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.


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 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,  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.

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.

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!

You can.  It's called:  building a better machine that reduces the workload.  

Even combat soldiers get fatigue and get pulled from the line.  During the battle, perhaps not.  But they do get pulled off the line and given R&R, leave, and other things that help them decompress, relieve stress, and be ready to do their jobs again.  In EMS, you're told "...if you don't like it, find another job."  I must disagree with you on another point.  A "PRO,"  just like a combat soldier, DOESN'T always recognize whether he or she is "getting hypoglycemic" (speaking figuratively).  Very often, others will recognize it first, and the one so affected won't realize how bad it was until they're removed from the situation.  A good manager, be it a First Sergeant, a Company officer, or a Line Supervisor will recognize it and intervene in a way that allows the affected individual to still be productive later on, while mitigating the present crisis.  

A machine won't.  A machine will go on until it breaks, instead of preventing the break in the first place.  Human element is human element, whether it's customer, or service provider.  History has proven that time and again.   

Skip Kirkwood said:

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

I'm not sure the "combat soldier" analogy works for me.  Combat soldiers don't work shifts, and don't get days off.  There are very few EMS organizations where medics run from call to call with no down-time in between.  Also, in EMS, we don't work in groups, with the regular presence of a supervisor.  It's you and your partner.  So, you've got to take care of yourself, and look out for your partner.  And if you don't feel well, say something, and take care if it.  And (being a diabetic I have learned) you can "take care of the machine" by providing preventative maintenance at regular intervals (like eating a bar or fruit between events).

Of course we need to take care of each other.  But I'm still caught up on the "excessive workload."  There are few EMS agencies where the UHU is 1.0, or even close.  There is down-time between calls.  And payment (for most companies) is piecework - no production (calls >> transports), no income.  What happens then?  If you reduce workload, many agencies go out of  business.  Is that in our best interests?  Or do people really sign up because they believe that EMS should mean "earning money sleeping"?

It was your analogy, so I ran with it!

.....Yeah!  We find ourselves discussing that one a lot, don't we?  LOL! 

To get back to the thread, my jurisdiction reviews every refusal at the Field Supervisor level--every one of them.  Like many folks, we feel it is just as much of a critique of our services as it is of our providers, and it's a great way to catch negative trends, commonalities, and to keep an eye out for "frequent flyer" patients who may, in fact,  be missing out on medical care they truly need, but don't get.  

To be sure, this area seems to be most commonly the subject in class that students are most likely to SLEEP THROUGH because they feel "it doesn't help us save lives," because they don't regard this topic as important because it's not a skill, or otherwise, something tactile they can "do" to a patient.  This is sad, because if you don't know what you're doing, you can not only hurt your patient, you can hurt yourself, your colleagues, and your organization.  

Skip Kirkwood said:

I'm not sure the "combat soldier" analogy works for me.  

.......  But I'm still caught up on the "excessive workload."  

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