Adequacy of Online Medical Command Communication and Emergency Medical Services Documentation of Informed Refusals

Abstract

Paramedic and OLMC physician communication for patients refusing out-of-hospital medical treatment and/or transport is inadequate in the Cleveland EMS system. A written nontransport worksheet improves documentation of the refusal encounter but does not ensure that every patient who refuses possesses medical decision-making capacity and the capacity to provide an informed refusal.

A patient-safety and professional perspective on non-conveyance in ambulance care: a systematic review

“…Non-conveyance rates for general patient populations ranged from 3.7% up to 93.7% [28, 30, 31, 33–35, 37, 38, 40–43, 45, 46, 49, 51, 52, 57, 60, 61, 64, 68, 77, 81]. Seventeen studies reported non-conveyance rates for specific patient populations.…”

“…Criteria to guide the (non-) conveyance decision described mostly are abnormal vital functions related to ‘breathing’ (respiration rate, respiratory distress, dyspnea), abnormal vital functions related to ‘circulation’ (systolic/diastolic blood pressure, pulse), suspected or confirmed ingestion of alcohol or drugs, and an altered level of consciousness (Glasgow coma scale) [28, 29, 39, 40, 43, 46, 51–54, 59, 70, 72, 73, 75, 79, 84, 88]. Ten of these studies described more specific flowcharts, tools, checklist or standard operating procedures for non-conveyance in general [43, 51, 72], patients who refuse conveyance [29, 40, 46], and patients who had fallen [84], with supraventricular tachycardia [39], with social problems [28], with hypoglycaemia [53], and post-ictal patients [53].…”

“…Ten of these studies described more specific flowcharts, tools, checklist or standard operating procedures for non-conveyance in general [43, 51, 72], patients who refuse conveyance [29, 40, 46], and patients who had fallen [84], with supraventricular tachycardia [39], with social problems [28], with hypoglycaemia [53], and post-ictal patients [53]. …”

“…Factors influencing the non-conveyance decision-making process are related to the professional, the patient and his relatives, the healthcare process/system, or supportive tools [26, 29, 49, 51, 57, 64, 65, 74, 77, 78, 80, 83–89] (Table 4). These factors can be present at (a) pre-arrival, when the professional forms an early opinion based on information from the emergency call, during (b) initial patient contact where the ambulance professional gets a first impression of the patient, during (c) patient assessment of vital signs and other parameters, and (d) during the actual (non-) conveyance decision moment [84].…”

“…Patient/relative2. Healthcare process/systemStuhlmiller (2005) USA [51]28/137 (20.4%) patients with whom the online medical control (OLMC) physician spoke during the encounter: 9/28 (32.1%) agreed to be transported, compared with nine (8.3%) of the 109 patients who did not speak to the OLMC physician ( p  = .001)1. Supportive toolsVan der Pols (2011) Netherlands [77]Motorcycle response vehicles with one ambulance nurse with additional training ( n  = 468) compared to regular ambulance ( n  = 1196): (1) treat and release 129/468 (27.6%) vs 149/1196 (12.5%) RR 2.21 (95%CI 1.80–2.73)1.…”