Transfer of Care, Beware

If you have been reading my columns, you know that EMS is my first love. And although I have moved beyond the arena of providing patient care in the field, my passion for the industry and the delivery of quality patient care is no less fervent.

Since my very first ride-along as an EMT student in 1987, I was hooked. I was captivated — and still am — by the myriad of characteristics that set EMS apart from other industries: entering where most people exit, standing strong while others falter, delivering hope to the hopeless, and impacting the lives of strangers in only moments before moving on. These characteristics do not exist in any other arena.

Perhaps the most fascinating aspect of EMS, to me, is the diversity and multiplicity of delivery systems. It seems that for every EMS agency, department and municipality out there in the world, is a different way to provide EMS care. There are countless ways to approach the single challenge of providing care to individuals in need and delivering them swiftly to a hospital.

While there are countless ways to deliver quality EMS, there are also certain aspects that do not vary among systems: an airway is always an airway, an IV is always an IV, a crying child is always a crying child. And the specter of legal perils and pitfalls is ever-present, for every provider, on every call, and in every system.

Procedurally, the transfer of care from ALS to BLS (called the “BLS pass-off” or “shipping”) is among the most common practices that create a threat of liability in nearly every system I have seen. Whether the agency utilizes paramedic rescue squads, paramedic engine companies, paramedic chase cars or traditional paramedic ambulances, the practice of subsequently shipping patients with on-scene BLS providers carries an unnecessary medical risk for patients and a legal risk for providers.

I will stipulate to the fact that there are circumstances under which ALS providers sending a patient with a BLS-only ambulance is proper. For instance, if ALS treatment is neither called for nor initiated despite the presence of ALS personnel and it is more reasonable, based on a variety of other factors, to keep the ALS resource available for the length of time it would otherwise take to transport or accompany the patient to the hospital.

However, the decision to “ship” a patient BLS is often made for reasons that are far less legally defensible. For example, shipping a patient BLS so that the rescue squad can respond to the report of a fire is not going to bode very well in court. Likewise, opting for BLS-only transport just because it’s a “busy night” or because “something more serious may happen,” will not likely provide much protection for the paramedics who made that choice.

As an ALS provider, before you decide to pass the patient off to BLS, ask yourself those important why, what and how questions.

Why do you want to pass the patient to BLS?
There are many reasons why a paramedic might want to pass the patient off to BLS, but very few of them will hold up against a lawsuit.

Imagine a situation where a dual-function firefighter/paramedic, who is preparing a patient for transport, hears a call for a structure fire go out over the radio and quickly ships the patient with the BLS ambulance rather than accompanying the patient to the hospital. This scenario is very common. Regardless of whether the BLS-only transport is valid or appropriate, the rationale applied to that decision is demonstrative of very dangerous thinking.

The law unambiguously disfavors conduct that shows a predilection for compromising the duty owed to patients. Any time ALS transport or escort is appropriate — and of course, when it is required — the law will almost never forgive the provider who dispensed with that care in favor of something more interesting or more fun, especially when other resources are available to handle it.

Why should you not pass the patient to BLS?
This is another important question to consider because it challenges perspective. Answering this question requires the provider to consider assessment and findings, the pertinent negatives and possible complications, the aggregate circumstances and conditions, and the reasonably foreseeable legal entanglements that might result from passing the patient off. Considering these factors will generate adequate documentation to support the decision to send the patient BLS-only, if that action is followed through.

It’s your patient, why would you want anyone else assuming field care?
As I have said about a million times, the law favors patients. EMS laws in every jurisdiction in the United States intend to ensure that individuals are entitled to receive the proper care and treatment. To that end, most jurisdictions maintain that the highest professional, duty-bound, medical authority on scene retains liability for patient care until the patient is properly released or passed to an even higher authority. Simply put, the paramedic who ships a patient BLS-only retains responsibility for that patient and potential liability for the acts of the BLS crew until the ambulance reaches the hospital.

Consider this perspective and ask the question again: why would you want anyone else assuming field care of your patient?

What would you do if [insert role model name] were here?
Human beings tend to act differently depending upon the audience. What we may do in the presence of some, we would never consider in the presence of others. Based on the inherent miscellany of environments in which EMS functions, I have no doubt whatsoever that every EMS provider can relate to this concept specifically. Answering this question before passing any patient off for BLS-only transport should put the decision into proper context. If, even in the presence of the person to whom you feel the most accountable, you would send the patient BLS-only, then chances are your decision is proper. If not, then no other questions need to be asked.

What would you do if the patient was your family member?
In most circumstances, this question destroys objectivity. However, when applied to this situation, it creates a solid and very reliable perspective. Nothing usually rates higher than family and we would no sooner play tag on the interstate than compromise the care of a loved one.

Taking this question in context, every patient is someone’s loved one and therefore deserves the same level of attention you would show for your own loved one. If the patient was your mother or child, and you would feel comfortable shipping them, then move forward.

What happens to you if the BLS provider makes a critical error?
This question yields the simplest answer of all: you are responsible. You can be subjected to liability as if the critical error was your’s personally.

How would you explain the pass off in court?
This is the final and most prudent question in your decision-making algorithm. When you are on the witness stand defending your decision to ship the patient, the opposing counsel will ask you some version of every question posed above. Unless your action can be unequivocally justified and proven beyond reproach — based on questions asked by opposing counsel and carefully crafted to make you appear wrong — the odds are stacked significantly against your success.

In the grand scheme of EMS, BLS ambulances are an indispensable component of a vital machine. As they say: “If paramedics save lives, then EMTs save paramedics.” Nevertheless, each part of the EMS machine has a duty and they are not transferable. When, as a higher medical authority, you find yourself confronted with the choice between shipping and escorting, I urge you to take the time to answer the why, what and how questions and base your decision on honest answers. When prudence overrides peer pressure and patient care outweighs personal preference, providers will then have less need for… people like me.

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