Re: Declining Transport.
I’m a medic in Onslow County, North Carolina, the home of U. S. Marine Corps Base Camp Lejeune. We’re an all-ALS third-service system answering about 13,000 county-wide 9-1-1 calls annually (though the Base has its own system). We operate seven 24-hour trucks on 12-hour shifts, and we’re lucky enough to have a progressive management team who’re willing to push the envelope. We’re an NC Model System, and we do RSI, C-spine rule-out, adult IO, air transport to the cath lab, etc., all without physician consultation. (And yes, we have openings!) The point is that we’re not strangers to innovation, or to the occasional controversy.
We’re considering a policy that would allow our medics to decline transport to patients who don’t require an ambulance. Obviously, this would be permitted only after a thorough history and physical examination, and only with the concurrence of our medical control physician. Additionally, this policy probably won’t apply to patients who even mention certain “magic words,” like “chest pain,” “trouble breathing,” etc. As part of our research, we’d like to hear from other systems that have implemented or considered similar policies.
Admittedly, this practice would be a double-edged sword. On the one hand, it’s a huge liability exposure. If we evaluate a patient and decline to transport them to higher care, we’ve assumed a lot of the liability for any poor outcome. It also won’t help our public image a bit. However, we all know that almost half of our transports don’t require an ambulance; they could safely use medical facilities other than an Emergency Department, or transport methods other than an ALS ambulance. Given the current business environment of budget cutbacks, staff shortages, and abysmal reimbursements, this policy could improve our service to the folks who actually need an ambulance. We’re hoping it will also improve response times, reduce overtime and fuel costs, etc.
So, what do you think, is this a good idea or a bad one? Does your system allow medics to decline transport to patients who don’t require an ambulance? What procedure do you use, and how has it worked for you? Do you have any data on outcomes yet? What kinds of experiences have you had, both good and bad? Did you educate the public about the policy, and how? Have you had any feedback from patients, politicians, physicians, etc? Do you leave these patients with any transport alternative, such as a taxi voucher? Have you implemented any of the other N11 numbers (2-1-1, 5-1-1, etc.), and have they helped? Have you considered the situation where the patient requests transport to someplace other than the closest facility with no medical justification? Does that fit into this policy? How do you handle non-emergent institutional requests (i.e., calls from nursing homes, doctor’s offices, etc)? Did I miss anything? ;-)
We’d particularly like to see a copy of your policy, if possible. My contact information follows, and if you have any questions please post them here or call my cell. Be warned, however, that I work nights! There’s a fair chance you’ll have to leave a message.
Mark Baribeault, Paramedic Sergeant
Onslow County Emergency Medical Services
1180 Commons Drive North
Jacksonville, NC 28546-6965