Exclusives, Operations, Patient Care

Balancing Patient Safety and Hospital Overload through Collegiate EMS Alcohol Refusal Protocol

George Washington Medical Response Group ambulances on the street. (Photo provided by the authors.)

Background

University-based volunteer emergency medical services (EMS) agencies across the United States offer collegiate emergency medical technicians (EMT) the opportunity to gain valuable experience in emergency care while also contributing to campus safety and emergency response. Alcohol intoxication complicates almost half of the calls they receive.

Multiple studies have reported that alcohol intoxication contributes to 17 to 44% of all university-based ambulance trips.1, 2 In addition to acute intoxication, alcohol use can lead to intentional physical assaults and accidental traumatic injuries that likewise require emergency department (ED) care.3 A 2019 study of over two million EMS calls showed ambulance demand exceeds population growth and identified alcohol/drug abuse as a driver of increased demand.4

Though relatively rare, university students across the country have experienced adverse outcomes as a results of alcohol intoxication including severe trauma, brain injury, and death.5 As a result, some universities have developed strict alcohol policies in an effort to reduce liability and discourage underage drinking. Some policies require mandatory ED evaluation of intoxicated persons encountered by first responders on campus. In an effort to reduce overburdening of an already stressed ED, EMS providers must carefully balance patient safety risks against high patient volumes in order to maximize the appropriateness of transport.

Objective

The purpose of this study was to evaluate a new EMS transport refusal protocol created for alcohol-related encounters and designed to identify those patients who require medical treatment for alcohol intoxication in an emergency department versus those who may safely refuse EMS care and transport.

Hypothesis

Institution of a new alcohol refusal policy will significantly decrease the number of alcohol-related patient transports to the emergency department without increasing adverse patient outcomes.

Methods

IRB approval #NCR191543 was obtained for this study. This was a retrospective observational chart review of patients intoxicated with alcohol who were evaluated by the George Washington University Emergency Medicine Response Group (EMeRG) between August 2017 and May 2019. EMeRG is a student-based volunteer EMS organization comprised of 57 licensed basic life support (BLS) providers and overseen by an attending physician and two resident physician medical directors. They provide 24-hour coverage of both the George Washington University (GW) Foggy Bottom and Mount Vernon campuses with two full-scale ambulances covering approximately one square mile of urban territory. Providers respond to an average of 650 calls per year. The majority of EMeRG patients requiring transport are brought to The GWU Hospital, a level-one trauma center and urban academic hospital located on the Foggy Bottom Campus.

Prompted by concerns from university students, EMeRG medics, and GWU Hospital ED physicians and nurses, the decision was made to reevaluate the existing campus policy that required mandatory medical evaluation of persons suspected of intoxication who encounter GW police. The existing policy was perceived as inflexible and causative of a large number of EMeRG activations and emergency department visits subsequently found to be unnecessary or punitive. In the summer of 2018, a university policy change transferred the decision for alcohol-related patient transports from GW police department officers to EMeRG medical providers.

In response to this policy change, EMeRG created a comprehensive transport refusal policy for patients encountered due to concern they might be “intoxicated” or have consumed alcohol (Figure 1). In order to refuse care, patients who admit to alcohol use must meet the following criteria: have legal competency to refuse; demonstrate orientation to person, place, time and event; walk with a steady gait; disclose the time of their last alcohol consumption; understand the risks of refusal; and agree to discontinue any alcohol or drug use for the evening (Figure 1).

Figure 1: Alcohol Refusal Flow Chart

The verbiage used to convey risks and consequences of a refusal includes describing potential symptoms and complications that can arise such as abdominal pain, vomiting and the risk of injury due to accident while intoxicated. The risk of aspiration is always described, and it is plainly stated that aspiration can cause death. The patient must then acknowledge these risks verbally back to the provider.

If all criteria are met, the senior supervisory EMT on duty can determine that the patient may refuse hospital transport. They are always encouraged to call EMS back if they feel as though their condition is worsening or if they no longer feel safe. If any criterion is not met, or if the senior supervisory EMT does not approve, the patient must be transported to the hospital per standing university policy. 

This revised alcohol protocol was approved in August 2018, at the start of the 2018-2019 academic year. Following the conclusion of the 2018-2019 academic year, the EMeRG electronic medical record (Electronic Health Record Software [EHR], manufactured by ESO) database was searched using the predetermined inclusion criteria and the results compiled for analysis. Charts were included in the study if at least one of the patient complaints or findings included a diagnosis of “alcohol intoxication.”

Similarly, alcohol-related patient transport data from the prior academic year (2017-2018), the last year in which the previous alcohol intoxication policy was used, were compiled for comparison. Both data sets were analyzed for the two primary outcomes: 1) affirmative decision to transport to the ED, and 2) Documented adverse events defined as, death, brain injury, trauma related to intoxication, or need for return visit by EMS for re-evaluation for a chief complaint related to acute intoxication.

Results

This study compared patients evaluated for alcohol intoxication during two contiguous academic years before and after a change in the responding EMS agency transport refusal policy for patients with acute alcohol intoxication. The patient demographics for both data sets were similar regarding patient age, gender, and enrollment status (Table 1).

The median age was 19 years in both cohorts. The average ages were similar: 21 years during the pre-protocol academic year and 23 years during the post-protocol academic year. Routinely, any patient requiring paramedic-level care is transferred to an advanced life support (ALS) EMS agency at the scene. Three patients required transfer to ALS EMS agencies for assessment and disposition in both academic year data sets.

The total all-complaint call volume decreased from 701 to 624 calls between the two time periods. Additionally, the percentage of total calls that were related to alcohol intoxication declined from 33% to 27%, respectively. During the period prior to the new protocol, 92% of patients admitting to alcohol use required transportation to the emergency department. Following institution of the refusal protocol, only 63% were transported. A chi-square test was performed and showed that the relationship between transport requirement and time period was significant, X2 (1, N = 395) = 51.0, p < 0.05).

During the study period, there were no major adverse events prior to or following the institution of the alcohol refusal protocol. No deaths and no traumatic injuries resulted from patient transport refusal under the new protocol. During the post-protocol study period, one patient called EMS for re-evaluation for abdominal pain after initially refusing care and transport. The review of the patient’s records showed no causative relationship between her abdominal pain and alcohol intoxication.

Discussion

Alcohol intoxication on college campuses is a major public health problem and a strain on local EMS and hospital systems.6 According to Mullins et al., alcohol-related visits to the emergency department are increasing at rate that supersedes the rate of increase in overall ED visits.7 Binge drinking represents a public health problem off campus as well: in the United States, one in six adults binge drink four times per month, and approximately 38% of college students engage in binge drinking.8

In 2014, 891 young adults died of alcohol-related overdose and 4105 suffered from unintentional injuries related to alcohol.5 In a study of alcohol-related mortality and morbidity among college students alone, researchers estimated that over 600,000 students were assaulted each year by another intoxicated student and that approximately 1,825 college students die from alcohol-related unintentional injuries each year.9

Regardless of intoxication, the decision to accept transport refusal is a common dilemma in any EMS agency. Despite obvious medical benefit and possible adverse outcomes, a patient may want to refuse care. Then the provider must balance evaluation of a patient’s capacity and the legality of transporting against a patient’s will. Two retrospective observational studies suggest that paramedics may under triage by as much as 9%, allowing patients to refuse transport who later require care.10, 11

However, Knight et al. revealed few adverse outcomes after prehospital refusal of care.12 In addition, the assessment of capacity may vary amongst types of providers. A recent study demonstrated that prehospital providers and physicians have low interrater reliability when determining capacity.13 Despite small variations, nearly every state condones the transport of dangerously intoxicated patients without the need for consent. However, in a patient who retains capacity, providers must respect patient wishes even if they contradict medical advice.

Particularly in the case of collegiate EMS, often decisions to transport are not based on medical need, but on legal issues including underage alcohol use, local law enforcement agency guidelines, and individual university policies. Such nonmedical policies can contribute to patient transport events that are not medically warranted, and also risk legal liability on the grounds of forced transportation.

Local EMS and hospital systems must address the risks of morbidity and mortality related to alcohol use in this population while limiting overburdening the healthcare system. Some universities may choose to implement medical amnesty policies to encourage students calling EMS for friends who they are concerned about, however this must come with the ability for EMS to evaluate if transport to the hospital is medically warranted.

We describe an alcohol refusal policy at one institution that aims to identify patients at low risk of harm and with capacity to refuse transport to the hospital. The goals of the new policy included a reduction number of medically unnecessary patient transports, to reduce burden on the EMS system and emergency department, and to improve trust between the EMS agency and the population it serves.

The data demonstrates a significant reduction in alcohol intoxication-related patient transports in the first year following implementation of the new policy. Importantly, no adverse events from were noted during the first year of use of the new refusal policy guidelines.

Limitations

As serious outcomes such as death from alcohol intoxication are relatively rare in our population, the sample size is limited, and data collection is ongoing to continue to verify the safety of this protocol. Further data is necessary over a longer period of time to establish whether high-risk outcomes are inappropriately triaged due to the refusal protocol. Our population is also unique in its geographical setting. This university campus is urban and therefore few students have access to automobiles making the risk of intoxicated driving substantially less than other campuses.  

Additionally, we recognize that some adverse events may not be recorded in our database and may have occurred without the university, university police, or EMeRG being aware. While we would be informed through the university system of any adverse outcomes in a student or staff member, we may not be notified of a negative impact on a non-university affiliate who represented outside our catchment area.

Conclusions

Collegiate EMS agencies need to address the risks of intoxicated patients given increased binge drinking on college campuses and additional outside agency pressures, such as university policies and campus police. This single-institution study indicates that a refusal policy for the acutely intoxicated patient implemented by an EMS agency may reduce unnecessary transports to the hospital, thereby appropriately identifying patients in need of transport and relieving burden on both the EMS agencies and hospital emergency departments. However, further studies are needed on other campuses to confirm the safety of such a protocol.

References

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2. McLaughlin MP. Alcohol-associated illness and injury and ambulance calls in a midwestern college town: a four-year retrospective analysis. Prehosp Emerg Care.2010;14(4):485-490.

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9. Hingson R, Heeren T, Winter M, Wechsler H. Magnitude of alcohol-related mortality and morbidity among U.S. college students ages 18-24: changes from 1998 to 2001. Annu Rev Public Health.2005;26:259-279.

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11. Schmidt TA, Atcheson R, Federiuk C, et al. Hospital follow-up of patients categorized as not needing an ambulance using a set of emergency medical technician protocols. Prehosp Emerg Care.2001;5(4):366-370.

12. Knight S, Olson LM, Cook LJ, Mann NC, Corneli HM, Dean JM. Against all advice: an analysis of out-of-hospital refusals of care. Ann Emerg Med.2003;42(5):689-696.

13. O’Connor L, Porter L, Dugas J, et al. Measuring Agreement Among Prehospital Providers and Physicians in Patient Capacity Determination. Academic Emergency Medicine.n/a(n/a).