ACAD EMERG MED • August 2002, Vol. 9, No. 8 • www.aemj.
org
Transport Refusal by Hypoglycemic Patients after
On-scene Intravenous Dextrose
Alix J. E. Carter, BSc, MD, Paul S. Keane, BMus, EMA II,
Abstract
Objectives: Administration of intravenous (IV) dextrose
to hypoglycemic patients is delegated to advanced care
paramedics in Ontario. Following a quality assurance re-
view, which revealed that 47% of patients refused trans-
port after receiving IV dextrose, the authors studied
whether such patients seek additional medical care in the
three days following the initial refusal. Methods: Se-
quential ambulance call reports for on-scene treatments
of hypoglycemia were examined, and a standardized tel-
ephone survey of the patients was conducted. Patient
satisfaction was assessed using a five-point Likert scale.
Data were collected from April 1999 to March 2000. Re-
sults: One hundred patients were studied, with ages
ranging from 20 to 92 years (mean 53.2 years). The av-
erage Glasgow Coma Scale (GCS) score on presentation
was 8.7 ⫾ 3.5. The average blood glucose level before
Between 34% and 69% of all hypoglycemic patients
refuse transport following paramedic contact,1 and
hypoglycemic patients account for 2.2% to 7% of
refusal of service/transport cases.2,3 A 1990 study
by Goldberg et al. noted a significant increase in
litigation involving emergency medical services
(EMS), and also found that 20% of these cases were
‘‘related to transport.’’4 Other medicolegal key is-
sues include the patient’s right to refuse, safety, and
utilization of resources.
A retrospective quality assurance review (Sep-
tember 1997–May 1998) revealed a significant re-
fusal of transport rate (47%) with no significant dif-
From the University of Western Ontario Faculty of Medicine,
London, ON, Canada (AJEC, JFD); Thames EMS, London, ON,
Canada (PSK); the London Health Sciences Centre, London,
ON, Canada (JFD); and the University of Manitoba Faculty of
-Medicine, Winnipeg, MB, Canada (AJEC).
Received November 27, 2001; revision received April 9, 2002;
accepted April 16, 2002.
Presented as a poster at the 2001 Annual Scientific Meeting of
the Canadian Association of Emergency Physicians, Calgary,
AB, Canada, March 2001.
Supported by the Department of Emergency Medicine, London
Health Sciences Centre, London, ON, Canada.
Address for correspondence and reprints: Dr. A. Carter, 噦 St.
Boniface Hospital, Emergency Department, A1119, 409 Tache
Avenue, Winnipeg, MB, R2H 2A6, Canada. E-mail: alixcarter@
yahoo.com.
855
Jonathan F. Dreyer, BSc, MD, CM
administration of IV dextrose was 1.91 ⫾ 0.63 mmol/L.
Sixty-eight percent of the patients refused transport. Sig-
nificant differences between the transported group and
the refusal group were age (transported 64.7 years, re-
fused 47.8 years, p = 0.002) and initial blood glucose
(transported 1.8, refused 2.1, p = 0.001). No difference
was found in terms of repeat access to health care for
related complaints. Patient satisfaction was high in both
groups, with no difference in the overall satisfaction with
paramedics’ care (4.76 ⫾ 0.58 vs 4.75 ⫾ 0.45). Conclu-
sions: The practice of treating patients for symptomatic
hypoglycemia and leaving them at the scene appears to
be safe. Further study is required to confirm this. Key
words: dextrose; hypoglycemia; prehospital; refusal of
transport. ACADEMIC EMERGENCY MEDICINE 2002;
9:855–857.
ference in repeat 911 calls for the same chief
complaint. A review of hospital charts for the same
time period also failed to reveal a significant dif-
ference in the rate of visits to the emergency de-
partment or hospital clinics for complaints related
to the initial event.
In order to determine whether 911 captured all
repeat visits, and to accurately assess the compli-
cation rate (defined as having a rebound hypogly-
cemia, hyperglycemia, or consequence of the initial
treatment), direct patient contact was needed. Con-
sequently, we conducted a prospective study to
examine the question, ‘‘Do patients who refuse
transport after receiving intravenous dextrose for
hypoglycemia have a higher complication rate, and
are patients satisfied with this practice?’’
METHODS
Study Design. We undertook a prospective de-
scriptive study of 100 sequential hypoglycemic pa-
tients who required intravenous (IV) 50% dextrose
from March 1999 to April 2000. Consent to partici-
pate in the survey was obtained at the outset of the
telephone call. This study was reviewed and ap-
proved by the University of Western Ontario Re-
view Board for Health Sciences Research Involving
Human Subjects.
856
Study Setting and Population. The setting of this
study was London, Canada, an urban community
in Southwestern Ontario. The area’s ambulance ser-
vice serves a population of 400,000, operating five
to ten ambulances during different periods of the
day (including two to four advanced life support
vehicles). Online medical support for paramedics is
provided by emergency medicine senior residents
and faculty of the University of Western Ontario.
Included patients were hypoglycemic, requiring
IV D50. Excluded patients included minors; patients
who did not speak English, were aphasic, or whose
telephone number was not recorded on the ambu-
lance call report (ACR) and was unlisted; and pa-
tients in nursing homes and other residential facil-
ities (due to the difficulty in directly contacting
these patients, and also possible differences in re-
fusal patterns).
Data Analysis. Results were analyzed using Stu-
dent’s two-tailed t-test (continuous variables) and
Pearson’s chi-square test (gender).
Study Protocol. When a patient is found to have a
decreased level of consciousness, the paramedic as-
sessment includes blood glucometry. If the blood
sugar is below 4.0 mmol/L, the paramedic admin-
isters 50 mL of 50% dextrose in water intrave-
nously. No further testing of blood glucose is per-
formed. When the patient’s Glasgow Coma Scale
(GCS) score returns to normal, and there is a re-
sponsible adult on scene, the decision of transport
is left to the discretion of the patient and the par-
amedic. Otherwise, the patient is transported to
hospital.
The ACRs were collected at the end of each shift
in a designated envelope. Patients were contacted
by telephone within 21 days of the ambulance call
and were asked standard questions regarding re-
peat access to health care and satisfaction (on a five-
point Likert scale). The ACRs were tracked to as-
certain repeat access to 911. If no contact was made
by day 21 despite near daily attempts, the patient
was deemed ‘‘not contacted.’’
RESULTS
The total number of patients receiving dextrose in
this study period was 157. Only 100 of these pa-
tients were eligible for the study, for the reasons
outlined. Of these, we were able to contact 60.
No significant difference was found between the
contacted and not-contacted groups with respect to
age, gender, or initial GCS. The mean blood glucose
was higher in the no-contact group (2.26 ⫾ 0.81 vs
1.88 ⫾ 0.61, p = 0.009).
Carter et al. • REFUSAL OF TRANSPORT AFTER DEXTROSE
We found no significant difference in gender, in-
itial GCS, or repeat 911 calls between the trans-
ported and not-transported patients (Table 1), but
the transport group did prove to be significantly
older, and had a higher initial blood glucose mea-
surement. Rates of repeat access to health care for
all complaints were 31.58% in the transported
group and 14.63% in the refusal group, but physi-
cian visits within three days were not for compli-
cations.
Patient satisfaction was high in both groups, with
no difference in the overall levels of satisfaction
with paramedics’ care (4.76 ⫾ 0.58 vs 4.75 ⫾ 0.45).
A sample of the comments includes: ‘‘Didn’t take
too long, very efficient,’’ ‘‘It’s too tiring to go to the
hospital,’’ ‘‘Very quick, made sure I ate,’’ and ‘‘This
new procedure of being able to stay home is excel-
lent—I know I don’t need to go to the hospital.’’
DISCUSSION
Refusal of transport following IV dextrose for hy-
poglycemia remains controversial in out-of-hospital
care. EMS and base hospital personnel face a di-
lemma: risk accusations of abandonment or negli-
gence, or fail to respect patients’ legal and ethical
right to refuse care and run the risk of battery
charges.5,6
We found a repeat access to 911 rate of 5.26% in
the transported group and 4.88% in the refusal of
transport group, as compared with 9% repeat ac-
cess in a study by Mechem et al.3 and 6.1% in a
study by Socransky et al.1 in similar populations.
Our finding that older patients are more likely to
be transported is borne out by previous studies1
noting that patients over age 55 are more likely to
be admitted or die,5 and patients over age 65 are
more likely to recontact EMS.3
With regard to the posthypoglycemic patient’s
competence to refuse care,6,7 Alicandro et al.’s
group developed criteria to identify patients at high
risk for adverse medical outcome,8 preserving their
right to refuse. Implementation of these criteria has
identified abnormal pulse or blood pressure, head
injury, and age >55 years as significantly associated
with need for hospital admission.7
If the administration of IV dextrose is delayed
until the patient is en route to the hospital, this may
interfere with the ethical obligation to respect the
patient’s right to refuse transport. Studies have also
suggested a shorter run time for refusal of transport
hypoglycemia calls,1 and transporting a patient to
the emergency department (ED) incurs the cost of
an ED visit and workup; perhaps this is not the best
use of resources.
ACAD EMERG MED • August 2002, Vol. 9, No. 8 • www.aemj.org 857

TABLE 1. Study Results

Refused Transport Transported
Repeat access to health care (all complaints) 6 (14.63%) 6 (31.58%)

Repeat access to 911 (same complaint) 2 (4.88%) 1 (5.26%)

Transported at second call? 1 1

Visited ED without 911 0 0

Visited walk-in clinic 0 0

Visited physician office 4: 5:

Chest infection MI
Increasing reactions Never had reaction before
Need to change medications Foot infection
Increasing reactions Need to change medications
ED arranged follow-up

N 41 19

ED = emergency department; MI = myocardial infarction.

LIMITATIONS and that the patient eats something. Patient satis-

Due to the exclusion criteria discussed, we nar-
rowed our study population; further, only 60% of
eligible patients could be contacted. This may bias
our results such that they may not be extrapolated
to these groups.
Has the knowledge that a study was taking place
influenced the paramedics’ practice patterns? We
suspect that any bias on the part of the paramedics
should lead to more caution and an increased trans-
port rate. A comparison of refusal rates in this
study with those from our retrospective review
demonstrates the opposite: an increase in refusal
rates from 47% to 68%.
Areas of future study include a review of total
out-of-service times for ambulance crews on these
calls, and further examination of possible high-risk
criteria, such as age, comorbidity, and use of oral
hypoglycemic agents, to develop a protocol for safe
refusal of transport.
CONCLUSIONS
Our data suggest that patients who refuse transport
following treatment of hypoglycemia with intra-
venous dextrose have no more complications than
those who are transported, given the current prac-
tice of ensuring the presence of a responsible adult
faction with this practice is also high.
The authors thank the paramedics of Thames EMS, and Dr. Karl
Theakston for statistical support.
References
1. Socransky SJ, Pirrallo RG, Rubin JM. Out-of-hospital treat-
ment of hypoglycemia: refusal of transport and patient
outcome. Acad Emerg Med. 1998; 5:1080–5.
2. Moss ST, Chan TC, Buchanan J, Dunford JV, Vilke GM.
Outcome study of prehospital patients signed out against
medical advice by field paramedics. Ann Emerg Med.
1998; 31:247–50.
3. Mechem CC, Kreshak AA, Barger J, Shofer FS. The short-
term outcome of hypoglycemic diabetic patients who re-
fuse ambulance transport after out-of-hospital therapy.
Acad Emerg Med. 1998; 5:768–72.
4. Goldberg RJ, Zautcke JL, Koenigsberg MD, et al. A review
of prehospital care litigation in a large metropolitan EMS
system. Ann Emerg Med. 1990; 19:557–61.
5. Burstein JL, Hollander JE, Henry MC, Delagi R, Thode
HC Jr. Association of out-of-hospital criteria with need for
hospital admission. Acad Emerg Med. 1995; 2:863–6.
6. Stark G, Hedges JR, Neely K, Norton R. Patients who ini-
tially refuse prehospital evaluation and/or therapy. Am J
Emerg Med. 1990; 8:509–11.
7. Adams JG, Arnold R, Siminoff L, Wolfson AB. Ethical con-
flicts in the prehospital setting. Ann Emerg Med. 1992; 21:
1259–65.
8. Alicandro J, Hollander JE, Henry MC, Sciammarella J, Sta-
pleton E, Gentile D. Impact of interventions for patients
refusing emergency medical services transport. Acad
Emerg Med. 1995; 2:480–5.