Selected topic: Prehospital care
EMS-Initiated Refusal of Transport: The Current State of Affairs

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Abstract

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.

Introduction

Emergency medical services are designed to rapidly treat and transport seriously ill or injured patients to the Emergency Department (ED). Currently, US emergency medical services (EMS) systems are being overburdened with a high volume of patients complaining of low-acuity illness or injury (1, 2, 3). Inappropriate EMS calls consume already-limited resources, making patients with true emergencies wait longer for appropriate care. As rapid response times are critical for most seriously ill or injured patients, delays likely result in increased morbidity and mortality. Abuse and overuse of the system also is a common complaint among pre-hospital providers. This impacts negatively on paramedic job satisfaction and likely on performance as well. In essence, the misuse of the 911 system is becoming a public health crisis.

One solution to this pressing problem would be to allow EMS providers to identify persons who do not need emergent ambulance transport. There is a paucity of literature in emergency medicine that addresses the issue of EMS-initiated refusal of transport. In fact, most US EMS systems transport all patients identified by 911 activation via ambulance unless the patients themselves refuse transport. A 1996 study by Jaslow et al. found that only 17% (34 of 200) of our nation's EMS systems participated in some form of EMS-initiated refusal of transport, and only 13% (n = 24) did so routinely (4). Jaslow et al. noted that only seven jurisdictions offered any type of alternative transport to those patients who are refused ambulance transport. As of 1996, a minority of US cities were attempting to identify and re-direct patients who activate the EMS system for minor medical issues. The lack of widespread implementation of such pre-hospital programs is likely based on concern for inadequate pre-hospital patient assessment and undertriage, with resultant mortality and morbidity. Concerns for medical liability have limited the desire for EMS physicians to pursue and implement such programs. At present, no prospectively validated triage tool has been identified to aid EMS agencies in the development of a safe and effective EMS-initiated refusal of transport (EMS-IROT) protocol.

The purpose of this study is to characterize the current extent of EMS-IROT in the US using 2004 data. An increase in the number of programs since Jaslow's study in 1996 might be indicative of advances in protocol development. In addition, we attempted to determine the nature and frequency of alternative transport mechanisms for those patients who are refused transport.

Section snippets

Study Design

Our study is a prospective, cross-sectional survey of large US EMS systems, designed to determine which jurisdictions permit EMS-IROT and to describe characteristics of each. This study was granted exemption from full review by the authors' institutional review board (IRB). Written informed consent by survey participants was waived by the IRB.

Population

The Journal of Emergency Medical Services (JEMS) 200-city survey published in February 2004 provides phone numbers for the first responders and transport

Results

Of the 200 EMS systems surveyed, 14 (7.0%) allowed some form of EMS-IROT. EMS-IROT without direct medical oversight is sanctioned in only five of these 14 systems. In these five systems, EMS providers are allowed to refuse transport based on established protocols and are not required to consult with an online medical control physician. In all five of these systems, the agency has specific written protocols governing the appropriate use of this policy. Similarly, each of the five systems allows

Discussion

The development of a pre-hospital triage protocol that could safely and accurately identify patients not in need of emergent ambulance transport would be of substantial value to pre-hospital care systems. The ability to identify patients with minor illness and offer alternative mechanisms of hospital transport would allow EMS to focus response on high-acuity patients in efforts to lower morbidity and mortality. Pre-hospital refusal of transport of low acuity patients would allow for rapid

Limitations and Future Questions

Our study results are limited by the survey answers given by each agency. Every attempt was made to speak with key persons within each agency who had in-depth knowledge of their EMS system. It is certainly a possibility that persons contacted were misinformed of their agency's practices. It must be noted that the JEMS list covers the nation's largest cities and may not include regional-based systems. Although we know of no other systems that allow EMS-initiated refusal of transport, we cannot

Conclusions

The ability of EMS providers to refuse patient transport is a rarely sanctioned concept within pre-hospital care systems in the United States.

Acknowledgments

We would like to thank Frank Counselman, md, reviewer; Sue Morgan, administrative support; the City of Norfolk Fire and Rescue, and Sentara Hospitals for their helpful contributions.

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