Study Objectives
EMS frequently encounters patients who decline transport. During the COVID-19 pandemic, many EMS systems implemented non-transport protocols for stable, low-risk patients with suspected COVID-19 to reduce the burden on overwhelmed EDs. There are little data to inform the safety of patient and/or paramedic-initiated Assess, Treat and Refer (ATR) protocols. We aimed describe patient perceptions and short-term outcomes after non-transport by EMS during the COVID-19 pandemic.
Methods
This was a prospective, observational study of a random sample of patients evaluated and not transported by EMS from August 2020 to March 2021 in a regional EMS system. We utilized the EMS database to randomly select a daily sample of adult patients for whom the disposition was ATR. ATR was authorized for stable, low-risk patients, based on paramedic assessment, and for patients requesting non- transport without paramedic concern for an ongoing emergency condition. We excluded those who signed out against medical advice (AMA), were in police custody, and sting-ray envenomation. Trained investigators contacted patients by phone to administer a standardized survey regarding symptom progression, follow-up care, and satisfaction with non-transport decision. Initial recontact of patients was attempted at 72-hours from the EMS encounter, and then daily until contact or three attempts were made. We determined the proportion of patients who re-contacted 9-1-1 within 72 hours by querying the EMS database, and unexpected deaths within 72-hours using coroner data. Descriptive statistics were calculated.
Results
Of 4613 non-transported patients, 1283 were excluded including 1036 who signed out AMA, 153 in police custody, 68 stingray envenomation, and 26 misclassified runs. The remaining 3330 patients for whom the disposition was ATR were included. Patients were 46% male and median age was 49 (inter-quartile range (IQR) 31-67). Median vital signs measurements fell within the normal range. Investigators successfully contacted 584 patients (18%). The most common reason for failure was lack of accurate phone number. Patients contacted were slightly older (median 4 years) with no significant difference in provider impressions or vital signs. The most common reasons patients reported for not going to the ED on initial encounter were: felt reassured after the paramedic assessment (26%), medical complaint resolved (19%), paramedic suggested transport was not required (13%), concern for COVID-19 exposure (10%), and initial concern was not medical (8%). Ninety-five percent were satisfied with the non-transport decision and half had already sought follow-up care. The majority (86%) reported equal, improved or resolved symptoms, while 80 patients (13%) reported worse symptoms, of whom 80% remained satisfied with the non-transport decision. Of those whose symptoms worsened one-third re-contacted EMS and 59 (74%) sought some additional care. Overall, there were 154 of 3330 (4.6%) 9-1-1 recontacts within 72 hours. Based on coroner data, three unexpected deaths (0.09%) occurred within 72 hours of the initial EMS call.
Conclusions
Paramedic disposition according to ATR protocols during the COVID-19 pandemic resulted in a low rate of 9-1-1 recontact. Unexpected deaths were extremely rare. The large majority of patients reported symptom improvement and most of those who did not, sought additional care. Patient satisfaction with the non-transport decision was high.
No, authors do not have interests to disclose