Medical Malpractice - The Effect of Short Term Outcomes

Transcription

1 OUTCOME OF TRAVELERS WHO REFUSE TRANSPORT AFTER EMERGENCY MEDICAL SERVICES EVALUATION AT AN INTERNATIONAL AIRPORT Robert J. Marsan, Jr., BS, Frances S. Shofer, PhD, Judd E. Hollander, MD, Edward T. Dickinson, MD, C. Crawford Mechem, MD Prehosp Emerg Care Downloaded from informahealthcare.com by on 09/03/11 ABSTRACT Objective. To determine the short-term outcome of patients refusing transport after emergency medical services (EMS) evaluation at an international airport. Methods. This was a prospective, descriptive, observational study of patients who refused transport after evaluation by Philadelphia Fire Department paramedics at Philadelphia International Airport from July 2003 through March Paramedics contacted a medical command physician (MCP), who recorded the patient s contact information. Three days later, one investigator attempted to contact the patient to administer a survey of the medical course in the three days following the initial encounter. Results. Of 90 patients enrolled, 64 (71%) were reached in follow-up. Their average age was 45 years (range 10 months to 80 years); 41 (63%) were female. The most common presenting complaints were trauma-related (22 patients, 34%), neurologic (12, 19%), and gastrointestinal (7, 11%). The most common reasons for refusing transport were belief that their complaint was not serious (48, 75%) and fear they would miss a flight (34 patients, 53%). In the three days following the initial encounter, no patients recontacted 9-1-1, 16 patients (25%) had a recurrence of their initial complaints, and 32 patients (50%) saw or talked to a physician. There was one hospitalization but no deaths. Among patients lost to follow-up, no deaths of U.S. citizens were detected. Conclusions. Most patients who refused transport after EMS evaluation at an international airport had good short-term outcomes. These results may assist paramedics and MCPs to manage refusals in this setting and to allow patients to make informed decisions. Key words: emergency medical services; treatment refusal; outcome assessment (healthcare). PREHOSPITAL EMERGENCY CARE 2005;9: Three percent to 10% of medical command physician (MCP) contacts by emergency medical services (EMS) personnel are for patient-initiated refusals of care. 1,2 In Received March 12, 2005, from the Department of Emergency Medicine, University of Pennsylvania School of Medicine (RJM, FSS, JEH, ETD, CCM), Philadelphia, Pennsylvania; and the Division of EMS, Philadelphia Fire Department (CCM), Philadelphia, Pennsylvania. Revision received May 18, 2005; accepted for publication May 23, Presented at the Society for Academic Emergency Medicine annual meeting, Orlando, Florida, May Address correspondence and reprint requests to: C. Crawford Mechem, MD, Department of Emergency Medicine, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA <mechemc@uphs.upenn.edu>. doi: / these situations, the physician reviews the details of the case and often speaks directly with the patient. The physician is able to explain the risks involved in refusing transport, thereby allowing the patient to make an informed decision. Speaking to an MCP has also been shown to cause some patients intent on refusing care to change their minds and agree to transport. 3 If the physician is comfortable with the patient s being released, the patient is then asked to sign a refusal-ofcare form. This practice of having the patient speak with an MCP and sign a refusal-of-care form is intended to improve patient outcome while theoretically reducing the liability of the EMS providers. However, despite the providers best efforts, patients who are not transported to a hospital continue to pose a liability for EMS systems. 4 To try to limit EMS liability, certain criteria should be met before a patient can refuse transport. First, the patient must demonstrate that he or she has the mental capacity to make an informed decision. This includes having an accurate understanding of the severity of the medical condition and a comprehension of the risks of refusing transport. 4 This process is made difficult in that no standardized definitions or distinct criteria are available to assess a patient s mental capacity. 1 In addition, patients may be mildly intoxicated or have partial alteration of mental status as a result of their acute medical conditions. 5,6 Patients with ethanol intoxication, respiratory symptoms, seizures, and diabetic complications appear to be more predisposed to refuse transport. 7 Because refusals of care in the prehospital setting are common, it is important to look at outcomes of patients who refuse transport in order to determine the safety of EMS policies dealing with this scenario. The outcomes of hypoglycemic diabetic patients and seizure patients who refuse treatment after EMS evaluation after returning to their baseline mental status have been previously reported. 8,9 The objective of the current study was to determine the short-term outcome of patients who refused transport after being evaluated by EMS personnel at a major international airport. Study Design METHODS This was a prospective, descriptive study of patients who were evaluated by EMS providers for any reason 434

2 at an international airport and subsequently refused transport to a hospital. The objective was to determine their short-term medical outcomes after they were released at the scene. This was accomplished through telephone follow-up. Patients were asked to give verbal consent at the time of MCP contact and prior to beginning the follow-up telephone interview. This study was approved by the Institutional Review Board of the University of Pennsylvania. Study Setting and Population Individuals at Philadelphia International Airport requiring EMS evaluation for any complaint who then refused transport to a local hospital between July 2003 and April 2004 were eligible for enrollment in the study. Specific inclusion criteria were: 1) the patient is aged more than 18 years, an emancipated minor, or a minor with a legal guardian present; 2) was accessed for any complaint; and 3) the patient refused transport by EMS. Patients were excluded if they were unaccompanied minors or were deemed to lack the mental capacity to refuse care. Philadelphia is the fifth largest city in the United States, covering 135 square miles. Its population in 2000 was 1,517,550. The Philadelphia Fire Department (PFD) is the sole medical response agency for the city. In 2003, PFD ambulances responded to 232,360 medical calls. The PFD has an advanced life support ambulance staffed by two paramedics stationed around the clock at Philadelphia International Airport to respond to medical calls on site. For the sake of this study, the paramedics were instructed to contact the study hospital to discuss all patients refusing transport. Study Protocol According to PFD paramedic protocols, a patient who refuses treatment and/or transport must demonstrate the mental capacity to make decisions and an understanding of the risks of refusing care. Paramedics contact an MCP to discuss all such cases. The physician also speaks with the patient. As part of this study, PFD paramedics at Philadelphia International Airport contacted the emergency department (ED) at the Hospital of the University of Pennsylvania exclusively whenever they encountered a patient meeting the study inclusion criteria. Apart from being in-serviced on the intent and logistics of the study, the MCPs did not receive any additional training on evaluating patients who were refusing care and/or transport. The physician spoke with the patient to establish orientation to person, place, time, and circumstances. The physician also reached an opinion regarding the patient s mental capacity to refuse transport and his or her understanding of the associated risks. The physician verified that the patient met the inclusion criteria and that the exclusion criteria did not apply. Finally, the physician completed a standardized medical command hospital patient encounter form and also recorded in a study log the date and the patient s name, address, and contact telephone number. The paramedics reiterated the risks of nontransport and urged the patient to recontact for any deterioration in his or her condition. The patient was asked to sign a refusal-of-care form and was encouraged to follow up with a primary care physician. A three-day follow-up interval was selected. Beginning three days after the initial encounter, one researcher (RJM) attempted to reach the patients by telephone to determine whether in the three intervening days they had experienced a recurrence of symptoms or any other adverse event that could be attributed to nontransport. The researcher obtained verbal consent prior to administering a brief questionnaire. Data from the telephone call were recorded on a standardized form. Details of the circumstances of the call and outof-hospital treatment rendered were obtained directly from the patients. Those who could not be reached on the third day following the initial encounter were telephoned repeatedly for up to 45 days. Patients who did not originally provide a telephone number, who could not be reached by telephone after multiple attempts, or whose telephones were out of service were sent a certified letter asking them to telephone one of the investigators (CCM). Those responding to the letter were then administered the questionnaire. To determine whether patients lost to follow-up had died, their names were entered into the Social Security Death Index ( com). The 30-day period following the initial EMS encounter was selected for this query. Because of the nature of this database, only the deaths of U.S. citizens would be detected. Data Analysis Data are reported as means ± standard deviations for continuous variables and frequencies and percentages with 95% confidence intervals (CIs) for categorical outcome data. RESULTS Ninety eligible patients were enrolled between July 2003 and March Of these, 64 (71.1%) could be reached in follow-up, 63 by telephone and one by certified letter. Of 26 certified letters sent, only this one (3.8%) resulted in a response. The average time to follow-up was 24 days, with a range of three to 67 days. Sixty-three percent of the patients reached in follow up were female, and the average age was 45 years (range 10 months to 80 years). Other characteristics of the patients reached in follow-up are shown in Table 1.

3 TABLE 1. Demographics of the Study Population Reached in Follow-Up TABLE 3. Patient Outcomes 72 Hours after the EMS Encounter Percent Percent (95% CI) Prehosp Emerg Care Downloaded from informahealthcare.com by on 09/03/11 Gender Male Female Age 0 20 years years years >65 years Chief complaint Trauma-related Neurologic Gastrointestinal 7 11 Respiratory 5 8 Psychiatric/intoxication-related 5 8 Cardiac 4 6 Musculoskeletal 3 5 Diabetes-related The 64 patients reached in follow-up had multiple reasons for refusing transport to the hospital. The most frequently cited reason, encountered in 75% of patients, was a belief that their complaint was not serious. Other reasons for refusing transport are listed in Table 2. Of the 64 patients reached in follow-up, 32 (50%) visited or spoke to a physician in the 72 hours after their EMS encounter at the airport. Sixteen (25%) had recurrence of their initial complaints. One patient (1.6%, 95% CI = 0% 4.6%) who had agreed with the paramedics to visit an ED on landing at his final destination was subsequently hospitalized. No patients recontacted 9-1-1, and no deaths were reported. Patient outcomes are presented in detail in Table 3. A query of the Social Security Death Index revealed that none of the U.S. citizen patients who were lost to follow-up had died in the 30-day period following the initial EMS encounter. DISCUSSION Sixty-three of 64 (98%) patients reached in follow-up after refusing ambulance transport at an international airport were managed as outpatients without the need TABLE 2. Patients Reasons for Refusing Transport Percent Felt the complaint was not serious Worried they would miss their flight Symptoms subsided People were waiting for them at the airport Did not know or want the EMS unit called initially Agreed to see a physician at final 6 9 destination Patients could cite multiple reasons for refusing transport. EMS = emergency medical services. Death 0 0% (0% 4.7%) Call to % (0% 4.7%) Hospitalization 1 1.6% (0% 4.6%) Visit to a physician 19 30% Phone call to a physician 13 20% Did not contact a physician 32 50% With recurrence of symptoms 5 8% Following injury 9 14% Recurrence of symptoms 16 25% Excluding injuries 7 11% for hospitalization during the three-day follow-up period. They could, therefore, be viewed as having favorable short-term outcomes. The one patient who was admitted to the hospital had a history of coronary artery disease, experienced chest pain, yet insisted on flying home and going to his regular hospital. He did agree to go directly to that hospital upon arrival at his destination, where he was found to have elevated cardiac enzyme levels, received a coronary artery bypass graft, and was released from the hospital in stable condition. The fact that most patients did well is reassuring, given the frequency of patient refusals in this setting. Cwinn et al. described the 12-month experience of a paramedic unit stationed at Denver s Stapleton Airport in the mid-1980s and reported a patient refusal rate of 14.6%. Patient outcomes were not provided. 10 In the current study, the refusal rate was 18.1% of all patients evaluated by PFD medics at Philadelphia International Airport. Based on these findings, EMS systems can be reassured that most patients who refuse transport in this setting may do so safely. The fact that the majority of patients who refused transport did well after their contacts with EMS is consistent with the results of similar studies in other settings. Vilke and associates looked at the outcomes of heroin overdose victims who refused EMS transport after out-of-hospital naloxone administration. Because naloxone s half-life is shorter than that of heroin, the concern was that some of the patients who refused transport would have a recurrence of their symptoms and perhaps die as a result. All EMS reports were reviewed for heroin overdose patients who refused transport after naloxone administration in San Diego County as well as medical examiner reports for heroin-related overdose deaths in San Diego County during the study period. No patient was found dead of a heroin overdose within 12 hours after being given naloxone by out-of-hospital care providers. 11 Another study looked at the short-term outcomes of 103 patients with known insulin-dependent diabetes who were treated for hypoglycemia and then refused transport. Of these, 94 patients (91%) had no recurrence of their hypoglycemia, three patients (3%) were admitted to a hospital, and

4 one patient (1%) died of an unrelated chronic medical condition. 8 More recently, the outcomes of patients with a known seizure disorder who experienced a seizure and subsequently refused transport to a hospital were studied. In the three-day follow-up period, only three of 52 patients (6%) had further seizure activity, one (2%) was hospitalized, and none (0%) died. These studies suggest that, in most cases, patientinitiated refusals of transport by EMS have favorable outcomes. However, there are certainly exceptions to this generalization. Burstein et al. obtained follow-up for 199 patients with a variety of medical complaints who refused EMS transport. Ninety-five sought medical care for the same condition within the subsequent week, and 13 were admitted to the hospital. 12 One of the admitted patients died. Similarly, Sucov et al. obtained follow-up for 94 patients who refused EMS transport. In the subsequent five days, six were admitted to the hospital. 13 There is also evidence that patients who refuse ambulance transport do not always fully understand the risks explained to them by out-of-hospital care providers. In one study, 26% of surveyed patients who had refused transport did not fully understand their conditions when they refused transport, only 22% recalled receiving an explanation of the risks of their refusal, and 18% stated they would accept transport if the incident were to recur. 14 This lends support to the argument that patient-initiated refusals of transport are not always safe, because the patients are not always making informed medical decisions. An interesting trend in how was activated at Philadelphia International Airport was noted during follow-up conversations with the study patients. While a wide variety of chief complaints were encountered, in many cases the EMS unit was called for very minor complaints by airport personnel trained to contact EMS for any medical issue. Many patients expressed annoyance that the medic unit had been called. For example, the paramedics were summoned for one patient who had asked for a bandage for a scratch his child had just received. In other instances, the paramedics were contacted by airline personnel who wanted assurance that it was safe for the patient to fly, a determination that paramedics are not in a position to make. In addition to the patient care issues noted, the results of this study raise questions regarding resource allocation at metropolitan airports. Large metropolitan airports are essentially small cities staffed around the clock and visited by large crowds of travelers whose numbers fluctuate throughout the course of the day. Security issues make access by EMS personnel to all areas of the airport difficult without the appropriate credentials and security clearance. It is therefore logical to have permanently-assigned EMS resources on site. A downside to this is that EMS personnel may be called upon to address very minor medical problems and to make medical decisions for which they have little training, such as employee health issues or medical clearance to travel. For larger airports, it may therefore make sense for there to be an alternative health care facility on the premises to handle these medical issues, leaving EMS personnel free to handle the true medical emergencies. Unfortunately, not all airports have sufficient resources for both types of medical staffing. LIMITATIONS Interpretation of the results of this study is limited in several ways. First, like most outcome studies, this study was limited by follow-up of only 71% of patients. While better than the follow-up rates of 62% 12 50%, 13 and 59% 15 cited in other EMS outcome studies, the fate of 26 of the 90 study patients is unknown. The Social Security Death Index was queried to determine whether patients lost to follow-up had died in the 30 days following the initial EMS encounter. While no deaths were detected, it should be noted that this database applies only to citizens of the United States. Deaths of foreign nationals would have been missed using this technique. Five foreign nationals were enrolled in the study, only one of whom could be reached in contact. Therefore, the fate of the remaining four could not be determined. It could also be argued that those patients lost to followup were inherently different from the study patients for whom outcome data were available. However, in both groups the majority were female (58% of patients lost to follow-up compared with 63% of patients with known outcomes) and their chief complaints were similar (predominantly musculoskeletal, trauma-related, gastrointestinal, and neurologic). Therefore, significant differences between the two groups are unlikely. Second, while 90 patients were enrolled in the study, a query of all runs by the airport medic unit during the study period revealed that 166 patients refused treatment and transport. Therefore, it appears that only 54.2% of potentially eligible patients were captured. There may have been several reasons for this. Patients may not have been enrolled if the paramedics or the MCP forgot about the study. This is a very real issue in ongoing prehospital clinical studies in large EMS systems. Alternatively, the physician may have failed to obtain contact information for patients whom they tried to enroll. The patient may have left the scene before medical command contact could be made. Finally, the medics may have felt that the acuity of the medical complaint was so low that medical command contact was not warranted. A final limitation of this study is the potential for recruitment bias. Medical personnel may have been tempted to encourage patients who were ambivalent about being transported to refuse transport, in order to recruit them into the study. Along similar lines, while only one medical command hospital was contacted to enroll patients, multiple MCPs with differing

5 years of experience and comfort levels took calls from paramedics. The extent to which different physicians attempted to persuade patients to accept transport was undoubtedly variable. CONCLUSION Most patients who refused transport after EMS evaluation at an international airport had good short-term outcomes. These results may assist paramedics and medical command physicians to manage refusals in this setting and to allow patients to make informed decisions. The authors thank the Philadelphia Fire Department paramedics of Medic 30 at the Philadelphia International Airport for their help with this study. References 1. Adams J, Verdile V, Arnold R, Ayres J, Kosowsky J. Patient refusal of care in the out-of-hospital setting. Acad Emerg Med. 1996;3: Stark G, Hedges JR, Neely K, Norton R. Patients who initially refuse prehospital evaluation and/or therapy. Am J Emerg Med. 1990;8: Alicandro J, Hollander JE, Henry MC, Sciammarella J, Stapleton E, Gentile D. Impact of interventions for patients refusing emergency medical services transport. Acad Emerg Med. 1995;2: Weaver J, Brinsfield KH, Dalphond D. Prehospital refusal of transport policies: adequate legal protection? Prehosp Emerg Care. 2000;4: Drane JF. Competency to give an informed consent: a model for making clinical assessments. JAMA. 1984;252: Holroyd B, Shalit M, Kallsen G, Culhane D, Knopp R. Prehospital patients refusing care. Ann Emerg Med. 1988;17: Brokaw J, Olson L, Fullerton L, Tandberg D, Sklar D. Repeated ambulance use by patients with acute alcohol intoxication, seizure disorder, and respiratory illness. Am J Emerg Med. 1998;16: Mechem CC, Kreshak AA, Barger J, Shofer FS. The short-term outcome of hypoglycemic diabetic patients who refuse ambulance transport after out-of-hospital therapy. Acad Emerg Med. 1998;5: Mechem CC, Barger J, Shofer FS, Dickinson ET. Short-term outcome of seizure patients who refuse transport after out-ofhospital evaluation. Acad Emerg Med. 2001;8: Cwinn AA, Dinerman N, Pons PT, Marlin R. Prehospital care at a major international airport. Ann Emerg Med. 1988;17: Vilke GM, Buchanan J, Dunford JV, Chan TC. Are heroin overdose deaths related to patient release after prehospital treatment with naloxone? Prehosp Emerg Care. 1999;3: Burstein JL, Henry MC, Alicandro J, Gentile D, Thode HC, Hollander JE. Outcome of patients who refused out-of-hospital medical assistance. Am J Emerg Med. 1996;14: Sucov A, Verdile VP, Garettson D, Paris PM. The outcome of patients refusing prehospital transportation. Prehosp Disaster Med. 1992;7: Schmidt TA, Mann NC, Federiuk CS, Atcheson RR, Fuller D, Christie MJ. Do patients refusing transport remember descriptions of risks after initial advanced life support assessment? Acad Emerg Med. 1998;5: Zachariah BS, Bryan D, Pepe PE, Griffin M. Follow-up and outcome of patients who decline or are denied transport by EMS. Prehosp Disaster Med. 1992;7: