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Refusals. Presence Regional EMS 2014. Objectives. Review the criteria for refusal of treatment and/or transport Describe situations that require contact with Medical Control Define situations that require a complete patient care report in addition to the PREMSS refusal form

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refusals

Refusals

Presence Regional EMS

2014

objectives
Objectives
  • Review the criteria for refusal of treatment and/or transport
  • Describe situations that require contact with Medical Control
  • Define situations that require a complete patient care report in addition to the PREMSS refusal form
  • Demonstrate the use of the revised PREMSS refusal form
introduction
Introduction
  • The PREMSS refusal form has been revised to allow for better documentation of refusal of treatment and/or transport of a patient.
  • In most cases only the refusal form will need to be completed however there are situations when a full patient care report should be completed in addition to the refusal form.
review of refusal criteria
Review of Refusal Criteria
  • Refusal of treatment/transport should be initiated by the patient.
  • At NO time should any EMS provider suggest or initiate a patient refusal.
  • Upon refusal of treatment and/or transport, the EMS provider should evaluate the patient.
evaluation mental status
Evaluation - Mental Status
  • Is the patient alert and oriented to person, place, time and event?
  • Is the patient free of the influence of drugs or alcohol?
evaluation vital signs
Evaluation - Vital Signs
  • Evaluate airway, breathing and circulation.
  • A complete set of vital signs should be obtained.
  • If patient refuses to have vital signs taken, the EMS provider should use a visual and verbal assessment to determine if vital signs are altered.
evaluation moi noi
Evaluation - MOI / NOI
  • Is the scene free of significant mechanism of injury?
  • Does the patient have a life-threatening chief complaint or evidence of significant signs and/or symptoms?
  • Is the patient free of “pertinent” medical history?
evaluation competence
Evaluation - Competence
  • Is the patient ≥ 18 years of age?
  • If the patient is not the appropriate age:
    • Does the patient proof of emancipation?
    • Is accompanied by parent or legal guardian?
review of refusal criteria1
Review of Refusal Criteria
  • Explain possible risks and complications that may occur if treatment and/or transport are not provided.
  • This may include “death or reduction in quality of life” if the patient’s condition is considered life threatening by the EMS provider or Medical Control.
refusal form documentation
Refusal Form Documentation
  • Complete the PREMSS Refusal form by answering all questions in the upper portion of the form.
  • Document scene and assessment findings in the space labeled “Notes/Comments”.
  • Document vital signs in the space provided.
medical control
Medical Control
  • Medical Control must be contacted when:
    • Any question in the upper portion of the refusal form has been answered “NO”
    • If a patient refuses transport after EMS treatment has been initiated
    • All AMA refusals
  • When Medical Control is contacted, check the box next to the hospital contacted and print the physician’s name on the line indicated
signatures
Signatures
  • Several signatures must be obtained on the refusal form
  • The EMS provider should read aloud the release statement to ensure that the patient understands what he/she is signing
patient signature
Patient Signature
  • The patient’s name is to be printed in the release statement in the space provided.
  • The patient (or parent/legal guardian) should sign on the line indicated.
  • If the patient refuses to sign the form, the reason must be documented on the refusal form.
  • The patient must also initial a reason for refusal in the space provided on the form
patient signature cont
Patient Signature (cont.)
  • If the EMS provider and/or Medical Control do not agree to the patient’s refusal of treatment and/or transport, the patient may still choose to refuse AGAINST MEDICAL ADVICE (AMA) provided that the patient is not a danger to himself or others.
ems provider signature
EMS Provider Signature
  • The EMS provider in charge must sign on the line indicated at the bottom of the refusal form.
  • The EMS provider must also indicate with whom the patient was left.
  • If the patient is turned over to law enforcement, the accepting officer must sign the form and include his/her badge number.
witness signature
Witness Signature
  • A witness should also sign on the line indicated.
  • Potential witnesses include any of the following persons present at the time the patient signs the refusal form:
    • Family members/friends
    • Law enforcement officials
    • Fire department personnel
    • Bystanders
    • Other EMS providers (it is recommended that this be a last resort as a witness)
revised premss refusal form
Revised PREMSS Refusal Form
  • The revised form allows the EMS provider to document all components of a patient refusal using only one form in most cases.
  • There are situations that still require a complete patient care report in addition to the refusal form.
revised premss refusal form1
Revised PREMSS Refusal Form
  • A complete patient care report should be completed in addition to the PREMSS refusal form when:
    • Any question in the upper portion of the form is answered “NO”.
    • Medical Control has been contacted for any reason.
    • Any EMS treatment has been provided.
summary
Summary
  • The revised form allows the EMS provider to document all components of a patient refusal using only one form in most cases.
  • A complete patient care report should be completed in addition to the PREMSS refusal form when any question in the upper portion of the form is answered “NO”, Medical Control has been contacted for any reason, any EMS treatment has been provided.
summary1
Summary
  • Refusal of treatment/transport should be initiated by the patient. At NO time should any EMS provider suggest or initiate a patient refusal.
  • Medical Control must be contacted when any question in the upper portion of the refusal form has been answered “NO”, if a patient refuses transport after EMS treatment has been initiated and for all AMA refusals.
review
Review
  • Consider the following questions as a group.
    • IDPH site code: Use site code assigned to your agency for 2014.
  • If doing this CE individually, please e-mail your answers to:
    • Shelley.Peelman@presencehealth.org
    • Use “Refusal 2014 CE” in subject box.
    • IDPH site code: 06-7100-E-1214W
  • You will receive an e-mail confirmation. Print this confirmation for your records and document in your PREMSS CE record book.
scenario 1
Scenario 1
  • You are dispatched for a 32 year old male patient with a diabetic problem. Upon arrival you find Tony lying in bed. He is unresponsive but breathing. His skin is pale, cool and clammy. You check his blood sugar and find it to be 40 mg/dl.
  • You obtain vascular access and administer

25g of 50% dextrose.

scenario 1 cont
Scenario 1 (cont.)

After administration of the dextrose, Tony wakes

up. He is a little slow to respond but is alert and

oriented x4. He wants to refuse transport to the

hospital.

Can Tony refuse transport?

How will you proceed?

scenario 2
Scenario 2
  • Patty was on her way home from work and has been involved in a minor vehicle accident. There is minimal damage to the front end of her car. She has a small bump on her forehead.
scenario 2 cont
Scenario 2 (cont.)
  • Patty is alert and oriented x4. She denies any loss of consciousness. Her vital signs are within normal limits. She states she doesn’t want to be transported to the hospital.

Can Patty refuse transport?

How will you proceed?

scenario 3
Scenario 3
  • Robert is a 68 year old male who called 911 when he began experiencing chest pain. Upon your arrival you find Robert sitting in a chair at the kitchen table.
  • He tells you the pain is not as bad now and he thinks it is indigestion. He has decided he doesn’t want to go to the hospital.
scenario 3 cont
Scenario 3 (cont)
  • Robert reports he has a prior history of heart problems. He allows you to take his vital signs but insists he does not want to be transported.
  • VS: B/P = 170/100; P = 86 irregular; R = 24
  • You hear slight wheezing when he breaths.

How will you proceed?

scenario 4
Scenario 4
  • You are called for a 47 year old female patient acting strangely. Upon arriving at the scene, you find your patient, Anne, being subdued by family members. Family tells you that Anne became confused and combative shortly after getting up this morning. They state she is diabetic but they have been unable to test her blood sugar because she is out of test strips.
scenario 4 cont
Scenario 4 (cont.)
  • You quickly check her blood sugar and find it to be 46 mg/dl. Since Anne is conscious and able to speak you decide to administer one tube of oral glucose.
  • Anne becomes more alert after the glucose and complains of a headache and feeling tired. She does not want to go to the hospital.

How will you proceed?

scenario 1 answer
Scenario 1 Answer
  • Yes, Tony may refuse transport. He is alert and oriented x4 and is over the age of 18.
  • Medical Control should be contacted because there were obvious life-threatening signs and symptoms present, there is pertinent medical history and EMS treatment was given.
  • Complete the PREMSS refusal form anda full patient care report.
answer scenario 2
Answer Scenario 2
  • If Patty is ≥ 18 years old, she does meet criteria for refusal.
  • Medical Control does not need to be contacted in this situation.
  • Document the refusal on the PREMSS refusal form. No additional documentation is needed.
answer scenario 3
Answer Scenario 3
  • Try convincing Robert to be transported to the hospital. Explain the potential risks involved with not seeking medical attention for his chest pain.
  • Contact Medical Control and explain the situation.
  • If Robert still refuses transport to the hospital, consider this an AMA refusal.
  • Complete the PREMSS refusal form anda full patient care report.
answer scenario 4
Answer Scenario 4
  • Anne meets criteria to refuse transport
  • You must still contact Medical Control since Anne has pertinent medical history associated with her signs and symptoms upon your arrival and EMS treatment was provided.
  • Complete the PREMSS Refusal form and a full patient care report.