1. The Art of the Refusal

2. Why are we holding this class?  Patient Advocacy  What is best for the patient  Education of the patient  Reassure the patient that their choices are right and meet their needs

3. Why are we holding this class?  Protection for the paramedic  Helping the paramedic to have the skill(s) to guide the patient to make good choices  Helping the paramedic to make sure that their decisions on refusals are legal and defensible  Helping the paramedic to make sure they are following Dr. Riccio’s direction as the Medical Director of SMFRA.

4. Protocols we’re bundling…  0007 General Guidelines: Patient Determination  0008 General Guidelines: Patient Non-Transport or Refusal  4015 Alcohol Intoxication  4012 Altered Mental Status

5. Presentation of Refusal Bundle Go to Refusal Bundle in EMS Bureau Folder: P Drive > EMS Bureau > Training > Company Training > 2014 Company Training > The Art of the Refusal > Copy of Refusal Bundle

6. Assessing Decision Making Capability Assess Decision Making Capability Are they a minor? Are they clinically sober? Do they slur their words? Is their gait ataxic? Do they make their own decisions? Who makes decisions for them? Do they understand nature of incident? Do they understand the risks? Have a plan if their condition deteriorates? Assess Decision Making Capability

7. Discussion of ARM Car Consult  Better disposition for the patient  Contacting ARM Car by Nextel early (potentially prior to their arrival)  What can the ARM Car do for the paramedic and the patient on scene?

8. Talking about better disposition - Dollars & Sense – Six easy ways to decrease your out-of-pocket health care expenses (Cigna flyer) 1.Utilize In-network care 2.Utilize Urgent Care  Average urgent care center cost - $131  Average hospital ER cost – $1523 3.Utilize convenience care or retail sites (Little Clinic in King Soopers)  Average convenience care clinic cost - $61  Average hospital ER cost - $1523

9. Dollars & Sense cont… 4.Lab and Pathology tests  Average lab cost - $24  Average outpatient hospital lab cost - $48 5.Radiology services (MRI or CT scan)  Average independent radiology facility cost - $591  Average outpatient hospital cost $1198 6.Colonoscopy, endoscopy, or arthroscopy  Average freestanding surgery center cost - $1438  Average outpatient hospital cost - $2821

10. The Plan Plan - "The Art" Step 1 - Acknowledge their complaint Step 2 - Assess their issue/complaint Step 3 - Help them make an informed decision of what to do (DISCUSS) Do they understand possible complications? Make a plan with them in case things get worse Step 4 - Discuss options: ARM Car Consult Refusal Transport Step 5 - Awesome biophone report that covers physical assessment, decision making capability, and plan for the patient with the doc! Discuss Plan - see box below

11. Documentation if a Refusal Documentation Required if a Refusal Document the elements of the patient's decision making capability Document the patient's complaint Document the patient's understanding of possible complications Document the patient's plan if things get worse Document any concerns the doc has from biophone report Document name of doc authorizing refusal PCR Needed