone thinks it is an emergency than it is. In the case you stated I would think that the mother thought it to be an emergency, right?

She percieved an emergency that upon exam was not an emergency. So with a service with right to deny you would deny transport. So far no law has been presented that says otherwise.

 

[Ridryder911]

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

 

[medic417]

Thank you Rid. Finally a voice of reason.

 

[Flight-LP]

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!

 

[medic417]

Telling someone no is not definitive education. It is an invitation to confrontation..............

Actually just like dealing with a small child sometimes reasoning accomplishes nothing. So you just have to say no and leave. After a few times being denied transport for the supper special they will get the picture if not then the discipline gets harsher as we start enforcing abuse of the 911 system laws.

Yes we play social worker, etc, etc. But some people are just calling for the free ride. They should be told no.

Also many minor injuries and illnesses can after an ALS exam be treated and allowed to go see a doctor by other means.

For a system that implements it there are checks involved to ensure that people that need EMS are not being denied. But honestly 95% of the calls that are allowed to be taken by a BLS crew could and should be denied transport in an ambulance. But in reality wth all the checks and balances you still transport the majority of those that request.

Yes I know what I propose would cost BLS jobs. Sorry. But emergency is emergency. It is not perceived emergency. Yes that stubbed toe may be the worst event to ever happen to that person but they need to be educated to the proper reason to request an ambulance and sometimes no is the only thing that gets through to them.

I am not saying deny over the phone. Yes I am good but I still need to get hands on see, hear, touch to complete an ALS exam. Should every provider be allowed to say no? NO. Only those that have been proven to be educated and not lazy. Yes I said lazy as we all know the medic that shirks their responsibility. You could never trust them. But with higher education standards coming weeding out the idiots will start to occur and then all systems can establish a denial protocol.

Oh and for any that think the fact I can deny makes my job easier. It doesn't. It involves more documentation. But it does educate the public. It does work. I have seen it in more than one place improve the publics understanding of when to dial 911 leading to ambulances being more readily available.

 

[Flight-LP]

Do you hear yourself?????????

"discipline gets harsher", "sometimes reasoning accomplishes nothing", "we play social worker, etc, etc".

Man, I can't believe you sit here and preach a gospel of professionalism when you fail to acknowledge any point that has been made (just as you did in your other thread). You are NOT the 911 police, you are supposed to be a professional medical provider who takes care of the needs of his patients. That goes beyond the immediate urgent life or death issues. How can you remotely believe that you promote education when you are in actuality promoting further obstruction of healthcare for some folks? I don't know where you provide care at, but I can speak from personal experience by saying that most of the time a person is TRUELY educated, they respond and listen. To accomplish this, one must focus the delivery of information at the level and interest of the receipients. Harsh discipline will turn people away and have them tune out. Seeing your written word on this forum gives me a strong visual impression of how you would deliver a message to the community. Personally, I'd ignore you....................

You have some very valid points. Your thoughts and beliefs of a better healthcare delivery system are admirable, but your execution seems a little over the top. Humor me if you will; take a breath, deflate a little bit, and respond to my last post. Address the rebuttal and provide an arguement off of the response. Other than disciplining your local community because they have been bad and called 911 when they shouldn't, what specifically is your agency doing to promote better community health and access to resources?

Oh and for any that think the fact I can deny makes my job easier. It doesn't. It involves more documentation. But it does educate the public. It does work. I have seen it in more than one place improve the publics understanding of when to dial 911 leading to ambulances being more readily available.

What statistically significant findings can you provide to back this statement up? Is your call volume down? Is your response time less because now more units are in service and not running all of the BS calls? What tangible evidence has it provided??????

 

[medic417]

Do you hear yourself?????????

"discipline gets harsher", "sometimes reasoning accomplishes nothing", "we play social worker, etc, etc".

Man, I can't believe you sit here and preach a gospel of professionalism when you fail to acknowledge any point that has been made (just as you did in your other thread). You are NOT the 911 police, you are supposed to be a professional medical provider who takes care of the needs of his patients. That goes beyond the immediate urgent life or death issues. How can you remotely believe that you promote education when you are in actuality promoting further obstruction of healthcare for some folks? I don't know where you provide care at, but I can speak from personal experience by saying that most of the time a person is TRUELY educated, they respond and listen. To accomplish this, one must focus the delivery of information at the level and interest of the receipients. Harsh discipline will turn people away and have them tune out. Seeing your written word on this forum gives me a strong visual impression of how you would deliver a message to the community. Personally, I'd ignore you....................

You have some very valid points. Your thoughts and beliefs of a better healthcare delivery system are admirable, but your execution seems a little over the top. Humor me if you will; take a breath, deflate a little bit, and respond to my last post. Address the rebuttal and provide an arguement off of the response. Other than disciplining your local community because they have been bad and called 911 when they shouldn't, what specifically is your agency doing to promote better community health and access to resources?

What statistically significant findings can you provide to back this statement up? Is your call volume down? Is your response time less because now more units are in service and not running all of the BS calls? What tangible evidence has it provided??????

Back off dude. I presented information in response sorry you feel it did not address what you wanted it to. I am not here to please you. I am not here to pat everyone on the back and say your doing a great job, I am here to push people to get off their butts and improve EMS or get out of EMS, their choice. I am tired of all the happy go lucky lets be friends crap. Its time for tough love as the the holding hands method has not worked.

Yes my facts are it improved response time as it made ambulances available, Call volume is down, recovery of expenses is up as there are fewer transports that do not meet medicare medicaid criteria. It also improves patient care as we focused on the social problems as well. We provide information to those that we deny transportion so they will have sources they can contact for assistance rather than sucking the life out of the emergency system. Our medics also develope better assessment skills. Plus we do treat many injurys and illness in the field and let them follow up with their doctor in the morning, so we also are helping unclog the emergency rooms which means when someone with a real emergency gets there they get seen much quicker.

And yes I said education by punishment. Those that abuse need to have the punishment of fines and even jail time. This is not something we do the first time they call we do it after repeated educational talks that ultimitly include the taboo "no". Sorry you do not feel competent enough to do it sounds like you need to get more education.

There hope that addresses enough of your points. Just as on the other topic that I did provide answers to I will not do all the work for you. Doing research and work for your self benefits you more. I will as I have been doing provide basic answers.

 

[Ridryder911]

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

 

[medic417]

Rid thank you for saying what I have been trying to say but in a much more organized method.

It is time for EMS to move forward or shut down. I am greatful I have a progressive medical director that encourages us to be independant thinkers. We are required to be educated and remain current in our education. Thus we are trusted to deny, to educate, to treat and release, etc.

 

[Flight-LP]

Back off dude. I presented information in response sorry you feel it did not address what you wanted it to. I am not here to please you. I am not here to pat everyone on the back and say your doing a great job, I am here to push people to get off their butts and improve EMS or get out of EMS, their choice. I am tired of all the happy go lucky lets be friends crap. Its time for tough love as the the holding hands method has not worked.

Sorry you do not feel competent enough to do it sounds like you need to get more education.

There hope that addresses enough of your points. Just as on the other topic that I did provide answers to I will not do all the work for you. Doing research and work for your self benefits you more. I will as I have been doing provide basic answers.

Actually no again you didn't address anything other than your self servent crusade for perceived success in EMS. As you are doing in the ALS thread, you are skipping around and applying justification to bits and pieces of information instead of intelligently communicating or debating. Combine that with the really lame competence jab (and I emphasize REALLY lame) and you have successfully in one post erased any amount of opaque view there is of who you are or what you stand for. You are standing there crystal clear...........

If you want to continue this debate as an adult, then we can continue. If you want to continue along this path, either shut up or take it to PM. I'd be more than happy to continue the conversation there in a more subtle tone.

 

[medic417]

Actually no again you didn't address anything other than your self servent crusade for perceived success in EMS. As you are doing in the ALS thread, you are skipping around and applying justification to bits and pieces of information instead of intelligently communicating or debating. Combine that with the really lame competence jab (and I emphasize REALLY lame) and you have successfully in one post erased any amount of opaque view there is of who you are or what you stand for. You are standing there crystal clear...........

If you want to continue this debate as an adult, then we can continue. If you want to continue along this path, either shut up or take it to PM. I'd be more than happy to continue the conversation there in a more subtle tone.

Have a nice day.