Impact of interventions for patients refusing emergency medical services transport.
OBJECTIVE
To evaluate the effect of a documentation checklist and on-line medical control contact on ambulance transport of out-of-hospital patients refusing medical assistance.


METHODS
Consecutive patients served by four suburban ambulance services who initially refused emergency medical services (EMS) transport to the hospital were prospectively enrolled. In phase 1 (control phase), all patients who initially refused medical attention or transport had an identifying data card completed. In phase 2 (documentation phase), out-of-hospital providers completed a similar data card that contained a checklist of high-risk criteria for a poor outcome if not transported. In phase 3 (intervention phase), 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 percentage of patients transported to the hospital.


RESULTS
A total of 361 patients were enrolled. Transport rate varied by phase: control, 17 of 144 (12%); documentation, 11 of 150 (7%); and intervention, 12 of 67 (18%) (chi-square, p = 0.023). Transport of high-risk patients improved with each intervention: control, two of 60 (3%); documentation, seven of 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 hospital, and only three of these 12 patients (25%) were released from the ED.


CONCLUSIONS
Contact with on-line medical control increased the likelihood of transport of high-risk patients who initially refused medical assistance. The appropriateness of the decreased transport rate of patients not meeting high-risk criteria needs further evaluation.
D000293:Adolescent; D000328:Adult; D000552:Ambulances; D000704:Analysis of Variance; D004282:Documentation; D004632:Emergency Medical Services / Q000379:methods / Q000706:statistics & numerical data* / Q000639:trends; D006801:Humans; D008875:Middle Aged; D009518:New York; D011446:Prospective Studies; D011786:Quality Control; D018570:Risk Assessment; D013686:Telemetry; D014187:Transportation of Patients / Q000379:methods / Q000706:statistics & numerical data* / Q000639:trends; D016312:Treatment Refusal