Hostname: page-component-848d4c4894-4hhp2 Total loading time: 0 Render date: 2024-05-19T09:57:54.041Z Has data issue: false hasContentIssue false
  • English
  • Français

Patient-Initiated Refusals of Prehospital Care: Ambulance Call Report Documentation, Patient Outcome, and On-line Medical Command

Published online by Cambridge University Press:  28 June 2012

David C. Cone ,
David T. Kim  and
Steven J. Davidson
David C. Cone
Affiliation:
Division of Emergency Medical Services, Department of Emergency Medicine, Medical College of Pennsylvania, Philadelphia, Pennsylvania
David T. Kim
Affiliation:
Division of Emergency Medical Services, Department of Emergency Medicine, Medical College of Pennsylvania, Philadelphia, Pennsylvania
Steven J. Davidson
Affiliation:
Division of Emergency Medical Services, Department of Emergency Medicine, Medical College of Pennsylvania, Philadelphia, Pennsylvania
Get access Rights & Permissions [Opens in a new window]

Abstract

Introduction:

There is a growing interest in cases in which emergency medical services (EMS) providers evaluate a patient, but do not transport the patient to a hospital. A subset of these cases, the patient-initiated refusal (PIR) in which the patient refused care and transport, was studied and evaluated. The objectives of the study were to examine the adequacy of ambulance call report documentation in PIR, to examine the clinical outcome of these patients in one hospital-based, suburban EMS system, and to assess the potential impact of on-line medical command (OLMC) on cases of PIR.

Methods:

The system studied is a hospital-based, transport-capable, advanced life support service in a suburban EMS system, with an annual call volume of 4,200 runs. During the 6-month study period, all ambulance call reports completed by the paramedics and medical command control forms completed by medical command physicians were examined, and cases of PIR collected. Each ambulance call report was examined for adequacy of documentation. Patient outcome was determined from emergency department records and telephone follow-up.

Results:

Eighty-five PIRs were documented during the study period. Four cases were excluded because of a missing ambulance call reports and/or medical command control forms, leaving 81 PIRs for analysis. Despite policy requiring OLMC in cases of PIR, OLMC was established in only 23 PIRs (28%). Of these, two (9%) had inadequate ambulance call report documentation. Of the 58 PIR in which OLMC was not established, 25 (43%) had inadequate ambulance call report documentation (p <0.001, Fisher's exact test). Follow-up was obtained for 54 (67%) PIR. Of these, 37 (68%) did not subsequently see a physician, and all needed no further medical care. Seven (13%) saw their own physicians within a few days of the initial refusal of prehospital care, and had no further problems. Ten patients were seen in an emergency department within a few days. Three (6%) were discharged, and did well. Seven (13%) were admitted to the hospital, with four (7%) admitted to monitored beds, and three (6%) to unmonitored beds. There were no deaths.

Conclusions:

Ambulance call report documentation is better with OLMC than without. Patients who initially refuse care may be ill, and some ultimately will be hospitalized. Further research may elucidate a role for OLMC in preventing refusals by incompetent patients, convincing patients who are competent but appear ill to accept transport, and assisting paramedics with other difficult or unusual circumstances.

Keywords

advanced life supportdocumentationemergency medical servicesemergency medical techniciansmedical command physicianon-line medical commandoutcomepatient nontransportrefusal
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 10 , Issue 1 , March 1995 , pp. 3 - 9
Copyright
Copyright © World Association for Disaster and Emergency Medicine 1995

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Stark, G, Hedges, JR, Neely, K, Norton, R: Patients who initially refuse prehospital evaluation and/or therapy. Am J Emerg Med 1990:8:509–511.CrossRefGoogle ScholarPubMed
2. Selden, BS, Schnitzer, PG, Nolan, FX, Veronesi, JF: The “no-patient” run: 2,698 patients evaluated but not transported by paramedics. Prehospital and Disaster Medicine 1991;6:135–142.CrossRefGoogle Scholar
3. Zehner, WJ, Davidson, SJ, Kelly, JJ, Cionni, D: Nontransport of prehospital patients: Is stronger medical control needed? Ann Emerg Med 1991;20:446. Abstract.Google Scholar
4. Holroyd, B, Shalit, M, Kallsen, G, et al. : Prehospital patients refusing care. Ann Emerg Med 1988;17:957–963.CrossRefGoogle ScholarPubMed
5. Sucov, A, Verdile, VP, Garettson, D, Paris, PM: The outcome of patients refusing prehospital transportation. Prehospital and Disaster Medicine 1992;7:365–371.CrossRefGoogle Scholar
6. Zachariah, BS, Bryan, D, Pepe, PE, Griffin, M: Follow-up and outcome of patients who decline or are denied transport by EMS. Prehospital and Disaster Medicine 1992;7:359–364.CrossRefGoogle Scholar
7. Goldberg, RJ, Zautcke, JL, Koenigsberg, MD, et al. : A review of prehospital care litigation in a large metropolitan EMS system. Ann Emerg Med 1990;19:557–561.CrossRefGoogle Scholar
8. Soler, JM, Montes, MF, Egol, AB, et al. : The 10-year malpractice experience of a large urban EMS system. Ann Emerg Med 1985;14:982–985.CrossRefGoogle Scholar
9. Carmichael, DH, Mohler, J: Refusal of care. Journal of Emergency Medical Services 1985;10:36–38.Google ScholarPubMed
10. Erder, MH, Davidson, SJ, Cheney, RA: On-line medical command in theory and practice. Ann Emerg Med 1989;18:261–268.CrossRefGoogle ScholarPubMed
11. Gausche, M, Henderson, DP, Seidel, JS: Vital signs as part of the prehospital assessment of the pediatric patient: A survey of paramedics. Ann Emerg Med 1990;19:173–178.CrossRefGoogle Scholar
12. Spaite, DW, Criss, EA, Valenzuela, TD, et al. : A prospective evaluation of prehospital patient assessment by direct in-field observation: Failure of ALS personnel to measure vital signs. Prehospital and Disaster Medicine 1990;4:325–333.CrossRefGoogle Scholar
13. Spaite, DW: Vital signs records omissions on prehospital patient encounter forms. Prehospital and Disaster Medicine 1993:8:27. Editorial Comment.CrossRefGoogle Scholar
14. Selden, BS, Schnitzer, PG, Nolan, FX: Medicolegal documentation of prehospital triage. Ann Emerg Med 1990;19:547–551.CrossRefGoogle ScholarPubMed
15. Moss, RL: Vital signs records omissions on prehospital patient encounter forms. Prehospital and Disaster Medicine 1993;8:21–27.CrossRefGoogle ScholarPubMed
16. Valenzuela, TD, Criss, EA: Data Collection and Ambulance Call Report Design. In: Kuehl, AE (ed), EMS Medical Director's Handbook. St. Louis: Mosby, 1989, pp 91–102.Google Scholar
17. Drane, JF: Competency to give an informed consent. JAMA 1984;252:925–927.CrossRefGoogle ScholarPubMed
18. Selbst, SM: Leaving against medical advice. Ped Emerg Care 1986;2:266–268.CrossRefGoogle ScholarPubMed
19. Mottley, L: Refusal of Medical Assistance in the Field. In: Kuehl, AE (ed), EMS Medical Director's Handbook. St. Louis: Mosby, 1989, pp 261–265.Google Scholar
20. Dernocoeur, J: Pitfalls of refusals. Journal of Emergency Medical Services 1982:7:79–83.Google Scholar