Introduction: Delegation of controlled medical acts by physicians to paramedics is an important component of the prehospital care framework. Where directives indicate that physician input is needed before proceeding with certain interventions, online medical control (a “patch”) exists to facilitate communication between a paramedic and a Base Hospital Physician (BHP) to request an order to proceed with that intervention. The clinical and logistical setting will contribute to the decision to proceed with or withhold an intervention in the prehospital setting. The aim of this study was to examine the impact of various clinical and situational factors on the likelihood of a patch request being granted. Methods: Prehospital paramedic calls that included a mandatory patch point (excluding requests exclusively for termination of resuscitation and those records which were unavailable) were identified through review of all patch records from January 1, 2014 to December 31, 2017 for Paramedic Services in our region. Written Ambulance Call Reports (ACRs) and audio recordings of paramedic patches were obtained and reviewed. Results: 214 patch records were identified and screened for inclusion. 91 ACRs and audio patch records were included in the analysis. 51 of 91 (56%) patch requests were granted by the BHP. Of the 40 paramedic requests that were not granted, the most commonly cited reason was close proximity to hospital (22/40; 55%) followed by low likelihood of the intervention making a clinical impact in the prehospital setting (11/40; 27.5%). Requests for certain interventions were more likely to be granted than other requests. All requests to perform needle thoracostomy for possible tension pneumothorax, administer atropine for symptomatic bradycardia and treat hemodynamically unstable hyperkalemia were granted (2/2, 3/3 and 7/7, respectively), while requests for synchronized cardioversion (7/19; 37%) and transcutaneous pacing (2/6; 33%) were approved less than half of the time. Conclusion: This retrospective review suggests that requests to perform certain critical and potentially time sensitive interventions are more likely to be granted which calls into question the requirement for a mandatory patch point for these procedures. Furthermore, the interplay between proximity to hospital and the decision to proceed with an intervention potentially informs future modifications to directives to facilitate timely, safe and efficient care.