Patient request to divert

[orangEMT246 6]

Just thought I would get an opinion here from everyone. Today I was transporting a psych. patient to Cornwall hospital. As my crew was getting onto the bridge to cross into Orange County, the patient changes his mind and wants to go to Poughkeepsie. This was not a problem because P.D. stated to take the patient to Cornwall. BUT, lets say you have a stable patient and start transporting to a hospital, and about 10 or 15 minutes into the transport, the patient changes their mind and want to go to a hospital a good 15 or 20 miles in the opposite direction. Do you divert, or continue to the first destination of choice. Example--stable BLS going to St. Lukes. Five minutes from hospital, patient wants to go to Vassar Hospital instead. Is this "kidnapping" because you are taking them to a hospital they don't want to go to now? Or do you just turn around and go to the new destination of choice? How would you handle this?

[mfc2257 464]

In my mind, if you are committed to a certain facility then that's where you are going, unless you get a report that the facility in question is on divert itself due to a lack of beds for the class of patient that you have OR if the patients condition changes and requires a different type of facility.

If you have departed for a particular facility and the patient changes their mind, they can be checked into the hospital that you are originally enroute to, and moved at a later date via an ambulance service.

My opinion is, that Acute Emergency (911 dispatched) EMS providers are not taxi drivers. It is their obligation to take the patient to the nearest facility that can treat the condition which the patient is suffering. Beyond that, it is up to the patient or their family to get them to a facility of preference after the Emergency Room as stabilized the patient and prepared them for admission. Emergency care should be transferred to a medical facility ASAP so that the patient not only has the full resources of a hospital ASAP, but so the unit that transported them can return to service ASAP.

Just my two or three cents.

[dadbo46 50]

He was a "psych" patient ???

[Guest]

I am assuming that you were transporting the patient under orders from crisis team or sending facility. If that is the case, you transport to where you are directed. You should always notify your supervisor of such and attempt to extend courtesy to the sending facility, etc whenever possible. 9/10 you are transporting the patient to one specific hospital because there is a bed and staff waiting for them already. Inform the patient of such, and if they are still adament about it they can always attempt to make their own arrangements to get transported to the other hospital of their choice when you get them to your intended destination.

Always always always inform your patient (no matter what the reason is for transport) that if they change their minds soo late in the game that they run the inevitable risk of delayed care, which may hinder recovery.

We are here to serve the population at large, but we also have the obligation to act in their best interests, even if it's not to the hospital of their dreams.

[orangEMT246 6]

He was a "psych" patient ???

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I understand a psych patient goes where PD or crisis team tells us to go. The question is about an alert stable patient.

[JetPhoto 626]

I understand a psych patient goes where PD or crisis team tells us to go.  The question is about an alert stable patient.

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That is not always the case not every psych call is due to a crisis team. Some call on thier own. When the pd is on the scene and wants the patient transported, unless they were directed and or going with you to said facility you should be going to

A.) the patients choice (if the patient is capable of makeing such a decsion, most that I delt with are.)

B.) If the patient is not in sound mind to make a descion you go where the pd or crisis team sends you.

or

It is generaly the EMS departments protocols that if a patient is not capable of making a descion, and the PD doesn't care, they go to their counties mental health hospital providing distance is not a factor.

[WAS967 97]

I've dealt with psych patients where the PD directed that the patient be taken directly to the WMC Psych ER. Would you take them there or to the closest medical facility? (Interested to see what people think).

[IzzyEng4 427]

Well this is a touchy issue. If a patient reguardless if a pyshic or nor, can make a conscience decision or has been treated at a facility he or she request previously then yes you need to take the patient to where they request. However you should patch to the hospital they request to find out if the request is reasonable and also the hospital you are going to. If a patient request a hospital then you should honor it. In the region where I operate as an EMT, we have to patch every trip to the hospital for triage. As for PD's sending where they want the patient to go, I never heard of that one, but the EMS system in the South Central Connecticut region is different also. I know we would have to notifiy PD of the change as well.

Another problem would be a diversion status. For me I have a person who wanted to go to Yale-New Haven, but they were on diversion to St. Raphel's (both in New Haven) during the transport time. Yale was overbrudened with a lot of psych patients and couldn't handle any more comming in via ambulance. The patient had requested Yale since the patient's doctor was there and had been treated there previously. I patched to Yale and explained the situation that the patient animately refused to go anywhere else but Yale. After a lenghty discussion I was able to bring the patient to Yale. Now this doesn't happen all the time and the patient, as long as not animate, can go to another facility. It is better to ask than just go to a facility if your unsure reguardless of a time frame.

As for "kidnapping" if a patient can make their own decision where to go, then they can understand your explanation why they can't go to the facility they requested. If they are of "unsound mind" then it is implied help and would not constitue as kidnapping.

[Guest]

BUT, lets say you have a stable patient and start transporting to a hospital, and about 10 or 15 minutes into the transport, the patient changes their mind and want to go to a hospital a good 15 or 20 miles in the opposite direction. 

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http://www.health.state.ny.us/nysdoh/ems/pdf/06-01.pdf

Snip...In non-emergency situations, ambulance services may make transports to facilities such as physician's offices, diagnostic and treatment centers (DT&C), free standing emergency clinics or other destinations. However, the ambulance crew must be aware of the emergency care capabilities of such facilities at the time of the patient request.

A patient's choice of hospital or other facility should be complied with unless contraindicated by state, regional or system/service protocol or the assessment by a certified EMS provider shows that complying with the patient's request would be injurious or cause further harm to the patient. Patient transfer can be arranged following emergency care and stabilization. In such cases, the EMT should fully document the patient's request and the reasons for the alternate destination decision, including any medical control consultation...Snip

Endnote:

Ambulance Patient's Bill of Rights, NYSEMS Council, 1998 Emergency Medical Services Plan

Access to Emergency Care in a Managed Care Environment, NYSEMS Council, 1998 Emergency Medical Services Plan

Adult and Pediatric Major Trauma Protocols, T-6, T-7, May, 2004

Suspected Stroke Protocol, M-17, January, 2005

[Guest]

"I understand a psych patient goes where PD or crisis team tells us to go. The question is about an alert stable patient."

Orange EMT, the above quote was your second sentence in your initial blog. Hence why we are all giving you tips about psych patients.

If it is a medical and stable patient then, you must confer with medical control and state pros and cons of such decisions to your patient. Let them speak to med. control. document such occurance on your PCR and what if at all the final decision was. CYA.

[orangEMT246 6]

I'm sorry if I wasn't clear in my post. It was a psych pt that wanted to change destinations, but we go where PD or crisis team tell us to go. BUT I was just wondering what to do if a NON-PSYCH asked for the same request. Thank you all for helping me with the question I posted earlier.

[mlfcemt093 0]

Any "diversion" status in N.Y. state is done on a "Please don't come here" kind of thing. New York state law pt's Bill of Rights sts u can take the pt any where they request (the pt must be stable of course) no matter diversion status and that hospital has to accept them....now it's up to u to tell the pt that the hospital they request is on diversion and they may not be seen in a timley fashion (like 10 hrs) because the hospital is over burdened now this applies to "psych" pt's and "normal" pt's who have decision making capabilities and u feel that ur not in harms way.....if u are then the closest hospital applies. I let no one tell me other than the pts which hospital I should choose and as usuall every situation is different but generaly thats what i follow.

[gmspro 3]

I need to add something to all of the comments I am finding here. There is a quagmyre being presented in all of this and that is that the Police Department, no matter where they are, are not medically-trained individuals. No offense to them at all, they have a very needed and well-performed function. But in the case of a patient that you have been dispatched to, even one who is a confirmed psych patient..... YOU HAVE TO ENSURE THAT THE PATIENT IS MEDICALLY CLEARED FIRST, BEFORE THEY ARE PLACED IN A NON-ED (PSYCH) SETTING.

One thing I have noticed in my years in this profession, particularly with the advent of HMO management and mis-management on the part of clinical practitioners, is that not even we (the EMT's and Paramedics) in the field, are in a position to determine if someone is a complete EDP. In fact, they may be a complete EDP, but there may be a medical component in play that if you miss, you can harm your patient, the care you provide to that patient and eventually when it catches up to you, your certification.

So many EMS professionals want to follow what they see from other seasoned staff, but the problem then is if the more experienced staff are lazy, or feel that they want to be apart of the old boys club and just follow what they police officers tell them to do; they are not living up to their training, certification or purpose.

The Emergency Emotional Health Warrant or Directive that Police Departments operate by, though nice to have, is inherently flawed and also puts the law enforcement agency at risk for liability and litigation; but this is a liability that the law enforcement departments accpet and are willing to live with. They are not trained to the level of medical care that EMT's and Paramedics are, and often facilities will just turn you away if your patient has a medical component on board or even the question of such.

Be very careful not to get caught in a trick bag and have your certification yanked by your local medical control if you act outside the scope of your findings. Unless you are performing the functions of a pre-arranged transport via a crisis team, generally all patients in the 911 system are to be transported to a 911 receiving Emergency Department. EDP's can and will lie, so just because they tell you that there is no involvement of substances does not mean it is true. YOU will be the one held ultimately responsible if anything happens to a patient that you transported to an incorrect facility.

Be a leader, not a follower!

Just a few thoughts.

I am assuming that you were transporting the patient under orders from crisis team or sending facility. If that is the case, you transport to where you are directed. You should always notify your supervisor of such and attempt to extend courtesy to the sending facility, etc whenever possible. 9/10 you are transporting the patient to one specific hospital because there is a bed and staff waiting for them already. Inform the patient of such, and if they are still adament about it they can always attempt to make their own arrangements to get transported to the other hospital of their choice when you get them to your intended destination.

Always always always inform your patient (no matter what the reason is for transport) that if they change their minds soo late in the game that they run the inevitable risk of delayed care, which may hinder recovery.

We are here to serve the population at large, but we also have the obligation to act in their best interests, even if it's not to the hospital of their dreams.

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