Duty Dr to the patch phone nonstat for orders…

1. Duty Dr to the patch phone nonstat for orders…

2. 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…

3. EMS Nontransports; Pitfalls and perils Karen Keats , MD, FRCP(C)

4. 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

5. 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

6. 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

7. 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

8. What options are available to legally transport this patient against her will ??

9. 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

10. 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

11. 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…

12. Thoughts ?

13. 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 ?

14. 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 ?

15. Assessing Competency

16. 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…

17. 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

18. 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)

19. Lesser Known DSM IV Disorders • Lesser known DSM IV psych diagnoses include • Insomnia • Erectile dysfunction • Premature ejaculation • Pain disorders • Caffeine related disorders

20. Caffeine Disorders ?

21. 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

22. 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

23. Calgary EMS Alert Data

24. 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

25. 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

26. The Politicians Perspective… • “As highly trained professionals, Liepert says EMS have the ability to make a decision about where a patient might be transferred, rather than direct every patient to an emergency room. “ • Medicine Hat Herald

27. The literature’s perspective • Relatively few outcome studies looking at safety of paramedics leaving patients in field

28. Can paramedics accurately identify patients who do not require emergency department care ?Silvestri et al Prehospital Emergency Care, Oct 2002

29. 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

30. Can paramedics safely decide which patient do not need ambulance transport or emergency department care ?M. Hauswald, Prehospital Emergency Care, October 2002

31. 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

32. What are the outcomes and characteristics of nontransported pediatric patients ?Kahale et al, Prehospital Emergency Care 2006 10:28-34

33. 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

34. The effect of quality improvement feedback loop on paramedic-initiated nontransport of elderly patients.Persse et al, Prehosp Emerg Care 2002 6:31-35

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%

36. How well do paramedics predict admission to the hospital ? A Prospective sttudyLevine et al Journal of Emergency MedicineVol 31 (1) pg 1-5, 2006

37. 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

38. What is our obligation to provide EMS medical control in cases involving potential nontransports ?

39. 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

40. 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

41. 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

42. Discussion Discussion