EMS based refusal of transport

[Just Plain Ruff]

Does anyone have a protocol they would like to share that allows your service to refuse transport to callers?

If you wish to share it with me privately please email it to ruffems@gmail.com

thanks

[FireMedic65]

Maybe EMTALA would be what you are looking for?

http://www.emtala.com/

[akflightmedic]

EMTALA applies to medical facilities not transport agencies (at least this is my understanding).

[tniuqs]

My protocol requires three "F___ O__'s" before I cancel.

[spenac]

Heres a generic one not from my service.

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

[croaker260]

I assume you are talking about EMS initiated refusals, not normal refusals or Treat and release with out medical control contact.

In otyherwords , us saying "we're not taking you, even though you want to go"

There is some research on this in various medical journals over the past 10 years and the results are not encouraging. Simply put, there are unfortunately limits to EMS assessment in the field.

Most of the stuff I have read over the years have indicated a fair number of ER visits, EMS recalls, and even hospital admissions (for serious conditions) with in 24 hours on patients who were in one form or another (AMA, refusal to transport, treat and release, what ever your term is...) left in the field.

Any refusal to transport policy is better written , implimented, etc with an alternative destination component.

In short, one should not "refuse to treat or transport" , but instead "refer to a more appropriate healthcare pathway". I'm not talking simple verbage, but Advanced practice paramedics (like Wake County's program), PA's in the field, Taxi vouchers to clinics, or other similar approaches are all safe, and IMHO BETTER, alternatives to simply EMS initiated refusals.

Edited May 14, 2009 by croaker260

[HERBIE1]

We cannot refuse to transport anyone who requests service. Obviously, if they endanger the crew, the police become involved but we cannot unilaterally decide we won't take them.

Just an FYI-

EMTALA does involve prehospital in some ways. If a crew does not properly hand off a patient to an ER- IE properly or inadequately notify a triage nurse, we can be held liable and that is an EMTALA issue.

[spenac]

We cannot refuse to transport anyone who requests service. Obviously, if they endanger the crew, the police become involved but we cannot unilaterally decide we won't take them.

Just an FYI-

EMTALA does involve prehospital in some ways. If a crew does not properly hand off a patient to an ER- IE properly or inadequately notify a triage nurse, we can be held liable and that is an EMTALA issue.

Yet there is no law federal or state that says an ambulance must transport all callers. 911 ambulances can not deny needed emergency care but they can say no to transport if the caller does not need it. Sadly to many take the lazy way and just transport all callers. I refuse to be used as a taxi. If after an exam if that stubbed toe is just a stubbed toe I will tell them they can not go by ambulance.

[VentMedic]

Yet there is no law federal or state that says an ambulance must transport all callers. 911 ambulances can not deny needed emergency care but they can say no to transport if the caller does not need it.

Not totally true. There have been several interpretations of EMTALA which have be applied to various state laws. This not only includes transport but also who has the ability to a screening exam. The ownership of the ambulance must also be taken into consideration and whether the patient is on hospital property. Thus, a blanket statment can not accurately be made for all situations.

Here is an example of one opinion that allows it under direct medical control.

http://www.ag.state.nd.us/opinions/2001/Formal/01-f-06.pdf

House Bill 1282 therefore permits an ambulance service to refuse to transport an individual

to a hospital only after it has been determined by a physician who is providing direct

medical control that the transportation of the individual to a hospital is not medically

necessary. This implies that the individual desiring transport must be examined by the

ambulance crew and a physician must be consulted before the individual is refused

transport.

Edited May 14, 2009 by VentMedic

[NOMedic119]

We can only refuse transport to someone during a state of emergency where only absolutely only seriously injured go to the hospital. During this time not even suicidal people doesn't get transported. but in normal situations we transport all who request transport. in Urban EMS there are lots of folks trying to find any way to sue EMS so by refusing EMS transport opens us up to litigation so we just transport.