EMS has come a long way in every aspect of patient care, but there is one area that has fallen by the wayside. In most situations when a patient refuses treatment and/or transport, EMS fails to meet the standard of care of most other medical professions. Normally, a crew member retrieves the clipboard and obtains a quick signature from the patient, telling him, "Sign here. This says you do not wish to be transported to the hospital." After a signature is obtained, the crew leaves and returns to service.
EMS should follow the lead of other medical professions and provide patients with some basic information specific to their injury or illness. Think about it: You expect your mechanic to tell you what to look for and when to call back after they've worked on your car. As EMS providers, we should give the same service to the people we serve. Instructions from EMS personnel at times of patient refusal are too often ignored and show a lack of communication with patients. At 3 a.m., no one expects providers to remember all of the instructions to give a patient who does not want to go to the hospital. The hospitals don't rely on memory for all of their instructions; they print out a discharge instruction sheet and review it with the patient. Using a standardized instruction form provides valuable and consistent information (that the patient both hears and receives in writing) and comprehensive documentation if a future legal issue arises. It is the standard of care in hospitals and clinics to offer patients instructions of some type after they are evaluated. Why are we different in the prehospital setting?
Standardized Patient Instruction Form
EMS agencies must ensure that all personnel give correct and consistent instructions/answers to all patients who refuse transport. The Council Bluffs (IA) Fire Department began by developing an instruction sheet for patients who were involved in minor motor vehicle accidents (MVAs), which describes signs and symptoms that commonly occur following minor vehicular crashes. With 10 years' experience in a trauma center and 19 years in EMS, I knew that a large number of patients experience sore muscles and stiffness in the hours following a crash. Some make an expensive and often unnecessary trip to an emergency department for these normal aches and pains that begin long after they get home. With the assistance of our medical director, we developed an MVA Instruction Sheet (Figure 1 on page 62) that responders give patients who refuse transport following a minor motor vehicle crash. The sheet includes a list of expected signs and symptoms, as well as other signs and symptoms that may indicate injuries that require further evaluation by a physician.
The Council Bluffs Fire Department also developed a Diabetic Information Sheet, which is used as often as the MVA form.
EMS responds to many diabetic emergencies. Often, those with hypoglycemia refuse transport after their blood glucose level is raised and signs/symptoms are reversed with glucose. EMS providers instruct the patient and/or caregiver to follow up with food, since the glucose given will be rapidly absorbed, and get a signed refusal. Later the patient may wonder what his blood sugar was, what medication was given, and if a call to a private physician is warranted. The patient information sheet shows the time of treatment, medication given, blood sugar level before and after medication administration, and follow-up instructions. The form also advises the patient to call a private physician and states that EMS is not a substitute for private physician care.
The instruction form can serve as a resource for family members who were not on scene at the time of the response. It documents how low the patient's glucose level was at the time EMS arrived and the treatment administered.
The instruction sheets provide the department with three things:
Information the patient can review later
A resource for medics when answering patients' questions
A formal way to document what information/advice is given to the patient at the time of refusal.
The instruction forms can be made in a carbon copy format, or they may be copied and made into pads for providers to use. The amount of information that will be added to the forms by providers will be minimal, so the need for a carbon copy is debatable. Consult a legal source for advice.
Addressing Legal Liability
The general public does not distinguish between provider levels. They only recognize that EMS providers have the education, training and expertise to provide assistance during their personal crises. Regardless of the level responding, the provider must be aware of the liability associated with a patient refusal. If a patient signs a refusal, can your system prove that your responders provided the patient adequate information and advice? More important, what specific advice did they provide?
A signed, complaint-specific patient information sheet proves what information is given to the patient and standardizes the information. In some instances, the form might even include a phone number for patients to call if they have additional questions. Benefits of the instruction sheets can be summarized as follows:
Documents what the patient was told
Is the format for EMS providers to give consistent information
Improves patient understanding with the use of common terms
Stresses that a definitive diagnosis should be made by their physician
Provides some guidance for what to do if the condition fails to improve, worsens or new symptoms develop
Helps build EMS personnel's confidence when teaching patients
May reduce time at scene needed for patient education
Serves as a resource for the patient and/or caregiver after EMS leaves.
Developing Instruction Sheets
The instruction sheet can take a variety of formats. A separate sheet can be developed for each specific condition that results in frequent refusals. A sheet might contain multiple categories and require providers to circle what is applicable to the situation. For example, a pediatric sheet might include upper respiratory infection, diaper rash, fever, sore throat and minor head injury. As providers circle the applicable situation, the conditions they choose will depend on the types of responses common to your system. Not all systems respond to calls for diaper rash complaints. The service may have a policy that all pediatric patients who have a febrile seizure are transported. Each service should develop sheets that are specific to their system, patient population and protocols. Regardless of the condition, personnel must always emphasize to patients that the instructions do not replace follow-up with a physician.
Your medical director should be actively involved in the development of any patient instruction form. Our medical director embraced the idea of a standardized instruction resource for patient use and helped us develop our forms. Your legal department should also review any forms.
Approximately 20% of all patients who are assessed by Council Bluffs Fire EMS providers refuse transport due to absence of any injury, minor injuries or illness that did not require medical attention. Using instruction sheets for this population has resulted in increased satisfaction with our EMS services.
There are two important things to remember when educating personnel on the use of instruction sheets. First, the sheet does not replace the need for EMS providers to discuss their assessment findings with the patient. It is used to enhance the discussion and give the patient a written resource to refer to later. The patient hears the information from the provider, sees it on the information sheet and can review it and/or show it to a family member. Second, there should not be an increase in the number of refusals EMS personnel obtain. Providers should continue to encourage the patient to be transported to the hospital for further medical care and evaluation. Patient information sheets should never take the place of credible, well-written documentation on the signed refusal of care report.
We have found that medics use the information sheets as resources during their documentation and communication with the patients. The medic documents in the refusal form that the information sheet was reviewed with the patient and the patient signs the refusal, acknowledging receipt of the form. Using standardized instruction sheets can improve both customer service and the image of prehospital care, as well as encourage providers to document and educate their patients who refuse transport.