Does your agency review patient refusals?

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Yes we do.  We do 100% peer audits everyday.  Every morning the oncoming shift audits all of the runs from the previous shift.  The only runs that are not audited are no patient runs (i.e, disregards, false medical alerts).  We have a standardize form, and if we feel it is needed we can forward to our manager, or directly to the medical director.  We send runs to the manager if there is a problem with procedure, or paperwork.  If the problem is with patient care it gets sent to the medical director.

Seth Kirkendall, NREMT-P

Paramedic Supervisor

Clinton County EMS, Indiana

More importantly - we have a philosophy and a policy that says that we will not discourage patients from being transported.  Any patient requesting transport will be transported.

Skip, 

I'm surprised that you would not throw the caveat out there of "under the current model of care" in there, without exploring the opportunity for for EMS to better partner with heath care systems and payors to better access more appropriate mechanisms of care than the ED. While I grant the point that most paramedics and EMS systems are far from the point of being able to refuse to transport (and that many medics erroneously encourage self transport or not pursuing further care), by not working towards being a part of the solution to a significant problem, EMS is missing out on a great opportunity to be a part of improving access to better chronic and primary care resources. 

Some states are currently limiting the number of ED visits for Medicaid recipients, many other states are increasing the roles of managed care in their Medicaid programs. Many Medical Service Organization's (Large physician practices) have expanded their services to provide non emergency transportation to their medical centers, and many are experimenting with longer office hours. Some managed care companies are even piloting in home physician visits for ultra utilizers to decrease unneeded ER utilization. 

Given a change in the model, there most certainly are ways for EMS to better deliver patients to the health care system (and deliver better value for services rendered) than simply transporting lower acuity cases to the ED. Yes, there is some risk that will have to be well managed, well QA'd, but given some of the things we already consult physicians about and do in the field there are some better options. 

If we are willing to step up, change our model of care, and think a little outside our current box. 

I don't disagree at all that the model needs to change.  However, we need to work in the current model, well, or nobody will trust us to do the new and better things going forward.

Right now, as the system exists, there is NO ONE who must see the patient except the ED.  We can't (even if we were trained to do so, but we are not) tell people to go to places that won't let them in the door because of lack of insurance or cash.  And paramedic school includes ZERO minutes of training on how to make those decisions, so is there any doubt that the research shows that we "get it wrong" an unacceptable proportion of the time we try it?

When we have protocol-driven patient navigation, AND we have paramedics who are educated in the navigation of the health care system, then we can talk about doing something but transporting.

Or, if we can't get our heads around that, we can give the keys to the nurses and PAs, who DO have the knowledge and skill to make those decisions appropriately. 

The model is already changing.  Example: A year ago when I left GEMS in Atlanta we were already transporting some patients to clinics.  

I can see this both ways.  Its good to have an example of an agency providing a model for improving care (like Wake County did for hypothermia). Someone going above and beyond the norm.  Someone to look to when evaluating how to change your own service...  Just because its not in the "normal" model does not make it inherently a bad idea.  We work pretty well in the current model, but there are those out there trying to help fix the problem without the needed training.  That's more the agency's fault than the employee's.  The employee is seeing the problem, and trying to do what they think is best for the patient (not taking them to the ER unnecessarily). 

On the other side of things, if we start easing the burden off the ER's and fixing the problem for free or for a loss, then we shoot ourselves in the foot...  The squeaky wheel gets the oil...  Or in this case, the money.  Its a problem we can fix, we just need to do it in a way that has long term sustainability.

To the original question posed in the thread.  Yes.

The trick is "replicability."  You can do what Grady was doing when you own both the primary care capacity and the ambulance - but that is not the case most places.  The other questions that must be answered are "safety" and "reliability."  I'm looking for the articles in the peer-reviewed journals that show that folks who are playing with this stuff on a small scale are looking at the outcomes and honestly evaluating what they are doing.

The "employee seeing the problem and trying to do what they think is best for the patient" is flat dangerous - it's called "free-lancing."  If those decisions are made by individuals not qualified by training, and not authorized by protocol, all will be fine, until something goes wrong. Then it will be called "outside the scope of practice" and "not according to protocol" - and the medic will be hanging by himself.  Here's the case of Fraley v Griffin, http://caselaw.findlaw.com/nc-court-of-appeals/1594518.html.  This medic is all on his own, the county cut him loose and he is the only defendant, in this wrongful death suit.

If you're an ambulance medic, don't free-lance.  "Fixes" like these must be done on a systematic basis.

I do agree that GEMS is in a unique position to provide this type of care.  I would also say that most agencies that are heavily supplemented by tax payer money, are also in a position to be able to provide this type of care.  I believe this is the EMS model of the future. I also agree that we need to make this change in a way that is measured and proven.  

Agreed, it must be done within a protocol.  The point I'm getting at is that there already appears to the the desire among providers to do what's best for the patient and the community by avoiding unnecessary transports to the ER.  It would make sense for agencies to look at providing training and protocols to those providers. Then measuring the results of those care plans to help the provider provide the best care possible.  I dont think you'd disagree that the best care for the patient is to stay out of the ER unless necessary.  Im not advocating going outside protocols with out consult, Im advocating agencies looking at the obvious problem and trying to address it.  An employee that always tries to do what's best for the patient is admirable.  Suppressing this quality should be avoided.  I would say that the agency needs to look at how to put the right tools in the providers hands to help them do whats best for that patient.  They just need to do it in a way that limits unnecessary liability.

Skip Kirkwood said:

The trick is "replicability."  You can do what Grady was doing when you own both the primary care capacity and the ambulance - but that is not the case most places.  The other questions that must be answered are "safety" and "reliability."  I'm looking for the articles in the peer-reviewed journals that show that folks who are playing with this stuff on a small scale are looking at the outcomes and honestly evaluating what they are doing.

The "employee seeing the problem and trying to do what they think is best for the patient" is flat dangerous - it's called "free-lancing."  If those decisions are made by individuals not qualified by training, and not authorized by protocol, all will be fine, until something goes wrong. Then it will be called "outside the scope of practice" and "not according to protocol" - and the medic will be hanging by himself.  Here's the case of Fraley v Griffin, http://caselaw.findlaw.com/nc-court-of-appeals/1594518.html.  This medic is all on his own, the county cut him loose and he is the only defendant, in this wrongful death suit.

If you're an ambulance medic, don't free-lance.  "Fixes" like these must be done on a systematic basis.

Within reason, I agree with you.  The problem is that until the health-care system undergoes MAJOR changes, there is no alternative but the ED.

What the research has shown is that medics do not make the right decisions when given the ability to do so.  An error rate of 20% or more is not acceptable.  It appears (reading the lawsuits and such) that the medics who get in trouble make their decisions not on the basis of clinical assessment, but on "other factors" that border on discriminatory - socioeconomic status, medic level of fatigue, hour of day, neighborhood, etc.  This is not a simple training issue - this is an issue that involves the ethics and values of whole EMS agencies and EMS systems.  Until we can get medics to "put the patient first" and stop simply trying to reduce their own workload, there can be nothing but trouble out there.

If you can build in mechanisms to take out the temptation to engage in "workload reduction" then we may have a place to start.

So are the errors made by those medics medical knowledge (training) failure or failure of compassion and moral / ethical values?  It seems what you're saying is that these cases come not from lack of education but from lack of good moral thought processes.  

I dont think the temptation to engage in dangerous workload reduction can be eliminated.  Ever.  Thats part of the problem of using humans instead of machines :)  

I think probably both.

There is something unique about some EMS providers.  Most people go to work, they expect to work through their shift, with perhaps a couple of breaks and a meal.  Some EMS folks seem to feel like "a call" is an interruption of what they are supposed to be doing (whatever that is).  Then we pass judgment on the "merit" of the call, and if the person doesn't meet our "severity standard" that shows that they patient is "worthy of our attention" - then the compassion machine turns off and we intimidate or discourage the patient from being transported.

It you're suggesting that people generally are so hopelessly lazy that they can't learn that their job is to provide compassionate care to all, well - - I sure hope that is not correct.

Im not saying that I think most people can be assumed to be generally lazy.  I do think many people are pretty lazy...  

What I was referring to is that humans have feelings and emotions (which can be enhanced by lack of food).  Some of those feeling will involve the desire to slack off.  Machines just keep going.  But thats really off topic.

Ones' mood surely can be influenced by lack of food.  But whether you're a medic on duty, or soldier in combat, or a cop on the beat, a pro will recognize when he or she is getting hypoglycemic and do something about it.  The ever-present cereal bar or power bar in the pocket should handle that trick!

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