Brief Reports

Patient transport via private vehicle in Sequoia and Kings Canyon national parks

Albert Sae MD^a,*, Stephen Haverly MD^a, Jeffery Uller MD^b,

Marc Shalit MD^a, Geoff Stroh MD^a

^aEmergency Medicine, University of California San Francisco-Fresno, University Medical Center, Fresno, CA 93702, USA

^bMid-Atlantic Emergency Medical Associates, Charlotte, NC 28269, USA

Received 11 December 2003; accepted 3 June 2004

Abstract

Objective: Emergency medical service providers frequently encounter patients with low acuity. Because of liability and Safety concerns, emergency medical service systems often prohibit privately owned vehicle (POV) transport. Thus, preHospital resources are used with questionable benefit. In Sequoia and Kings Canyon National Parks, our primary objective was to determine the feasibility of POV. We assessed patient compliance, satisfaction, and safety. Our hypothesis was that POV is feasible with online physician medical control.

Methods: This study was a prospective observational analysis of outcomes from POV during a 1-year period. All POV patients were advised to seek medical attention at a hospital. POV patients were asked questions about their medical complaint and the events during transport and at the hospital.

Results: No documented admissions or patient deterioration was noted. During the survey, all patients were either ball better Q (86%) or bsomewhat better Q (14%).

Conclusion: We conclude that POV with carefully selected patients and online physician medical control is feasible and deserves further study in other systems.

D 2005

Introduction

Emergency medical service (EMS) providers frequently encounter Hemodynamically stable patients with medical complaints of low acuity. These patients are at low risk of worsening and are unlikely to require measures for continued stabilization or pain control. According to multiple studies, 11% to 52% of EMS transports are

Presented at the Western Society for Academic Emergency Medicine Annual Meeting, May 2001.

* Corresponding author. Tel.: +1 559 459 5105; fax: +1 559 459 3844.

E-mail address: [email protected] (A. Sae).

medically unnecessary [1- 4]. However, this type of utiliza- tion continues to increase [5], and the activation of the EMS system often results in EMS transport. Despite this growing problem, only 17% of EMS systems have protocols that allow alternatives to EMS transport for those patients thought to have minor medical conditions [5].

One possible solution to this dilemma is the concept of privately owned vehicle (POV) transport. However, not providing supervised patient transport has both legal and medical ramifications for EMS systems. Once a professional EMS provider has made contact and advised a bpatient,Q the requirement of a duty to act can be argued in court [6]. If the interaction results in the patient leaving the care of the

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provider, either according to or against the advice of the provider, a potential for breach of duty exists [6]. In fact, 50% to 90% of EMS-related lawsuits involve medical nontransport [7,8].

Beyond legal concerns, significant medical risks may also exist. As reported by Pointer et al [9], paramedics with 30 minutes of additional triage training were unable to triage patients effectively. Pointer et al [9] also demonstrated that emergency medical technician (EMT)- intermediates undertriaged patients almost 50% of the time. In addition, patients were often unable to remember or misunderstood EMS instructions. In one study address- ing patient refusal of transport, 45% of patients did not recall receiving instructions, and 26% did not fully understand the circumstances surrounding the activation of EMS [10].

These concerns are magnified in our wilderness setting for several reasons. First, the transport time to definitive care is long. Sequoia and Kings Canyon National Park (SEKI) is in the Sierra Nevada mountain range, and ground transports routinely take more than 2 hours to the nearest hospital. Second, Parkmedics provide the highest level of prehospital care in SEKI. Although these Parkmedics are extensively trained in patient assessment, the use of a Combitube (Kendall-Sheridan Catheter Corp, Argyle NY), intravenous therapy, and the pharmacology of 26 authorized medications, they practice only in this wilderness setting. As a result, they have less experience and fewer patient contacts than their urban counterparts. All the SEKI EMS providers combined (EMT Basics and Parkmedics) respond to approximately 350 calls per year, and each individual provider encounters a range of 0 to 50 patients each year. Third, these providers are park rangers whose other responsibilities often include Search and rescue, law enforcement, and firefighting. Therefore, ambulance trans- port is a major human resource commitment that may leave large portions of the national park without other vital services. Consequently, POV is integral to park system operations and, in many instances, is the only logistically feasible alternative. Because of these factors, our setting could be considered a particularly challenging environment to rigorously test the efficacy and feasibility of safe alternative modes of transport.

Table 1 Patient demographics and medical complaints

Sex

^a Complaints included: 1) dizziness and tingling in hands,

2) headache, vomiting, and chills, 3) went limp, 4) bumps on torso,

5) lower abdominal pain, 6) eye redness and soreness, 7) eye swelling and redness, 8) shortness of breath, 9) fever, 10) constipation, and

11) headache and dizziness.

Despite the distant wilderness setting and less- experienced EMS providers, there are indications that under certain circumstances, POV may be feasible. According to Burnstein et al [11], patient compliance with medical instructions increases with physician involvement. In addition, the accuracy of triage decision making improves with online physician supervision [12]. As a result, our study attempts to assess the feasibility of POV transport with the benefit of 100% online physician medical control. The literature in this area suffers from several limitations. Most studies are retrospective and rely on contacting patients to inquire about their outcome long periods after the encounter. This follow-up has proven to be difficult to

accomplish, and contact success rates have been poor. In fact, with an exhaustive Pubmed literature search, we were unable to locate any studies that evaluated outcomes of EMS refusal or Non-EMS transport with 100% online physician medical control. For these reasons, we feel our wilderness setting provides an ideal situation to evaluate outcomes of EMS transport via POV transport using online physician medical control for decision making. We attempted to determine if patients could remember and follow Parkmedics or EMT-basic instructions, if the expec- tations of patients were fulfilled, and whether the transport was safe. Ultimately, we hoped to demonstrate that POV is a feasible Mode of transport and a viable alternative for carefully selected prehospital patients.

Methods

This study was a prospective observational study of all patient encounters in SEKI for a period of 1 year (1999). SEKI EMS providers are required by policy to contact a base hospital physician for authorization of POV transport, and this permission was documented on the EMS runsheet. All patients who were determined to be suitable for POV transport by an online physician were included in the study. Once POV authorization was established, all patients were given verbal instructions to seek additional care at a hospital. Although the physician may request to speak with a patient directly, the usual practice is for all instructions to be relayed via the EMS provider. In addition, many patients receive comfort measures per SEKI EMS protocol before this transport. These measures include splints, ice, elevation, dressings, and on occasion medications.

Male	33 (66%)
Female	17 (34%)
Age (y)
0-5	13 (26%)
6-12	8 (16%)
13-19	13 (26%)
20-29	6 (12%)
30-49	4 (8%)
z50	6 (12%)
Medical complaint
Musculoskeletal complaint	18 (36%)
Lacerations	11 (22%)
Minor burns	7 (14%)
Stings/bites	3 (6%)
Othersa	11 (22%)

Physicians overseeing the SEKI EMS system perform a comprehensive physician review of all runsheets as part of Continuing Quality Improvement (CQI). From this review, a list of all POV transports during the study period was provided to the researchers. Patient names, addresses, phone numbers, and medical conditions were retrieved from the runsheets.

A study physician or trained researcher called each patient. A brief description of the study and an assurance of confidentiality were provided. At the time of the survey, all patients were consented for the interview and the potential review of any hospital records. Patients who consented to participate in the study were asked 8 questions using a standardized collection form (Table 2). We then calculated statistics for the answers to survey questions.

Medical records were reviewed for any patient who was admitted to the hospital. CQI, which includes a physician review of all patient encounters (runsheets) and patient tracking for poor outcomes, was conducted during the study period, thus ensuring review of all park POV transports.

This study was approved by the Fresno/Kings/Madera EMS Agency Medical Control Committee, SEKI, and the institutional review board of Community Medical Centers.

Results

Of 381 patient encounters generated during the 1-year study period, 113 (30%) patients with the agreement of the online physician were selected for POV transport. Of these, 50 (44%) were successfully recontacted and consented for the study. The majority of the patients were recontacted within a 3- to 6-month period. Delayed recontacts occurred up to a maximum of 8 months. Demographics for the 50 patients including age, sex, and medical complaint are delineated in Table 1. Survey questions and responses are noted in Table 2.

Of the 50 patients contacted, 42 (84%) stated that they were advised to see a physician, 2 (4%) stated that they were not advised, and 6 (12%) could not remember. A review of the runsheets in the 8 cases in which patients claimed that they were not advised or could not recall advice revealed documentation that all these patients stated their intent to transport by POV for further medical care. Of the 42 patients that remembered the POV instructions, 30 (71%) presented to hospitals for evaluations, thus 60% of the patients contacted both remembered and followed their disposition instructions.

Table 2 Survey questions and number (percentage) of responses

1) How are you doing now?
All better: 43 (86%)	Somewhat better: 7 (14%)	Same: 0
Somewhat worse: 0	Much worse: 0

1. Were you advised to go to the hospital?

Yes: 42 (84%) No: 2 (4%)^a Can’t remember: 6 (12%)^b

1. Did you go to the hospital?

Yes: 30 (71%) No: 12 (29%)

1. Were you admitted to the hospital? How many days total?

No: 41 (98%) Yes: 1 (2%) – 1 day^c

1. How comfortable were you during your ride to the hospital (scale 0-10 from no pain to extreme pain)? 0 (5) 1 (1) 2 (0) 3 (1) 4 (4) 5 (5) 6 (2) 7 (5) 8 (4) 9 (1) 10 (2)^d
2. Did your condition change during your drive?

All better: 0 Somewhat better: 3 (10%) Same: 22 (73%)

Somewhat worse: 2 (7%) Much worse: 3 (10%)

1. For your medical problem, would you have preferred to go by ambulance if you had to pay for it personally ($500-$700)? Yes: 15 (30%) No: 34 (68%) Not sure: 1 (2%)
2. Would you be willing to pay extra taxes for a government-funded ambulance service in the national parks? Yes: 38 (76%) No: 8 (16%) No answer: 2 (4%)

Possibly: 2 (4%)

^a The complaints included Bee sting and wrist pain.

^b The complaints included elbow abrasion, back laceration, constipation, foot abrasion, rash, and abdominal pain.

^c The complaint was knee pain, and the patient stated that he was admitted to the hospital, but a review of hospital records showed no admission.

^d Pain ratings of 5 to 10 had complaints of headache, vomiting, abdominal pain, red eye, lip laceration, eye swelling, 2 burns, and 7 isolated musculoskeletal injuries.

At the time of the survey, 43 (86%) of the 50 contacted stated that they were ball better.Q The other 7 (14%) patients stated that they were bsomewhat better.Q None of the patients contacted stated that their condition was the same or worse than when EMS first arrived. Of the 30 patients who sought physician evaluation, 1 patient reported being admitted overnight. A review of the hospital records showed that the chief complaint for this patient was knee pain sustained from a fall while running, with no evidence of hospital admission.

While en route, 14 (47%) of the 30 patients who went to the hospital reported pain at a level greater than 5 on a scale of 1 to 10. Of the 14 patients who reported pain greater than a 5, only 4 (29%) stated that they would have been willing to pay US$500 to US$700 for Ambulance transport. In contrast, 8 (50%) of the 16 who rated their pain a 5 or less reported that they would have been willing to pay. Only 5 patients stated that they became somewhat worse or much worse during POV, but 4 (80%) of the 5 stated that they would not want ambulance transport if they had to pay for it. Although most patients, 34 (68%) of 50, would not have been willing to pay for their transport at the US$500 to US$700 range, the majority, 38 (76%) of 50, were willing to pay taxes to provide this service.

Discussion

Our study attempted to determine if POV with 100% online physician medical control is a feasible alternative to ambulance transport. To achieve this goal, several questions needed to be answered. First, are patients able to remember and follow instructions that they are given? Second, can patient expectations be fulfilled by POV? Lastly, is POV with 100% online physician medical control safe?

For POV to be a viable option of patient transport, one must be assured that patients will understand, remember, and follow instructions. Our data reflect a high percentage (84%) of patients remembering their disposition instructions and also following these instructions, by going to the hospital (60%). In comparison to other studies, this is a high rate of recollection and follow-up. Schmidt et al [10] found a 55% recall of instructions with online medical control limited only to bobvious high-riskQ medical conditions. In addition, Burnstein et al [13] reported that only 48% of 199 patients who signed out against medical advice with instructions to seek additional medical care followed these recommenda- tions. However, 2 years later in another study of out-of- hospital refusals, Burnstein et al found that patient compli- ance with medical instructions increased from 19% to 81% when an online physician was involved [11]. This result supports the contention that the higher rate of compliance found in our study is partially caused by this demonstrated effect of online physician medical control. However, it may also be caused by the nature of the patients’ complaints in our study or other unrecognized variables.

To assess if POV met patient expectations, patients were asked to report the amount of pain they experienced while en route to the hospital by POV. patient comfort is of particular interest because it is one area where an EMS provider can significantly intervene by providing parenteral pain medication and subsequent relief, which is unavailable during POV. Interestingly, patients with the worst initial subjective pain did not prefer ambulance transport if they were required to pay. A similar phenomenon was noted when patients with worsening pain during transport also reported that they would not have preferred ambulance transport if required to pay. With these 2 seemingly counterintuitive results, one might conclude that patients with severe pain and subjectively worsening medical conditions during transport had low expectations that care during ambulance transport would significantly improve their conditions.

With respect to POV safety, all patients stated that their medical condition had resolved or improved. It should also be noted that no patient in our study group had a worsening long-term outcome, based upon the patient’s reported condition at the time of the survey, or required hospital admission. In addition, our CQI procedure, which includes 100% review of all Patient care reports, regardless of inclusion in our study, was conducted, and no POV poor outcomes were identified. As a result, we can be somewhat assured that those patients who were not recontacted or did not consent to the study did not have a bad outcome. Thus, the lack of any poor outcomes in our study is encouraging and supports the contention that a subset of EMS patients, with the assistance of online physician medical control, can be accurately and safely triaged for POV. If our 30% POV rate were applied to most other EMS systems, it would represent a significant reduction in transports and potential savings in manpower, time, and money.

Our study has several limitations. Our favorable results concerning the safety of POV transport must be tempered by the number of patients who we were able to contact and also by the overall small number of patients enrolled in the study. It is to be hoped that this lack of follow-up was counter- balanced by the CQI procedures used in our EMS system. In addition, a population bias may exist. National park visitors are often outdoor enthusiasts who may have an elevated socioeconomic status, higher educational level, or a heightened awareness of their health. In general, SEKI patients are often vacationers who travel with friends and/or family, and this might make POV a more attractive option. Lastly, our measure of a bbad outcome,Q whether a patient felt worse at the time of the survey or was admitted to a hospital, is an admittedly crude measure of patient safety. However, it does reasonably preclude the possibility of missing significant poor outcomes.

Most patients selected for POV transport remembered and followed their instructions, including seeking evaluation by a physician. In addition, the majority would rather be

transported by POV than have to pay ambulance fees. In our study, POV transport from the wilderness setting, with 100% online physician medical control, was not associated with any detectable adverse outcomes. Thus, we conclude that POV transport in carefully selected cases with online physician medical control is likely a feasible alternative to ambulance transport. The majority of patients were satisfied and compliant with POV transport, and no poor outcomes were detected from this practice. However, future large- scale studies should be conducted with improved patient follow-up in representative settings to validate our findings before a generalized practice of POV can be instituted.

Acknowledgments

The authors thank Greg Hendey, MD, Brandy Snowden, BS, and Tricia Soliz, MS, RN, for their support and contribution to this paper.

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