title: Adequacy of online medical command communication and emergency medical services documentation of informed refusals.
abstract: BACKGROUND
  In the out-of-hospital setting, when emergency medical services (EMS) providers respond to a 9-1-1 call and encounter a patient who wishes to refuse medical treatment and/or transport to the hospital, the EMS providers must ensure the patient possesses medical decision-making capacity and obtain an informed refusal. In the city of Cleveland, Ohio, Cleveland EMS completes a nontransport worksheet that prompts the paramedics to evaluate specific patient characteristics that can influence medical decision-making capacity and then discuss the risks of refusing with the patient. Cleveland EMS then contacts an online medical command (OLMC) physician to authorize the refusal. OLMC calls are recorded for review.
  
  
  OBJECTIVE
  To assess the ability of EMS to determine medical decision-making capacity and obtain an informed refusal of transport.
  
  
  METHODS
  This study was a retrospective review of a cohort of recorded OLMC refusal calls and of the accompanying written documentation by Cleveland EMS. The completeness of the verbal communication between the paramedic and OLMC physician and the written documentation on the nontransport worksheet were measured as surrogate markers of the adequacy of determining medical decision-making capacity and obtaining an informed refusal.
  
  
  RESULTS
  One hundred thirty-seven OLMC calls for patient-initiated refusals were reviewed. Vital signs and alertness/orientation were verbally communicated more than 83% of the time. The presence of head injury, presence of alcohol or drug intoxication, and presence of hypoglycemia were verbally communicated less than 31% of the time. Verbal communication stating that the risks of refusing had been discussed with the patient occurred 44.5% of the time. The written documentation of the refusal encounter was more complete, exceeding 95% for vital signs and alertness/orientation, and exceeding 80% for the remaining patient characteristics. The rate of written documentation that the risks of refusing had been discussed with the patient was 48.7%. Discrepancies between the verbal and written paramedic reports were clinically insignificant.
  
  
  CONCLUSIONS
  Paramedic and OLMC physician communication for patients refusing out-of-hospital medical treatment and/or transport is inadequate in the Cleveland EMS system. A written nontransport worksheet improves documentation of the refusal encounter but does not ensure that every patient who refuses possesses medical decision-making capacity and the capacity to provide an informed refusal.
authors.affiliation: University of Medicine & Dentistry of New Jersey, Newark, NJ 07103, USA. stuhlmillerd@emamd.com
authors.forename: David F E
authors.initials: DF
authors.lastname: Stuhlmiller
authors.forename: Michael T
authors.initials: MT
authors.lastname: Cudnik
authors.forename: Scott M
authors.initials: SM
authors.lastname: Sundheim
authors.forename: Melinda S
authors.initials: MS
authors.lastname: Threlkeld
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Collins
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000488:Allied Health Personnel / Q000706:statistics & numerical data; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003142:Communication; D032962:Consent Forms / Q000592:standards / Q000706:statistics & numerical data*; D004282:Documentation / Q000592:standards / Q000706:statistics & numerical data*; D004631:Emergency Medical Service Communication Systems / Q000592:standards / Q000706:statistics & numerical data*; D004635:Emergency Medicine / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D008875:Middle Aged; D009820:Ohio; D009862:Online Systems / Q000592:standards / Q000706:statistics & numerical data*; D010348:Patient Care Team / Q000706:statistics & numerical data; D012189:Retrospective Studies; D016312:Treatment Refusal / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data