An opportunity for reform: A comprehensive evaluation of non-transport patterns in an urban emergency medical services setting

Abstract

Study objectives: Patients who summon 911 paramedics and are subsequently not transported represent a high-risk patient group for an emergency medical services (EMS) system. In an effort to understand the magnitude and construct of our EMS system's nontransport population, we undertake a comprehensive review of every nontransport in our urban EMS system during 1 month's time. Our EMS system serves a population of 1.4 million and has a dual (private and fire-based) paramedic response. Methods: During January 2002, every 911 call in which paramedics made patient contact and that did not result in a patient transport was reviewed. A detailed data collection form and predetermined data dictionary were used for chart abstraction. EMS agencies and providers were blinded to the study details and purpose. Runs that did not result in a patient contact and all patients who were declared dead on arrival were excluded from the study. Our intent was to examine 4 important areas: (1) to quantify the total number and type of high-risk patients who were encountered; (2) to assess the quality of the EMS evaluation and documentation; (3) to determine whether decisionmaking capacity was assessed or documented by paramedics; and (4) to determine the amount of effort that was put forth by the paramedics to persuade the patients to go to the hospital. All data were abstracted and entered into a database (MS Access) by 2 of the emergency physician authors, and statistical analysis was performed using MS Excel. Results: During the 31-day study period, there were 755 nontransport charts submitted for review; of these, 732 had complete information and constitute the analysis cohort. The average patient age was 40.3±0.84 years (range 6 months to 98 years). Two hundred fifty-six (35%) patients represented high-risk chief complaints. Of the 12 high-risk chief complaints that were sought, 6 (shortness of breath: n=66; syncope: n=45; chest pain: n=44; altered mental status: n=29; abdominal pain: n=26; and traumatic neck pain: n=23) accounted for 91% of the high-risk chief complaint cases. One hundred thirty-one (19%) of the patients who were not transported had abnormal vital signs, and only 8% of these had vital signs repeated. One hundred seventy-two (24%) represented patients who were difficult, if not impossible, to establish decisionmaking capacity because of being a minor (n=111), being intoxicated (n=45), or because of communication barriers (n=16). And finally, 142 (19%) had advanced care provided (12-lead ECG, intravenous access, parenteral medications) and were subsequently released. In terms of documentation, an adequate medical history was recorded and physical examination performed in 82% (602/732) and 68% (495/732) of the cases, respectively. Decisionmaking capacity was documented in 41% (301/732) of the cases, and a complete set of vital signs (blood pressure, pulse rate, respiratory rate, for all and Spo 2 for patients with shortness of breath and chest pain) were taken in 48% (348/732) of the cases. The most consistently documented aspect of the entire against medical advice (AMA) process was completion of the AMA Form. In 655 (89.5%) of the cases, paramedics had a signed form before release. Paramedics documented that they had encouraged transport in 258 (35%) of the cases, explained the risks of not being transported in 112 (15%), enlisted the help of others in 173 (24%), contacted medical control in only 8 (1%), and instructed patients to re-call 911 if their condition worsened or if they changed their mind in 140 (19%) of the cases. This study's limitations include its being performed in a single system and that it represents only a single time interval. The high-risk chief complaints need prospective validation and comparison to outcomes to truly determine amount of risk. Conclusion: In our EMS system, there is an opportunity to improve the entire process of nontransport documentation and decisionmaking by our paramedics. Because just over one third of nontransported patients are high-risk cases, and the vast majority of these cases are accounted for by 6 chief complaints, our results may have important educational and performance improvement implications for similar EMS systems.