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Adequacy of online medical command communication and emergency medical services documentation of informed refusals
David F E Stuhlmiller1, Michael T Cudnik, Scott M Sundheim
1University of Medicine & Dentistry of New Jersey, Newark, NJ 07103, USA. stuhlmillerd@emamd.com
Insights
Emergency medical services (EMS) often struggle to adequately assess patient capacity for refusing medical treatment. While documentation improved with a nontransport worksheet, communication remains insufficient for informed refusal in out-of-hospital settings.
Area of Science:
- Emergency Medicine
- Pre-hospital Care
- Medical Decision-Making Capacity
Background:
- Emergency Medical Services (EMS) providers must assess decision-making capacity and obtain informed refusal for patients declining medical treatment or transport.
- Cleveland EMS uses a nontransport worksheet and Online Medical Command (OLMC) physician authorization for patient refusals, with call recordings for review.
Purpose of the Study:
- To evaluate the effectiveness of EMS in determining medical decision-making capacity and securing informed refusal of transport.
- Assessing the adequacy of communication and documentation during out-of-hospital patient refusals.
Main Methods:
- Retrospective review of 137 recorded OLMC refusal calls and associated Cleveland EMS nontransport worksheets.
- Measured completeness of verbal communication between paramedics and OLMC physicians.
- Assessed written documentation on nontransport worksheets as indicators of capacity assessment and informed refusal.
Main Results:
- Verbal communication of vital signs and patient orientation was >83%, but factors like intoxication or hypoglycemia were communicated <31%.
- Discussion of refusal risks was verbally communicated in 44.5% and documented in 48.7% of cases.
- Written documentation was more complete (>95% for vitals/orientation, >80% for other factors), but did not guarantee informed refusal.
Conclusions:
- Communication between paramedics and OLMC physicians regarding patient refusals is inadequate in the Cleveland EMS system.
- Nontransport worksheets improve documentation but do not ensure patients possess medical decision-making capacity for informed refusal.
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.
Objectives:
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.
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