Duty Dr to the patch phone nonstat for

orders…

FMC it’s Medic 202 on scene at a nursing home with a 90 yr female

who fainted this morning. She currently denies any

complaints,but is a little demented. She has stable vitals

and a normal 12 lead. She is refusing transport so we’re just

touching base to see if you have any advice…

EMS Nontransports; Pitfalls and perils

Karen Keats , MD, FRCP(C)

Outline The 3 classes of EMS nontransports Case reviews The Paramedic’s perspective The Emergency Physician’s perspective The Politician’s perspective The literature’s perspective The College of Physician’s perspective CMPA’s perspective Discussion

3 Classes of EMS Nontransports

Nontransport sanctioned by medical control protocols SVT/NCT hypoglycemia

Nontransports related to patient refusal Nontransports based on EMS personnel belief

that the patient does not require transport to hospital Generally discouraged but clearly some patients

do not require E.D. assessment

Case 1… 90 yr female

Emergency Physician receiving patch identifies this as a high risk patient and provides the paramedic orders to transport the patient

Patient continues to adamantly refuse transport

EMS crew believes they are working under a “verbal” Form 1 and transport the patient against her will

Case 1… 90 year female On arrival to hospital she is triaged to the hallway with EMS

where she is persistently abusive toward EMS and triage The crew are surprised to learn that there is no Form 1 in

place and request that an ED MD assess the patient as they may be holding her illegally

After a 2 hr hallway wait, an ED physician assesses her in the hallway and deems her to be competent enough to decline further care

She is taken back to the lodge and continues to provide the crew descriptive feedback on their intelligence, professionalism and family lineage during the return trip

EMS and the Form 1

Form 1 is only applicable when the patient has been directly examined and assessed by the completing physician … telephone Form 1 is not valid

If a Form 1 has been completed (ie-interfacility transfer), EMS does have legal authority to hold the patient for the purpose of transport

EMS policy states that crews will not transport Form 1 or Form 10 patients who are a threat without CPS accompanying them

EMS and the Form 10

EMS can contact CPS for any patient whom they feel meets the criteria for Form 10

Emergency physicians have the authority either autonomously or through EMS, to request CPS to locate a patient for the purpose of immediate assessment and conveyance (via Form 10) to a facility

Case 2

EMS patch; we are at a private residence with a 78 year old female who has had a fall, she denies any complaints at this point but we’re a little concerned with her O2 sat which is only 87%, she is a smoker and appears to be working to breath, her vitals are otherwise stable, she is adamantly refusing transport

We’re looking for some advice on what to do from here…

Case 2 ED physician advises a Form 10 be pursued and the

patient be transported CPS attend patient and determine she does not meet

criteria for Form 10 EMS opt to transport the patient against her will On arrival to ED she is placed under Form 1 based on

depression and self neglect She is admitted and expires of pneumonia/respiratory

failure within 24 hrs of admission Did she truly meet criteria for Form 1 or Form 10 ?

Case 3 It’s Medic 2 , we’re on scene outside Cowboys with

a guy who was hit in the back of the head with a baseball bat, witnesses state there may have been LOC, he admits to at least 12 beer and has a large 8 cm lac to the back of his as well as a large hematoma to his forehead. There’s a pretty big pool of blood on scene here but he’s refusing transport or spinal immobilization

Any suggestions ? Form 10 ? Sedation ?

Assessing Competency

Assessing competency by telephone

Can be very difficult !! A number of conditions can render a patient

incompetent Psychiatric issues Intoxication Medical (hypoglycemia, hypoxia, hypotension,

infection etc)

The Mental Health Act does not specifically address the medically incompetent (no DSM IV defined mental disorder) patient who refuses transport or medical assessment…

How does the Mental Health Act define mental disorder ??

One of the issues which commonly arises is what constitutes a mental disorder for the purpose of the Mental health Act

DSM IV is considered the gold standard in most jurisdictions Section 1(g) of the Mental Health Act states “mental

disorder means a substantial disorder of thought, mood, perception, orientation or memory that grossly impairs i) judgement Ii) behavior iii) capacity to recognize reality Iv) Ability to meet the ordinary needs of life

Most applicable to the high risk nontransport, the DSM specifically lists Substance abuse/substance dependence Dementia Depression

Criteria for a Form 10 Reasonable and probable grounds that

The person apprehended is suffering from a mental disorder

The person apprehended is in a condition presenting a danger to him/herself or others

The person apprehended should be examined in the interest of his/her own safety or that of others

The circumstances are such that to proceed under Section 10 of the Mental Health Act would be dangerous (this refers to the Form 8/Judges warrant)

Lesser Known DSM IV Disorders

Lesser known DSM IV psych diagnoses include Insomnia Erectile dysfunction Premature ejaculation Pain disorders Caffeine related disorders

Caffeine Disorders ?

The CPS Perspective CPS generally do an excellent job managing the

mentally ill It is not reasonable or practical to expect them to

have a comprehensive understanding of the DSM IV classification

The concept that an individual can represent a threat to him/herself through simple self neglect is not widely understood

Though difficult to facilitate, a direct dialogue between the E.D. physician and the CPS officer on scene may be helpful to resolve disputes over the appropriateness of the Form 10

The paramedics perspective Compared to other EMS systems Calgary Medical Control

Protocols provide medics ++ autonomy Patches are relatively rare Calgary EMS policy dictates that EMS offer transport to all

patients who request their services Average EMS wait time for bed in Calgary ED = 1 hr 5

minutes, EMS benchmark is 30 minutes Number of alerts is constantly rising despite ongoing

addition of field resources Yellow = 11 units or less available Orange = 5 units or less available Red=0 units available

Calgary EMS Alert Data

The Paramedics Perspective Some medics believe that by avoiding or deferring transport

to hospital they may lessen the burden that Emergency depts face

Most medics detest hallway waits Some medics will seek medical advice via patch as a way of

avoiding the hallway wait Some medics overestimate their capacity to rule out serious

injury/illness in the field Many cases arise in the field in which the patients decisions

are not in their best interests and medics are seeking advice from the base physician on potential methods of facilitating transport

The Emergency Physicians perspective

What are the paramedics asking for ? Why should I get involved… I’m not there ! Don’t they have protocols that tell them what to do

? High risk medicolegal situations… being asked to

provide advice on patient we’ve never seen/assessed and will likely not have any further contact with

The Politicians Perspective…

The literature’s perspective

Relatively few outcome studies looking at safety of paramedics leaving patients in field

Can paramedics accurately identify patients who do not

require emergency department care ?

Silvestri et al Prehospital Emergency Care, Oct 2002

Silvestri et al Paramedics were surveyed to determine whether

they thought patient needed ED assessment Considered necessary if pts were admitted, required

consultation or advanced radiologic procedures 313 pts enrolled, sensitivity 81%, specificity 34% 18% of those in whom transport was deemed

unnecessary were admitted to hospital, 6% were admitted to ICU

Conclusion: paramedics cannot reliably predict which patients do and do not require emergency dept care

Can paramedics safely decide which patient do not need

ambulance transport or emergency department care ?

M. Hauswald, Prehospital Emergency Care, October 2002

Hauswald Prospective survey/questionnaire of paramedics for each patient

transported by EMS during 1 month study period… 183 pts included Medics surveyed whether ambulance transport or E.D. assessment

were required Reviewed by blinded emergency physician to determine if, based on

diagnosis, patient required ambulance transport or care not available in community urgent care centers

Medics recommended alternate (non ambulance) transport for 97 pts, 23 of whom were subsequently identified as requiring ambulance transport

Medics recommended nonhospital care for 71 patients, 32 of whom were subsequently determined to require ED care

Conclusion: Paramedics cannot safely determine which patients require ambulance transport or E.D. care

What are the outcomes and characteristics of

nontransported pediatric patients ?

Kahale et al, Prehospital Emergency Care 2006 10:28-

34

Kahale et al Authors previously demonstrated 28% of pediatric

patients were not transported Prospectively followed 5 mths of patient contacts, 345

peds not transported (mean age 6 years) 51 were seen in an ED within 48 hrs of the initial call 8.7% of these were subsequently admitted to hospital No deaths were reported in any of the children during the

study period Conclusions; Most nontransported children do not require

immediate or urgent care, the short term outcome of these patients is good but paramedic documentation needs improvement

The effect of quality improvement feedback loop on

paramedic-initiated nontransport of elderly

patients.Persse et al, Prehosp Emerg

Care 2002 6:31-35

Persse et al Examined effect of paramedic feedback loop and

educational program on nontransport of patients 65 and older

Telephone survey to determine if nontransported pts sought medical help within 24 hrs, whether they were admitted to hospital and who was responsible for the nontransport decision

After intervention nontransport rate remained constant (11.5 vs 10.7%) as did % of pts seeking medical attention within 24 hrs (37.1 vs 33.9%)

% requiring hospitalization declined from 12.6 to 6.4%

How well do paramedics predict admission to the

hospital ? A Prospective sttudyLevine et al Journal of Emergency Medicine

Vol 31 (1) pg 1-5, 2006

Levine et al Medics in large urban EMS system completed

questionnaire asking whether they felt pt needed hospital admission and, if so, whether it was to ward bed or ICU bed

1349 consecutive pts enrolled, 985 surveys returned Sensitivity of predicting hospital admission was 62%

with positive predictive value of 59% For ICU admission sensitivity was 68% and positive

predicitive value was 50% Conclusion: Prehospital diversion policies should not

be based solely on paramedic determination

The CPSA Perspective Calgary EMS, in response to a number of critical

incidents, sought an opinion from the College of physicians regarding Emergency Physicians duty to provide EMS advice in the field or the hallway…

It is within the regular duties of an emergency physician to provide medical guidance to EMS personnel upon request

Any intentional refusal to provide such guidance constitutes a breach of duty but it is recognized that an ED may have multiple patient commitments at any time and it is not always reasonable to leave a patients beside to take an EMS patch

The CMPA perspective Opinion sought re obligation of Emergency

Physicians to provide orders/advice/assessment to patients in care of EMS (in the field or in the hallway)

CMPA opinion was that physicians assume much greater risk by refusing to provide guidance/assistance to EMS than by providing advice in patient who subsequently has poor outcome

They did recognize that sanctioning EMS to defer/cancel transport was associated with some risk to the physician and that these decisions would be need to be made on a case by case basis… CMPA would defend ED physicians in litigation resulting from these incidents

The CMPA Perspective Documentation of paramedic patches continues to be a

problem Patch forms generally not integrated into chart

(initiative underway to update forms and have them become part of medical record)

Discussions between EMS and ED physicians are all recorded at 911 dispatch and kept for 6 years

Now that we are billing, these records are kept on file by RMES for 7 years

Billing on a patient greatly increases risk of being named in a suit… lawyers typically survey AB Health billings to get names of physicians who might be litigation targets

Discussion