REFUSAL OF OUT-OF-HOSPITAL MEDICAL-CARE - EFFECT OF MEDICAL-CONTROL PHYSICIAN ASSERTIVENESS ON TRANSPORT RATE

Objective: Previous studies have shown that contacting an on-line medi cal-control physician increases the transport rate of patients who att empt to refuse medical assistance, The authors studied the physician-p atient interaction to determine the type of interaction that was more likely to result in patient transport. Methods: A prospective, observa tional study of patient-initiated refusals of medical assistance (RMAs ) was performed in a suburban volunteer emergency medical services (EM S) system, with 12 receiving hospitals county-wide, Medical-control co ntact was required for all patient-initiated RMAs. Consecutive patient s who attempted out-of-hospital RMA over a 3-month period were monitor ed. Structured data instruments were completed by the medical-control operator and medical-control physician for all patients who attempted RMA, Data collected included patient demographics and contact informat ion, scene characteristics, history and physical examination data, len gth of time of interaction, and the physician's assessment of the need for transport and the patient's capacity to refuse transport. The ope rator and physician independently graded the physician's assertiveness in talking to the patient on a continuous 10-point scale, Results: Th ere were 130 patients who attempted RMA; 69 (53%) refused transport ev en after discussion with the medical-control physician, while 61 (47%) were transported to a hospital, The patients who were transported did not differ from those not transported with respect to age, chief comp laint, vital signs, or presence of police on scene. Using the operator s' independent assessments, the physicians were more assertive when th ey graded the patient as being more ill (needs transport, 8.8; may nee d transport, 7.7; doesn't need transport, 4.1; p < 0.01). When the phy sicians were more assertive, the patients were more likely to agree to transport (assertiveness >8, 81% transport; assertiveness <8, 19% tra nsport; p < 0.01), Conclusions: Contact with a medical-control physici an appears to markedly improve the transport rate for patients who ini tially attempt to refuse out-of-hospital medical care. This is especia lly so when physicians are more assertive in recommending transport.