UTSW/BioTel Policy: Patient Evaluation & Transport

Purpose: This policy establishes a standardized definition of a PATIENT, sets performance standards for the assessment of patients in the out-of-hospital setting, assists paramedics in determining when a patient should be transported to a hospital, and dictates the documentation requirements for all patients, regardless of whether or not a patient is transported to a receiving facility.

  1. Scope:

This policy is intended to guide UTSW/BioTel paramedics in determining which of the many persons that they encounter shall be considered to be a PATIENT and therefore require emergency evaluation.  In addition, this policy sets forth the minimum elements of history-taking and physical assessment that shall be performed, as well as the required data elements needed for appropriate documentation.  Lastly, this policy shall guide the decision-making process regarding which patients require transportation to a Dallas-area hospital emergency department, as well as the required documentation for patients who are not transported.

  1. Patient Definition:

BioTel paramedics shall consider a patient to be:

  1. Exceptions to the Definition of a Patient (NASIP – “Not A Sick or Injured Person”):
    1. Minor motor vehicle collisions (MVCs) and third party reports of a “sick person or person down”:

      Some individuals involved in minor MVCs may not be injured and would, therefore not be considered to be a patient. In addition, some persons for whom EMS is called may not be patients (example: a person sleeping on a park bench).
      1. In order not to be considered a patient, an individual must:
        1. Be awake, alert, oriented, and cooperative.
        2. Calmly, clearly, and lucidly state the he or she is not injured and he or she does not wish to evaluated by EMS personnel.
        3. Be ambulatory without assistance, or at their baseline level of ambulation.
        4. Not exhibit any external signs of recent trauma such as lacerations, abrasions, etc.
        5. Not exhibit signs of gross alcohol or drug intoxication (slurred speech, odor of alcohol on breath, ataxic gait).
        6. Be willing to give their name for the purposes of documentation that they were involved in the incident and do not wish to be evaluated.
        7. Not have been involved in a traumatic event that meets any Trauma Center Criteria.
      If a person meets ALL of the above criteria, his or her name shall be documented on the Prehospital Care Report (ePCR) as being involved in a minor MVC, and that he or she does not meet the criteria for being a patient.  Two paramedics or a paramedic and an officer will sign the ePCR indicating that the person meets ALL of the above criteria.  The disposition code shall be “NASIP” (Not a sick or injured person).  Multiple non-patient NASIPs may be documented on a single ePCR.
      1. If any of the above criteria are NOT met, the person shall be considered to be a patient and must be fully evaluated by paramedics and appropriate documentation shall be completed.  If such a patient refuses assessment the paramedics shall immediately notify an EMS Field Supervisor or BioTel for consultation and direction.
    2. If a law enforcement official has requested that paramedics evaluate a person, that person shall be considered to be a patient.  If a person in custody refuses evaluation by EMS, paramedics shall immediately contact an EMS Supervisor and/or BioTel for further direction.  Paramedics may elect to simply transport the patient to the closest appropriate receiving hospital emergency department.  If this occurs, BioTel shall be notified that an incompletely assessed patient is en route.

    3. Assessment Notes:
      1. Not a Sick or Injured Person (NASIP) is not the same as Unable to Locate (UTL).
      2. NASIP requires that a visual and verbal assessment has been made of a person on scene.
      3. UTL implies that no person was identified on scene who called 911 or for whom 911 was called.
  2. Patient Assessment and Documentation
    1. All persons who meet the definition of a patient shall be assessed in a manner that is consistent with standard paramedic practice, unless it is unsafe to perform such an assessment.
    2. If the physical location of the patient is felt to be potentially unsafe the paramedic shall either:
      1. Move the prospective patient to a place where it is no longer unsafe to assess the patient while maintaining a basic airway, ventilation and SPINAL MOTION RESTRICTION, as necessary; OR
      2. Perform whatever aspects of the assessment that may be safely performed and then expedite transport to a hospital emergency department, as indicated.
    3. All patients for whom it is not unsafe to do so shall have a full set of vital signs measured (blood pressure, pulse, and respiratory rate, oxygen saturation and temperature) and the determination of a Glasgow Comma Scale (GCS) Score.  ALL of these values shall be recorded on the ePCR.
    4. The following data elements MUST be documented on the ePCR for every patient, unless it is documented on the ePCR why such information is not obtainable.
      1. Name, age, date of birth, home address, and phone number, and social security number.
      2. Chief Complaint (CC)
      3. History of Present illness  (HPI)
      4. Past Medical History (PMH)
      5. Medications
      6. Allergies to medications
      7. Vital signs INCLUDING:
        • Palpated pulse rate (HR)
        • Blood pressure (BP)
        • Respiratory rate RR)
        • Oxygen saturation (SpO2)
          NOTE: Unstable patients shall have repeat vital signs documented every 5-10 minutes.
      1. Glasgow Coma Score
      2. Physical Examination, which should minimally include assessment of the head, neck, chest/lungs, abdomen/pelvis, extremities, and a basic neurological exam
      3. All interventions performed and the response to those interventions
      4. All medications given, including dose, route and clinical response to those medications
      5. Disposition of the patient, including justification of the need for transport or explanation of why the patient was NOT transported
      6. Patient signature
      7. Signatures of two paramedics, OR one paramedic and an EMS agency officer
  3. Transport Decision Making – Refer to the DESTINATION Policy for Additional Guidance:
    1. Following a complete assessment of a patient, BioTel paramedics shall generally offer patients transport to a Dallas area hospital emergency department via ambulance.
    2. Patients who do not meet specialty hospital criteria, such as Trauma Centers, Stroke Centers and STEMI Centers, who do not have any of the criteria listed in Section 8 below, who have normal vital signs, and do not meet any of the "exceptions" listed in Section “C” below, may be informed that they will be transported to the closest open and appropriate hospital emergency department.  If that patient refuses transport to the closest open and appropriate ED, then they may be considered to be a “Patient Declining Transport” or “PDT”.  Proceed to Section 6 for further instructions.
    3. Exceptions to #5b:
      1. Pregnant patients who report receiving prenatal care shall be transported to the ED that is associated with their prenatal care provider, or if no such facility exists, to their facility of choice, as long as there is no indication to transport the patient and infant to an Obstetrics Specialty Care facility.
      2. Patients who are post-op/post-procedure within 90 days and have a chief complaint that could be related to their surgery/procedure shall be transported to the ED of the hospital that performed their surgery/procedure.
      3. Patients undergoing chemotherapy or radiation treatment shall be transported to the ED that is associated with their cancer treatment center.
      4. Consider “sister hospital” relationships. For example, if a patient wants to go to a Baylor Hospital ED that is far away, but (s)he has a minor medical condition and normal vital signs, the patient could be transported not to the closest ED, but, rather, to the closest Baylor campus.
      5. VA Patients: Patients who report that they are veterans, who do not meet specialty care criteria, and who express the desire to be transported to the VA hospital may be transported there. Patients who are not veterans shall NOT be transported the VA, unless they have an unstable airway and the VA hospital is by far the closest ED.
      6. Finally, use good judgment. If there are other unique or extenuating circumstances, transport th patient to the hospital you believe is most appropriate, report those circumstances to the receiving hospital staff upon arrival, and document your decision-making process on the ePCR.
    4. EMS personnel shall not initiate a discussion of the cost of being transported by ambulance or be given an estimate of waiting times at the receiving emergency department. If asked, paramedics may state:

      “Transport generally costs a few hundred to a thousand dollars, but what is most important is that we get you to the hospital right now….”

      “We don’t know how long the wait is at any given ER at any given time”.
    1. If one paramedic on-scene has determined that a patient should be transported by ambulance to a given hospital emergency department, the patient shall be transported. IF there is disagreement between paramedics as to the need for ambulance transport or what the appropriate destination should be, an EMS Supervisor or BioTel shall be immediately consulted to resolve the conflict.
  4. Patients Declining Transport (PDT):
    1. Following a physical examination and an offer to transport the patient to a hospital, some patients may decline transport and choose to find their own way to the doctor or hospital, or may seek some alternative treatment.
    2. Competent patients who are not in custody of law enforcement (“under arrest” or under Emergency Detention) maintain the right of self-determination and shall be allowed to refuse transportation to a hospital emergency department ONLY if ALL of the following criteria are met:
      1. A paramedic has determined that the patient has decision-making capacity to refuse transport; and
      2. A paramedic has discussed the potential risks of non-transport with the patient and the patient’s family, when present, and has documented that discussion on the ePCR; and
      3. A paramedic has made a determination that the patient understands and accepts those risks and has documented this determination on the ePCR.
    3. If paramedics believe that a patient does not have an illness or injury in which a decision by the patient to decline transport could result in harm, OR if a patient declines transport to the closest appropriate ED, paramedics shall ask the patient to sign a Patient Declines Transport (PDT) form.  Paramedics shall complete the PDT portion of the ePCR and obtain the patient’s signature and the signature of a witness.
  5. Mandatory Offer of Transport Criteria and Requirements for Patients Declining Transport Against Medical Advice – (AMA):
    1. Paramedics shall follow their EMS agency specific policies regarding mandatory transport and decisions made “Against Medical Advice” and utilize sound judgment and common sense.
    2. A patient with ANY of the following criteria should be offered transport by paramedics in an ambulance to a hospital ED.  If the patient does not consent to ambulance transport, (s)he shall be considered to decline transport “Against Medical Advice” or “AMA”.  These criteria include any patient:
      1. Who has been administered any medication by a UTSW/BioTel paramedic.
      2. Complaining of non-traumatic chest pain.
      3. Complaining of shortness of breath or difficulty breathing.
      4. Complaining of vomiting blood or rectal bleeding.
      5. Meeting Trauma Center Triage Criteria (refer to the DESTINATION Policy and the TRAUMA Guideline).
      6. Over age 50 with abdominal pain.
      7. Adult with a pulse rate less than 50 or higher than 110 BPM.
      8. Adult with a systolic blood pressure greater than 180 or less than 95 mm Hg.
      9. Adult with a diastolic blood pressure greater than 110 mm Hg.
      10. Who has had a seizure in the previous 60 minutes.
      11. Who has had a syncopal event.
      12. SpO2 less than 93% on room or ambient air, or while using baseline supplemental oxygen.
      13. Who reports a loss of consciousness related to the 911 request for service.
      14. Who reports signs or symptoms consistent with acute stroke or Transient Ischemic Attack (TIA).
      15. Under the age of 18, unless proof of emancipation is provided by a copy of a court order.
      16. For whom there is any concern regarding the possibility of their abuse or neglect.
      17. In the custody of law enforcement for whom law enforcement officers request ambulance transport.
      18. Who is or might be pregnant for whom signs and symptoms could be reasonably be related to the pregnancy.
      19. Over the age of 75.
      20. Who meet Burn Center Criteria (Refer to the DESTINATION Policy and the BURNS Guideline).
      21. Who present with signs or symptoms of smoke inhalation.
      22. Who might be suicidal, including those for whom a 3rd party reported a concern for suicidal thoughts or actions.
      23. Reported or suspected of having an intentional or unintentional drug or other substance overdose.
      24. With diabetes for whom any paramedic-measured Point of Care (POC) blood glucose measurement  is less than 90 mg/dL or greater than 300 mg/dL.
      25. With an Acute Life-Threatening Event (ALTE).
      26. For whom paramedics are unclear regarding the appropriateness or safety of a patient refusing transport.
    3. AMA patients shall always be advised that they should re-contact 911 at any time in the future if their condition should worsen or if they change their mind about ambulance transport.
  6. Paramedic Initiated Refusal of Service – (PIRS):
    1. UTSW/BioTel paramedics are encouraged NOT to decline ambulance transport to a person who meets the definition of a patient.
    2. Should paramedics elect to refuse transport for a patient who requests ambulance transport, they shall document the reasons for their refusal to transport and shall notify their EMS supervisor prior to leaving the scene.
    3. UTSW/BioTel agencies are encouraged to review 100% of Paramedic Initiated Refusals of service for documentation and appropriateness of the decision to refuse transport.
  7. General Guidelines for Patients in Custody (Refer to the CUSTODY & RESTRAINT Policies):
    1. All persons for whom EMS has been requested by a member of the law enforcement community in order to provide a medical evaluation shall be considered to be a patient and shall be fully assessed and documented, provided that it is safe to assess them.  Once an assessment is completed, paramedics shall follow their EMS agency specific guidelines for determining the destination for patients in custody.
    2. Paramedics cannot “medically clear” a patient in police custody.  If paramedics do not believe that a patient in custody requires transport to a hospital, an EMS Supervisor or BioTel shall be contacted for consultation and approval for the law enforcement agency to transport the patient either to jail or to a receiving hospital. Paramedics must be confident that the patient does not require additional medical evaluation, because if such a patient is determined by jail personnel to require additional medical evaluation, another ambulance will be summoned to the jail. All reasonable attempts should be made to avoid this scenario.
    3. Occasionally persons in custody may exhibit combative behavior and altered mental status.  This condition is often referred to as EXCITED DELIRIUM and is often associated with drug ingestions, particularly cocaine, PCP and/or amphetamines.  A number of medical conditions may, however, mimic drug-induced EXCITED DELIRIUM, and only sophisticated testing in an emergency department can determine the exact cause of this patient presentation.  Paramedics should be aware that this represents a true medical emergency and these patients are at high risk of hyperthermia, hypoxia, hyperkalemia, hypoglycemia, and sudden cardiac arrest.  These patients MUST be transported by ambulance. Patients who have been handcuffed MUST have a law enforcement officer capable of removing the handcuffs riding in the back of the ambulance to the hospital.
    4. If it is unsafe to assess a combative patient, then the patient shall be placed in the back of an ambulance and the number of law enforcement officers required to control the patient shall ride with the paramedics to an appropriate ED.  No such patient shall ever be transported without the presence of law enforcement officers.  When it is safe to do so, paramedics shall obtain vital signs, a blood glucose determination, initiate cardiac monitoring, and administer oxygen.  Early notification to BioTel of the transport of an incompletely assessed combative patient in custody is MANDATORY.
  8. EMS Incident Disposition Codes:

UTSW/BioTel paramedics shall utilize ONLY one of the following disposition codes on the ePCR and when reporting the disposition of the call to their communications centers, and when closing out the run on the ePCR:

CAN                 Canceled or disregarded en route to the scene (document by whom)
UTL                  Unable To Locate a person who called 911 or for whom 911 was called
NASIP              Not a Sick or Injured Person
TX                    Transported to a hospital
PDT                  Patient Declined Transport
AMA                Against Medical Advice
PIRS                Paramedic Initiated Refusal of Service
POL                 Police to transport
Signal 27         Medical Examiner’s Case (no resuscitation attempted)
TERM               Field Resuscitation Attempt Terminated