IMPACT OF INTERVENTIONS FOR PATIENTS REFUSING EMERGENCY MEDICAL-SERVICES TRANSPORT

Objective: To evaluate the effect of a documentation checklist and on- fine medical control contact on ambulance transport of out-of-hospital patients refusing medical assistance. Methods: Consecutive patients s erved by four suburban ambulance services who initially refused emerge ncy medical services (EMS) transport to the hospital were prospectivel y enrolled. In phase 1 (control phase), all patients who initially ref used medical attention or transport had an identifying data card compl eted. In phase 2 (documentation phase), out-of-hospital providers comp leted a similar data card that contained a checklist of high-risk crit eria for a poor outcome if not transported. In phase 3 (intervention p hase), a data card similar to that used in phase 2 was completed, and on-line medical control was contacted for all patients with high-risk criteria who refused transport. The primary endpoint was the percentag e of patients transported to the hospital. Results: A total of 361 pat ients were enrolled. Transport rate varied by phase: control, 17 of 14 4 (12%); documentation, 11 of 150 (7%); and intervention, 12 of 67 (18 %) (chi-square, p = 0.023). Transport of high-risk patients improved w ith each intervention: control, two of 60 (3%); documentation, seven o f 70 (10%); and intervention, 12 of 34 (35%) (chi-square, p = 0.00003) . Transport of patients without high-risk criteria decreased with each intervention: control, 15 of 84 (18%); documentation, four of 80 (5%) ; and intervention, 0 of 33 (0%) (p = 0.0025). Of the 28 patients for whom medical control was contacted, 12 (43%) were transported to the h ospital, and only three of these 12 patients (25%) were released from the ED. Conclusion: Contact with on-line medical control increased the likelihood of transport of high-risk patients who initially refused m edical assistance. The appropriateness of the decreased transport rate of patients nor meeting high-risk criteria needs further evaluation.