EMS Provider Determination of Necessity for Transport

Posted by Patrick Lickiss on Jun 20, 2012 in Current Events, EMS 2.0, General | 4 comments

One of the hallmarks of advanced paramedic programs and really the future of EMS in general is the ability of providers to determine if a patient NEEDS to go to the emergency department.  If the goal of such programs is to reduce the utilization of ED resources, field practitioners must be able to safely determine if alternate transport or non transport is appropriate.

Approximately a year ago, the National Association of EMS Physicians (NAEMSP) issued a position statement on this topic and determined that:
• There may be potential for EMS providers to avert unnecessary emergency department
visits by providing a medical assessment to determine whether patients can safely be
managed without emergency transport to an acute care facility.
• While evidence supports determination of necessity of transport to acute care facilities
by EMS providers in certain select situations, in general evidence is currently lacking to
establish that EMS providers can universally make determinations about necessity of
transport.
• Prior to adoption of EMS provider initiated non-transport programs, there should be
evidence in the peer-reviewed literature that demonstrates that EMS initiated nontransport for the specific situation is a safe practice.
• A prerequisite to EMS provider decision to not transport requires at minimum:
additional education for the providers, a quality improvement process, and stringent
physician oversight.
The entire document can be viewed here (PDF).

I appreciate a few aspect of this position statement.  First, the NAEMSP acknowledges that EMS plays a pivotal role in the reduction of utilization of ED resources for non-acute patients.  Second, the position paper calls for evidence-based standards and adequate training and oversight when developing such programs.  In the current state of EMS, however, there is little incentive to develop non-transport guidelines as there is no reimbursement for patients that are not transported.

In another position paper published at the same time, the NAEMSP addresses issues surrounding reimbursement:
• When callers access 9-1-1 (or a similar emergency call center) requesting emergency
medical response, third party payers—including federal and state programs, their agents,
and private insurers—should provide fair and reasonable reimbursement for those
services.
• Retrospective determination that a transport was not medically necessary should not
result in denial of payment. Payment for 9-1-1 emergency response should be based on
the prudent layperson standard.
• When EMS systems that possess adequate educational, medical direction and quality
improvement resources choose to implement EMS-initiated non-transport policies
(including, but not limited to, treat and release protocols, termination of resuscitation or
on-site care for mass gatherings), third party payers should consider the relative cost
savings associated with providing on-scene care without subsequent transport, and
provide fair and reasonable reimbursement for those services
The entire document can be viewed here (PDF).

Note, in particular, the last bullet point. A system that takes the effort to building an appropriate non-transport program should be reimbursed fairly.  Makes good sense to me.

The resource document for both of these position statements can be found here (PDF).

So what do you think?  How close are we to researching the ability of paramedics to make a determination not to transport?  Are there cases where we can do this already?  Does your system get reimbursed for non-transports?  Let me know in the comments.