Is Having More Ambulances The Solution?

[JaxSage]

The agency I work for does something that very, very few places in this nation do: we could legally deny a patient transport to the hospital if we do not think it is necessary. I don't mean that we try to talk patients out of going to the hospital, but that we could flat-out refuse to take anyone. This agency is just over thirty years old and from my understanding it has always had the authority to refuse pt. transport. Personally, I think it just makes sense for all 911 EMS agencies to have this authority. We're made for emergencies only, not to baby people and kiss their booboo's

EMS in general isn't a place that could offer sufficient coverage. People everywhere complain of a lack of ambulance coverage, EMT/medic shortages, long response times, etc., etc. The common solution offered seems to be to have more money to put out more ambulances. Probably would be a great solution if you had enough people interested in working for EMS. But as you know, there's a high turnover rate in EMS and not enough people are that interested in the field.

So, if it were up to you and you had to solve the issue of lack of coverage, how would you solve it?

[Dustdevil]

All of the above.

[spenac]

The agency I work for does something that very, very few places in this nation do: we could legally deny a patient transport to the hospital if we do not think it is necessary. I don't mean that we try to talk patients out of going to the hospital, but that we could flat-out refuse to take anyone. This agency is just over thirty years old and from my understanding it has always had the authority to refuse pt. transport. Personally, I think it just makes sense for all 911 EMS agencies to have this authority. We're made for emergencies only, not to baby people and kiss their booboo's

So, if it were up to you and you had to solve the issue of lack of coverage, how would you solve it?

Would you please post your protocol for denying patients that do not need transport? Thank you.

I would solve it by running and hiding. :shock: Just kidding let me see more money, more ambulances, just say no to taxi rides, I could go on and on.

[JaxSage]

Would you please post your protocol for denying patients that do not need transport? Thank you.

The interesting thing about our protocols is that they are more like "guidelines" rather than regulations, leaving us with the ability to make our own judgment. Our protocol for refusing patient transport is the same way. In a nutshell, we are allowed to refuse any person transportation as long as we consider important criteria such as mental status, chief complaint, age, vital signs, medical history, overall impression, etc., etc. When we refuse, we have to of course make sure that we clearly document why we refused a person transport. The only exceptions for refusing transport are minors who are not emancipated and infants under 6 months old. These we have to transport no matter what. If there is any doubt as to whether or not a person needs an ambulance, then we have to transport. Both partners must agree that transportation isn't necessary. Pretty much, it's about thinking for yourself and making the best judgment regarding refusing transport.

It's understood that not all emergencies are true emergencies. Some problems may need to be evaluated, but not all those problems require EMS transportation. For instance, someone with cancer doesn't need an ambulance. Someone who suffers from chronic pain doesn't need an ambulance. A person with a stroke DOES need one. Someone with a nasty foot fungus DOESN'T.

We also could arrange for alternative mode of transportation if a patient doesn't need a 911 EMS unit. Sometimes we call up a private service that is dedicated to non-emergent transportation. These are for patients who may need to see a doctor but aren't critical enough for an emergency ride.

[akroeze]

Just something to think about but it sounds like they are setting you up to take all the blame if something goes wrong. Without proper policies they can wash their hands of you.

[Just Plain Ruff]

is anyone alarmed by this other than me? To not have protocols but merely guidelines this sounds like if you haven't been caught with your service's pants down you will be, it's only a matter of time.

I know spenac will argue this but I'd be a little nervous about refusing to take someone to the hospital without a strict list of items that I have to complete. I'd also like to see the guideline.

I'd also like to see what the patient signs.

There are many patients I'd like to say - No I'm not taking you but until I get a list of items backed by the medical director to allow me to refuse transport I'm gonna shy away from this one.

[JaxSage]

Just something to think about but it sounds like they are setting you up to take all the blame if something goes wrong. Without proper policies they can wash their hands of you.

Not really. Whether we call it "rules," "guidelines," or even "suggestions," it's still protocol despite how strict or how loose it is. If we did something in accordance to protocol and something goes wrong, hey, it all falls on the medical director's head and the EMS director's head. We just simply did what they said we could do...or not do.

When I say that the protocols are seen more like "guidelines," I mean to say that it's recognized that treating a patient isn't always black and white. Ultimately, your best judgment will determine the best treatment for your patient as long as you're working within your scope of practice. For example, should you give everybody morphine for pain? Morphine is simply a comfort drug (unless used for pulmonary edema and such), and it's definitely not a necessity for survival if it'll be used only for pain control. It'll be up to you whether or not you want to give it. Under strict protocol, you might be COMMANDED to give morphine for pain control period unless there are some medical contraindications. Under our protocol, we'll make our own judgment as to whether or not we'll give it.

Under our protocol, we are allowed to cancel first responders, to downgrade or upgrade our response status, to clear C-spine, basically stuff that typical EMS agencies wouldn't allow their personnel to do on the job. We could put an IV anywhere in the patient as long as there is a vein, we could drill them with an IO needle, use central access lines, and arrange for alternative transportation to the hospital. We could determine whether or not to attempt CPR, when to discontinue CPR (under medical control's approval), etc.

What I like about our protocol is that it recognizes the power of pure common sense. Someone with knee pain that he had for years doesn't need an ambulance to the hospital. Calls that are simply nonsense doesn't require a lot of thought to determine whether or not an ambulance is needed. I think everybody could agree with that Now obviously not everybody is suited to make decisions to deny transport. This authority is for those who are competent in their skills, education, and judgment to make that bold determination to flat out deny someone transport. Unfortunately, there are draw backs to this. I have seen patients denied whom I thought should have been taken. I have seen medics rule out cardiac-related chest pain prematurely and denied pt. transport. Some people could get a bit cocky and make the mistake of refusing the wrong patient. NEVERTHELESS, I believe my system as a whole makes great decisions as to whom to transport and whom to deny.

On a typical day, we run about 16 ambulances for an entire county of nearly 300,000. On most days, we nearly run out of ambulances, and on some occasions we run out completely. We can't afford to take everybody to the hospital just to "be on the safe side." While we're messing around with a woman having menstral cramps, there's a person who's having a MI and there is no unit available for him. I know everybody is afraid of getting sued, but the best interest in the city as a whole is more important than worrying if some numbnut would take us to court for not taking his toothache seriously enough.

So, I'd much rather have a protocol that would allow for necessary adjustments than to have one that is so regulated that there is no room to think for yourself. I'm sure many of you would disagree with our protocol...but man, it feels good to know that when someone calls, you ain't got to always haul

[Just Plain Ruff]

funny, I can do everything that you said you can do. I can put an iv in anywhere that there is a vein, I can decide whether or not to c-spine someone, I can decide whether or not to RSI some poor chap and many other things. I can also spike and hang blood without a nurses OK.

Can you with 100% certainty say that all your paramedics are smart enough to know the difference that the knee pain that has been going on for weeks or years is not this time a blood clot?

Can you for 100% certainty say that the menstrual bleeding is not a miscarriage? Or one of the other pregnancy complications that I can't for the life of me think of right now.

I'm still leary of letting every paramedic in any system have the ability to refuse transport.

Let's discuss children now, child has a fever that started yesterday? Are you sure that all your paramedics in your system can differentiate between pneumonia or bronchitis, or RSV?

Sorry to disagree but I'm going to have to continually be leary of letting every medic in any system do this. The ones who are competent and educated can do this but by the logic that begs to happen here, can you be 100% sure that all your medics are as educated as you say you are?

just disagreeing

[crotchitymedic1986]

The answer would vary service to service, based on the issues that are unique to that service and geographic area:

1. If you have alot of low-acuity calls that do not require transport, you could add more BLS trucks, or ALS first responders to handle those calls and keep ALS transport units available.

2. Does your work schedule match peak call volume. Lets say you are running 10 24/48 trucks that all come up at the same time. Would you do better to shut down some of those 24 hour cars during the after midnight hours to put up some peak-time trucks during the day ?

3. Are you suffering because the hospital is too far away ? Could you use private ems to do the longer transports ?

4. Are supervisors being utilized to handle call-volume, or are the desk-jockeys.

5. Can you set longer response time parameters for BS calls. Who says everyone that calls 911 should get an ALS ambulance in 8 minutes. IF someone calls for the flu or stumped toe, why cant they wait 20-30 minutes for a non-emergent response ?

6. Can your service obtain free bus tokens from your transit authority. Hand the flu pt a bus token, and let him go to the hospital on his own ?

7. Should you embrace the non-emergent transports (convalescent), much like Fire has had to reluctantly embrace EMS calls to keep their budget alive ? The extra revenue could help, and allow you to have more ambulances on the road (it is more difficult for government agencies to do this, but often your competition is a fly-by-night sleeze service that may not have the intelligence to fight you in court).

Edit: Forgot one:

8. Are you maximizing your collections ? How many days do the bills sit before they are processed ? Are you getting all of the revenue you can / Lets say you are the average 911 agency that only transports 60% of your calls. If you upped that to 70%, could you improve your revenues: Lets say you run 20,000 calls, and average $200.00 collected for every call (average includes calls not paid, semi-paid, and fully paid). Transport 60% = 12000 calls transported = 2.4 million --------- Transport 70% = 14000 calls transported = 2.8 million

[spenac]

is anyone alarmed by this other than me? To not have protocols but merely guidelines this sounds like if you haven't been caught with your service's pants down you will be, it's only a matter of time.

I know spenac will argue this but I'd be a little nervous about refusing to take someone to the hospital without a strict list of items that I have to complete. I'd also like to see the guideline.

I'd also like to see what the patient signs.

There are many patients I'd like to say - No I'm not taking you but until I get a list of items backed by the medical director to allow me to refuse transport I'm gonna shy away from this one.

Well Ruff while I to enjoy the right to say no at one service, seeing some of the crap lately in the news that other EMS people have done I am beginning to swing more towards most really do not have the education or the common sense to work under such a weighty responsibility. Maybe we really all should just haul all callers even the one that just wants to go eat lunch. Hell I don't know anymore. I am disgusted with the things people in our field are doing. Sometimes makes me think I should give up and leave.

I also would like to see this posters form that they have signed when they deny transport as opposed to the patients refusing.