Refusing to transport???

[Handsome Robb]

Are you sure you want Linuss writing your MD?

Meh, why not? Is there something I don't know? Did I make an *** of myself and make Linuss not like me? :unsure:

 

[ffemt8978]

Meh, why not? Is there something I don't know? Did I make an *** of myself and make Linuss not like me? :unsure:

Not that I'm aware of...I just wasn't sure Linuss would be the most credible source of info. :rofl:


I kid. Maybe a MD to MD letter would carry more weight than an out of state medic to MD letter.

 

[Shishkabob]

I was actually going to recommend your MD speak to my MD (well.. DO ) as he has the specifics I don't. I just know we do it.

But NOOOOO... ffemt has to steal my thunder, insult me and beat me to it! I see how it is!

 

[Melclin]

Haven't a few members on here worked at agencies that have refusal of transport protocols for their providers?

While we technically cant refuse to take people to hospital because of wording in the ambulance act (as is my understanding at least), we certainly don't take people to hospital if its not necessary.

I think the language is all wrong in this kind of discussion.

As I've said before, some decent research done here has suggested that people in our system call 000, not because they think they are having a medical emergency or that they need to go to hospital, but because they lose the ability to cope with a situation that is healthcare related. We turn up and either we cope with the situation or we help them too do it themselves. Taking a person to hospital is one option but its not predominantly why people call. Often at the end of a discussion with a pt they ask, "So what do ya reckon? Do I need to go to hospital?" I summarise their situation, give them their options and give them my own recommendation and help them to make a decision.

All the language used here is so adversarial. I'd like to think that I discuss the need for hospital with pts and we come to a consensus about what is best for them, generally both we and the pt are happy.

An exception might be those problems callers who don't need us or an ED but call 3 times a day. They go every time for various logistical reasons. But then how they are dealt with in the long term, things like how and when and on what priority they will get an ambulance in the future is managed at a higher level. Psych and ?OD pts are almost always transported too, on account of the complex nature of psych issues and the need for more expert and in depth assessment. Most kids go as well, but that is a personal thing because I don't see enough kids, nor do I have sufficient paeds expertise to feel comfortable making those decisions.

 

[bw2529]

I don't know at what level the rule comes from, but at my volunteer agency in NYS (MLREMS), you call: we haul. Patients can refuse transport, in most cases, but if they want to go we have to take them. It may be possible to get medical control to direct us otherwise, but I've never heard of that happening. Our techs always tell people "Our position is always going to be if you had a problem that you felt warranted calling 9-1-1, you should go to the hospital." In order to sign someone off we have to go through a whole spiel about how the patient could die a horrible terrible death if they don't let us transport them.

My agency pays by the transport, and normally only bills if we transport, so in most cases everyone wants a transport to happen (the pt., the crew, and the agency). I feel very fortunate when I say that we don't really have an issue with resources. We have a lot of volunteers, and three well stocked rigs (most of the time only one is out at a time).

 

[MedicBrew]

And that's how many of the dinosaurs see it,

Dang I'm not even 40 yet

Plus, you know what can be done while talking to the patient? EDUCATION! Educate them on their concern. Then you probably save yourself repeated calls in the future, and actually HELP your patient.

Seems a little presumptuous to draw that conclusion from a simple forum post?


As far as our earlier discussion, as promised I did further research and ……… are you ready???

Linuss you are correct!! I grovel at your feet.

I contacted our area State rep and spoke with him about this topic. His reply was that it is covered under the “Duty to Act” clause. There is no direct statue that precludes provider initiated refusals, but he did advise against for similar reasons I stated prior.

So,

When I’m wrong, I say I’m wrong.

I stand corrected sir.

 

[Tigger]

My agency pays by the transport, and normally only bills if we transport, so in most cases everyone wants a transport to happen (the pt., the crew, and the agency). I feel very fortunate when I say that we don't really have an issue with resources. We have a lot of volunteers, and three well stocked rigs (most of the time only one is out at a time).

Transporting someone because it gives an agency the right to bill is terrible reasoning for transporting everyone. Fear of litigation is at least something that is often brought about by lawyers and not the agency itself. EMS agencies are charged with serving the public, not taking everyone who calls to the hospital. It is a complete breach of the citizens' trust to transport everyone for the sake of what amounts to fundraising, sadly this unfolds every day all over the place.

 

[ShannahQuilts]

It would make a difference in my decision-making if I felt that by giving someone an "unneeded" transport, I would be potentially denying help to someone else.

In a situation with 3 rigs and only one out at a time, usually, I would be a lot more keen to transport than in a situation where resources were a lot more scarce.

I think that, in situations where you have people who don't know what they are doing making requests (the patients, usually), the best you can do is use your judgment, follow any rules you need to, and just hope you don't wind up on the wrong side of a lawsuit.

I do wonder, though, if it sounds a lot more scary than it really is. I wonder what percentage of requested transports (whether the patient is transported or not) result in a lawsuit. Isn't that pretty vanishingly rare?

 

[Tigger]

It would make a difference in my decision-making if I felt that by giving someone an "unneeded" transport, I would be potentially denying help to someone else.

In a situation with 3 rigs and only one out at a time, usually, I would be a lot more keen to transport than in a situation where resources were a lot more scarce.

I think that, in situations where you have people who don't know what they are doing making requests (the patients, usually), the best you can do is use your judgment, follow any rules you need to, and just hope you don't wind up on the wrong side of a lawsuit.

I do wonder, though, if it sounds a lot more scary than it really is. I wonder what percentage of requested transports (whether the patient is transported or not) result in a lawsuit. Isn't that pretty vanishingly rare?

It should not be the field provider's job to determine the allocation of ambulances to a region. You have one patient and that's the one in front of you. Potential patients don't count, you provide the best care for the patient that presently exists. If you think they need to go the hospital because that's how they get the best care, then they go to the hospital. If taking them to the hospital is not getting them the best care, then you don't take them. It's that simple.

 

[bw2529]

Transporting someone because it gives an agency the right to bill is terrible reasoning for transporting everyone. Fear of litigation is at least something that is often brought about by lawyers and not the agency itself. EMS agencies are charged with serving the public, not taking everyone who calls to the hospital. It is a complete breach of the citizens' trust to transport everyone for the sake of what amounts to fundraising, sadly this unfolds every day all over the place.

We don't force anyone who doesn't want to go to go.

 

[Shishkabob]

We don't force anyone who doesn't want to go to go.

Okay... but how many people go because they think that since EMS was called, they have to?

How many goes because they think that going by EMS is the quickest way in to the ER?

How many goes because they think EMS is registration for the hospital, and that to be seen, you have to go by ambulance?




Do you educate the people, or do you say "Hop on, what hospital do you want to go to?"

I've noticed something... the way you phrase your transporting of them either increases or decreases the likelihood of transport. My partner, who's been doing this for 20 years, says "What hospital are we taking you to?" I ask "Would you like us to take you to the hospital?" I get so many more people refusing transport then he does. When you give someone the option, they will decide for themselves, rather then thinking that they HAVE to go. When they realize that they DON'T have to go by you, they ask what their options are, and what you, the educated professional, thinks is best.

 

[46Young]

And that's how many of the dinosaurs see it, but that doesn't make it right. You then cost the ER a bed, hospital wasted personnel time, insurance companies wasted money, Medicare and Medicaid wasted reimbursement, and the average person higher taxes and insurance premiums.


Hence why some of the most progressive agencies are doing at home care and/or provider initiated refusals... and actually getting good publicity from it and its savings for the general public, both in money and available resources for more legit concerns.

My department has failed to see the benefit to provider initiated refusals, home care, triage over the phone by a nurse, etc. What I've been told is that we can curb the 911 volume by doing these things, but then that recduces our revenue. Same for the hospitals. They don't want to fund or initiate any of these measures as that will similarly reduce their revenue. I work in an affluent, predominately young county, so many of our residents have commercial insurance, and most of the remainder have Medicare.
Also, unless things have changed in the last 4+ years, when I worked in the NYC 911 system, we were legally required to transport anyone that requested it, no matter the reason. Not transporting someone could get us fired in a hurry. NYC providers are extremely litigation phobic, and will take the easy road to guard against any liability.

I know many of us are geeked up hearing about Advance Care Paramedics, provider initiated refusals and all, but this simply isn't a reality in many areas due to lack of vision by the powers that be.

 

[46Young]

Transporting someone because it gives an agency the right to bill is terrible reasoning for transporting everyone. Fear of litigation is at least something that is often brought about by lawyers and not the agency itself. EMS agencies are charged with serving the public, not taking everyone who calls to the hospital. It is a complete breach of the citizens' trust to transport everyone for the sake of what amounts to fundraising, sadly this unfolds every day all over the place.

Agreed, but how would you suggest I change the minds of my department and the area hospitals, whose priorities are protecting revenue and preventing lawsuits? How would this change be beneficial to them? They need a really good reason, or it will continue to be business as usual.

 

[Sasha]

We don't force anyone who doesn't want to go to go.

Not true! Psychs and demented patients!

 

[46Young]

Okay... but how many people go because they think that since EMS was called, they have to?

How many goes because they think that going by EMS is the quickest way in to the ER?

How many goes because they think EMS is registration for the hospital, and that to be seen, you have to go by ambulance?




Do you educate the people, or do you say "Hop on, what hospital do you want to go to?"

I've noticed something... the way you phrase your transporting of them either increases or decreases the likelihood of transport. My partner, who's been doing this for 20 years, says "What hospital are we taking you to?" I ask "Would you like us to take you to the hospital?" I get so many more people refusing transport then he does. When you give someone the option, they will decide for themselves, rather then thinking that they HAVE to go. When they realize that they DON'T have to go by you, they ask what their options are, and what you, the educated professional, thinks is best.

When it appears early on that the pt will need an ambulance and the hospital, we will ask if they want to go to the hospital, so that we can move to the ambulance and begin any invasive therapies. Usually, if it's bullcrap, we can identify that pretty early on, and the question will instead be, "What would you like us to do for you?" Sometimes we can explain how an urgent care or private MD visit "or even a call to the local Pharmacist is more cost effective and appropriate for them." The problem is, department S.O.P.'s and our EMS manual mandate that we tell them we're always going to recommend transport (officially), no matter the situation. All this other stuff is explained off the record.

 

[Tigger]

We don't force anyone who doesn't want to go to go.

Well I should hope not, otherwise you'd be running afoul of those pesky kidnapping and false imprisonment laws.

The public trusts you to decide for them whether or not they need to go to the hospital. Whether or not that trust is misplaced is an entirely different matter, but the point still stands. If someone is wishy washy on whether or not they want to go (remember it is their choice most of the time), and you say "we'll take you to the ER for 'precautionary testing,'" when you really mean "we'll take you to the hospital and then bill you/your insurance," you are doing your patient a disservice.

Agreed, but how would you suggest I change the minds of my department and the area hospitals, whose priorities are protecting revenue and preventing lawsuits? How would this change be beneficial to them? They need a really good reason, or it will continue to be business as usual.

I'd be the first to admit that my argument is completely shredded by elementary economic theory. It will not protect revenue, and it's possible that an increase in litigation ensues. It's business as usual at 99% of EMS agencies nationwide. When healthcare is a for-profit system, it only makes sense to see as many patients as possible, even when the patients should not be patients in the first place. It's a universal theme. Those places that are "progressive" are likely taking a loss by being so. Reducing overall system costs does not generally translate into profit.

 

[46Young]

I'd be the first to admit that my argument is completely shredded by elementary economic theory. It will not protect revenue, and it's possible that an increase in litigation ensues. It's business as usual at 99% of EMS agencies nationwide. When healthcare is a for-profit system, it only makes sense to see as many patients as possible, even when the patients should not be patients in the first place. It's a universal theme. Those places that are "progressive" are likely taking a loss by being so. Reducing overall system costs does not generally translate into profit.

The only entities that would benefit financially right away would be the insurance companies, and Medicare/Medicaid. I don't see them funding or otherwise subsidizing Advance Care Paramedic programs, or anything else mentioned earlier for that matter.

Perhaps in a densely populated area with many patients being uninsured or at most on Medicaid, the municipality and the hospitals could see a benefit by not treating some of these patients, since these are uncompensated/undercompensated billing events.

 

[ShannahQuilts]

It should not be the field provider's job to determine the allocation of ambulances to a region. You have one patient and that's the one in front of you. Potential patients don't count, you provide the best care for the patient that presently exists. If you think they need to go the hospital because that's how they get the best care, then they go to the hospital. If taking them to the hospital is not getting them the best care, then you don't take them. It's that simple.

I was thinking in terms of situations where it wasn't so clear cut. I've read a lot of comments by experienced folks who seem to think that not every case is obviously either transport or don't.

Sure, if someone clearly needs transport, I'd do whatever I could do to get them that transport. I also know there are cases where it's a judgement call. Or even an educated guess.