patient right to demand ambulance transport

[Epi-do]

Around here, we cannot refuse to transport anyone that requests an ambulance takes them to the ER. That being said, most crews have learned how to "strongly encourage" those that would be better suited seeing their primary care physician, or treatment somewhere other than an ER, to find other modes of transportation. That being said, there will always be those out there that continue to insist the ambulance take them, regardless of what is going on at the time.

As for which ER we transport to, it really depends upon the situation. There are a couple hospitals within 10-15 minutes of the area I work in. One of the campuses has a heart center and is a stroke center. The three level I trauma centers are about double that away, and then there are a handful of other hospitals we also go to, all about 30 minutes or so drive away.

If the patient is having a STEMI, they all go to the closest heart center for stabilization. They can then be transferred to the hospital of choice from there, if they desire. The same goes for stroke patients.

If the patient's issue requires the resources of one of the level I's that we have, even though they are sicker than most patients, they get the slightly longer ride. All of the level I's are within 5 minutes of each other, so if the pt is conscious, we can still give them a choice of hospitals, although it is much more limited, if we choose to do so. Often times, we choose which level I we are going to take them to for treatment, though.

All other patients get to choose the hospital we take them to for treatment, as long as it is within the county I work in. We have two hospitals that are exceptions to that, and we do transport to them, despite their locations being in another county, because they are within 20-30 minutes transport time.

 

[LondonMedic]

I don't understand some of your American systems.

When we were debating patients' right to refuse treatment, how many people wanted to wait until the patient was unconscious before kidnapping them and dragging them in?

Now we're talking about patient that want to go in...

 

[CAOX3]

The patient is allowed hospital of choice "within reason". However I determine whats "within reason"

I will take you where you want to go but Im not driving across the state because your cousins half sisters daughter is a CNA there.

Sorry.

 

[usalsfyre]

I don't understand some of your American systems.

When we were debating patients' right to refuse treatment, how many people wanted to wait until the patient was unconscious before kidnapping them and dragging them in?

Now we're talking about patient that want to go in...

The problem is most paramedic schools here spend all of about 4 hours on legal issues. So everything gets distilled down to "call med control, and take the patient in if any doubt otherwise YOU'LL GET SUED!! ". True informed consent and refusal as well as patient self-determination are fairly foreign concepts.

Couple this with a lack of alternative care pathways and a system that values emergency over routine care and you end up with this odd dichotomy.

 

[Shishkabob]

When we were debating patients' right to refuse treatment, how many people wanted to wait until the patient was unconscious before kidnapping them and dragging them in?

Now we're talking about patient that want to go in...

A patient that had their toe nail ripped off wants a CT of their head done even though there is no reason. Do you comply?

 

[JPINFV]

The problem is most paramedic schools here spend all of about 4 hours on legal issues. So everything gets distilled down to "call med control, and take the patient in if any doubt otherwise YOU'LL GET SUED!! ". True informed consent and refusal as well as patient self-determination are fairly foreign concepts.

Couple this with a lack of alternative care pathways and a system that values emergency over routine care and you end up with this odd dichotomy.

...and isn't it about 0 hours of training in determining which patients actually needs a hospital?

 

[usalsfyre]

...and isn't it about 0 hours of training in determining which patients actually needs a hospital?

Depends on the program. I actually had to take some pathophys and assessment classes that aided in that area greatly.

A "just enough to get past the NR" program? Probably zero hours.

Didn't the last paper on the subject say (granted I wasn't thrilled with it) paramedics are great at determining need for prehospital intervention but not need for admission?

 

[JPINFV]

Didn't the last paper on the subject say (granted I wasn't thrilled with it) paramedics are great at determining need for prehospital intervention but not need for admission?

News flash, people who aren't trained in something are generally bad at it.

 

[usalsfyre]

News flash, people who aren't trained in something are generally bad at it.

Yep, that was the big issue I had with the publication. If I remember correctly it made no attempt to quantify education levels of the medics involved, and then, after determination that they do indeed suck at determining need for admission no education was provided to see of the deficiency could be easily corrected.

 

[JJR512]

In addition, who determines "closest appropriate" when say insurance is involved? Because if you refuse to go 15 minutes further to a hospital that's in-network for me I'm going to be seriously pissed, and your not doing your patient any favors sticking them with a higher bill.

Insurance isn't factored into the equation at all, period. "Closest appropriate" means "closest medically appropriate. The decision is made based on the medical needs of the patient, which in my opinion, is all that matters. Making medical decisions based on insurance or financial or convenience considerations is a big part of what's wrong with medicine today, in my opinion.

Further in my opinion—and a whole separate topic can be started from what I'm about to say—a patient shouldn't have to pay more in an emergency because the ambulance personnel decided the patient should go to Hospital Y instead of Hospital X.

Finally, if I have to transport you an additional 15 minutes out, and have a 15 minute additional return to quarters time, for no real medically relevant reason, is the 30-minute loss of time available fair to the community I'm supposed to be serving?

Finally, yes I poked at your myopic defense of the Maryland EMS system. I urge you again to explore the world outside of MD and why the only people who say they are the best are involved in the MD EMS system.

Why should I "explore the world outside of MD"? I live in MD. I have no intention of ever moving out of MD. Knowing what Texas or South Dakota would do in a particular situation won't help me in that situation because I can only do what MD allows me to do.

I read this forum and I read JEMS magazine, and occasionally some sources. I read them with an attitude of "what can I learn", not "how are other jurisdictions better than mine".

Finally, I don't recall ever saying that MD EMS is the best EMS system. I think you're stereotyping me, assuming that because I'm in EMS in MD, I'm exactly the same as some other MD EMS people you've experienced. I know several other MD EMS people on this forum and they don't really fit your stereotype, either. Maybe your stereotype is flawed.

 

[JPINFV]

Making medical decisions based on insurance or financial or convenience considerations is a big part of what's wrong with medicine today, in my opinion.

So the solution is to make the situation worse in the short term in a manner that would do nothing to generate a long term solution?

Finally, if I have to transport you an additional 15 minutes out, and have a 15 minute additional return to quarters time, for no real medically relevant reason, is the 30-minute loss of time available fair to the community I'm supposed to be serving?

Sure, when it saves you an equal 30 minutes of time holding the wall because the ED isn't waiting for the local IFT service to transport your prior patient to, when all things are considered, the most appropriate facility.

Why should I "explore the world outside of MD"? I live in MD. I have no intention of ever moving out of MD. Knowing what Texas or South Dakota would do in a particular situation won't help me in that situation because I can only do what MD allows me to do.

I read this forum and I read JEMS magazine, and occasionally some sources. I read them with an attitude of "what can I learn", not "how are other jurisdictions better than mine".[/quote]

Because what MD allows will never change?

If another jurisdiction is doing something better than you, shouldn't that be something that you would want to introduce to make your own system better?

 

[Sasha]

Insurance isn't factored into the equation at all, period. "Closest appropriate" means "closest medically appropriate. The decision is made based on the medical needs of the patient, which in my opinion, is all that matters. Making medical decisions based on insurance or financial or convenience considerations is a big part of what's wrong with medicine today, in my opinion.

Further in my opinion—and a whole separate topic can be started from what I'm about to say—a patient shouldn't have to pay more in an emergency because the ambulance personnel decided the patient should go to Hospital Y instead of Hospital X.

Finally, if I have to transport you an additional 15 minutes out, and have a 15 minute additional return to quarters time, for no real medically relevant reason, is the 30-minute loss of time available fair to the community I'm supposed to be serving?


Why should I "explore the world outside of MD"? I live in MD. I have no intention of ever moving out of MD. Knowing what Texas or South Dakota would do in a particular situation won't help me in that situation because I can only do what MD allows me to do.

I read this forum and I read JEMS magazine, and occasionally some sources. I read them with an attitude of "what can I learn", not "how are other jurisdictions better than mine".

Finally, I don't recall ever saying that MD EMS is the best EMS system. I think you're stereotyping me, assuming that because I'm in EMS in MD, I'm exactly the same as some other MD EMS people you've experienced. I know several other MD EMS people on this forum and they don't really fit your stereotype, either. Maybe your stereotype is flawed.

Insurance should be taken into consideration for that. Who are you helping by sticking them with a big bill they cant pay? Its time to stop thinking of the patient as an emergency and start thinking of them as a patient and take into consideration what their best interest is, within reason.

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[usalsfyre]

Insurance isn't factored into the equation at all, period. "Closest appropriate" means "closest medically appropriate. The decision is made based on the medical needs of the patient, which in my opinion, is all that matters. Making medical decisions based on insurance or financial or convenience considerations is a big part of what's wrong with medicine today, in my opinion.

So doing what's right for the patient isn't really important in your view?

Further in my opinion—and a whole separate topic can be started from what I'm about to say—a patient shouldn't have to pay more in an emergency because the ambulance personnel decided the patient should go to Hospital Y instead of Hospital X.

I agree 100%, but it's not the reality of the situation at the moment.

Finally, if I have to transport you an additional 15 minutes out, and have a 15 minute additional return to quarters time, for no real medically relevant reason, is the 30-minute loss of time available fair to the community I'm supposed to be serving?

So your more concerned with potential patients than the overall well-being of the patient who presents to you? This is why unit move-ups and mutual/automatic aid exist. The stress and anxiety over "how am I going to pay for this" (a very real concern to many people) is not going to be helpful. This is one of the big issues I have with viewing EMS through the "public safety" prism rather than the "medicine" prism.

Why should I "explore the world outside of MD"? I live in MD. I have no intention of ever moving out of MD. Knowing what Texas or South Dakota would do in a particular situation won't help me in that situation because I can only do what MD allows me to do.

Because one day you may be in a position to make policy.

I read this forum and I read JEMS magazine, and occasionally some sources. I read them with an attitude of "what can I learn", not "how are other jurisdictions better than mine".

Recognizing flaws is important in the QA/QI process.

Finally, I don't recall ever saying that MD EMS is the best EMS system. I think you're stereotyping me, assuming that because I'm in EMS in MD, I'm exactly the same as some other MD EMS people you've experienced. I know several other MD EMS people on this forum and they don't really fit your stereotype, either. Maybe your stereotype is flawed.

Like all stereotypes, it's by nature flawed. But your continual defense of MDs system makes you somewhat of a target.

 

[JJR512]

So the solution is to make the situation worse in the short term in a manner that would do nothing to generate a long term solution?

Can you explain how transporting a patient to the closest medically-appropriate facility is making the situation worse in the short term?

If there are two hospitals and both are equally medically suitable for the patient's needs, isn't going to the closer of the two, thus getting the patient to the care he or she needs sooner, the soundest medical decision?

Sure, when it saves you an equal 30 minutes of time holding the wall because the ED isn't waiting for the local IFT service to transport your prior patient to, when all things are considered, the most appropriate facility.

First of all, do recall that I already stated the patient is going to an appropriate facility. Therefore, when I bring the patient into the ED, they're already in the appropriate facility, and there is no medical reason for the patient to be transported somewhere else.

Secondly, we are not held at a hospital to wait for an IFT service to show up to transfer the patient from our stretcher to theirs. It just doesn't happen. I don't know if there are rules against that or if the hospitals around here just have too much common sense for that, but if that's the kind of thing that happens where you are, sorry for your luck. And now that your objection has been eliminated, the question remains: Is it fair to the community I'm supposed to serve for me to be unavailable for extended periods of time just because a patient had a non-medical desire to go to a farther hospital, when there was a closer hospital that was able to handle the patient's needs just as well?

Because what MD allows will never change?

If another jurisdiction is doing something better than you, shouldn't that be something that you would want to introduce to make your own system better?

Although some members here would vehemently disagree, MD can and does change. I've seen numerous changes to the protocols just about every year since I first became an EMT-B in 2006. But I am nowhere near experienced or knowledgeable enough yet to know what is better, nor am I in any position to introduce improvements. Maybe someday, but not now. And I can say with certainty right now that I will never automatically assume that just because some other state is doing it differently from Maryland, that they are automatically better, and again, I'm sure some people here will strongly disagree with that. But when people like that tell me it's stupid to believe that MD is always best (which I don't, nor have ever said), they fail to realize that it's equally stupid to believe that MD is always worst.

 

[Shishkabob]

Maybe if enough people get pissed at getting bills from hospitals because their insurance refuses to pay even though it's the most medically appropriate facility, congress will do it's job and fix the problems that really matter, instead of the ones that make them look good...???



Ha.. congress do it's job. I'm a comedian today.

 

[JPINFV]

Can you explain how transporting a patient to the closest medically-appropriate facility is making the situation worse in the short term?

Increased out of pocket costs. I'm not saying that a 911 unit in Maryland needs to transport a patient to San Diego, but if the in-network hospital is 10 minutes further away, then I find it hard to justify not transporting the majority of patients to their hospital of preference.

If there are two hospitals and both are equally medically suitable for the patient's needs, isn't going to the closer of the two, thus getting the patient to the care he or she needs sooner, the soundest medical decision?

It depends. Assuming the patient isn't in an immediate life-threatening state, if the patient is going to be transferred prior to admission, then how does transporting to the non-home hospital make a sound medical decision? If the patient wants to go to hospital B because that's what the hospital their primary care physician has practice rights at, then the sound medical decision is to transport the patient to his home hospital. The vast vast majority of patients are not suffering from a condition where an additional 10 minutes is going to change their outcome.

How is transporting a patient to a hospital where treatments may be denied due to insurance/reimbursment issues make a sound medical decision?

Where does increasing out of pocket expense for no medical gain make a sound medical decision?

First of all, do recall that I already stated the patient is going to an appropriate facility. Therefore, when I bring the patient into the ED, they're already in the appropriate facility, and there is no medical reason for the patient to be transported somewhere else.

Do you understand how insurance works? Are you seriously suggesting that patients are not transferred between hospitals for insurance reasons?

Secondly, we are not held at a hospital to wait for an IFT service to show up to transfer the patient from our stretcher to theirs. It just doesn't happen. I don't know if there are rules against that or if the hospitals around here just have too much common sense for that, but if that's the kind of thing that happens where you are, sorry for your luck. And now that your objection has been eliminated, the question remains: Is it fair to the community I'm supposed to serve for me to be unavailable for extended periods of time just because a patient had a non-medical desire to go to a farther hospital, when there was a closer hospital that was able to handle the patient's needs just as well?

No, you're going to hold the wall because some of the beds are inhabited by patients who need to be admitted and are waiting to be transferred to the most appropriate hospital for them, which includes issues like insurance. This isn't about your stretcher to another service's stretcher. This is about opening up a bed so that you can move your patient to the hospital's bed. Last time I checked, gurneys don't get doubled up with patients.

So, no, the comment has not been eliminated because you misunderstood the concern. Have you never had to hold the wall because of no beds available?

But I am nowhere near experienced or knowledgeable enough yet to know what is better, nor am I in any position to introduce improvements.

Damn, it must suck to not be able to talk to people who move and shake things, even though I bet they have this new fangled thing like e-mail that facilitates communication. Similarly, I feel sad that you feel you're incapable of gathering information to make suggestions. Heck, even asking, "Why don't we have/do ____" may plant the seed in someone who can directly effect change.

I don't buy the "I can't directly change anything, therefore it doesn't matter what I know or don't know" line.

And I can say with certainty right now that I will never automatically assume that just because some other state is doing it differently from Maryland, that they are automatically better, and again, I'm sure some people here will strongly disagree with that.

Because I so completely said that anything different automatically means that Maryland is wrong. :unsure:

 

[Sasha]

Cost can be a discouraging factor when a patient needs an ambulance but doesnt want to call because of the bill, especially when the ambulance wont take them to the in network hospital

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[JJR512]

Increased out of pocket costs. I'm not saying that a 911 unit in Maryland needs to transport a patient to San Diego, but if the in-network hospital is 10 minutes further away, then I find it hard to justify not transporting the majority of patients to their hospital of preference.
...
It depends. Assuming the patient isn't in an immediate life-threatening state, if the patient is going to be transferred prior to admission, then how does transporting to the non-home hospital make a sound medical decision? If the patient wants to go to hospital B because that's what the hospital their primary care physician has practice rights at, then the sound medical decision is to transport the patient to his home hospital. The vast vast majority of patients are not suffering from a condition where an additional 10 minutes is going to change their outcome.

Your talking about a financial situation. I'm talking about a medical situation. I'm an EMS provider, not a financial advisor. The patient called 911 because they believed they had an emergency need to get to the hospital. If the patient's medical condition is such that an extra 10, 15, or even 30 minutes in an ambulance is of no medical signficance, then in my opinion, they don't really need to be in the ambulance in the first place, and it would be cheaper for them to call a taxi or pay a friend some gas money to take them wherever they want to go. There, I just saved the patient a bunch of money (ambulance rides being much more expensive than taxis) and freed up valuable EMS resources in one fell swoop. Yippee!

How is transporting a patient to a hospital where treatments may be denied due to insurance/reimbursment issues make a sound medical decision?

In Maryland, by law, life-saving treatments cannot be withheld due to the patient's financial status or ability (or lack thereof) to pay. Period.

Now you may point out that you're not talking about life-saving treatments. Again, if the patient really has time to worry about saving some money, they should call a taxi.

Do you understand how insurance works? Are you seriously suggesting that patients are not transferred between hospitals for insurance reasons?

I said, "...there is no medical reason for the patient to be transported somewhere else." Let me re-emphasize part of what I said: "no medical reason". What part of me talking about medical reasons makes you think I'm suggesting something based on insurance reasons?

Personally, I feel that transferring a patient solely for insurance reasons is stupid. It costs more money to transfer someone by ambulance than it does to just treat them where they are, and insurance companies only willing to pay some doctors and not others is a big problem with modern healthcare. But that's a whole different topic right there.

No, you're going to hold the wall because some of the beds are inhabited by patients who need to be admitted and are waiting to be transferred to the most appropriate hospital for them, which includes issues like insurance. This isn't about your stretcher to another service's stretcher. This is about opening up a bed so that you can move your patient to the hospital's bed. Last time I checked, gurneys don't get doubled up with patients.

If I go to Hospital A and all, say, 40 ER beds are occupied, and 10 of those are people waiting to get transfered to other hospitals due to insurance reasons, then like you say, I'll have to wait. But Hospital B also has people waiting to get transfered for insurance reasons, too. If I had gone there instead, I'd still have to wait.

But what if all patients always go to the hospital of their (insurance company's) choice? I'd still have to wait. There would still be just as many people going to the ER. Whether the 40 people in Hospital A's ER are all in the right place or some are waiting to get transfered, they still have all 40 beds occupied, and I'm still going to have to wait for a bed.

So, no, the comment has not been eliminated because you misunderstood the concern. Have you never had to hold the wall because of no beds available?

Yes, and let me reiterate that it doesn't matter why the beds aren't available. If we eliminate those who should have (by your standards) gone somewhere else in the first place, those beds would be instead occupied by patients who are at that moment in other hospitals but should have gone where I am in the first place (by your standards). Either way, I'm waiting.

No matter how you cut it, time spend unnecessarily driving is time wasted, time I'm not available to my community.

Damn, it must suck to not be able to talk to people who move and shake things, even though I bet they have this new fangled thing like e-mail that facilitates communication. Similarly, I feel sad that you feel you're incapable of gathering information to make suggestions. Heck, even asking, "Why don't we have/do ____" may plant the seed in someone who can directly effect change.
You can take your sarcastic attitude and shove it. In deference to forum rules I won't say where.

For me, at this point, to think that I know any better than all those above me and before me is just plain arrogant. I watch and listen. I ask questions, including "why" and "why not". There's way too much I don't know and don't understand that to make a suggestion at this stage would be disastrous. I would get grilled on why is my suggestion better and I won't have all the answers because I don't even know what are all the answers I should have. And then I'd just look stupid.

 

[JPINFV]

I'm done. If you want to continue living in the fantasy world where insurance doesn't matter and the only thing people use the 911 system is for immediate life threatening conditions, then so be it. The rest of us, who live in the real world, realize that this isn't the case can continue this discussion.

Oh, and there's power in "why" and "why not," and someone who asks those questions can very easily get a reply along the lines of, "I don't know, why don't we do that?" Viola, the system is changed.

 

[Akulahawk]

Insurance is just ONE reason to select one hospital over another. Another thing to consider is which facility has the patient's medical records. That's usually the facility that the patient normally goes to, where their insurance is normally accepted...

Sure, the hospital might get patient records sent over, but how long will that take? What about you just transported someone to the closest facility and now the patient has to be transported to another one for "repatriation"... how does that improve a patient's care if you can take them directly to the requested facility in the first place?

A key thing to remember is that you should transport the patient to the closest, most appropriate, facility. This becomes more clear when dealing with specialty care facilities. Sure, that ED that's 8 minutes away can deal with that 35%TBSA burn patient... (they'll eventually send 'em out)... or you can transport that patient another 18 or 25 minutes to a designated Burn Center and bypass having the patient hold in a relatively poorly equipped ED for the next 2-4 hours for an available CCT unit...