Quality of Care Issues at the Sending Facility
Transport teams may arrive and find that care the patient is receiving is different from that the transport team or receiving center recommended or would like to have provided. This may lead to a temptation to be critical in the medical record.
It is important to simply document the facts of patient care, without opinion, criticism, or editorial comment. Initial entries should always state what was first observed about the patient and the ongoing treatment on arrival. Commenting on what drugs had been given, current monitoring, what procedures were conducted, and whether intravenous lines were in place and functional are among items that would typically be documented. Following the same procedure on all documentation will adequately record information without value judgments appearing in the record.For concerns about the adequacy of care, an internal quality process should exist for review. A risk-management specialist and/or qualified attorney can assist the service to develop a process that meets the requirements for confidentiality in the state involved. Incident or quality reports should recite the facts but not include editorial comments or opinions. In most cases, the rule for incident reports is that if the facts are reported sufficiently, the issues should be evident without the need to point them out. The only exception to this approach would be for circumstances that require reporting under state law, in which case, the team should follow mandated reporting procedures.
Duty to Act
What is the duty of EMS personnel to respond to an emergency? In 2009, there was a highly publicized case of 2 uniformed New York City EMTs who did not assist a pregnant woman who collapsed in the restaurant where they were on a coffee break. The pair did call 911 but provided no other assistance. The woman and her baby both died. Both EMTs were suspended without pay, a civil lawsuit has been filed, and one of the EMTs (the other subsequently passed away) was arrested and charged with official misconduct, a crime that carries up to 2 years in prison.
High-profile cases notwithstanding, there is no universal answer to the question surrounding the duty of EMS personnel to act when they encounter an emergency. Medical practice, as well as one's duty to respond in an emergency, is primarily regulated by the states. For example, an off-duty paramedic may or may not be not required to stop at a car wreck while driving to the store. An in-service EMS unit may have a duty to stop at the same accident if not on a higher-priority call based on local rules, laws, and community protocols.
In transfer situations, the transport team may receive total deference when it arrives and care is ceded to them, sometimes to the point of almost literally stopping mid-procedure to hand the patient over to the transport team. Occasionally, when the transport team arrives at the sending hospital, transport personnel may believe that the ongoing or planned care is not optimal or in the best interest of the patient. This can be an extremely challenging situation for the team regarding how and when to intervene to help provide optimal care to the patient without alienating the providers at the same time. Keep in mind that the transport team is usually not privileged to treat patients in the sending hospital and has no inherent right to assume care of the patient. At the same time, failure to draw attention of the hospital staff to an issue raises a concern of moral duty and a possibility that the patient may receive less-than-optimal care.
So what should be done? Remember that there is a chain of command and a physician-patient relationship while the patient is still in the transferring hospital. When there is unresolved disagreement, the transport team should contact its medical director or the medical control physician to discuss the patient's care with the referring physician. The team should document any significant issues in a matter-of-fact, nonaccusatory manner. Consultation with the medical director or the medical control physician may be helpful to discuss alternatives and potential plans of action.