1. Termination of a Provider/Patient Relationship Dona Ana County Release of Liability 2-16-2011

2. Objectives 1. Understand the “why” and the process behind the termination of a provider/patient relationship 2. Understand and implement the changes to approach and documentation 3. Establish standards for capacity, documentation and supervision 4. Apply this policy to scenarios

3. The Why: Why are we changing our current process? We have no clear policy on how to terminate a patient relationship Our system offers little guidance to our pre-hospital personnel It is necessary to establish and follow a standardized approach to include the process and form You have an obligation to the agency for which you work

4. The Why: Where did this policy come from? Our policies, a combination of best practices from other EMS Systems across the country Our policies, a combination of best practices from other EMS Systems across the country Changes were made to adapt to our system. Changes were made to adapt to our system. The policy and forms have gone through legal and medical direction review The policy and forms have gone through legal and medical direction review

5. The Why: Review of Abandonment, Negligence The act of leaving a patient without treatment or transportation without the patient’s informed consent The act of leaving a patient without treatment or transportation without the patient’s informed consent Failure to use such care as a reasonably prudent EMS provider would use in similar circumstances Failure to use such care as a reasonably prudent EMS provider would use in similar circumstances

6. The Why: Reality Check Most refusals are obtained for non- eventful situations Most refusals are obtained for non- eventful situations EMTs are not likely to recall the event or patient years after the call EMTs are not likely to recall the event or patient years after the call Failure to document to serve as proof of the events that day will be very damaging to an EMT’s defense Failure to document to serve as proof of the events that day will be very damaging to an EMT’s defense

7. The Why: Another reality check Lack of documentation is Lack of documentation is A response to increasing call volume A response to increasing call volume Need for proper medical and legal categorization of patients and non-patients Need for proper medical and legal categorization of patients and non-patients

8. The Process: What has been changed? A countywide policy was created A countywide policy was created The “Refusal Form” has been revised – now called the “Dona Ana County Release of Liability Form” The “Refusal Form” has been revised – now called the “Dona Ana County Release of Liability Form” The cancellation form/documentation has been revamped The cancellation form/documentation has been revamped

9. The Process: Who is a patient? A. A person consenting (informed or implied) to assessment and/or treatment; B. Any person having a current history, or perceived or observable condition, of any of the following: 1. A physical or psychological complaint; 2. Altered level of consciousness; 3. Alcohol or drug use; 4. Medical history that has a potential to worsen or complicate present condition; 5. A person presenting with an obvious injury; 6. A person suffering from a significant MOI, regardless of injury; or 7. Any patient who has an ambulance summoned on their behalf AND requires medical assessment and/or intervention.

10. The Process: You have a patient relationship. Now what? Consenting, competent adults who allow assessment, treatment and transport, no problem, right? Proceed as usual and document in a PCR. Consenting, competent adults who allow assessment, treatment and transport, no problem, right? Proceed as usual and document in a PCR. My patient wishes to refuse assessment, treatment, transport, or all of the above…. My patient wishes to refuse assessment, treatment, transport, or all of the above….

11. The Process: Establishing Standards for Competency and Capacity Competency: Only a judge or physician can determine whether a person is incompetent. Competency: Only a judge or physician can determine whether a person is incompetent. Capacity: EMTs are required to determine whether a patient has the capacity to refuse care. Capacity: EMTs are required to determine whether a patient has the capacity to refuse care. To start, a patient must be To start, a patient must be 18 years old 18 years old Alert to person, time, place, events (AAOx4) Alert to person, time, place, events (AAOx4) Have a GCS of 15 Have a GCS of 15

12. The Process: Establishing Capacity – a better way It’s fairly easy to justify taking a sick person to the hospital. Justifying why you left them at home takes a lot more effort. Ultimately, the EMT must determine the patient’s ability to comprehend the risks of refusing care and/or treatment. Ultimately, the EMT must determine the patient’s ability to comprehend the risks of refusing care and/or treatment. AAOx4 is a conclusion. Don’t rely on this alone. AAOx4 is a conclusion. Don’t rely on this alone. How did you get there? How did you get there? Document the questions and the answers used to determine mental capacity/competence. Document the questions and the answers used to determine mental capacity/competence. You can use many methods to do so. You can use many methods to do so.

13. The Process: Establishing Standards for Documentation Best way to complete a refusal is to complete a PCR as if the patient were transported. Best way to complete a refusal is to complete a PCR as if the patient were transported. Note anything that may affect capacity (alcohol, drugs, head injury, blood loss), MOI Note anything that may affect capacity (alcohol, drugs, head injury, blood loss), MOI Review DAC Release of Liability Items 1- 10 Review DAC Release of Liability Items 1- 10

14. The Process: Establishing Standards for Documentation Complete the DAC Release Form Complete the DAC Release Form Ensure items 1-10 are completed Ensure items 1-10 are completed Obtain appropriate signature Obtain appropriate signature Obtain witness signature (who witnessed items 1-10) Obtain witness signature (who witnessed items 1-10) Document items 1-10 in a PCR Document items 1-10 in a PCR

15. The Process: Establishing Standards for Supervision Review items 11 and 12 Review items 11 and 12 Whenever possible, EMTs should ask medical control to supervise a patient’s refusal of transport. Whenever possible, EMTs should ask medical control to supervise a patient’s refusal of transport.

16. When do you complete the Against Medical Advice section? Arrive on scene Arrive on scene Make contact with the person to whom you responded Make contact with the person to whom you responded The person DOES meet the criteria for a patient The person DOES meet the criteria for a patient The patient refuses transport by EMS The patient refuses transport by EMS Document all items in a PCR including that the pt had the capacity at the time of refusal. Document all items in a PCR including that the pt had the capacity at the time of refusal.

17. When do you complete the Juvenile/Incompetent/In Custody section? Arrive on scene Arrive on scene Make contact with the person to whom you responded Make contact with the person to whom you responded The person meets the criteria for a patient The person meets the criteria for a patient The person is under the age of 18 OR The person is under the age of 18 OR The person is considered legally or medical incompetent OR The person is considered legally or medical incompetent OR The person is in the custody of a law enforcement agency The person is in the custody of a law enforcement agency Document all items in a PCR Document all items in a PCR

18. Review: Emancipated Minors in NM To be emancipated a minor must be at least 16 and To be emancipated a minor must be at least 16 and 1) has been married, even if he no longer is; 2) is in the active duty military; or 3) has been emancipated by the court. For example, a 14 year old who is married is not emancipated. (32A-21-3).

19. Juvenile/Incompetent/In Custody (cont.) It is not the EMS provider’s responsibility to medically “clear” persons before they are transported to jail. It is not the EMS provider’s responsibility to medically “clear” persons before they are transported to jail. If contact is made and the patient is not treated or transported, a signed release of liability must be obtained from the patient. If contact is made and the patient is not treated or transported, a signed release of liability must be obtained from the patient. If the patient refuses or cannot sign because they are handcuffed, document the verbal refusal and have the police officer witness it. If the patient refuses or cannot sign because they are handcuffed, document the verbal refusal and have the police officer witness it. If the officer is refusing EMS transport for the patient, then that officer must sign the refusal as the patient’s guardian. If the officer is refusing EMS transport for the patient, then that officer must sign the refusal as the patient’s guardian. As with any refusal, read the appropriate section of the liability release to the patient/officer, document that and their apparent understanding in the PCR narrative. As with any refusal, read the appropriate section of the liability release to the patient/officer, document that and their apparent understanding in the PCR narrative. In the event we cannot obtain a signature for whatever reason, document the “exception” in detail. In the event we cannot obtain a signature for whatever reason, document the “exception” in detail.

20. When do you complete the Non-Patient section? If the individual is not a patient, then there was no relationship to begin with. Arrive on scene Arrive on scene Make contact with the person to whom you responded Make contact with the person to whom you responded The person does NOT meet the criteria for a patient. The person does NOT meet the criteria for a patient. Per protocol - see next slide! Per protocol - see next slide! Complete documentation per your agency’s policy Complete documentation per your agency’s policy

21. Who is NOT a patient? Non-Patient. Use this section when a person has NO MEDICAL COMPLAINT, INJURY OR ILLNESS. A person who meets ALL of the following criteria is NOT considered a patient if he or she: Non-Patient. Use this section when a person has NO MEDICAL COMPLAINT, INJURY OR ILLNESS. A person who meets ALL of the following criteria is NOT considered a patient if he or she: Did not request an ambulance. Calls to 9-1-1 are not always intended by the caller to be an ambulance request, although an ambulance may be dispatched (i.e. minor MVAs); Did not request an ambulance. Calls to 9-1-1 are not always intended by the caller to be an ambulance request, although an ambulance may be dispatched (i.e. minor MVAs); Presents with NO current physical or psychological complaints/symptoms; Presents with NO current physical or psychological complaints/symptoms; Has NO signs or symptoms of an active significant medical illness or injury; Has NO signs or symptoms of an active significant medical illness or injury; Is a legal adult; and Is a legal adult; and Is not under the influence of drugs including alcohol. Is not under the influence of drugs including alcohol.

22. Who is NOT a patient? It is up to the EMT to use their: It is up to the EMT to use their: common sense common sense and good judgment to determine who is a patient and who is not a patient. and good judgment to determine who is a patient and who is not a patient. Complete documentation per your agency’s policy. Complete documentation per your agency’s policy.

23. AMR Non-patient documentation A PCR must be completed to account for the run. A PCR must be completed to account for the run. In the narrative section give a brief description of the events and why it qualifies as a non-patient. In the narrative section give a brief description of the events and why it qualifies as a non-patient.

24. LCFD Non-patient documentation in Red Alert A PCR must be completed to account for the run. A PCR must be completed to account for the run. Enter required info on a PCR (see video Enter required info on a PCR (see video In the PCR: In addition to the demographic information, fill out the required fields: In the PCR: In addition to the demographic information, fill out the required fields: Turned over to: Enter “Non-Patient” Turned over to: Enter “Non-Patient” Disposition: Enter “4830” (No treatment Required) Disposition: Enter “4830” (No treatment Required) Condition Code: Enter “-25” (Not Reporting) Condition Code: Enter “-25” (Not Reporting) Location, Symptoms, Provider Impression: Enter “-25” Location, Symptoms, Provider Impression: Enter “-25” C/C: Enter “Non-Patient/No complaint or injury” Use quotes. C/C: Enter “Non-Patient/No complaint or injury” Use quotes. Level of Care for Needed and Provide: “Non-Patient” Level of Care for Needed and Provide: “Non-Patient” Reported Complaint, Location Type, Primary Cause of Injury, Intend of Injury: “-25” Reported Complaint, Location Type, Primary Cause of Injury, Intend of Injury: “-25”

25. LCFD Non-patient documentation in NFIRS NFIRS – Section C Incident Type NFIRS – Section C Incident Type Use 322 for an MVA with injuries if there is at least one patient. Use 322 for an MVA with injuries if there is at least one patient. Use 324 for an MVA with no injuries and all persons at the scene were non-patients. Use 324 for an MVA with no injuries and all persons at the scene were non-patients.

27. PATIENT CONTACT DEFINED Discussion

28. Patient contact and cancellations The first due FIRE unit arrives on scene Makes contact with the person to whom you responded Makes contact with the person to whom you responded The person meets the criteria for a patient (or non-patient) The person meets the criteria for a patient (or non-patient) Pt does NOT need ALS assessment and the patient refuses/may refuse transport by EMS Pt does NOT need ALS assessment and the patient refuses/may refuse transport by EMS Fire unit makes decision to cancel or not to cancel the transport agency Fire unit makes decision to cancel or not to cancel the transport agency If no pt contact made by transport agency – FIRE gets refusal If no pt contact made by transport agency – FIRE gets refusal If contact is made by transport agency or pt care is TOT transport agency for whatever reason, transport agency gets refusal documentation If contact is made by transport agency or pt care is TOT transport agency for whatever reason, transport agency gets refusal documentation First due does not need to get duplicate refusal documentation First due does not need to get duplicate refusal documentation First due unit documents in PCR that pt turned over for transport, refusal or unknown disposition First due unit documents in PCR that pt turned over for transport, refusal or unknown disposition

29. Patient contact and cancellations First due TRANSPORT UNIT arrives on scene Makes contact with the person to whom you responded Makes contact with the person to whom you responded The person meets the criteria for a patient or (non-patient) The person meets the criteria for a patient or (non-patient) Pt is assessed and the patient refuses/may refuse transport by EMS Pt is assessed and the patient refuses/may refuse transport by EMS Transport unit makes decision to cancel or not to cancel the fire unit Transport unit makes decision to cancel or not to cancel the fire unit No pt contact made by fire unit – TRANSPORT AGENCY gets refusal No pt contact made by fire unit – TRANSPORT AGENCY gets refusal Pt care should never be TOT from an ALS transport unit to a fire unit for any reason Pt care should never be TOT from an ALS transport unit to a fire unit for any reason Fire unit does not need to get duplicate refusal documentation Fire unit does not need to get duplicate refusal documentation Fire unit documents in PCR that pt turned over for transport, refusal or unknown disposition Fire unit documents in PCR that pt turned over for transport, refusal or unknown disposition FIRST DUE UNIT CANNOT GET CANCELLED BY SECOND DUE UNIT WHY?

30. AMR documentation Continue to use the “cancellation form” Continue to use the “cancellation form” Complete Quicnet “bubble” form Complete Quicnet “bubble” form

31. LCFD NFIRS Cancellation Codes You don’t make it on-scene. You don’t make it on-scene. NFIRS 611/Dispatched and cancelled enroute and NO patient contact is made; No PCR NFIRS 611/Dispatched and cancelled enroute and NO patient contact is made; No PCR You arrive on-Scene and NO patient contact is made. You arrive on-Scene and NO patient contact is made. NFIRS 622/No incident found on arrival at incident address; No PCR NFIRS 622/No incident found on arrival at incident address; No PCR Medical Assists Medical Assists 311 with PCR (pt relationship does exist including vitals taken, assisting with pt packaging and loading) 311 with PCR (pt relationship does exist including vitals taken, assisting with pt packaging and loading) Lift Assists Lift Assists 554 (5-Service call, 55 Public Service Assistance, 554 Assist Invalid) OR 554 (5-Service call, 55 Public Service Assistance, 554 Assist Invalid) OR 321 EMS call excl. accident with injury with PCR if you have a patient 321 EMS call excl. accident with injury with PCR if you have a patient

32. Other County Non-patient documentation  A Patient Care Report must be completed.  The ROL form must be filled out.  The data must be entered into NMEMSTARS as either a cancelled run or no patient found.

33. Other county agencies documentation Continue to fill out the Run form Continue to fill out the Run form NMEMSTARS entry made for cancellation NMEMSTARS entry made for cancellation

34. For unusual circumstances… Call medical control Call medical control Call your supervisor Call your supervisor Cover your bases: Cover your bases: Complete the Release of Liability form Complete the Release of Liability form Complete a PCR Complete a PCR Call your supervisor and/or Medical Director for additional clarification Call your supervisor and/or Medical Director for additional clarification “Nobody will mess you up for doing too much documentation.” – Rob Campion

35. Who’s Responsible? Everyone is responsible. Everyone is responsible. The highest level of provider on scene is ultimately responsible for patient care. The highest level of provider on scene is ultimately responsible for patient care. Look up state statue Look up state statue

36. Multiple Patients How are MCIs categorized? How are MCIs categorized? Figure out how many people are involved, regardless of the categorization. Figure out how many people are involved, regardless of the categorization. When it’s all said and done, the transporting agency and the fire department should document When it’s all said and done, the transporting agency and the fire department should document The total number of patients involved The total number of patients involved How many were treated by the transport agency How many were treated by the transport agency How many were treated by the fire department How many were treated by the fire department How many identified themselves as Non-patients How many identified themselves as Non-patients

37. AMR Record Keeping The DAC Release of Liability Form will replace the current “refusal” form in circulation. The DAC Release of Liability Form will replace the current “refusal” form in circulation. A PCR still must be completed in its entirety. A PCR still must be completed in its entirety. A Quicnet “bubble” form must be completed A Quicnet “bubble” form must be completed Both forms will be inserted inside the PCR and then placed in the shift envelope. Both forms will be inserted inside the PCR and then placed in the shift envelope.

38. LCFD Record Keeping What forms get filled out and what goes where? What forms get filled out and what goes where? Pt Assessment Forms, i.e., cheat sheets, will be in duplicate – one for us and one for the transporting agency and will be filed as below. Pt Assessment Forms, i.e., cheat sheets, will be in duplicate – one for us and one for the transporting agency and will be filed as below. Completed DAC Release of Liability forms – they will be single – will be filed in a designated file folder at the stations to be collected at each station each week to be filed by the department. Completed DAC Release of Liability forms – they will be single – will be filed in a designated file folder at the stations to be collected at each station each week to be filed by the department. If any person wishes a copy of a release, direct them to Station 1. If any person wishes a copy of a release, direct them to Station 1.

39. County Agencies Record Keeping  The new ROL form will replace any refusal forms in use  The ROL form will be kept with a copy of the NMEMSTARS report, or run form currently being utilized by the agency  Each call should generate a run form (paper or NMEMSTARS)  Each call will be entered into NMEMSTARS

40. In a nutshell… Your interactions will always depend upon your assessment of the scene and/or the patient. Your interactions will always depend upon your assessment of the scene and/or the patient. Failure to document those assessments can open the door to claims of abandonment or other forms of negligence. Failure to document those assessments can open the door to claims of abandonment or other forms of negligence.QUESTIONS?