Moss S T, Chan T C, Buchanan J, Dunford J V, Vilke G M
Department of Emergency Medicine University of California, San Diego, Medical Center 92103, USA.
Ann Emerg Med. 1998 Feb;31(2):247-50. doi: 10.1016/s0196-0644(98)70315-4.
To describe the incidence and demographic data of prehospital patients who contact paramedics by way of the 911 system, refuse transport against medical advice (AMA), then call 911 and are subsequently reevaluated by paramedics in the following 48 hours.
We conducted a retrospective observational review of records using the San Diego County Quality Assurance Network database for prehospital providers. All paramedic 911 responses that made base hospital contact over a 3-month period were reviewed to identify patients who signed out AMA. The main outcome measure was to identify patients who signed out AMA and then called 911 again within 48 hours. The demographics, complaints, treatments, and dispositions of these patients are described.
Of 6,512 total 911 responses reviewed, 443 (7%) involved patients who signed out AMA. Of these patients, 156 cases (35.2%) were listed as trauma and 287 (64.8%) were medical, with cardiac chest pain, seizure, and respiratory distress/shortness of breath the most frequently noted medical subcategories. Fifty-one (11.5%) such patients received treatment; 34 received dextrose, 12 naloxone, 4 albuterol, and 1 a splint. Patient names were available in 5,515, of the total 6,512 responses and 431 of the 443 AMA cases, permitting computer searching of reevaluations by paramedics. Of the 431 AMA patients for whom a name was available, 10 (2%) called 911 again within 48 hours. All 10 callbacks were made for a related chief compliant, and all 10 of these patients were transported (4 admitted to hospital, 1 died en route, 1 transferred to another facility, 4 discharged from the ED). Of these 10 patients, 7 (70%) were older than 65 years, compared with 17% of all AMA patients older than 65 years.
On the basis of our findings, patients over the age of 65 years have a propensity to recontact paramedics and should be aggressively encouraged to seek emergency medical treatment. Future prospective studies should be mounted to examine at patient outcome and to assess why patients sign out AMA after making contact with paramedics.
描述通过911系统联系护理人员、违背医嘱拒绝转运（AMA）、随后拨打911并在接下来48小时内接受护理人员再次评估的院前患者的发病率和人口统计学数据。
我们使用圣地亚哥县院前急救人员质量保证网络数据库对记录进行了回顾性观察性研究。对3个月内所有与基地医院取得联系的护理人员911响应记录进行审查，以确定签署AMA出院的患者。主要观察指标是确定签署AMA出院并在48小时内再次拨打911的患者。描述了这些患者的人口统计学特征、主诉、治疗情况和处置方式。
在审查的6512次911响应中，443次（7%）涉及签署AMA出院的患者。在这些患者中，156例（35.2%）被列为创伤患者，287例（64.8%）为内科患者，其内科亚类中最常见的是心前区疼痛、癫痫发作以及呼吸窘迫/呼吸急促。51例（11.5%）此类患者接受了治疗；34例接受了葡萄糖治疗，12例接受了纳洛酮治疗，4例接受了沙丁胺醇治疗，1例接受了夹板固定。在总共6512次响应中的5515次以及443例AMA病例中的431例中可以获取患者姓名，从而能够通过计算机搜索护理人员的再次评估记录。在有姓名记录的431例AMA患者中，10例（2%）在48小时内再次拨打了911。所有10次回电均是因为相关的主要主诉，并且这10例患者均被转运（4例入院，1例在途中死亡，1例转至另一机构，4例从急诊科出院）。在这10例患者中，7例（70%）年龄超过65岁，而在所有年龄超过65岁的AMA患者中这一比例为17%。
根据我们的研究结果，65岁以上的患者有再次联系护理人员的倾向，应积极鼓励他们寻求紧急医疗救治。未来应开展前瞻性研究，以检查患者的治疗结果，并评估患者在与护理人员接触后签署AMA出院的原因。
