title: Patient-initiated refusals of prehospital care: ambulance call report documentation, patient outcome, and on-line medical command.
abstract: BACKGROUND
  There is a growing interest in cases in which emergency medical services (EMS) providers evaluate a patient, but do not transport the patient to a hospital. A subset of these cases, the patient-initiated refusal (PIR) in which the patient refused care and transport, was studied and evaluated. The objectives of the study were to examine the adequacy of ambulance call report documentation in PIR, to examine the clinical outcome of these patients in one hospital-based, suburban EMS system, and to assess the potential impact of on-line medical command (OLMC) on cases of PIR.
  
  
  METHODS
  The system studied is a hospital-based, transport-capable, advanced life support service in a suburban EMS system, with an annual call volume of 4,200 runs. During the 6-month study period, all ambulance call reports completed by the paramedics and medical command control forms completed by medical command physicians were examined, and cases of PIR collected. Each ambulance call report was examined for adequacy of documentation. Patient outcome was determined from emergency department records and telephone follow-up.
  
  
  RESULTS
  Eighty-five PIRs were documented during the study period. Four cases were excluded because of a missing ambulance call reports and/or medical command control forms, leaving 81 PIRs for analysis. Despite policy requiring OLMC in cases of PIR, OLMC was established in only 23 PIRs (28%). Of these, two (9%) had inadequate ambulance call report documentation. Of the 58 PIR in which OLMC was not established, 25 (43%) had inadequate ambulance call report documentation (p < 0.001, Fisher's exact test). Follow-up was obtained for 54 (67%) PIR. Of these, 37 (68%) did not subsequently see a physician, and all needed no further medical care. Seven (13%) saw their own physicians within a few days of the initial refusal of prehospital care, and had no further problems. Ten patients were seen in an emergency department within a few days. Three (6%) were discharged, and did well. Seven (13%) were admitted to the hospital, with four (7%) admitted to monitored beds, and three (6%) to unmonitored beds. There were no deaths.
  
  
  CONCLUSIONS
  Ambulance call report documentation is better with OLMC than without. Patients who initially refuse care may be ill, and some ultimately will be hospitalized. Further research may elucidate a role for OLMC in preventing refusals by incompetent patients, convincing patients who are competent but appear ill to accept transport, and assisting paramedics with other difficult or unusual circumstances.
authors.affiliation: Department of Emergency Medicine, Medical College of Pennsylvania, Philadelphia 19129-1121, USA.
authors.forename: D C
authors.initials: DC
authors.lastname: Cone
authors.forename: D T
authors.initials: DT
authors.lastname: Kim
authors.forename: S J
authors.initials: SJ
authors.lastname: Davidson
mesh_terms: D000328:Adult; D000359:Aftercare; D000368:Aged; D000369:Aged, 80 and over; D000552:Ambulances; D004631:Emergency Medical Service Communication Systems / Q000592:standards*; D004632:Emergency Medical Services / Q000592:standards / Q000706:statistics & numerical data*; D005260:Female; D006302:Health Services Research; D006801:Humans; D008297:Male; D008499:Medical Records / Q000592:standards*; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010817:Physician-Patient Relations; D016312:Treatment Refusal