ORIGINAL CONTRIBUTION prehospital care, documentation
Medicolegal Documentation of Prehospital Triage Patients evaluated by paramedics but not transported to the hospital account for 50% to 90% of emergency medical services lawsuits. We reviewed 2,698 consecutive paramedic run reports to examine documentation in the~e c~sep. Documentation criteria for prehospital patient release were history, physical examination, vital signs, mental status, lack of significant mental impairment, and for patients refusing care, that risks of refusing were understood. Criteria for appropriate release were m e t in 65.2% of cases. Criteria omitted in inappropriate releases were risks of refusing care in 481 (51.3% of inappropriate releases), vitals in 320 (34.1%), mental status in 188 (20.0%), lack of impairment in 120 (12.8%), and history or physical in 19 (2.0%) cases. Age from 0 to 14 and 65 or more years and prehospital assessment of hyperventilation, psychiatric emergency, choking, infection, and patient deceased were significantly associated with appropriatekzelease. Age from 35 to 54 years and prehospital diagnosis of no injury, head injury, seizure, minor trauma, and ethanol use were significantly associated with inappropriate releases. There was no association of appropriate release or inappropriate release with patient sex, contact with medical control, length of encounter, or time of day. Only one patient complication was believed due to inappropriate triage; this could be improved by implementation of standardized criteria. [Selden BS, Schnitzer PC, Nolan FX: Medicolegal documentation of prehospital triage. Ann Emerg Med May 1990;19:547-551.]
INTRODUCTION Prehospital care incidents in which patients are evaluated by paramedics but not transported to the hospital ("no-patient" runs [NPR]) represent a large percentage of runs in many emergency medical services (EMS) systems (26% of patient contacts in the system studied). Although these patients can represent some of the most complicated cases, written documentation of these incidents in many EMS systems is usually much less than the usual prehospital run report or not done at all. Quality assurance review of paramedic incidents often excludes NPR cases. Of equal and increasing importance, these patients are the major source of paramedic malpractice risk, representing 50% to 90% of litigation against EMS personnel.1, 2 Because there is no study in the literature of this population, we reviewed a large consecutive series of NPR incidents to examine medicolegal documentation in prehospital patient release and paramedic decisions allowing patients to refuse care. In addition, a search also was conducted for patients in this group who may have been inappropriately triaged to assess validity of paramedic field decisions and determine populations potentially at medical risk or who increase medicolegal risk for the paramedic.
Brad S Selden, MD* Patricia G Schnitzer, RN, MSt Francis X Nolan, MICP:~ Anchorage, Alaska From the Emergency Department, Humana Hospital -- Alaska;* the College of Nursing and Health Sciences, University of Alaska Anchorage;t and the Anchorage Fire Department Emergency Medical Services,:~ Anchorage, Alaska. Received for publication May 10, 1989. Revision received November 6, 1989. Accepted for publication December 21, 1989. Presented at the Society for Academic Emergency Medicine Annual Meeting in Minneapolis, Minnesota, May 1990. Research supported in part (photocopying costs) by a grant from Southern Region Emergency Medical Services, Inc, Anchorage, Alaska. Address for correspondence (no reprints available): Brad S Selden, MD, Good Samaritan Regional Medical Center, Department of Medical Toxicology, 1130 East McDowell Road, Suite A-5, Phoenix, Arizona 85006.
METHODS The Anchorage Fire Department EMS system was the sole EMS provider for the municipality of Anchorage during the study period, performing all medical emergency runs and other patient transports within the city and its major suburb. All study patients were seen by fire department paramedics. The criterion for inclusion in this study was any incident in which a medic unit was dispatched and a patient was examined by a paramedic
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DOCUMENTATION Selden, Schnitzer & Nolan
but not transported to the hospital between January 1, and December 31, 1987. All 1987 NPR paramedic run reports were reviewed by the authors, and data were extracted directly from the run report. In the fire department EMS system, no patients requesting paramedic care or transport to the hospital are refused. The only w r i t t e n guidelines concerning the release of patients or refusal of care are that vital signs should be taken and the pat i e n t " m u s t appear r e a s o n a b l e . " Therefore, a set of generally accepted emergency medical care documentation criteria for release or ability to refuse care were added to these existing criteria for study purposes (Figure 1). 3 W h i l e t h e s e s t a n d a r d s were adapted from emergency department guidelines, a we believed that these fairly represented the standard of care for minimum documentation criteria acceptable for release from emergency medical care at any level. It is important to note that these criteria were developed and applied retrospectively as a research instrument and that the paramedics were not instructed in these guidelines before or during the study period. If all criteria for release were documented, the patient was designated as appropriately released. Omission of one or more criteria constituted an inappropriate release. Omission of up to three of these criteria was recorded for each incident. Documentation of risks of refusing treatment was a requirement only for those patients who were refusing care or transport to a hospital. In the case of pediatric patients, the parent or guardian was considered able to refuse care and responsible for accepting risks of refusal. A modification of these criteria was made for some of the patients with no apparent problem other than ethanol intoxication. It is the standard of care in our EMS system that these patients may be released to an emergency medical technicianstaffed c o m m u n i t y service patrol, which takes ambulatory, intoxicated patients without injury or medical complaint to a detoxification center where they are seen by a nurse with training in the evaluation and care of intoxicated patients. All other intoxicated patients are transported to an ED. Therefore, intoxicated patients with altered mental status released 94/548
to the C o m m u n i t y Service Patrol were considered to be appropriately released if all other criteria were met. Patients presenting for some other complaint with ethanol use as an incidental finding were considered to be without "significant impairment" if documented to be alert, oriented to person, place, and time and without other overt signs of intoxication (ie, ataxia or slurred speech). Patients considered a threat to themselves were not considered competent to refuse care, regardless of mental status. The release of violent patients restrained in police custody for transport to jail (where evaluation by a physician assistant is performed) or to the ED was also considered appropriate. Variables examined for association with appropriate release or inappropriate release included patient age, sex, and prehospital assessment or condition; paramedic unit time out of service (defined as from the time of dispatch until the time the paramedic unit documented notifying the dispatcher that they were able to take another call); time of day; medical control physician contact; and reason for nontransport. Because many patients presented with more than one problem and to better describe this population, up to three prehospital assessments or conditions were coded per run report. These conditions were categorized by the authors (Figure 2), and included but were not limited to the paramedic prehospital assessment. Data analysis was done using a VAX computer and the spss statistical program, with additional statistical tests performed by the authors. The X2 test was used to examine the above variables, with Yates' correction used where indicated. All associations reported in the results section were statistically significant at the P < .05 level unless otherwise indicated. A computer search was conducted of fire department EMS records for the study period to find any patients who r e - e n t e r e d the EMS s y s t e m within two calendar days of NPR contact, and these incidents were evaluated.
RESULTS Anchorage, Alaska, is a municipality with a population during the study period of January 1 through DeAnnals of Emergency Medicine
cember 31, 1987, of 210,000. 4 The paramedic runs dispatched during the study period generated a total of 11,780 run reports. Of these, 2,698 fit criteria for study inclusion. A h i s t o r y was d o c u m e n t e d in 2,696 cases (99.9%). Full vital signs (pulse, blood pressure, and respirations) were recorded in 2,185 (81.0%), not documented in 320 (11.9%), and documented as refused by 193 patients (7.2%). An appropriate physical examination for the presenting c o m p l a i n t was recorded in 2,626 (97.3%), omitted in 23 (0.9%), and refused by 49 (1.8%) patients. Mental status examination was recorded in 2,510 patients (93%). This increased to 95.4% in those patients diagnosed as having a central nervous system event (eg, blunt force injury to the head, seizure, syncope or other neurologic complaint). Pupillary examination was documented in 699 of these patients (87.2%) and other more extensive neurologic examination in 514 (65.5%). Using the criteria for release only (Figure 1), appropriate releases were seen in 2,099 i n c i d e n t s (77.8%). When a d d i t i o n a l criteria to sign a g a i n s t m e d i c a l a d v i c e w e r e included, this decreased to 1,760 incidents (65.2%) for failure to document that risks were explained to these patients, all of w h o m were refusing care or transport. There was no relationship found between appropriate release and patient sex, time of day, or c o n t a c t with the medical control physician. Medic unit time out of service was similar with 18.7 and 18.6 minutes/ incident for appropriate release and inappropriate release, respectively. Patient age was associated with appropriateness of release. Age from 0 to 14 years and 65 or more years was significantly associated with appropriate release when compared with all age groups, whereas age from 35 to 54 years had a significantly higher proportion of inappropriate release. When compared with all prehospital patient assessments, the following were s i g n i f i c a n t l y a s s o c i a t e d with appropriate release: hyperventilation, behavioral and psychiatric emergencies, choking, infectious or febrile illness, and patient deceased (Figure 2). Conversely, assessment of no injury or illness, blunt force injury to the head and face, seizure, minor trauma/orthopedic/burn, or ethanol 19:5 May 1990
FIGURE 1. M i n i m u m prehospital report documentation for patients released or signing out against medical advice.
Criteria for Release History* Vital signs* Physical e x a m i n a t i o n a p p r o p r i a t e for c o m p l a i n t *
FIGURE 2. Appropriate patient releases by prehospital assessment or condition.
Mental status a s s e s s m e n t (alert a n d oriented) No significant i m p a i r m e n t d u e to drugs, alcohol, other o r g a n i c cause, or m e n t a l illness
vital signs were missed in 320 inappropriate release incidents (34.1%) and mental status examination was not recorded in 188 (20.0%). Failure to demonstrate no impairment from recorded head trauma, ethanol or other drug use, or psychiatric illness was seen in 120 of inappropriate release cases (12.8%), and a pertinent history or physical examination was omitted in 19 (2.0%) (percentages do not equal 100% because 438 inappropriately released patients [46.7%] failed more than one criteria).
A d d i t i o n a l Criteria for Patient to be A l l o w e d to Sign Out Against Medical Advice Risks of refusing c a r e or t r a n s p o r t e x p l a i n e d and u n d e r s t o o d b y patient *The first three criteria were considered met if clearly documented as attempted by pararpedics but refused by the patient.
Patient deceased Infectious disease or febrile Diabetic complications Trauma or orthopedics or burns Alchol use or intoxication Toxic or allergic Obstetric or gynecologic Abdominal Respiratory or pulmonary Choking Chest pain or cardiac Isolated ear, eye, nose, throat problem Syncope or other neurologic Seizure Psychiatric Hyperventilation Blunt trauma to head No injury or illness
77 53 57 50 69 54 63 65 85 59 70 63 53 71 74 59 57 10
Appropriate releases (%)
use or intoxication was associated with inapproporiate release. There was no association between appropriateness of release and other conditions (Figure 2). Evaluation of patient disposition revealed a significant association with appropriate release for the 612 patients (22.7% of NPR) transported to other medical care (ED or private physician) by private vehicle. No significant association was found for 1,251 patients (46.5%) treated and released or the 174 patients (6.5%) released to police custody. Refusal of care or transport by 642 patients (23.8%) was associated with inapp r o p r i a t e r e l e a s e ; o v e r a l l , 528 (82.2%) of this group were considered inappropriately released. When 339 of these patients were designated appropriately released who were inap19:5 May 1990
propriately released only because risks of refusing care were not documented, this group still had a significantly lower rate of appropriate release (70.5%) than those not refusing care (77.8%) (P < .001). Six h u n d r e d f o r t y - t w o p a t i e n t s (23.8% of all NPR) were documented as refusing care or transport. Of these, 567 (88.3% of those refusing) did not sign a refusal of care form, and 75 (11.8%) signed, had a friend or relative sign for them, or were documented as refusing to sign. Documentation that risks of refusing care were explained to the patient was seen in 161 of these incidents (25%). Failure to document explanation of the risks of refusing care to the patient was the study criteria failed m o s t frequently in 481 incidents (51.3% of inappropriate releases). Full Annals of Emergency Medicine
DISCUSSION Our data show that when examined against a generally accepted set of e m e r g e n c y care standards, adequate documentation of prehospital patient release was performed in 65.2% of cases in the system studied. We believe that similar results would be found in other EMS systems that have not developed specific guidelines in the care of these patients. It is again noted that paramedics had no instruction in or knowledge of the study criteria for appropriate release of patients. Our criteria were implemented for study purposes to reflect the experience of one EMS system compared with a generally accepted standard of care for patients released from e m e r g e n c y medical evaluation and treatment. This is evident in that the most frequent reason patients were designated inappropriately released (36% of those inappropriately released) was because of failure to document risks of refusing care, which is a deficiency in medicolegal protocol rather than safe patient management (eg, omitting vital signs). This was the most frequent reason for inappropriate release in all but three assessment groups. Even without knowledge of these guidelines, discussion of the risks of refusing care was charted by paramedics in 25% of cases where patients refused care. There was no association between appropriate release and hour of the 549/95
DOCUMENTATION Selden, Schnitzer & Nolan
day. While the frequency of appropriate release was lowest in the very early morning hours, this difference was n o t s t a t i s t i c a l l y significant. There was also no significant difference in appropriate release seen with radio or telephone contact with the medical control physician, although there may have been too few of these patients (2.1% of all NPR incidents) to adequately assess this effect. The paramedics in this system work from an extensive set of written standing orders that minimizes the number of calls made to medical control; there is no special requirement to call the medical control physician concerning prehospital patient release. Patient age was found to be associated with appropriateness of release (P < .01). A significantly greater incidence of appropriate release was seen in the very young and elderly patient populations. Most inappropriate releases in the pediatric age group were due to lack of d o c u m e n t a t i o n of complete full vital signs or mental status (67 of 76 inappropriate release cases [88%]), i n d i c a t i n g that the strict criteria used for full vital signs may not be the standard of care for pediatric patients. A recent large s t u d y in a n o t h e r EMS s y s t e m showed that full vital signs were obtained in only 52% of pediatric patients, s Most inappropriate releases in the elderly population were again due to not d o c u m e n t i n g that the risks of refusing care were explained to the patient. There were no notable differences found to explain the increased frequency of inappropriate release seen in the 35-to-54-year-old age group. Prehospital assessment or condition also was associated with appropriateness of release (P < .001). Assessment of no injury or illness; blunt force injury to the head and face; seizure; minor trauma/orthopedic/burn injury; and ethanol use or intoxication were significantly associated with inappropriate release, and are discussed below for this reason. Two thirds of the no-injury or illness group who were inappropriately released did not have full documentation of vital signs and mental status; perhaps they were omitted because the patient stated or otherwise gave the initial impression that there was nothing wrong. However, 26% of the no-injury or illness group who were inappropriately released had 96/550
evidence in the prehospital medical record of potential central nervous system impairment from drugs, alcohol, organic causes, or psychiatric illness, and lack of impairment that was n o t d o c u m e n t e d . It is well k n o w n that i n t o x i c a t e d , psychiatrically disturbed, or organically impaired patients are the most difficult to fully evaluate, and this effect may be demonstrated here. Inadequate documentation of vital signs and/or mental status were also the most common reasons for inappropriate release in the patients with minor trauma (54% of inappropriate releases in this group). The next most frequent reason for inappropriate release in the minor trauma group was failure to document risks of refusing treatment for their injuries (46%), probably most important in those with neck pain after falls or motor vehicle accidents. Patients with blunt force injury to the head and those with seizures were most often inappropriately released (65% and 67%, respectively) because risks of refusing care were not documented. While these potential central nervous system patients who were inappropriately released had inadequate d o c u m e n t a t i o n of mental status in 11% and lack of other central nervous system impairment in 8%, acceptable mental status was charted in 95% of these patients overall (appropriate release plus inappropriate release). Alcohol use or intoxication also was significantly associated with inappropriate release and was the condition associated with the highest percentage of inappropriate release at 50%. The most frequent reason for inappropriate release in this group was again failure to document explanation of risks of refusing care (40% of inappropriate release). We believe that the major documentation concern in this group is proving competence to refuse care and the ability of the patient to care for himself on prehospital release. However, we found failure to document lack of significant impairment from alcohol ingestion in 34% of inappropriate releases. D o c u m e n t a t i o n of vital signs or mental status was omitted in 25% of inappropriately released patients who had used alcohol. We believe that this also may reflect the unwillingness of medical personnel (in both the prehospital phase and hospital Annals of Emergency Medicine
phase) to fully evaluate and carefully provide disposition for the intoxicated patient because these patients are often the most difficult encounters. However, these data show that these patients are at the highest risk for inappropriate release of any condition studied and require more careful evaluation and disposition from prehospital care. Refusal of prehospital care and/or transport was significantly associated w i t h i n a p p r o p r i a t e release, even when patients who only lacked documentation of criteria B (risks of refusing care not explained) were designated appropriate release for comparison w i t h those not refusing care (criteria B not required). Patients refusing care require and traditionally receive more thorough chart documentation. This was not found, although history, physical examination, and vital sign criteria were considered met if clearly documented as refused by the patient. These data show that these patients, like others who are difficult to manage, may also be more frequently subject to incomplete evaluation in the field. Refusal of care or against medical advice forms were signed (or documented as "patient refused to sign form") by 20.2% of patients refusing care and 5.3% of NPR overall. This reflects the general opinion of the paramedics studied that a formal signed refusal is unnecessary in most NPR incidents. Many patients w i t h o u t apparent injury or illness also were routinely documented as "refused treatment and transport" even though it was clear from the run report that both the patient and paramedic agreed that ambulance transport to the hospital was unwarranted. Some believe that the wording of refusal forms may be inflammatory and frightening to the patient, thereby generating inappropriate paramedic unit transport to the hospital. Strongly stating the risks of refusing care and absolutely insisting that the form be signed, however, is sometimes done to encourage a recalcitrant patient to be transported to the hospital w h e n paramedics think it is indicated. Refusal forms were signed most often in cases of chest pain (17.1% of that patient assessment group released from care), diabetic complications (13.6%), and o b s t e t r i c and gynecologic problems (12.5%), perhaps in 19:5 May 1990
part reflecting the i m p o r t a n c e of possible sequelae of these conditions as perceived by the paramedic. S e v e n t y - t w o p a t i e n t s (2.7% of all NPR) c a l l e d p a r a m e d i c s a n d w e r e seen again w i t h i n two calendar days of t h e i r i n i t i a l N P R c o n t a c t . Of these, 40 (1.5% of all N P R and 56% of t h o s e r e - e x a m i n e d ) w e r e t r a n s p o r t e d to t h e h o s p i t a l for the s a m e c o m p l a i n t , an u n r e l a t e d e p i s o d e of the s a m e p r o b l e m (ie, anxiety, seizure, or e t h a n o l intoxication), or a c o m p l e t e l y u n r e l a t e d complaint. The 32 r e m a i n i n g patients were re-evaluated by paramedics and again a decision was m a d e n o t to t r a n s p o r t patients to the hospital by ambulance. G i v e n our evaluation of prehospit a l r u n r e p o r t d o c u m e n t a t i o n as above, there was t h o u g h t to be an adverse o u t c o m e in only one N P R patient w h o was seen again w i t h i n two days. This p a t i e n t was a 42-year-old i n t o x i c a t e d m a n w h o i n i t i a l l y had an i n c o m p l e t e e v a l u a t i o n by paramedics and was left at the scene w i t h o u t observation. It was d o c u m e n t e d that a radio request was m a d e for C o m m u n i t y S e r v i c e P a t r o l e v a l u a t i o n and transport to the detoxification center. One hour later, paramedics were called by the C o m m u n i t y Service Patrol to see the p a t i e n t again. In the interim, he had fallen and suffered a scalp laceration and facial abrasions. H e w a s also a s s e s s e d t h i s t i m e as p o s s i b l y h y p o t h e r m i c and h a d cold injuries to b o t h hands t h a t were not n o t e d on t h e p r e v i o u s e x a m i n a t i o n . On this re-evaluation, the patient was transported by the m e d i c s to an ED. L i m i t a t i o n s in t h e study design inc l u d e d t h e i n a b i l i t y to f o l l o w t h e m e d i c a l o u t c o m e of all N P R patients after p r e h o s p i t a l release; o n l y t h o s e who re-entered the EMS s y s t e m were evaluated. It was n o t possible to follow all s t u d y patients w i t h such diverse d e s t i n a t i o n s as all m u n i c i p a l hospital EDs and i n p a t i e n t units, private p h y s i c i a n offices, the detoxifica-
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t i o n u n i t , jails, p r i v a t e r e s i d e n c e s , public shelters, city streets, or a sequence thereof. Even if this was possible to do prospectively (perhaps in a very isolated, t i g h t l y c l o s e d population a n d / o r c o m p l e t e l y c o m p r e h e n sive h e a l t h care system), the degree of i l l n e s s n e c e s s i t a t i n g p a r a m e d i c care and transport r e m a i n s a subjective e v a l u a t i o n . Also, w h i l e it m a y be debated t h a t our study of the preh o s p i t a l m e d i c a l record was a v a l i d r e f l e c t i o n of a c t u a l o c c u r r e n c e s in the field, w e thought it was our best a s s e s s m e n t of the prehospital triage process and t h e o n l y m e d i c o l e g a l l y defensible r e p r e s e n t a t i o n of t h e patient encounter. To o p t i m i z e p a t i e n t care and m i n i m i z e legal risk, EMS s y s t e m s should i m p l e m e n t and follow strict criteria for the release of p a t i e n t s from prehospital care. Rather than an abbrevia t e d f o r m or s m a l l s e c t i o n on t h e back of the usual run report, the release f o r m m u s t be at l e a s t as det a i l e d as t h e u s u a l i n c i d e n t r e p o r t and produce m u l t i p l e copies. Special a t t e n t i o n s h o u l d be g i v e n on t h e form to d o c u m e n t a t i o n of criteria for release or allowing the p a t i e n t to refuse care, including a p r i n t e d checklist and areas for the additional docum e n t a t i o n of each necessary e l e m e n t as required. In addition to i m p r o v e d m e d i c o l e g a l d o c u m e n t a t i o n , this allows the p a r a m e d i c to reconsider the appropriateness of release as the criteria are reviewed. T h e risks of refusing care or transport s h o u l d be clearly l i s t e d b y t h e p a r a m e d i c on this form. T h e c h a r t should include a section that can be d e t a c h e d a n d g i v e n to t h e p a t i e n t that includes any agreement on disp o s i t i o n , r i s k s of refusal of care, or i n s t r u c t i o n s received by the patient. A l l c o p i e s s h o u l d s h o w t h e signatures of the patient, paramedics, and any available witnesses. The chart can be designed to facilitate data ent r y for o n g o i n g c o m p u t e r - a s s i s t e d q u a l i t y assurance audit. P a r a m e d i c s
Annals of Emergency Medicine
should be trained in w r i t i n g meticulous and d e t a i l e d r u n reports, especially in those cases in w h i c h care or transport was refused. Police should be liberally involved in cases of possibly i n c a p a c i t a t e d or o t h e r w i s e inc o m p e t e n t p a t i e n t s refusing care or postseizure patients w h o insist they will drive. CONCLUSION A retrospective s t u d y of 2,698 patients was performed to e x a m i n e the m e d i c o l e g a l d o c u m e n t a t i o n of param e d i c e n c o u n t e r s w i t h p a t i e n t s rel e a s e d f r o m p r e h o s p i t a l care, w i t h study d o c u m e n t a t i o n criteria for release m e t i n 65.2% of cases. T h i s c o u l d be i m p r o v e d b y i m p l e m e n t a tion of standardized criteria such as t h o s e studied. We b e l i e v e t h a t our findings in this previously u n s t u d i e d patient p o p u l a t i o n have i m p l i c a t i o n s for all prehospital care providers and that p o l i c i e s and p r o c e d u r e s regarding t h e i r care s h o u l d be e x a m i n e d and refined. The authors acknowledge Lyle Personnette and Alan Larson, MICP, for their computer assistance and the Anchorage Fire Department EMS for their cooperation.
1, SolerJM, Montes MF, Egol EB, et al: The tenyear malpractice experience of a large urban EM8 system. Ann Emerg Med 1985;14:982-985. 2. Ayres JR Jr: The Law and You: Causes of Lawsuits: Emergency Medical Update (videocassette series). Winslow, Washington, Ellen Lockert and Assoc, Inc, 1988, vol 1, p 4. 3. Purdie FRJ, Honigman B, Rosen P, et al: Prudent handling of patients signing out against medical advice. ER Reports 1982;3:73-78. 4. Community Planning Department, Municipality of Anchorage: 1987 Anchorage Population Profile. Anchorage, Alaska, Municipality of Anchorage, 1988. 5. Gausehe M, Henderson DP, Seidel JS: Vital signs as part of the prehospital assessment of the pediatric patient: A survey of paramedics. Ann Emerg Med 1990;19:173-178.