Cone D C, Kim D T, Davidson S J
Department of Emergency Medicine, Medical College of Pennsylvania, Philadelphia 19129-1121, USA.
Prehosp Disaster Med. 1995 Jan-Mar;10(1):3-9. doi: 10.1017/s1049023x0004156x.
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.
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.
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.
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.
急诊医疗服务（EMS）人员对患者进行评估但未将患者转运至医院的情况越来越受到关注。对其中一部分情况，即患者主动拒绝（PIR），也就是患者拒绝治疗和转运的情况进行了研究和评估。本研究的目的是检查PIR中救护车呼叫报告文件记录的充分性，研究在一个基于医院的郊区EMS系统中这些患者的临床结局，并评估在线医疗指挥（OLMC）对PIR病例的潜在影响。
所研究的系统是一个基于医院的、具备转运能力的郊区EMS系统中的高级生命支持服务，年呼叫量为4200次。在为期6个月的研究期间，检查了护理人员填写的所有救护车呼叫报告以及医疗指挥医生填写的医疗指挥控制表格，并收集了PIR病例。检查每份救护车呼叫报告的文件记录是否充分。通过急诊科记录和电话随访确定患者结局。
研究期间记录了85例PIR。由于缺少救护车呼叫报告和/或医疗指挥控制表格，排除了4例，剩下81例PIR用于分析。尽管政策要求在PIR病例中进行OLMC，但仅在23例PIR（28%）中建立了OLMC。其中，2例（9%）的救护车呼叫报告文件记录不充分。在未建立OLMC的58例PIR中，25例（43%）的救护车呼叫报告文件记录不充分（p<0.001，Fisher精确检验）。对54例（67%）PIR进行了随访。其中，37例（68%）随后未看医生，且均无需进一步医疗护理。7例（13%）在最初拒绝院前护理后的几天内看了自己的医生，且没有进一步问题。10例患者在几天内到急诊科就诊。3例（6%）出院，情况良好。7例（13%）入院，4例（7%）入住监护病房，3例（6%）入住非监护病房。无死亡病例。
有OLMC时救护车呼叫报告的文件记录比没有时更好。最初拒绝护理的患者可能患病，有些最终会住院。进一步的研究可能会阐明OLMC在防止无行为能力患者拒绝、说服有行为能力但看起来患病的患者接受转运以及在其他困难或特殊情况下协助护理人员方面的作用。
