Tuesday, April 21, 2020

Patient Refusals in the Age of COVID-19 - PART I

The people you do not bring to the hospital scare the S%*# out of me.  There, it feels good to say that out loud…

If we want to pull on that thread a little more, any EM or EMS doc can tell you a litany of stories/anecdotes about patients who presented to us with benign sounding stories and ended up having something deadly/scary.  Although we tend perseverate on the patients we almost sent home, the ones that really keep us up at night (and our psychiatrist/therapists employed), are the ones we sent home, then realize on our drive back from work that we could have missed something bad.  Sometimes we follow-up with the patient the next day with an innocuous phone call (this is my preferred method to avoid multiple sleepless nights), sometimes we just lose a little sleep and keep that experience for our next shift so you don’t make the same mistake again.  And we always DREAD the words of our colleagues:  “Remember that patient you saw last week…” which usually ends in painful self-reflection and learning for next time.

Those of us who have been in EMS for a while have probably had these moments ourselves.  Picture this:  It is late and you are roused from bed to go to an address you know by heart, for a complaint that sounds like nonsense.  You get there and the patient looks the same as every other time you have been there and does not want to be transported.  You obtain your refusal, entering the patient information by memory and return to the station for some much-needed rest before shift change and heading home. You wake up from your post-shift nap to a text string from your shift relief:  They just cleared the hospital after intubating/stabilizing/coding your refusal from the night before.  After you get over your nausea and period of reflection, you can see already see the QA email coming your way, the root cause analysis meeting with your medical director, and most importantly, a bad outcome for your patient.

So how do we sort this all out? Do we just bring them all to the hospital?  Are we really just playing roulette every time we take a refusal?

Kind of.  Here is the thing:  These patients trust you.  You represent the healthcare system to them and they do not know the limitations of your evaluation.  When you take their vitals and say they “look ok” they hear “you are fine.”  When you look at the EKG and say it “looks good” they weigh this the same as having serial troponins, a cardiology evaluation and stress test in the hospital.  Combine this with an exaggerated fear of the hospital right now and you have a recipe for disaster (and poor patient outcomes). 

So does COVID really change this?

You bet it does!  First of all patients are TERRIFIED to come to the hospital right now, which should make you think about how worried they were about their complaint to make them call 911 in the first place.  Some anecdotal data from our system has somewhere around 1/3rdof the patients who are refusing citing COVID as their main reason. The key is not to anchor on the fact that they are refusing now as proxy for their not being sick.  Additionally, we need to realize there is a lot of potential badness out there in the world that we need to sort through in our assessment and presentation of the risks of refusal to the patient.

Thanks for scaring the S*&# out of me doc, will I ever be able to sleep again?

 Yes!  The key is to obtain a good history and exam on your patients.  Think about what could be causing their symptoms and encourage ED evaluation for patients who call for help.  If the patient insists on refusing, think of all the bad stuff that could happen to them if they were not evaluated and explain that to them.  Do not be overly reassured by vital signs and “normal” EKGs, as you know, these are meant to identify the critically ill, not to screen the population for moderate illness.  Most importantly, the more worried you are about them, the more you play dirty:  Scare the heck out of them, use the words “up to an including death” as part of your refusal spiel, CALL their family members and put the patient on the phone, promise delicious turkey sandwiches, ginger ale and backrubs in the ED.  Finally, seek assistance from online medical control as there is evidence (1) that just speaking to a physician on the phone can encourage 50% of patients refusing transport to come to the hospital!

Stay Tuned for Part II:  The "shelter in place" protocol in RI...



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