How do we prevent this from TIPing over?

Governor signs bill prohibiting Arizona's EMTs from persuading patients into not going to hospital

By Rob Lawrence and Matt Zavadsky

The hottest EMS news of the week saw an Arizona bill signed into law by Gov. Doug Ducey, prohibiting emergency medical technicians from “diagnosing” patients or discouraging them from seeking transport to a hospital. House Bill 2431 caused some consternation amongst EMS folks and sent many people to the comments pages of our various industry social media pages.

The bill and subsequent law were introduced by State Rep. Amish Shah, a medical doctor, representing AZ District 24. Dr. Shah became directly involved after he attended a friend who had been counselled by Phoenix Fire-EMS personnel that she didn’t need to go to the ER.

"EMS agencies, including medical directors, must find ways to continually prove, with data, dashboards, research and such, that we have a good handle on the safety and quality of care we are delivering (and have the patient outcomes to prove it)." (Photo/Wikimedia Commons)

He introduced the bill after identifying research suggesting Phoenix had a high rate of non-transports compared to other jurisdictions.  Dr. Shah told 12 News Phoenix that “we have reviewed a lot of different cases that have come through not only in Phoenix, there have been other municipalities, but what we have seen in these cases is a pattern of counseling people out.” 12 News reported that the state investigation into the call that inspired the bill resulted in Phoenix FD being exonerated from blame. Despite this, the complaint turned into a bill, and the bill is now a law.

The law and what they can’t do

To break out and explain the situation, we must first go beyond the news headline and examine the statute. Statutes are laws passed by the Arizona Legislature and, in this case, language contained within the Emergency Medical Services chapter was amended, and states:  

  • An Emergency Medical Care Technician shall comply with either emergency medical standards and protocols established by the regional council or the medical direction for the local jurisdiction when considering emergency transport, including the appropriate use of telecommunications.
  • An emergency medical care technician may not do either of the following:
    • Provide a patient with a presumptive medical diagnosis and use that medical diagnosis as the basis for counseling the patient to decline emergency medical services transportation.
    • Counsel a patient to decline emergency medical services transportation, except as part of a specific alternate destination or treat-and-refer program that includes quality management and comprehensive medical direction oversight.
  • An emergency medical care technician shall explain to a patient the risks and consequences to the patient's health of not being transported.

In case readers think that this law applies only to EMTs, Arizona defines an Emergency Medical Care Technician as “an individual who has been certified by the department as an emergency medical technician, an advanced emergency medical technician, an emergency medical technician I-99 or a paramedic.”

The language and what it does NOT do

The new law does not place a blanket ban on leaving or treating a patient in place (TIP), since it identifies that existing alternate destination or treat-and-refer programs may be used.  Arizona’s treat-and-refer program allows EMS providers to treat patients who have accessed 911 or a similar public emergency dispatch number, but whose illness or injury does not require ambulance transport to an emergency department based on the clinical information available at the time. Similarly, agencies involved in models such as ET3 can also continue to operate within authorized protocols and conventions.

Refusal vs. persuasion

The patients always have the right to refuse transport – forcing them to the hospital could be construed as kidnapping. The language in the new statute is designed to prevent EMS personnel from persuading someone out of going to the hospital, based on a presumptive diagnosis (really a clinical impression) without the EMS personnel discussing that with an emergency physician.  Most quality EMS systems with close medical oversight would prevent this from occurring by protocol.  Medics who appear to employ the use of this practice should be identified and remediated.

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Downstream ramifications/implications

Once we got over the shock of the headline and musings about the potential implications of limiting EMS providers’ ability to navigate patients who access 911 (the best bet for proving our value to those who pay for our service, by the way), many EMS leaders felt more comfortable with the language of the new law.  However, it is something we should all monitor closely to ensure there is no interpretation creep that limits appropriate innovative medical procedures that enhance the value of EMS.

The bigger, although not openly discussed concern, is the growing trend of legislative bodies passing laws that dictate how clinical EMS is delivered, when it is much more appropriate to leave EMS delivery, including medical protocols, to – well – medical professionals.

The recent statutory bans on the use of drugs, such as ketamine are likely the most flagrant example.

Politicians (yes, we’re using that term specifically – there is a difference between an elected official and a politician) are too often influenced by those who may have agendas other than appropriate medical care. Imagine a scenario where Acme Pharmaceuticals has a new drug they want EMS to use and have a lot of political friends in the legislature that they can convince to pass a law requiring EMS to use their drug, and not leaving those decisions to the medical directors.  This trend is much more concerning.

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Bill prohibiting EMT diagnosis: The bottom line

We need to watch the implementation of this new law to prevent scope creep.  But, more importantly, EMS agencies, including medical directors, must find ways to continually prove, with data, dashboards, research and such, that we have a good handle on the safety and quality of care we are delivering (and have the patient outcomes to prove it).  If we fail to do that effectively, we will continue to be at the whim of weathervane politics, which can dramatically change how EMS is delivered by a simple majority of politicians who raise their hands when asked “All those in favor?”

About the authors

Rob Lawrence has been a leader in civilian and military EMS for over a quarter of a century. He is currently the director of strategic implementation for PRO EMS and its educational arm, Prodigy EMS, in Cambridge, Massachusetts, and part-time executive director of the California Ambulance Association. 

He previously served as the chief operating officer of the Richmond Ambulance Authority (Virginia), which won both state and national EMS Agency of the Year awards during his 10-year tenure. Additionally, he served as COO for Paramedics Plus in Alameda County, California.

Prior to emigrating to the U.S. in 2008, Rob served as the COO for the East of England Ambulance Service in Suffolk County, England, and as the executive director of operations and service development for the East Anglian Ambulance NHS Trust. Rob is a former Army officer and graduate of the UK's Royal Military Academy Sandhurst and served worldwide in a 20-year military career encompassing many prehospital and evacuation leadership roles.

Rob is a board member of the Academy of International Mobile Healthcare Integration ( AIMHI) as well as chair of the American Ambulance Association’s Communications Committee. He writes and podcasts for and is a member of the EMS1 Editorial Advisory Board. Connect with him on Twitter.

Matt Zavadsky, MS-HSA, EMT, is the chief transformation officer at MedStar Mobile Healthcare, the exclusive emergency and non-emergency Public Utility Model EMS system for Fort Worth and 14 other cities in North Texas that provides service to 436 square miles and more than 1 million residents and responds to over 170,000 calls a year with a fleet of 65 ambulances. MedStar is a high-performance, high-value Emergency Medical Services system, providing advanced clinical care with high economic efficiency. 

MedStar is one of the most well-known EMS agencies in the county, and operates a high-performance system with no tax subsidy, and the recipient of the EMS World/NAEMT Paid EMS system of the Year, and the only agency to be named an EMS10 Innovator by JEMS Magazine.   

He is also the co-author of the book “Mobile Integrated Healthcare – Approach to Implementation” published by Jones and Bartlett Publishing.

He has 42 years’ experience in EMS and holds a master’s degree in Health Service Administration with a Graduate Certificate in Health Care Data Management. Matt is a frequent speaker at national conferences and has done consulting in numerous EMS issues, specializing in high-performance EMS operations, finance, mobile integrated healthcare, public/media relations, public policy, transformative economic strategies, and EMS research. 

Matt is also immediate past president of the National Association of EMTs, and chairs their EMS Economics Committee. 

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