Are ‘Treat-&-Release’ Protocols Worth the Trouble?

It’s hard to argue against using “treat-and-release” protocols, especially in large systems with overwhelmed call-takers, long queues for EMS response and units trying to be in three places at once. But instituting a treat-and-release protocol is not as easy as it looks.

Since the days of Squad 51, we’ve assumed EMS organizations have a duty to respond, assess, treat and transport all those who request prehospital care. It is important to note, however, that the only duty codified in law is the duty of EMS to respond and assess. The duty to treat and transport is a traditional obligation, but not a legal duty. Recognizing this gives overburdened and resource-poor EMS services an opportunity to explore treat-and-release protocols.

A treat-and-release protocol allows an EMS provider to deny transport to an EMS patient. Transport is denied only after patient assessment and initial care to ensure the patient meets any criteria the medical director establishes under the treat-and-release program. Instructions for the patient to continue care always accompany EMS release, and EMS providers may call private transport agencies, taxi companies or family members to arrange transport for follow-up care.

Treat-and-release protocols incur further customer service burdens on an EMS agency. If the service will deny patients an expected service (and EMS transport is considered by many to be a right), an intense community and on-site educational program is essential to maintain customer satisfaction and community goodwill.

Another major issue refers to our previous discussion defining an EMS patient. We noted that it’s easier to use “negative criteria” to designate patients than to use “positive” characteristics. But the use of the negative only gets us so far. Using negative criteria allows us to identify those individuals who are not EMS patients, but it does not help us define who requires emergent care. We need a new definition one that attempts to define what are not signs and symptoms of a potentially emergent medical problem. And now we’ve run into the problem that haunted us when we first approached the issue: What is a satisfactory list of signs and symptoms that does not undertriage any person with a potential threat to life or limb?

You may remember our previous definition of “who is not a patient” included the phrase, “presents with no signs or symptoms of illness or injury,” so to some extent we’ve reviewed this issue before. But this situation is somewhat different. In the current scenario, the patient requests EMS care, and we want to ensure we can safely deny it. So we need to pay more attention to what those signs and symptoms actually are, and that brings us back to the realm of “positive criteria.” And because potentially serious problems produce large lists of possible signs and symptoms, our desire to avoid undertriage (refusing transport to those with a potential life threat) means the list is extensive. If we add severe pain as an emergent complaint, the list is almost infinite, and we have complex decision rules that are difficult to use.

Because of this, treat-and-release protocols often focus on isolated body parts or systems, such as the skin (rashes) or extremities (toe fractures). The restricted focus of these programs undoubtedly adds clinical and medicolegal security to the treat-and-release efforts, but minimizes the programs’ applicability to the EMS population at large.

Other issues surrounding treat-and-release protocols center on the business side of EMS. A common reason given to institute a treat-and-release program is the potential cost savings to an EMS system. This argument may be flawed. Let’s look at a single-tier EMS system with a fixed number of units (as usual, we will look at the simplest possible analogy to illustrate the point). These EMS units are available 24 hours a day, 365 days each year. The great majority of the cost (vehicles, staffing, equipment, maintenance and other “fixed” costs) of these units has been built into an annual budget, so there are no fixed-cost savings in running eight calls per shift instead of 10. Savings that might occur are based on “variable costs (e.g., gasoline, consumable supplies), but these are likely minimal in the scope of the overall budget. Indeed, the EMS unit still needs to respond to the scene of injury or illness to institute the treat-and-release system, so some of these consumables actually become fixed costs. In fact, the system might experience some revenue loss because even those patients who do not require intense EMS treatment or care may still be sources of revenue when billed for transport.

The only true “cost” to the system may be an “opportunity cost” of time spent in EMS response that could have been spent in other activities (e.g., training, eating, sleeping, etc.). If a critical number of patients qualify for treat and release, the need for one or more of these units may vanish realizing true cost savings. However, logic would indicate the restricted focus of a treat-and-release program might not affect enough of the EMS population to significantly impact EMS volumes.

Are there any non-financial advantages to a treat-and-release protocol? In the case of EMS organizations where call volumes exceed resources available to deal with them, a treat-and-release protocol may serve to decrease patient wait times. This advantage may be more prominent in two-tier systems. However, it depends on the assumption that the treat-and-release procedures take significantly less time to perform than do field care and hospital transport. (As we all know, patient negotiation can take a long time.) A treat-and-release protocol may help field morale by increasing EMT and paramedic autonomy and enhancing the percentage of work time spent caring for critical patients. The down side, however, is that removing units from the system because of decreasing call volumes may increase response times for the remaining units.

In addition, there may be significant political hazards in denying transport to those who have come to expect EMS transport as a right and enhanced medicolegal risks from disgruntled patients or field staff’s failure to adhere to the program rules.

The institution of a treat-and-release protocol places an extra burden on the skills of the field medic, imposes further risk to the medical director and forces administration to renegotiate a long-standing community trust. Although treat-and-release programs may help some systems, in others it may be better to stay with the devil we know.

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