What is an acceptable refusal/no transport percentage

[TechMedic05]

If the AMR model is right and you only kill 1 out of every 100 that refuse (1%)' date=' that number can sound reasonable. But if you are running 50,000 calls a year, that equates to 500 patient deaths. quote']

I understand where you're coming from, GA - However your numbers are flawed. If you run 50,000 calls a year, not every call will be a non-transport. Even at, say, 25% non-transport/ AMA, your number should be [50,000 * 25%* 1%] about 125 patients.

I just saved 375 lives.

So may I now sign off people after midnight?

I believe more issues lay at certain individuals and playing number games than letting people 'sign off'.

If someone is sick, or even remotely needs to go to the hospital, I will bend over backwards to get them to go to be evaluated. I do believe also that there are patients we see who do not need to be evaluated. It's not every patient, but they're out there. Why not let them sign off?

[whit72]

GAmedic wrote:

How do you know that your employees educated the patient properly, and did all that they could to get an AMA patient to go to the hospital ? Is what the patient is being told consistent, by all crews, and at all times of the day or night

We cant, you just have to hope that the people you put in place reflect the practices you desire. The ones that don't need remediation or removal. This like any other field isn't perfect however our mistakes are magnified due to the consequences that could arise from our actions or lack of action in this case.

[TechMedic05]

GAmedic wrote:

How do you know that your employees educated the patient properly, and did all that they could to get an AMA patient to go to the hospital ? Is what the patient is being told consistent, by all crews, and at all times of the day or night

We cant, you just have to hope that the people you put in place reflect the practices you desire. The ones that don't need remediation or removal. This like any other field isn't perfect however our mistakes are magnified due to the consequences that could arise from our actions or lack of action in this case.

Three weeks ago I'd have never thought I'd say this...but.

Whit, I agree with you.

We can't assume that what patients are being told is consistent. Does it need to be consistent? As long as everyone covers the absolutely required minimums by your services...for example - What to look out for, multiple attempts to convince for tx, contact primary physician, and to call EMS back if worsens/ reoccurs. Granted, they need to be consistent in those aspects - but if I want to explain "Your wrist will hurt for a few days" and my partner Ace tapes 13 articles about calcification of bones, bruise formation, internal bleeding, and the possible differential diagnosis of potetially undiagnosed carpal fractures - that's fine. But not truly 'consistent'

All in all, Be smart, stay clean, and CYA.

[whit72]

Techmedic wrote:

I do believe also that there are patients we see who do not need to be evaluated. It's not every patient, but they're out there. Why not let them sign off?

I agree with you totally, I go to mva's all the time where bystanders called 911, there were no injuries they sign and there on their way. We come in contact with people who never called 911 it was called in by someone who witnessed something. If they have no complaints, they sign off. I just don't talk anyone who wants to go, out of going.

Our policies on refusals are simple you still have the fill out the paperwork, plus a refusal, so in many cases I would rather just take them. I think that was the reasoning behind the policy. It also may eliminate multiple call backs at the same address. My transports also do not take 2 hours, I can be done with a call from start to finish in 30 mins especially if its bullsh*t. If your call takes 3 hours to do people may be more inclined not to transport a pt without a true emergency. I cant speak on that, I have no experience in that situation.

[Ridryder 911]

Just like in the Emergency Rooms when people leave, do you think they are warned on every potential ?.. Heck no. Let's be realistic, I have worked in ER for over 16 years, and as of yet to tell them when the time limit is to be sutured (by the way facial and other dermal areas are different, and is that knowledge in the EMT/P curriculum? Giving medical advise can be a problem as well, and can cause more litigations, than refusals). A blanket statement is given such as " You could have potential life threatening injuries that we are not able to foresee, the worse case scenario is death, infection, and other associated complications." I recommend being evaluated by a physician. Period.. paralysis can be substituted if applicable.

I always give the same statement every time when AMA or actually patient refusal, which is not the same thing! I even had this tested in a a court case against a physician. The patient AMA from ER and later died with an AMI. Family sued stating they did not know the risks, on my paper work, I again stated previous statement, and patient signed with family witness.

Did not make into court... after attorney seen "death" as risk (always considered wost case) it was a no brainer.

Yes, document the heck out, but at the same time use words wisely, and appropriately. Never leave anything out, but as well, don't fence yourself in a situation as well.

R/r 911

[vs-eh?]

Just to comment on the Toronto EMS stats...

Speaking from personal experience, 9% non-transport does seem pretty accurate. I think Toronto (or any large American city) would be a good model for analysis of refusal or non-transport. The non-transport numbers are absolutes for EMS transport as well as Toronto EMS is the only service that transports 911 patients. Varying non-transport rates will likely vary depending on what area of the city you are in as well (my opinion).

There is a difference however between refusal and non-transport. Refusal is where a patient is assessed (hopefully) and given the option of transport, but refuses and a signature is obtained. Non-transport could be many scenarios, HBD walked away, no patient found, police canceled/transport, fire canceled (us off a fire), call concealed prior to arrival, etc... That could skew numbers if it was incorporated. On an average shift (5-6 calls) I would say at least 1 falls into the refusal/non-transport category (at least one).

I find it very very very hard to believe services have numbers of 50% and 36% refusal/non-transport rates, unless, as said before, they are "handing" patients off to another transport service. The patient is still going to the hospital by ambulance, just not theirs. We don't have that option here though...

[GAmedic1506]

Thanks for the percentage correction, yes that was a brain fart -- but anything over "1" is scary. As far as consistency, we did find some variances among staff, especially among diabetics. Some were telling the patient to use a sliding scale, some were telling them to recheck blood sugar every 30 minutes, every hour, every four hours -- some gave no instruction other than "let your doctor know what happened". Child with fever was also concerning in that this was the category where a patient was most often told they could see their personal physician versus going to the ER. Many medics felt it safe to assume that the patient had OM, but without the ability to look in the Ear, or run a CBC, or r/o pneumonia with a chest x-ray, we found that we needed to change this practice.

About the statisics, in the south, for whatever reason, we tend to roll all no transports into the refusal category. I think we have a false sense of lawyer-proofing ourselves if everyone signs a refusal. I know of a few departments that have a "not needed" category for the minor stuff, but the vast majority have the patient sign a refusal. This might be why some are so confused over my 50% quote. Maybe I should have asked everyone to divide the total number of patients transported by the total number of calls, as it is obvious that we all categorzie the ones who were not transported differently. I seriously doubt that any 911 service is transporting 90-100% of patients seen, but maybe its different in Canada. Maybe we should start there:

FOR YOUR SERVICE, WHAT PERCENTAGE OF 911 PATIENTS SEEN, ARE TRANSPORTED BY AMBULANCE TO THE ER ? If this formula doesnt work for you, what formula would you prefer to use, so that we are all comparing apples to apples ?

[vs-eh?]

Maybe I should have asked everyone to divide the total number of patients transported by the total number of calls, as it is obvious that we all categorize the ones who were not transported differently. I seriously doubt that any 911 service is transporting 90-100% of patients seen, but maybe its different in Canada. Maybe we should start there:

FOR YOUR SERVICE, WHAT PERCENTAGE OF 911 PATIENTS SEEN, ARE TRANSPORTED BY AMBULANCE TO THE ER ? If this formula doesn't work for you, what formula would you prefer to use, so that we are all comparing apples to apples ?

You have already seen the percentages for Toronto EMS. A city of 4-5 million people (depending on the day) and a call volume of 350,000+ per year. All calls are handled by one municipal service, there are no other ambulances period that do 911 calls in the city.

I can't give an exact formula because I have no idea of actual numbers, I can only speak of experience and extrapolation.

The 9% patient REFUSAL, I would deem as accurate (and obviously it was as close as possible for the study). This is a patient being explained risks, being assessed, etc...and having to sign a form which is usually witnessed by another person. It should also be noted that Ontario uses a standard ACR for the entire province, which includes cancellation criteria on the back.

Now doing a call and NOT TRANSPORTING a patient is different and lumps in to the above, with obvious examples that I made in my previous post. These percentages will obviously be higher and as I said I would wager one out of every 5-6 calls is a non-transport (say 16% or roughly double refusals). This of course is going to vary depending on where you work in the city. Obviously those who work in the downtown core, rather than outlying areas are likely to have an increased percentage of certain types of calls and inherently a higher percentage in the grouping of NON-TRANSPORTS.

Whatever...using stats of 36% and 50% just leads to controversy and things have to be separated and variables stated in order to justify said stats.

[hfdff422]

But what are the out of pocket expenses for a patient in Toronto? In the US, it could be up to the entire bill, depending on insurance.

[GAmedic1506]

Yes that does seem low, compared to the US. I wonder if due to Socialized Medicine, the Canadians may not abuse EMS and the ER for routine low-acuity medical problems as much as they do in the US ? Or if ambulance is covered by socialized medicine, is the expectation that the ambulance is supposed to transport everything. Can you comment as to what % of your calls are "ambulance was really necessary", they couldnt have went by other means ? Or could you comment on the differences that socialized medicine (sorry if i am calling it the wrong name) makes to EMS.