EMS-initiated refusal of transport: the current state of affairs

The objectives of this study were 1) to determine the number and characteristics of emergency medical services (EMS) agencies within the 200 largest US cities that sanction EMS-initiated refusal of transport; and 2) to determine the extent of no-cost alternative transport mechanisms among those agencies that allow EMS-initiated refusal of transport. EMS agencies located within the 200 largest US cities were contacted via telephone and surveyed as to whether their agency sanctioned EMS-initiated refusal of transport (EMS-IROT). Agencies with a policy were further questioned regarding its components and usage patterns. The telephone survey contacted 100% (200) of the target population. Currently, 7.0% (14) of EMS agencies have EMS-IROT protocols, with 64% (9) of those requiring direct medical oversight. Five (2.5%) of the 200 agencies sanctioned EMS-IROT without requiring online medical approval. Average annual call volume of the five agencies not requiring direct medical oversight was 70,800; their EMS-IROT protocols have been in existence a mean of 19.8 years. None of these agencies had a no-cost alternative transport mechanism. Three (1.5%) agencies terminated EMS-IROT protocols in the past. EMS-initiated refusal of transport continues to be a rare entity among US EMS agencies. Those that do not require direct medical oversight tend to have well-established programs, though no agency offered a formal no-cost alternative transport mechanism.     

院前急救病人情况调查分析

目的:了解本市区通过120电话获得急救的病人情况。方法:对2004年度本市区3929例院前急救病例进行分析。结果:65.82%病例年龄集中在16～45岁,急诊呼救频率最高的时间段为17:00～19:00,急救现场发病率最高的前6位病种分别为:车祸外伤、心脑血管疾病、中毒、外伤、呼吸系统疾病和产科分娩,按病情轻重分类,按病例数由多到少排顺依次为:中度病人、轻度病人和危重病人,院前急救死亡率最高的前4位病种分别为:心脑血管疾病、车祸、服毒、外伤。     

Refusal of Out-of-hospital Medical Care: Effect of Medical-control Physician Assertiveness on Transport Rate

Objective: Previous studies have shown that contacting an on-line medical-control physician increases the transport rate of patients who attempt to refuse medical assistance. The authors studied the physician-patient interaction to determine the type of interaction that was more likely to result in patient transport. Methods: A prospective, observational study of patient-initiated refusals of medical assistance (RMAs) was performed in a suburban volunteer emergency medical services (EMS) system, with 12 receiving hospitals county-wide. Medical-control contact was required for all patient-initiated RMAs. Consecutive patients who attempted out-of-hospital RMA over a 3-month period were monitored. Structured data instruments were completed by the medical-control operator and medical-control physician for all patients who attempted RMA. Data collected included patient demographics and contact information, scene characteristics, history and physical examination data, length of time of interaction, and the physician's assessment of the need for transport and the patient's capacity to refuse transport. The operator and physician independently graded the physician's assertiveness in talking to the patient on a continuous 10-point scale. Results: There were 130 patients who attempted RMA; 69 (53%) refused transport even after discussion with the medical-control physician, while 61 (47%) were transported to a hospital. The patients who were transported did not differ from those not transported with respect to age, chief complaint, vital signs, or presence of police on scene. Using the operators' independent assessments, the physicians were more assertive when they graded the patient as being more ill (needs transport, 8.8; may need transport, 7.7; doesn't need transport, 4.1; p < 0.01). When the physicians were more assertive, the patients were more likely to agree to transport (assertiveness >8, 81% transport; assertiveness <8, 19% transport; p < 0.01). Conclusions: Contact with a medical-control physician appears to markedly improve the transport rate for patients who initially attempt to refuse out-of-hospital medical care. This is especially so when physicians are more assertive in recommending transport.     

Association of Out-of-hospital Criteria with Need for Hospital Admission

Objective: To validate high-risk historical and physiologic out-of-hospital criteria as predictors of the need for hospitalization following ED evaluation.
Methods: Consecutive patients entered into the Suffolk County advanced life support system were enrolled. Previously proposed historical and physiologic "high-risk" criteria for hospitalization were prospectively collected. Criteria were associated with the need for hospital admission following ED evaluation.
Results: 1,238 patients were enrolled; 391 were released from an ED after transport. Most patients (843/1,238; 68%) were admitted to a hospital; and four died in the ED. Factors associated with an increased likelihood of admission or death among the transported patients were: bradycardia (90% admitted, p < 0.02); hypotension (80%, p < 0.03); hypertension (89%, p < 0.03); and age > 55 years (81%, p < 0.0001). Unresponsiveness and other abnormal vital signs were not associated with admission on univariate analysis. Logistic regression analysis identified two other factors associated with admission or death: tachycardia (72%, admitted, p < 0.01) and head injury (78% admitted. p < 0.001).
Conclusions: Abnormal pulse or blood pressure, head injury, and age > 55 years are associated with patients' requiring hospital admission after accessing the emergency medical services system. These criteria may aid the design of out-of-hospital refusal-of-care policies.     

Do Patients Refusing Transport Remember Descriptions of Risks after Initial Advanced Life Support Assessment?

Abstract. Objective : To determine patient recall and understanding of instructions given to patients who refuse transport after initial paramedic assessment and medical treatment. Methods : Following patient consent, a phone interview was completed for consecutive persons living in a large urban area for whom 9-1-1 was contacted but who subsequently refused transport after advanced life support (ALS) assessment. Subjects were asked about their recall of explained risks and benefits of transport, their understanding of those risks at the time of assessment, and subsequent use of medical care, including hospitalization. Results : From October 1, 1996, to February 23, 1997, 324 people refused transport after ALS arrival. Sixty-eight people could not be contacted, providing a response rate of 79% (256/324). Six percent were subsequently admitted to the hospital for the same problem and an additional 59% sought care from a health care provider (66 ED visits, 63 personal physician, 16 urgent care, 5 other). There were no unexpected deaths. Ninety (35%) respondents were still experiencing symptoms at the time of phone contact. Despite the routine practice of providing a verbal explanation of risks and written instructions, only 141 (55%) recalled receiving written instructions and 56 (22%) recalled an explanation of risks. Twenty-six percent believed they did not fully understand their conditions or circumstances surrounding the 9-1-1 call when they refused transport and 18% would now take an ambulance if the same incident were to recur. Conclusion : A substantial proportion of patients refusing transport do not recall receiving verbal or ritten instructions and would reconsider their transport decision, raising doubts about people's ability to make informed decisions at a time of great vulnerability. The majority of patients accessed health care after refusing transport and 6% were hospitalized.     

Out-of-hospital Treatment of Hypoglycemia: Refusal of Transport and Patient Outcome

Abstract. Objectives: Patient refusal of transport after treatment of hypoglycemia is common in urban emergency medical services (EMS) systems. The rate of relapse is unknown. The goal of this study was to compare the outcomes of diabetic patients initially refusing transport (refusers) and those transported to an ED. Methods: All paramedic runs from January to July 1995 were retrospectively reviewed. Inclusion criteria were adult patients with a field assessment of hypoglycemic signs/symptoms, and a fingerstick glucose < 80 mg/dL. Data for analysis included paramedic run duration, patient demographics, and refusal or acceptance of transport. Patient outcome was obtained from a review of hospital and medical examiner records. Relapse was defined as hypoglycemia necessitating EMS activation or an ED visit within 48 hours of the initial episode. Student's t-test and x² analysis were used to compare means and rates, respectively. Results: Over the 7 months, 374 patients made 571 calls to 9-1-1 that met inclusion criteria (5.2% of all paramedic runs). Of these, 412 were refusers (72.2%) and 159 were transported patients (27.8%). The hospital records of 4 transported patients were unavailable. Sixty-three transported patients were admitted (11.2%), with 1 death from prolonged hypoglycemia. The rates of relapse did not differ between the refusers and the transported patients (p < 0.05). Twenty-five relapses occurred among the refusers (6.1%), with 14 repeat refusals, 11 transports, 5 admissions, and no deaths. There were 7 relapses among the transported patients (4.4%), with 2 refusals, 5 transports, 2 admissions, and no deaths. The paramedic run time was significantly shorter for the refusers than for the transported patients (p < 0.05). Conclusions: The out-of-hospital treatment of hypoglycemic diabetic patients appears to be effective and efficient. Independent of the patient's refusal or acceptance of transport, the out-of-hospital treatment of hypoglycemic patients in this system appears to be safe.     

Patient Refusal of Care in the Out-of-hospital Setting

A case vignette of out-of-hospital refusal of emergency care is reported with accompanying discussion. This case illustrates the challenges faced by out-of-hospital emergency care personnel in these scenarios and provides guidance to the emergency physician and emergency medical technician. Recommendations are provided for preparing the emergency medical services system to handle these cases.     

The use of national highway traffic safety administration uniform prehospital data elements in state emergency medical services data collection systems

Objective

Although the concept of emergency medical services (EMS) has existed for 30 years, there is little scientific evidence validating its impact on morbidity and mortality. A significant barrier to conducting meaningful assessments relates to the lack of reliable and uniform EMS data. The objective of this study was to determine the extent to which states incorporate the Uniform Prehospital EMS Data Elements into statewide EMS data collection systems.

Methods

Study investigators requested and compared data elements from all states with a statewide prehospital data collection system.

Results

During the study period, 43 states with statewide EMS data collection systems captured, on average, 79% of the Uniform Prehospital EMS Data Set. Variables considered essential to EMS evaluation were more likely collected (84%) than variables considered desirable (72%). Only eight (10%) of the 81 uniform data elements are collected by all 43 participating states.

Conclusions

Findings suggest that related EMS data variables are collected by the majority of states across the country. This degree of similarity provides a foundation for establishing common fields that can be used to develop a national EMS registry.     

Out-of-hospital Provider Use of Epinephrine for Allergic Reactions: Pilot Program

Objective: To describe experience with an out-of-hospital provider program for the recognition and field management of allergic reactions by advanced life support (ALS) and basic life support (BLS) providers.
Methods: Data sheets completed between June 1, 1988, and August 31, 1993, and records from receiving sites (physicians' offices or EDs) were reviewed for information regarding the presentation of the allergic reaction, the time course and treatment provided out of hospital, and the clinical outcome at the receiving health care facility.
Results: Thirty-seven data sheets were completed during the study period. Fourteen (38%) of the providers were BLS providers. The epinephrine was supplied from the emergency medical services (EMS) provider's personal kit in 35% of the cases, from an EMS vehicle in 57% of the cases, and by the patient in 8% of the cases. Availability of the kits allowed administration of epinephrine prior to the arrival of the first EMS vehicle in 41 % of the instances and prior to physician on-line medical command in 65% of all the instances (predominantly by BLS providers). Overall, 77% of the patients experienced alleviation of their symptoms of respiratory difficulty, swelling, or rash after epinephrine administration, while 20% were unchanged and 3% worsened. All patients receiving epinephrine had an ED diagnosis of allergic reaction, and no adverse event was encountered on follow-up of the patients treated.
Conclusions: Severe allergic reactions can be reliably identified and safely managed by out-of-hospital providers, including BLS providers. Providing personal anaphylactic treatment kits and increasing the pool of providers trained to manage allergic reactions (including BLS providers) can often decrease the time to treatment.     

Strategies of High-Performing EMT-Basic Educational Programs

Introduction. The objective of this project was to identify the specific educational strategies used by emergency medical technician (EMT) educational programs that have attained consistently high success rates on the National Registry of Emergency Medical Technicians (NREMT) examination. Methods. NREMT data from 2001 to 2005 was analyzed in order to identify consistently high-performing EMT-Basic educational programs. Representatives from each program were invited to participate in a focus group. Using the nominal group technique (NGT), participants were asked to answer the following question: “What are specific strategies that lead to a successful EMT-Basic educational program?” Results. Ten out of the 12 EMS educational programs meeting the eligibility requirements participated. After completing the seven-step NGT process, 12 strategies were identified as leading to a successful EMT-Basic educational program: 1) accept students who are highly motivated to succeed; 2) assure institutional support; 3) administer multiple assessments; 4) develop standardized lesson plans; 5) have a passing standard that is above the minimum competency level; 6) hire qualified/certified instructors; 7) maintain effective communication between didactic, practical, andfield instructors; 8) maintain instructional consistency; 9) provide clearly defined objectives; 10) provide immediate feedback for written, practical evaluations to students; 11) require prerequisites; and12) teach test-taking skills. Conclusions. Twelve specific strategies were identified by high-performing EMT-Basic programs. From these, seven recommendations to improve programmatic pass rates on the NREMT certification exam were derived. Further study should be conducted to determine if implementation of these recommendations improves programmatic pass rates on the NREMT certification exam.     

Legislative and regulatory description of ems medical direction: A survey of states

Objective. To assess regulatory trends in EMS medical direction by examining state EMS legislation and regulations, and legal qualifications for medical direction.

Methods. A two-page survey was mailed to all 50 state EMS directors, with a repeat mailing to nonresponders and telephone follow-up as needed. Copies of EMS legislation and regulations were requested to assist in the interpretation of answers to survey questions. The questions focused on two physician roles in the oversight of the practice of paramedics: off-line ALS service medical director (ASMD) and on-line medical command (OLMC).

Results. Thirty-nine surveys were returned (78%). Only one state (IL) requires that ASMDs be board-certified in emergency medicine. Thirteen others (33%) permit physicians with primary care specialization or various ACLS/ATLS certifications to serve as ASMDs. Twenty-two states (56%) require only that the ASMD be a physician; three states (8%) have no requirements at all. Eight states (21%) have no requirements for personnel providing OLMC, and another 25 (64%) require only physician licensure. Six states (15%) require various ACLS/ATLS certifications. Several states do not differentiate between the two physician roles. Twenty-four states (62%) provide some type of Good Samaritan protection for medical direction, but in two of these only unpaid medical directors are protected.

Conclusions. There is tremendous variation in regulatory requirements for physician participation in EMS medical direction activities at the ALS level. Few states have specific training or background requirements for the provision of OLMC, and a requirement for board certification in emergency medicine is the exception, not the rule.     

Measuring quality and effectiveness of prehospital ems

Introduction. In today's health care environment, the demand for objective comparative information about the performance of health care organizations and providers has created a need for data-driven evaluation processes. In response, national organizations and federal agencies have established quality indicators, created tools to measure performance according to those indicators, and issued report cards for individual providers, as well as health care organizations. Purpose. Emergency medical services (EMS) systems are no different from other health care systems in the need for objective comparative system information to assist government officials at all levels in establishing relevant policy, selecting appropriate system design, and monitoring system quality and effectiveness. Governmental decision makers, payers, and consumers are demanding objective evidence that they are receiving value and quality for the cost of EMS. EMS systems administrators also require objective feedback about performance that can be used internally to support improvement efforts and externally to demonstrate accountability to the public and other stakeholders. To date, there are few validated indicators of effectiveness and quality in EMS systems. Moreover, most potential indicators have not been studied for use in systemwide evaluation. As a result, there are no universally accepted methods of measurement. The following paper examines traditional efforts to assure quality in EMS systems, while assessing the need to go beyond the traditional to establish measurable indicators of system quality. Valid and measurable indicators will provide a basis for establishing benchmarks of performance. In the future, these benchmarks will facilitate comparisons of a system with itself, as well as with other systems.     

普及院前急救知识与技能培训效果研究

目的 了解公众对院前急救知识掌握的现状,寻求有效提高公众院前(现场)急救意识、急救知识与技能的方法。 方法 市紧急救援中心联合新余市红十字会对4 997人进行院前急救知识与技能培训。采用自制问卷对客运司机、机关干部、社区居民、中学生999人进行院前急救知识现场调查,比较培训前后公众对院前急救知识的知晓率。 结果 培训后公众对院前急救认识显著提高;培训后公众对院前急救知识知晓率明显高于培训前。 结论 应加快普及提高公众的急救知识与技能。     

Program Accreditation Effect on Paramedic Credentialing Examination Success Rate

Objectives. Program accreditation is used to ensure the delivery of quality education andtraining for allied health providers. However, accreditation is not mandated for paramedic education programs. This study examined if there is a relationship between completion of an accredited paramedic education program andachieving a passing score on the National Registry Paramedic Certification Examination. Methods. We used data from the National Registry Paramedic Certification Examination for calendar year 2002. Successful completion (passing) of the examination was defined as correctly answering a minimum of 126 out of 180 (70%) of the questions andmeeting or exceeding the individual subtest passing scores. Accredited paramedic training programs were certified by the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CoAEMSP) on or before January 1, 2002. Candidates reported demographic characteristics including age, gender, self-reported race andethnicity, education, andemployer type. We examined the relationship between passing the examination andattendance at an accredited paramedic training program. Results. A total of 12,773 students completed the examination. Students who attended an accredited program were more likely to pass the examination (OR = 1.65, 95% CI: 1.51–1.81). Attendance at an accredited training program was independently associated with passing the examination (OR = 1.58, 95% CI = 1.43–1.74) even after accounting for confounding demographic factors. Conclusion. Students who attended an accredited paramedic program were more likely to achieve a passing score on a national paramedic credentialing examination. Additional studies are needed to identify the aspects of program accreditation that lead to improved examination success.     

Effect of vehicle speed on the quality of closed-chest compression during ambulance transport

Introduction

Transport of patients with ongoing cardiopulmonary resuscitation (CPR) occurs frequently. It may not be possible to obtain rapid hospital access while maintaining CPR quality, because the ambulance's high speed can cause increased vibration and vehicle movement. We aimed to assess how the speed of ambulance affects chest compressions.

Materials and methods

Five cycles of CPR were performed to the Resusci Anne manikin with the PC skill reporting system by experienced emergency medical technicians in ambulance traveling at one of four different speeds: stationary, 30, 60, or 90 km/h. Performance and acceleration data of chest compressions at different speeds were compared using repeated measures analysis of variance (ANOVA).

Results

Fractions of chest compressions with adequate depth, duty cycles, average rates of chest compressions, and no flow fractions showed significant differences among different speeds (p = 0.026, <0.001, <0.001, 0.005, respectively), while average depth of chest compressions did not. Accelerations of 2 Hz component and ratios of 3-12 Hz to 0-2 Hz components showed significant differences among different speeds (p = 0.001 for all). None of the outcome variables showed a significant difference between the two types of ambulance.

Conclusions

The speed of ambulance affects some aspects in the quality of chest compression during transport. Chest compressions with excessive depth, the average rate of chest compressions, and no-flow fraction increase as the speed of ambulance increase. Increase in the speed of ambulance also causes relative increase of high frequency acceleration in the chest compression, which represents unnecessary movement and force applied.     

Can First Responders Be Sent to Selected 9‐1‐1 Emergency Medical Services Calls without an Ambulance?

OBJECTIVES: To evaluate the feasibility and safety of initially dispatching only first responders (FRs) to selected low-risk 9-1-1 requests for emergency medical services. First responders are rapidly-responding fire crews on apparatus without transport capabilities, with firefighters trained to at least a FR level and in most cases to the basic emergency medical technician (EMT) level. Low-risk 9-1-1 requests include automatic medical alerts (ALERTs), motor vehicle incidents (MVIs) for which the caller was unable to answer any medical dispatch questions designed to prioritize the call, and 9-1-1 call disconnects (D/Cs). METHODS: A before-and-after study of patient dispositions was conducted using historical controls for comparison. During the historical control phase of six months, one year prior to the study phase, basic life support ambulances (staffed with two basic EMTs) were dispatched to selected low-risk 9-1-1 incidents. During the six-month study phase, a fire FR crew equipped with automated external defibrillators (AEDs) was sent initially without an ambulance to these incidents. RESULTS: For ALERTs (n = 290 in historical group vs. 330 in study group), there was no statistical difference in the transport rate (7% vs 10%), but there was a statistically significant increase in the follow-up use of advanced life support (ALS) (1% vs 4%, p = 0.009). No patient in the ALERTs historical group required airway management, while one patient in the study group received endotracheal intubation. No patient required defibrillation in either group. Analysis of the MVIs showed a significant decrease (p < 0.0001) in the patient transport rate from 39% of controls to 33% of study patients, but no change in the follow-up use of ALS interventions (2% for each group). For both the ALERTs and MVIs, the FR's mean response time was faster than ambulances (p < 0.0001). Among the 9-1-1 D/Cs with FRs only (n = 1,028), 15% were transported and 43 (4%) received subsequent ALS care. Four of these patients (0.4%) received intubation and two (0.2%) required defibrillation. However, no patient was judged to have had adverse outcomes as a result of the dispatch protocol change. CONCLUSIONS: Fire apparatus crews trained in the use of AEDs can safely be used to initially respond alone (without ambulances) to selected, low-risk 9-1-1 calls. This tactic improves response intervals while reducing ambulance responses to these incidents.