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Paramedic Uses Enhanced Patient Refusal Process


You may not have noticed lately, but video rental stores seem to have gone the way of the elevator attendant and the telegraph repairman. Technology has been marching on, and consumers now have myriad other options in the marketplace to get instant access to the products and services once wholly the domain of the video store. With the Internet and the Red Boxes out there, why wouldn’t people change their buying habits?

Just today my girlfriend and I wanted to rent a movie for the evening, and she did something I didn’t know was possible. She opened up her smartphone, selected a movie from a list and reserved it for us at the local video-rental vending machine—conveniently located in the parking lot of a store we were going to anyway. It was easy, and it only took a minute to get what we wanted. It was cool, it was progress, and things just like that have changed an entire small segment of our economy.

As they usually do, my thoughts turned to EMS and how something like that might work for us. Not for renting videos, of course, because people (usually) don’t call 9-1-1 to have a video rental delivered. Instead, I wondered how technology and a network like this could work to revolutionize our industry. On the streets, how could we use something like this to usher in our inevitable change to EMS 2.0?

And I think I have just that sort of idea.

Patient Refusals
We EMS folk don’t have a way to not take people to the hospital very well, and I think some ideas from the change in tech and the video rental revolution could help. I believe EMS needs a better way to have people refuse care and transport from us as I believe the Against Medical Advice (AMA) refusal of care is the single stickiest legal issue facing EMS today.

The case-law libraries are full of examples of law suits for AMA refusals-gone wrong, and it’s time to fix the myriad loose procedures that have developed in the absence of a real system.

Contemporary EMS has no real, legal form of treating and releasing patients. I don’t really think there’s any U.S. jurisdiction in which EMS can legally treat and release. As I’ve written before, Medicare has decreed that the EMS fee schedule is a “transport benefit,” and they don’t pay us to medically take care of people, we just do.

The AMA refusal is the closest thing we have to treating and releasing someone. But in all reality, it’s just a piece of paper that serves to weakly protect EMS crews and their medical director from being sued when they don’t kidnap someone who encounters EMS yet doesn’t wish transport. The whole system relies on the patient saying, “No, I don’t want to be cared for by you, and I’m signing this piece of paper to say it was my decision that I didn’t want to be cared for.”

If the patient doesn’t want the full gamut of EMS care and transport, they sign that it was their choice to not go to the emergency department (ED) against the wishes of the EMS staff and medical establishment who legally cannot recommend anything other than transport to an ED, even when it’s clearly not needed, or more commonly, not the optimal healthcare pathway for the patient.

EMS refusals need to meet a few requirements to be more than just shoddily written pieces of paper. Patients have the right to be fully informed of the potential consequences of their decision. But providers need to inform the patient that the EMS crew may not know of all the potential consequences.

Patients must also know that it’s not the provider’s opinion that they not go to the hospital. Legally, we can’t tell someone that, even when it’s obvious a patient shouldn’t be transported by ambulance to a fully-equipped ED for their torn hangnail at 3 a.m.

Patients have the right to receive enough information to give “informed consent” about their medical care. They also have the right to be taken to the ED by EMS, no matter what. Although it’s never good practice for any provider to refuse to take a patient to the ED after a call for service, what if we could give them a better option when it was appropriate?

The Idea
The technology exists to improve the EMS refusal process. I call it the “enhanced refusal process.” Although it’s not a true EMS treat-and-release procedure, I believe it’s an idea EMS agencies could adopt in the current legal environment. I also think it could work today without a fundamental change in the laws governing what we do. EMS providers have the tools available at present to make this work, and I think we should.

The enhanced refusal process could be used for patients who access and accept EMS care from a paramedic or EMT and are given a thorough physical assessment. This would be for cases in which providers have used the full gamut of EMS diagnostic tools as appropriate. Then, with criteria established by the service’s medical director (and probably a contact to online medical control until the kinks are worked out), the EMS crew could offer alternative options to the patient, in addition to the standard transport to the ED (if, of course, it was allowed in that state).

EMS crews would then forward their assessment information to those alternative treatment options, such as a clinic or urgent care center. They could possibly even schedule a cab or medivan-transport for the patient if needed. A system like this would necessitate EMS agencies working with their local medical establishment to identify the additional pathways for care, such as urgent care facilities and primary-care physicians who would accept EMS referrals and see patients in a timely fashion. Agencies should tailor their referral options to their local healthcare marketplace.

In my own practice, I’ve occasionally done something similar to this for years by informing patients with minor medical conditions about the local healthcare options if they refuse EMS care and transport. I let them know their options for care if they don’t want to go to the ED. But the enhanced refusal process would formalize this process by ensuring a well-documented and proper patient assessment. The patient would obtain a document detailing the EMS providers’ assessments for the purposes of providing informed consent, and they would be given clear options to make their own decisions for their treatment pathway under the guidance of EMS professionals and medical direction.

Here’s why I believe this will work. The patient has to choose to enter the program, and the EMS professional has to choose to allow the patient to enter the program. At no time would a service employing the enhanced refusal process ever deny care or transport to an ED when it’s legally and ethically appropriate.

Patients who call 9-1-1 have the right to be transported to an ED in nearly every jurisdiction and will always be transported to an ED if it is appropriate or the patient requests it.

For the patient to access the alternative healthcare pathways that the enhanced refusal process offers, they would have to meet criteria established by the service medical director, be given the information to provide informed consent, be of sound mind and able to make rational decisions and have willingly entered the program.

Patients would still have to agree to the same risks of and meet the criteria for the present AMA refusal process. They would have the option to seek medical care or call 9-1-1 again if needed or desired.

In a strictly legal sense, unless the state laws change, EMS will be forced to only recommend transport to an ED, but the enhanced refusal process will provide a second-best option to offer the patient. It allows EMS to serve as a guide to the local healthcare system and help patients navigate their options for care.

Technology can be employed to provide referral information to the receiving alternative pathway, such as transporting a non-acute 12-lead ECG or point-of-care lab test. The patient might directly deliver their chart to the facility, or EMS may electronically transmit it.

The Benefits
I believe this idea would reduce EMS liability by documenting that we fully instructed and attempted to assist the patient in accessing physician-level medical care after an activation of EMS. Patients who seek alternative care pathways under this program would be receiving medical care and could be referred back to the emergency healthcare system by the healthcare professional that sees them through an EMS refusal if deemed necessary, or more likely could be given appropriate and more cost-effective care.

As I’ve stated before, the “ambulance to ED” method for patient access to primary care is the single most cost-inefficient method of primary care delivery. I believe EMS can be a major force in improving access to primary care for a vast segment of the population.

We need to step into the roles that patients are asking us to play and expand our tool kit to help our communities in meaningful ways. With the enhanced refusal process, we can decrease our legal exposure and overall healthcare costs in a meaningful way. We can provide our patients with better options for accessing healthcare.

Sounds like a solid idea to me. What do you think?


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