Coronavirus, Exclusives, Patient Care

COVID-19: Is Now the Time for EMS-initiated Refusal?

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The emergency department is overcrowded, the ICUs are full, and 911 calls are at a record high. What once was a doomsday scenario is now day-to-day life in New York City and northern New Jersey.

Although most other systems have not seen markedly increased volumes, we can only assume they will occur. With such a tax on the on the healthcare and emergency medical systems, now is the time to consider an EMS provider-initiated triage and transport protocol.

Paramedic Initiated Refusals

After an extensive literature review, there are only a 11 peer-reviewed papers addressing paramedic initiated refusals.1,5,6,7 Most recently, a 2016 meta-analysis performed by Fraess-Phillips published in Prehospital and Disaster Medicine, examined these 11 studies.1

These studies date back to 1999 and include a multinational cohort with varying experimental designs. The qualitative conclusion found that agreement between paramedics and emergency physicians vary greatly in their assessment of paramedic triaged non-urgent patients and are limited in their ability to predict hospital admission or resource utilization.

They further conclude that the literature provides limited support for the safety of paramedic triage. The rates of under-triage and subsequent hospitalization reported in multiple studies are between 10-20% and thus such a practice should not be widely adopted.1

However, training, scope of practice and protocol development have greatly progressed since these studies were performed and the meta-analysis published. Systems in the United States are trialing alternative destination protocols and other countries are currently using such protocols.2,3

Unfortunately, there is not an updated robust data set examining these same questions. Additional patient-centered studies need to be performed to examine the ability of paramedics to safely triage to alternative destinations or prioritize access to healthcare care before a universal protocol should be adopted.

Non-paramedic Initiated Refusals

The literature regarding non-paramedic-initiated refusals is more limited than with paramedic providers. In a single 2001 study, performed by Cone and Wydro and published in Prehospital Emergency Care, they evaluated the ability of basic life support providers to determine whether patients transported via ambulance required advanced life support (ALS) intervention.4

They examined a total of 52 cases in which the first arriving basic life support crew had canceled ALS. Emergency medicine physicians examined the cases and found 40 (77%) were inappropriate cancelations. This retrospective chart review was based on the nature of the chief complaint (i.e. chest pain, shortness of breath etc.), vital signs, or physical exam findings (i.e. focal neurologic deficit). In addition, 45 patients (87%) required immediate intervention upon ED arrival.

Unfortunately, this study was not outcome driven and had multiple opportunities for bias on the part of the assessing physician. Similar to the paramedic driven protocol, more research is needed to examine patient centered outcomes before allowing providers trained below the paramedic level to assess for medical necessity.

COVID-19 Considerations

Combining the results of both paramedic and non-paramedic provider-initiated refusal data, a generalized non-transport medical decision-making protocol is not supported. However, none of these studies were performed during a global pandemic or used to evaluate for resource necessity in a specific pathology. The goal for such a protocol is to evaluate patients with an influenza like illness (ILI) who require hospitalization.

The Maryland Institute for Emergency Medical Services System (MIEMSS) recently implemented an ALS Viral Syndrome Pandemic Triage Protocol for Emergency Department Transport. Though this is initially implemented as an ALS protocol, there are provisions to allow for the expansion to BLS providers if volumes and resources become scarce.


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This simple protocol attempts to risk stratify patients based on age, comorbid conditions as well as vital signs. However, as data regarding COVID-19 continues to evolve, risk stratification has become increasingly challenging. Though incorporated into this protocol, the question remains, what comorbid conditions are most important to consider? Current data suggests any comorbid condition (coronary artery disease, lung disease, diabetes, immunocompromised, etcetera) increases the patient’s risk for a poor outcome and the greater number of comorbid conditions, the worse the outcome.8,13

Age considerations are conservatively based on current CDC guidelines which include age > 65. Out of an abundance of caution, MIEMSS used age > 55 to account for geographic variances in health disparities. The rest of the protocol is based on abnormal vital signs or assessments. This makes intuitive sense and has been part of all refusal forms. It is worth noting that being febrile is not part of the triage protocol for Maryland.

COVID-19 is a febrile illness and there is no data to support the presence or absence of a fever has any correlation with the severity of symptoms. The rest of the assessment, tachycardia, tachypnea, hypoxemia, and hypotension are data extrapolated from the CURB-65 clinical decision tool for community acquired pneumonia mortality risk and need for inpatient therapy.10 They are also indications the patient may require advanced emergency department or critical care therapies however, there is no concrete published data to support this. At present, the COVID severity index used to stratify COVID patients can be found in the below table:14

Unfortunately, the applicability of this chart to EMS providers in the field is minimal with the exception of the vital sign abnormalities. This should, however, be used as a guide in protocol development.

Lung sounds are also not part of any of these decision tools, though also noted in the Maryland protocol. There is no quantitative data that supports lung sound abnormalities correlate with disease severity. In fact, current expert opinion is questioning the utility of chest computerized tomography (CT) in these patients, the once gold standard screening tool.15 In a recent position statement by The American Academy of Radiology, it is recommended against using chest CTs for screening and recommended its use sparingly in symptomatic hospital patients.

They go on to say “a normal chest CT does not mean a person does not have COVID-19 infection – and an abnormal CT is not specific for COVID-19 diagnosis.”15 From this information, one can extrapolate that lung sounds have very little diagnostic utility and should not be included on a triage protocol. There is also no data that supports ambulatory dysfunction is clinically significant in COVID-19 or a reason for emergency department transport. Alternatively, if clinically concerned about exertional dyspnea, ambulatory pulse oximetry should be utilized as a better assessment of pulmonary and cardiovascular reserve.

For pediatric populations, severe and critical disease has been reported to be uncommon.11 The age criteria <2 is not based on any current clinical guidelines, however, is based on a pre-publication retrospective review of 2,000 patients which found 13 cases categorized as critical where 8 were under age 1.11

The same study also found 90% of the patients were either asymptomatic, mild or moderate severity.11 When assessing pediatric populations, special consideration should be given to patients with congenital or developmental comorbidities especially patients with a history of bronchopulmonary dysplasia.

Though this suggestion is extrapolated from physiology, pathogenesis and risk for decompensation, until more quantitative data is available for analysis, these patients should be transported for further emergency department evaluation and management.

Lastly, the statement of the patient being agreeable to homecare should be used judicially. There should be shared decision making between field providers and the patient. It is extensively documented in the EMS literature people call 911 because they think they are having an emergency, believe EMS is a faster means of transportation, lack of transportation, or socioeconomic factors.16-20

Anecdotally, there can sometimes be difference of opinion between patients and EMS providers as to the medical necessity of the 911 activation.20 The purpose of such a protocol is to triage patients appropriate for home self-care. A patient’s unwillingness to self-isolate at home or a desire for hospital evaluation is not appropriate in the current healthcare environment.

Other systems have followed suite in their initiation of EMS triage protocols, New Jersey (NJ) recently published their own protocol in the beginning of April which has since been revised to remove the fever > 100.4 F as a criterion to transport from the assessment box.12 This protocol/waiver removes the transport requirement from the NJ EMS protocol.

Regardless of the specifics of the protocol, the following goals should be kept in mind with protocol development:

  • Decrease unnecessary strain on EMS
  • Decrease emergency department volumes of non-emergent patients
  • Decrease healthcare provider exposure to possible COVID cases
  • Decrease public and patient exposure to COVID
  • Maintain patient safety and quality of care
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With any of these protocols, there should be a provision that allows any patient to be transported based on the clinician’s gestalt.

Though unproven, initiation of a viral triage protocol has the potential to decompress both the emergency department and EMS systems while also protecting healthcare providers. In these uncertain times, implementation of such a protocol should be highly considered.

Take Home Points

  1. A generalized non-transport medical decision-making protocol is not supported by the current prehospital literature.
  2. A specific Viral Syndrome Triage Protocol should be highly considered early to help decompress and prevent a surge of non-urgent ILI/COVID patients.
  3. Provider and patient safety should be emphasized though all aspects of protocol development and implementation.

References

1. Fraess-Phillips AJ. Can Paramedics Safely Refuse Transport of Non-Urgent Patients? Prehospital and disaster medicine. 2016;31:667-674.

2. Maryland Institute for Emergency Medical Services System. The Maryland Medical Protocols for Emergency Medical Services Providers, 2019.

3. NHS England. Transforming urgent and emergency care services in England: Clinical models for ambulance services, 2015. https://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR-ambulance-guidance-FV.PDF.

4. Cone DC, Wydro GC. Can basic life support personnel safely determine that advanced life support is not needed? Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2001;5:360.

5. Williams JG, Bachman MW, Jones AW, et al. Retrospective Validation of a Protocol to Limit Unnecessary Transport of Assisted-living Residents Who Fall. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2015;19:68.

6. Jaslow D, Barbera JA, Johnson E, Moore W. EMS-initiated refusal and alternative methods of transport. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 1998;2:18.

7. Millin MG, Brown LH, Schwartz B. EMS provider determinations of necessity for transport and reimbursement for EMS response, medical care, and transport: combined resource document for the National Association of EMS Physicians position statements. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2011;15:562.

8. Guan W, Liang W, Zhao Y, et al. Comorbidity and its impact on 1590 patients with Covid-19 in China: A Nationwide Analysis. The European respiratory journal. 2020.DOI: 10.1183/13993003.00547-2020.

9.https://www.miemss.org/home/Portals/0/Docs/Guidelines_Protocols/2019-Protocol-COVID-19-Viral-Syndrome-Pandemic-Triage-Protocol-20200317.pdf?ver=2020-04-07-221011-260.

10. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58(5):377–382. doi:10.1136/thorax.58.5.377.

11. Dong Y, Mo X, Hu Y, et al. Epidemiological Characteristics of 2143 Pediatric Patients With 2019 Coronavirus Disease in China [published online ahead of print, 2020 Mar 16]. Pediatrics. 2020;e20200702. doi:10.1542/peds.2020-0702.

12.https://www.state.nj.us/health/ems/documents/BLS%20triage%20to%20home%20waiver.pdf.

13. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention [published online ahead of print, 2020 Feb 24]. JAMA. 2020;10.1001/jama.2020.2648. doi:10.1001/jama.2020.2648.

14. The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020[J]. China CDC Weekly, 2020, 2(8): 113-122. http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51.

15. https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection.

16. Gardner GJ. The use and abuse of the emergency ambulance service: some of the factors affecting the decision whether to call an emergency ambulance. Arch Emerg Med. 1990;7: 81–9.

17. Shah MN, Davis CO, Bauer C, Arnold J. Preferences for EMS transport and pediatric emergency department care. Prehosp Emerg Care. 2008;12:169–75.

18. Seltzer AG, Vilke GM, Chan TC, Fisher R, Dunford JV. Outcome study of minors after parental refusal of paramedic transport. Prehosp Emerg Care. 2001;5:278–83.

19. Billittier AJ, Lerner EB, Moscati RM, Young G. Triage, transportation, and destination decisions by out-of-hospital emergency care providers. Prehosp Disaster Med. 1998;13: 22–7.

20. Kawakami C, Ohshige K, Kubota K, Tochikubo O. Influence of socioeconomic factors on medically unnecessary ambulance calls. BMC Health Serv Res. 2007;7:120.