Medic-initiated Patient Refusals

[Guest guest]

While much has been said and written about the proper way to obtain a patient

refusal, most EMS managers ignore the 800 lb. gorilla in the EMS room -

Medic-initiated patient refusals.

We all know who they are. There is a small number of medics who pride

themselves in their ability to talk patients out of going to the hospital. And,

we

all know the tricks of the trade: " You know that it'll cost you $1,000? " ; " Don't

you have a relative who can take you? " ; " You can always call us back if it

gets worse. "

Why do they do it? Excessive call volume? Patient parking at hospitals?

Arrogance? Laziness? EMS managers need to stop " whistling past the cemetery " and

get control of this problem before their organization is sued into oblivion.

Below is yet another example of this malignant practice - and the trial

lawyers are quickly catching on.

http://www.washingtonpost.com/wp-dyn/content/article/2008/12/03/AR200812030369

6.html?hpid=sec-metro

Bob Kellow

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[Guest guest]

MVA's should always be excluded when calculating documented patient refusals

because they skew the results when comparing medic to medic. For example,

medic A responds to an MVA where a school bus nicks a telephone pole resulting

in

35 (uninjured) patient refusals. Medic B has no such occurrence for the same

reporting period. Comparing the two is both immaterial and irresponsible.

Although anecdotal, I've determined that if the number of signed patient

refusals exceeds 9.1% (not counting MVA's) then an organization has a problem.

The

calculus for this is simple. Take a one year sample of response data. Delete

MVA's, canceled enroute, no patient found, etc., from the sample. Then, assign

the number of signed patient refusals to each medic and divide it by the

number of patient contacts. Then, percentile rank all of the medics. The

culprits

will quickly surface.

It's interesting to note that the worst that I've seen is one medic who

obtained refusals on 38% of all patients with whom he came into contact. The

lowest

was 0 in the same district. Then, when I eliminated the 7-8 top offenders

from the mix, the refusal percentage (companywide) dropped below 9%. Claims of

negligence (or worse) not withstanding, the impact to net revenue, for any

organization, is extraordinary. Think of this when you didn't get the raise that

you think you deserved.

As I've always said, the greatest number of patient refusals are obtained

between 5 PM and 8 PM on Superbowl Sunday.

Bob Kellow

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[Guest guest]

Rule #1: If they have " injuries " they are a patient.

Rule # 2: If they have injuries, their injuries get assessed unless they

absolutely refuse.

Rule # 3: If they want to refuse you must:

a. determine and document that they have the present mental capacity

to understand and appreciate their condition and to make a rational medical

decision about treatment and transport.

b. inform them of the possible consequences of their refusal and

document that.

c. if they have the capacity to refuse, you must document in factual

language, not conclusions, that they understand the possible consequences of

refusal.

d. document that, understanding fully the possible consequences of

refusal, they still refuse.

Rule # 4: When you persuade a patient to go by POV or otherwise refuse

treatment and transport, immediately send your lawyer a $5,000 retainer, because

the odds are that you will be needing his services soon.

Most medics have no idea how to complete such an informed refusal

documentation adequately, and only about 1% of the printed refusal forms that I

have seen

are worth a penny in court.

Most medics have no idea how to (1) determine whether a patient has the

present mental capacity to refuse nor to (2) document that in any way other than

stating conclusions. [i.e. patient is A & A & Ox4 is a pure conclusion unless you

document the facts that lead to that conclusion.]

So a medic-initiated refusal is an open invitation to a lawsuit, and believe

me, now that the docs have damage caps and the paramedics do not, lawyers are

targeting paramedics and EMS services.

Gene Gandy, JD, LP

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[Guest guest]

You are exactly right, Gene.

Bob Kellow

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[Guest guest]

That is an interesting topic. As a paramedic student (about to finish the

intermediate portion), I had the opportunity to witness this " phenomenon " .

My first clinical rotation and we pull up to a MVA (car vs. itself) with 4

potential patients. The lead paramedic, in my opinion, spent more time

explaining to everyone they could go POV to have injuries looked at. (Note,

there were no immediate life threats, 3 of the four passengers were in the

back seat and restrained, airbag deployed.)

That's all fine and good, but I don't recall seeing that person even put

hands on to do an assessment on any of the potential patients.

Okay - educational opportunity. Aren't we supposed to asses first and then

provide options? Or, do you become seasoned enough to where you can look at

MOI and general impression and then " direct " accordingly? (FYI, this is

rhetorical.I know what I would do as lead paramedic in the same similar

situation.but I would like to hear your feedback.)

Toni Crippen

NREMT-B

From: texasems-l [mailto:texasems-l ] On

Behalf Of als79@...

Sent: Sunday, December 07, 2008 08:20

To: texasems-l

Subject: Medic-initiated Patient Refusals

While much has been said and written about the proper way to obtain a

patient

refusal, most EMS managers ignore the 800 lb. gorilla in the EMS room -

Medic-initiated patient refusals.

We all know who they are. There is a small number of medics who pride

themselves in their ability to talk patients out of going to the hospital.

And, we

all know the tricks of the trade: " You know that it'll cost you $1,000? " ;

" Don't

you have a relative who can take you? " ; " You can always call us back if it

gets worse. "

Why do they do it? Excessive call volume? Patient parking at hospitals?

Arrogance? Laziness? EMS managers need to stop " whistling past the cemetery "

and

get control of this problem before their organization is sued into oblivion.

Below is yet another example of this malignant practice - and the trial

lawyers are quickly catching on.

http://www.washingtonpost.com/wp-dyn/content/article/2008/12/03/AR2008120303

69

6.html?hpid=sec-metro

Bob Kellow

**************

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and favorite sites in one place. Try it now.

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& amp;

icid=aolcom40vanity & amp;ncid=emlcntaolcom00000010)

[Guest guest]

Why am I not surprised? Forrest for trees. And, the Superbowl reference was a

joke <sigh>.

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[Guest guest]

Bob,

Help me with this one...how would you suggest agency leaders overcome this

problem in an industry where EMS crews are sent out in pairs almost totally

unsupervised.? If medics are doing this of their own accord, and it is not an

agency accepted practice, how should agencies address this before the oblivion

lawsuit comes?? The DC issue is a multiple decades culture issue that will not

be corrected in a few short months....

I agree, I think we all know we have folks who do this from time to time for a

multitude of reasons...but in agencies where we desire free-thinking care

providers....how do we address this?

Dudley

Medic-initiated Patient Refusals

While much has been said and written about the proper way to obtain a patient

refusal, most EMS managers ignore the 800 lb. gorilla in the EMS room -

Medic-initiated patient refusals.

We all know who they are. There is a small number of medics who pride

themselves in their ability to talk patients out of going to the hospital. And,

we

all know the tricks of the trade: " You know that it'll cost you $1,000? " ; " Don't

you have a relative who can take you? " ; " You can always call us back if it

gets worse. "

Why do they do it? Excessive call volume? Patient parking at hospitals?

Arrogance? Laziness? EMS managers need to stop " whistling past the cemetery " and

get control of this problem before their organization is sued into oblivion.

Below is yet another example of this malignant practice - and the trial

lawyers are quickly catching on.

http://www.washingtonpost.com/wp-dyn/content/article/2008/12/03/AR200812030369

6.html?hpid=sec-metro

Bob Kellow

**************

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and favorite sites in one place. Try it now.

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[Guest guest]

This seems like an awfully " agency " specific formula.? I will take exception

because I believe MVA's are some of the worst prone areas for these

refusals...if we are going to exclude any calls from this calculation, I would

think you would exclude ALL 3rd party calls.? Those calls where EMS was called

by someone other than the patient or someone with the patient.

It would appear to me that your PD agency didn't call you guys out much for

domestic issues when someone got slapped or punched, or sent your units on calls

for suicidal ideations where the patient is voicing harming themselves but has

not taken any action....

BTW, I checked our refusals...and in the last 6 years we have not had a refusal

during the Superbowl....In addition I would suggest when people review their

stats in a method that makes sense for their particular agency...I would not say

we should set a hard fast floor or ceiling for transport %.? I would instead

suggest we review all our medics and address the outliers individually...

Dudley

Re: Medic-initiated Patient Refusals

MVA's should always be excluded when calculating documented patient refusals

because they skew the results when comparing medic to medic. For example,

medic A responds to an MVA where a school bus nicks a telephone pole resulting

in

35 (uninjured) patient refusals. Medic B has no such occurrence for the same

reporting period. Comparing the two is both immaterial and irresponsible.

Although anecdotal, I've determined that if the number of signed patient

refusals exceeds 9.1% (not counting MVA's) then an organization has a problem.

The

calculus for this is simple. Take a one year sample of response data. Delete

MVA's, canceled enroute, no patient found, etc., from the sample. Then, assign

the number of signed patient refusals to each medic and divide it by the

number of patient contacts. Then, percentile rank all of the medics. The

culprits

will quickly surface.

It's interesting to note that the worst that I've seen is one medic who

obtained refusals on 38% of all patients with whom he came into contact. The

lowest

was 0 in the same district. Then, when I eliminated the 7-8 top offenders

from the mix, the refusal percentage (companywide) dropped below 9%. Claims of

negligence (or worse) not withstanding, the impact to net revenue, for any

organization, is extraordinary. Think of this when you didn't get the raise that

you think you deserved.

As I've always said, the greatest number of patient refusals are obtained

between 5 PM and 8 PM on Superbowl Sunday.

Bob Kellow

**************

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favorite sites in one place. Try it now. (http://www.aol.com/?optin=new-dp & amp;

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[Guest guest]

Thanks Dave. I lurked for several months before posting.

Bob Kellow

**************

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[Guest guest]

Hey Bob, no opinion on your issue here just wanted to say its good to see you

back posting again. Guess you been lurking.

Welcome back!

Dave

Dave

Sent via BlackBerry by AT & T

Re: Medic-initiated Patient Refusals

Why am I not surprised? Forrest for trees. And, the Superbowl reference was a

joke <sigh>.

**************

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and favorite sites in one place. Try it now.

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0000010)