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Bosson N, Toy J, Chang A, Haase D, Kipust A, Korotzer L, Warren J, Kim YS, Kazan C, Gausche-Hill M. Short-Term Outcomes and Patient Perceptions after Paramedic Non-Transport during the COVID-19 Pandemic. PREHOSP EMERG CARE 2023; 28:418-424. [PMID: 37078829 DOI: 10.1080/10903127.2023.2205512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/13/2023] [Accepted: 04/18/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND EMS frequently encounter patients who decline transport, yet there are little data to inform the safety of patient and/or paramedic-initiated assess, treat, and refer (ATR) protocols. We determined patient decision-making and short-term outcomes after non-transport by EMS during the COVID-19 pandemic. METHODS This was a prospective, observational study of a random sample of patients evaluated and not transported by EMS from August 2020 to March 2021. From the EMS database, we randomly selected a daily sample of adult patients with disposition of ATR. We excluded patients dispositioned against medical advice (AMA) and those in police custody. Investigators contacted patients by phone to administer a standardized survey regarding decision-making, symptom progression, follow-up care, and satisfaction with non-transport decision. We also determined the proportion of patients who re-contacted 9-1-1 within 72 h, and unexpected deaths within 72 h using coroner data. Descriptive statistics were calculated. RESULTS Of 4613 non-transported patients, 3330 (72%) patients for whom the disposition was ATR were included. Patients were 46% male with a median age of 49 (inter-quartile range (IQR) 31-67). Median vital signs measurements fell within the normal range. Investigators successfully contacted 584/3330 patients (18%). The most common reason for failure was lack of accurate phone number. The most common reasons patients reported for not going to the ED on initial encounter were: felt reassured after the paramedic assessment (151/584, 26%), medical complaint resolved (113/584, 19%), paramedic suggested transport was not required (73/584, 13%), concern for COVID-19 exposure (57/584, 10%), and initial concern was not medical (46/584, 8%). Ninety-five percent (552/584) were satisfied with the non-transport decision and 49% (284/584) had sought follow-up care. The majority (501/584, 86%) reported equal, improved, or resolved symptoms, while 80 patients (13%) reported worse symptoms, of whom (64/80, 80%) remained satisfied with the non-transport decision. Overall, there were 154 of 3330 (4.6%) 9-1-1 recontacts within 72 h. Based on coroner data, three unexpected deaths (0.09%) occurred within 72 h of the initial EMS calls. CONCLUSION Paramedic disposition by ATR protocols resulted in a low rate of 9-1-1 recontact. Unexpected deaths were extremely rare. Patient satisfaction with the non-transport decision was high.
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Affiliation(s)
- Nichole Bosson
- Los Angeles County EMS Agency, Santa Fe Springs, California
- Harbor-UCLA Medical Center Department of Emergency Medicine and the Lundquist Institute for Research, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jake Toy
- Harbor-UCLA Medical Center Department of Emergency Medicine and the Lundquist Institute for Research, Torrance, California
| | - Allen Chang
- Los Angeles County EMS Agency, Santa Fe Springs, California
- Harbor-UCLA Medical Center Department of Emergency Medicine and the Lundquist Institute for Research, Torrance, California
| | - David Haase
- Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Adam Kipust
- University of California Los Angeles, Los Angeles, California
| | | | - Jonathan Warren
- Harbor-UCLA Medical Center Department of Emergency Medicine and the Lundquist Institute for Research, Torrance, California
| | - Yun Son Kim
- Los Angeles County Fire Department, Los Angeles, California
| | - Clayton Kazan
- Los Angeles County Fire Department, Los Angeles, California
| | - Marianne Gausche-Hill
- Los Angeles County EMS Agency, Santa Fe Springs, California
- Harbor-UCLA Medical Center Department of Emergency Medicine and the Lundquist Institute for Research, Torrance, California
- David Geffen School of Medicine at UCLA, Los Angeles, California
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Ward CE, Singletary J, Hatcliffe RE, Colson CD, Simpson JN, Brown KM, Chamberlain JM. Emergency Medical Services Clinicians' Perspectives on Pediatric Non-Transport. PREHOSP EMERG CARE 2022; 27:993-1003. [PMID: 35913148 DOI: 10.1080/10903127.2022.2108180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/25/2022] [Indexed: 10/16/2022]
Abstract
OBJECTIVES Emergency medical services clinicians do not transport one-third of all children assessed, even without official pediatric non-transport protocols. Little is known about how EMS clinicians and caregivers decide not to transport a child. Our objectives were to describe how EMS clinicians currently decide whether or not to transport a child and identify barriers to and enablers of successfully implementing an EMS clinician-initiated pediatric non-transport protocol. METHODS We conducted six virtual focus groups with EMS clinicians from the mid-Atlantic. A PhD trained facilitator moderated all groups using a semi-structured moderator guide. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus. RESULTS We recruited 50 participants, of whom 70% were paramedics and 28% emergency medical technicians. There was agreement that caregivers often use 9-1-1 for low acuity complaints. Participants stated that non-transport usually occurs after shared decision-making between EMS clinicians and caregivers; EMS clinicians advise whether transport is necessary, but caregivers are responsible for making the final decision and signing refusal documentation. Subthemes for how non-transport decisions were made included the presence of agency protocols, caregiver preferences, absence of a guardian on the scene, EMS clinician variability, and distance to the nearest ED. Participants identified the following features that would enable successful implementation of an EMS clinician-initiated non-transport process: a user-friendly interface, clear protocol endpoints, the inclusion of vital sign parameters, resources to leave with caregivers, and optional direct medical oversight. CONCLUSIONS EMS clinicians in our study agreed that non-transport is currently a caregiver decision, but noted a collaborative process of shared decision-making where EMS clinicians advise caregivers whether transport is indicated. Further research is needed to understand the safety of this practice. This study suggests there may be a need for EMS-initiated alternative disposition/non-transport protocols.
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Affiliation(s)
- Caleb E Ward
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia, USA
- The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Judith Singletary
- Department of Sociology and Criminology, Howard University, Washington, District of Columbia, USA
| | - Rachel E Hatcliffe
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia, USA
- The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Cindy D Colson
- Division of Trauma & Burn Surgery, Children's National Hospital, Washington, District of Columbia, USA
| | - Joelle N Simpson
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia, USA
- The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Kathleen M Brown
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia, USA
- The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - James M Chamberlain
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia, USA
- The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
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Breyre AM, Sporer KA, Davenport G, Isaacs E, Glomb NW. Paramedic use of the Physician Order for Life-Sustaining Treatment (POLST) for medical intervention and transportation decisions. BMC Emerg Med 2022; 22:145. [PMID: 35948964 PMCID: PMC9367154 DOI: 10.1186/s12873-022-00697-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Physician Order for Life-Sustaining Treatment forms (POLST) exist in some format in all 50 states. The objective of this study is to determine paramedic interpretation and application of the California POLST for medical intervention and transportation decisions. METHODS This study used a prospective, convenience sample of California Bay Area paramedics who reviewed six fictional scenarios of patients and accompanying mock POLST forms. Based on the clinical case and POLST, paramedics identified medical interventions that were appropriate (i.e. non-invasive positive pressure airway) as well as transportation decisions (i.e. non-transport to the hospital against medical advice). EMS provider confidence in their POLST interpretation was also assessed. RESULTS There were 118 paramedic participants with a mean of 13.3 years of EMS experience that completed the survey. Paramedics routinely identified the selected medical intervention on a patients POLST correctly as either comfort focused, selective or full treatment (113-118;96%-100%). For many clinical scenarios, particularly when a patient's POLST indicated comfort focused treatment, paramedics chose to use online medical oversight through base physician contact (68-73;58%-62%). In one case, a POLST indicated "transport to hospital only if comfort needs cannot be met in current location", 13 (14%) paramedics elected to transport the patient anyway and 51 (43%) chose "Non-transport, Against Medical Advice". The majority of paramedics agreed or strongly agreed that they knew how to use a POLST to decide which medical interventions to provide (106;90%) and how to transport a patient (74;67%). However, after completing the cases, similar proportions of paramedics agreed (42;36%), disagreed (43;36%) or were neutral (30;25%) when asked if they find the POLST confusing. CONCLUSION The POLST is a powerful tool for paramedics when caring patients with serious illness. Although paramedics are confident in their ability to use a POLST to decide appropriate medical interventions, many still find the POLST confusing particularly when making transportation decisions. Some paramedics rely on online medical oversight to provide guidance in challenging situations. Authors recommend further research of EMS POLST utilization and goal concordant care, dedicated paramedic POLST education, specific EMS hospice and palliative care protocols and better nomenclature for non-transport in order to improve care for patients with serious illness.
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Affiliation(s)
- Amelia M Breyre
- University of California San Francisco, Department of Emergency Medicine, San Francisco, USA.
| | - Karl A Sporer
- Alameda County Emergency Medical Services Agency, San Leandro, USA
| | - Glen Davenport
- Columbia University, Columbia Center for Teaching and Learning, Oregon, USA
| | - Eric Isaacs
- University of California San Francisco, Department of Emergency Medicine, San Francisco, USA
| | - Nicolaus W Glomb
- University of California San Francisco, Department of Emergency Medicine, San Francisco, USA
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Heinonen K, Puolakka T, Salmi H, Boyd J, Laiho M, Porthan K, Harve‐Rytsälä H, Kuisma M. Ambulance crew-initiated non-conveyance in the Helsinki EMS system-A retrospective cohort study. Acta Anaesthesiol Scand 2022; 66:625-633. [PMID: 35170028 PMCID: PMC9544076 DOI: 10.1111/aas.14049] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 01/23/2022] [Accepted: 02/06/2022] [Indexed: 11/30/2022]
Abstract
Background Ambulance patients are usually transported to the hospital in the emergency medical service (EMS) system. The aim of this study was to describe the non‐conveyance practice in the Helsinki EMS system and to report mortality following non‐conveyance decisions. Methods All prehospital patients ≥16 years attended by the EMS but not transported to a hospital during 2013–2017 were included in the study. EMS mission‐ and patient‐related factors were collected and examined in relation to patient death within 30 days of the EMS non‐conveyance decision. Results The EMS performed 324,207 missions with a patient during the study period. The patient was not transported in 95,909 (29.6%) missions; 72,233 missions met the study criteria. The patient mean age (standard deviation) was 59.5 (22.5) years; 55.5% of patients were female. The most common dispatch codes were malaise (15.0%), suspected decline in vital signs (14.0%), and falling over (12.9%). A total of 960 (1.3%) patients died within 30 days after the non‐conveyance decision. Multivariate logistic regression analysis revealed that mortality was associated with the patient's inability to walk (odds ratio 3.19, 95% confidence interval 2.67–3.80), ambulance dispatch due to shortness of breath (2.73, 2.27–3.27), decreased level of consciousness (2.72, 1.75–4.10), decreased blood oxygen saturation (2.64, 2.27–3.06), and abnormal systolic blood pressure (2.48, 1.79–3.37). Conclusion One‐third of EMS missions did not result in patient transport to the hospital. Thirty‐day mortality was 1.3%. Abnormalities in multiple respiratory‐related vital signs were associated with an increased likelihood of death within 30 days.
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Affiliation(s)
- Kari Heinonen
- Department of Emergency Medicine & Services Helsinki University Hospital and University of Helsinki Helsinki Finland
- Department of Anesthesiology & Intensive Care Medicine Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Tuukka Puolakka
- Department of Emergency Medicine & Services Helsinki University Hospital and University of Helsinki Helsinki Finland
- Department of Anesthesiology & Intensive Care Medicine Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Heli Salmi
- Department of Anesthesiology & Intensive Care Medicine Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - James Boyd
- Department of Emergency Medicine & Services Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Mia Laiho
- Parliament of Finland Helsinki Finland
| | - Kari Porthan
- Helsinki City Rescue Department Helsinki Finland
| | - Heini Harve‐Rytsälä
- Department of Emergency Medicine & Services Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Markku Kuisma
- Department of Emergency Medicine & Services Helsinki University Hospital and University of Helsinki Helsinki Finland
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O'Connor L, Porter L, Dugas J, Robinson C, Carrillo E, Knowles K, Nelson KP, Gigliotti R, Tennyson J, Weisberg S, Rebesco M. Measuring Agreement Among Prehospital Providers and Physicians in Patient Capacity Determination. Acad Emerg Med 2020; 27:580-587. [PMID: 32065493 DOI: 10.1111/acem.13941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/11/2020] [Accepted: 02/14/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES If a patient wishes to refuse treatment in the prehospital setting, prehospital providers and consulting emergency physicians must establish that the patient possesses the capacity to do so. The objective of this study is to assess agreement among prehospital providers and emergency physicians in performing patient capacity assessments. METHODS This study involved 139 prehospital providers and 28 emergency medicine physicians. Study participants listened to 30 medical control calls pertaining to patient capacity and were asked to interpret whether the patients in the scenarios had the capacity to refuse treatment. Participants also reported their comfort level using modified Likert scales. Inter-rater reliability was calculated utilizing Fleiss' and Model B kappa statistics. Fisher's exact tests were used to calculate p-values comparing the proportion in each cohort that responded "no capacity." Primary outcomes included inter-rater reliability in the physician and prehospital provider cohorts. RESULTS The inter-rater agreement between the physicians was low (Fleiss' kappa = 0.31, standard error [SE] =0.06; model-based kappa = 0.18, SE = 0.04). Agreement was similarly low for the 135 prehospital providers (Fleiss' kappa = 0.30, SE = 0.06; model-based kappa = 0.28, SE = 0.04). The difference between the proportion of physicians and prehospital providers who responded "no capacity" was statistically significant in five of 30 scenarios. Median prehospital provider and physician confidence, on a 1 to 4 scale, was 2.00 (Q1-Q3 = 1.00-3.00 for prehospital providers and Q1-Q3 =1.0-2.0 for physicians). CONCLUSIONS There was poor inter-rater reliability in capacity determination between and among the prehospital provider and physician cohorts. This suggests that there is need for additional study and standardization of this task.
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Affiliation(s)
- Laurel O'Connor
- From the, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Liam Porter
- From the, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Julianne Dugas
- the, Department of Emergency Medicine, Boston Medical Center, Boston, MA, USA
| | - Conor Robinson
- From the, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Eli Carrillo
- the, Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kenneth Knowles
- the, Department of Emergency Medicine, Baystate Medical Center, Springfield, MA, USA
| | - Kerrie P Nelson
- and the, Department of Biostatics, Boston University, Boston, MA, USA
| | - Ronald Gigliotti
- From the, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Joseph Tennyson
- From the, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Stacy Weisberg
- From the, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Matthew Rebesco
- From the, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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Rai B, Tennyson J, Marshall RT. Retrospective Analysis of Emergency Medical Services (EMS) Physician Medical Control Calls. West J Emerg Med 2020; 21:665-670. [PMID: 32421517 PMCID: PMC7234714 DOI: 10.5811/westjem.2020.1.44943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 01/31/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Although emergency medical services (EMS) standing-order protocols provide more efficient and accurate on-scene management by paramedics, online medical direction (OLMD) has not been eliminated from practice. In this modern era of OLMD, no studies exist to describe the prevalence of reasons for contacting OLMD. OBJECTIVES The primary goal of this study was to describe the quantity of and reasons for calls for medical direction. We also sought to determine time diverted from emergency physicians due to OLMD. Finally, we hoped to identify any areas for potential improvement or additional training opportunities for EMS providers. METHODS This was a descriptive study with retrospective data analysis of recorded OLMD calls from January 1, 2016, to December 31, 2016. Data were extracted by research personnel listening to audio recordings and were entered into a database for descriptive analysis. We abstracted the date and length of call, patient demographic information (age and gender), category of call (trauma, medical, cardiac, or obstetrics), reason for call, and origin of call (prehospital, interhospital, nursing home, or discharge). RESULTS The total number of recordings analyzed was 519. Calls were divided into four categories pertaining to their nature: 353 (68.5%) medical; 70 (13.6%) trauma; 83 (16.1%) cardiac; and 9 (8%) were obstetrics related. Repeat calls regarding the same patient encounter comprised 48 (9.4%) of the calls. Patient refusal of transport was the most common reason for a call medical direction (32.3% of calls). The total time for medical direction calls for the year was 26.6 hours. The maximum number of calls in a single day was seven, with a mean of 2.04 calls per day (standard deviation [SD] ± 1.18). The mean call length was 3.06 minutes (SD ± 2.51). CONCLUSION Our analysis shows that the use of OLMD frequently involves complex decision-making such as determination of the medical decision-making capacity of patients to refuse treatment and transport, and evaluation of the appropriate level of care for interfacility transfers. Further investigation into the effect of EMS physician-driven medical direction on both the quality and time required for OLMD could allow for better identification of areas of potential improvement and training.
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Affiliation(s)
- Balaj Rai
- The Christ Hospital, Department of Internal Medicine, Cincinnati, Ohio
| | - Joseph Tennyson
- University of Massachusetts Medical School, Department of Emergency Medicine, Worcester, Massachusetts
| | - R Trevor Marshall
- Stony Brook University, Department of Emergency Medicine, Stony Brook, New York
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A Descriptive Analysis of Pediatric Prehospital Refusal of Medical Assistance Within a Single Service Provider System. Pediatr Emerg Care 2020; 36:26-30. [PMID: 31895200 DOI: 10.1097/pec.0000000000002018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Pediatric refusal of medical assistance (RMA) is a potentially high-risk event with implications for both individual patient outcomes and greater emergency medical services system efficiency. The purpose of this study was to describe characteristics of pediatric RMA calls and outcomes. METHODS Single emergency medical services agency retrospective study of calls between January 1, 2011, and December 31, 2015, for pediatric patients resulting in RMA was performed. Dispatch complaint-matched case-control group was generated from transported patients. RESULTS The percentage of pediatric calls that resulted in RMA was 12.7%, compared with 5% adult calls (P < 0.0001). The 3 most common RMA dispatch complaints were seizures, difficulty breathing, and traffic accidents. Furthermore, 65.1% pediatric RMA calls were emergently dispatched, compared with 56.4% of transported pediatric patients (P = 0.01). Medical control was contacted for 4.6% RMA calls. The average ± SD word count for RMA patient care narratives was 179 ± 99 words, compared with 164 ± 139 words for controls (P = 0.11). Documentation of risk-benefit discussion occurred in 28.6% RMA narratives. Outcome data were available for 83.8% RMA patients. The percentage of RMA patients with documented alternative plans who completed the alternative plan was 61.6%. Within 72 hours of RMA, 5.0% of calls with known outcome resulted in unexpected emergency department visit. No unexpected emergency department visits resulted in admission. Five percent of RMA patients were admitted; 1 patient was admitted to the intensive care unit. No emergent surgeries or deaths occurred during the study period. CONCLUSIONS Pediatric RMA is common within our study population, and two thirds involve emergent dispatch. Although outcomes are generally good, refusal documentation is sparse and medical control is seldom contacted. Multiple opportunities for systems improvement exist.
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Yeung T, Shannon B, Perillo S, Nehme Z, Jennings P, Olaussen A. Review article: Outcomes of patients who are not transported following ambulance attendance: A systematic review and meta‐analysis. Emerg Med Australas 2019; 31:321-331. [DOI: 10.1111/1742-6723.13288] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 02/24/2019] [Indexed: 11/27/2022]
Affiliation(s)
| | - Brendan Shannon
- Department of Community Emergency Health and Paramedic Practice, Monash University Melbourne Victoria Australia
- Ambulance Victoria Melbourne Victoria Australia
| | - Samuel Perillo
- Department of Community Emergency Health and Paramedic Practice, Monash University Melbourne Victoria Australia
| | - Ziad Nehme
- Department of Community Emergency Health and Paramedic Practice, Monash University Melbourne Victoria Australia
- Ambulance Victoria Melbourne Victoria Australia
| | - Paul Jennings
- Department of Community Emergency Health and Paramedic Practice, Monash University Melbourne Victoria Australia
- Ambulance Victoria Melbourne Victoria Australia
| | - Alexander Olaussen
- Alfred Hospital Melbourne Victoria Australia
- Department of Community Emergency Health and Paramedic Practice, Monash University Melbourne Victoria Australia
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Ebben RHA, Castelijns M, Frenken J, Vloet LCM. Characteristics of non-conveyance ambulance runs: A retrospective study in the Netherlands. World J Emerg Med 2019; 10:239-243. [PMID: 31534599 DOI: 10.5847/wjem.j.1920-8642.2019.04.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Remco H A Ebben
- HAN University of Applied Sciences, Faculty of Health and Social Studies, Research Department of Emergency and Critical Care, Nijmegen, the Netherlands
| | | | - Joost Frenken
- Ambulance Service Brabant Zuid Oost, Eindhoven, the Netherlands
| | - Lilian C M Vloet
- HAN University of Applied Sciences, Faculty of Health and Social Studies, Research Department of Emergency and Critical Care, Nijmegen, the Netherlands.,Radboud University Medical Center, Nijmegen, the Netherlands
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10
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Ramgopal S, Owusu‐Ansah S, Martin‐Gill C. Factors Associated With Pediatric Nontransport in a Large Emergency Medical Services System. Acad Emerg Med 2018; 25:1433-1441. [PMID: 30370989 DOI: 10.1111/acem.13652] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/17/2018] [Accepted: 10/24/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pediatric patients attended to by emergency medical services (EMS) but not transported to the hospital are an at-risk population. We aimed to evaluate risk factors associated with nontransport by EMS in pediatric patients. METHODS We reviewed medical records of 24 agencies in a regional EMS system in Southwestern Pennsylvania between January 1, 2014, and December 31, 2017. We abstracted demographics (age, sex, medical complaint, median household income by zip code, race, ethnicity), clinical characteristics (abnormal vital signs by age, procedures done), and transport characteristics. We excluded patients ≥ 18 years, interfacility transfers, scene assists, cardiac arrest, and those without a patient encounter. We used unadjusted and adjusted logistic regression to identify factors associated with nontransport, reporting adjusted odds ratios (aOR) with 95% confidence intervals (CIs). RESULTS We included 30,663 pediatric patients (52.9% male, mean ± SD age = 8.5 ± 6.2 years), of whom 5,002 (16.3%) were nontransports. In adjusted analysis (aOR, 95% CI), nontransports were associated with medical categories of trauma (4.32, 3.57-5.23), respiratory (4.03, 3.09-5.26), toxicologic (2.53, 1.66-3.86), and syncope (5.97, 3.78-9.41). Nontransports were less likely for psychiatric (0.52, 0.34-0.79) complaints; for black patients compared to white (0.31, 0.26-0.37); and in patients 6 to <12 years (0.76, 0.65-0.90), 2 to <6 years (0.77, 0.65-0.91), 1 to <2 years (0.53, 0.42-0.66), and 1 month to 1 year (0.52, 0.40-0.66) compared to patients ≥ 12 years of age. Nontransport was associated with longer scene time (1.03, 1.02-1.04) and with fall compared to winter (1.29, 1.08-1.54) and was less likely in those with abnormal mental status (0.45, 0.33-0.62), medication administration (0.16, 0.08-0.31), or monitor application (0.10, 0.06-0.15). CONCLUSION Pediatric nontransports are associated with traumatic, respiratory, and toxicologic complaints and older age. These findings can facilitate development of refusal protocols and research on outcomes of these at-risk patients.
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Affiliation(s)
- Sriram Ramgopal
- Division of Pediatric Emergency Medicine Department of Pediatrics University of Pittsburgh School of Medicine Children's Hospital of Pittsburgh Pittsburgh PA
| | - Sylvia Owusu‐Ansah
- Division of Pediatric Emergency Medicine Department of Pediatrics University of Pittsburgh School of Medicine Children's Hospital of Pittsburgh Pittsburgh PA
| | - Christian Martin‐Gill
- Department of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh PA
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11
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Vloet LCM, de Kreek A, van der Linden EMC, van Spijk JJA, Theunissen VAH, van Wanrooij M, van Grunsven PM, Ebben RHA. A retrospective comparison between non-conveyed and conveyed patients in ambulance care. Scand J Trauma Resusc Emerg Med 2018; 26:91. [PMID: 30373652 PMCID: PMC6206905 DOI: 10.1186/s13049-018-0557-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 10/09/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Not all patients where an ambulance is dispatched are conveyed to an emergency department. Although non-conveyance is a substantial part of ambulance care, there is limited insight in the non-conveyance patient population. Therefore, the study aim was to compare demographics, initial on-scene reasons for care, and vital signs between conveyed and non-conveyed patients attended by an ambulance. METHODS A retrospective study of ambulance runs from 2 EMS regions in the Netherlands in 2016 was performed. For each ambulance run demographics (age, gender and geographical location), initial reasons for care categorised into the ICD-10 classification system, and vital functions or observational scales (according to the national ambulance care protocol) were collected and analyzed. RESULTS 54.797 ambulance runs met the inclusion criteria, of which 14.383/54.797 (26.2%) resulted in non-conveyance. There was no significant difference in gender, but the non-conveyance group was significantly younger (48.5 (±26.4) years) compared to the conveyance group (60.7 (±22.2) years) (p = .000). The most common initial reasons for care for the conveyance group could be classified into chapter-9 diseases of the circulatory system, chapter-19 injury, poisoning and certain other consequences of external causes, and chapter-10 diseases of the respiratory system. The most common reasons for care in the non-conveyance group could be classified into the chapter-9 diseases of the circulatory system, chapter-19 injury, poisoning and certain other consequences of external causes, and -chapter-5 mental, behavioral and neurodevelopmental disorders. The total percentage abnormal vital functions/observation scales between the conveyance (69.5%) and non-conveyance group (58.6%) was significantly different (p = .000). 15 out of 17 vital functions/observation scales are significantly different between the conveyance and non-conveyance group. CONCLUSIONS This study shows that non-conveyed patients are younger, are more likely to be in (highly) rural areas, and more often have initial reasons for care related to mental, behavioral and neurodevelopmental disorders (ICD-10 chapter 5). Although abnormal vital functions/observation scale were more prevalent in the conveyance group, 58.6% of the non-conveyed patients had at least one abnormal vital function/observation scale.
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Affiliation(s)
- Lilian C. M. Vloet
- Faculty of Health and Social Studies, Research Department of Emergency and Critical Care, HAN University of Applied Sciences, PO Box 6960, 6503 Nijmegen, GL The Netherlands
- Radboud Institute for Health Sciences IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arjan de Kreek
- Regional Emergency Medical Service Veiligheidsregio Gelderland-Midden, Arnhem, The Netherlands
| | - Emmelieke M. C. van der Linden
- Faculty of Health and Social Studies, Research Department of Emergency and Critical Care, HAN University of Applied Sciences, PO Box 6960, 6503 Nijmegen, GL The Netherlands
| | - Jori J. A. van Spijk
- Faculty of Health and Social Studies, Research Department of Emergency and Critical Care, HAN University of Applied Sciences, PO Box 6960, 6503 Nijmegen, GL The Netherlands
| | - Vince A. H. Theunissen
- Faculty of Health and Social Studies, Research Department of Emergency and Critical Care, HAN University of Applied Sciences, PO Box 6960, 6503 Nijmegen, GL The Netherlands
| | - Maud van Wanrooij
- Faculty of Health and Social Studies, Research Department of Emergency and Critical Care, HAN University of Applied Sciences, PO Box 6960, 6503 Nijmegen, GL The Netherlands
| | - Pierre M. van Grunsven
- Regional Emergency Medical Service Veiligheidsregio Gelderland-Zuid, Nijmegen, The Netherlands
| | - Remco H. A. Ebben
- Faculty of Health and Social Studies, Research Department of Emergency and Critical Care, HAN University of Applied Sciences, PO Box 6960, 6503 Nijmegen, GL The Netherlands
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A patient-safety and professional perspective on non-conveyance in ambulance care: a systematic review. Scand J Trauma Resusc Emerg Med 2017; 25:71. [PMID: 28716132 PMCID: PMC5513207 DOI: 10.1186/s13049-017-0409-6] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 06/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This systematic review aimed to describe non-conveyance in ambulance care from patient-safety and ambulance professional perspectives. The review specifically focussed at describing (1) ambulance non-conveyance rates, (2) characteristics of non-conveyed patients, (3) follow-up care after non-conveyance, (4) existing guidelines or protocols, and (5) influencing factors during the non-conveyance decision making process. METHODS We systematically searched MEDLINE, PubMed, CINAHL, EMBASE, and reference lists of included articles, in June 2016. We included all types of peer-reviewed designs on the five topics. Couples of two independent reviewers performed the selection process, the quality assessment, and data extraction. RESULTS We included 67 studies with low to moderate quality. Non-conveyance rates for general patient populations ranged from 3.7%-93.7%. Non-conveyed patients have a variety of initial complaints, common initial complaints are related to trauma and neurology. Furthermore, vulnerable patients groups as children and elderly are more represented in the non-conveyance population. Within 24 h-48 h after non-conveyance, 2.5%-6.1% of the patients have EMS representations, and 4.6-19.0% present themselves at the ED. Mortality rates vary from 0.2%-3.5% after 24 h, up to 0.3%-6.1% after 72 h. Criteria to guide non-conveyance decisions are vital signs, ingestion of drugs/alcohol, and level of consciousness. A limited amount of non-conveyance guidelines or protocols is available for general and specific patient populations. Factors influencing the non-conveyance decision are related to the professional (competencies, experience, intuition), the patient (health status, refusal, wishes and best interest), the healthcare system (access to general practitioner/other healthcare facilities/patient information), and supportive tools (online medical control, high risk card). CONCLUSIONS Non-conveyance rates for general and specific patient populations vary. Patients in the non-conveyance population present themselves with a variety of initial complaints and conditions, common initial complaints or conditions are related to trauma and neurology. After non-conveyance, a proportion of patients re-enters the emergency healthcare system within 2 days. For ambulance professionals the non-conveyance decision-making process is complex and multifactorial. Competencies needed to perform non-conveyance are marginally described, and there is a limited amount of supportive tools is available for general and specific non-conveyance populations. This may compromise patient-safety.
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Porter A, Snooks H, Youren A, Gaze S, Whitfield R, Rapport F, Woollard M. Should I stay or should I go?’ Deciding whether to go to hospital after a 999 call. J Health Serv Res Policy 2016; 12 Suppl 1:S1-32-8. [PMID: 17411505 DOI: 10.1258/135581907780318392] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objective In most UK ambulance services, crews attending someone who has phoned the emergency services on ‘999’ will take the patient to hospital, unless the patient makes the decision to stay at home (or wherever they happen to be when the ambulance arrives). Safety concerns have been raised about non-conveyance decisions. Weunder took a study of one UK Ambulance Service to examine ambulance crew members’ views on how decision-making about non-conveyance works in practice in relation to non-urgent calls. Methods A total of 25 paramedics took part in three focus groups. Focus groups were transcribed and analysed thematically. Results The ambulance service's apparently straight forward guidance on decision-making about non-conveyance proved tricky in the messiness of the real world, for two reasons. The first was to do with the notion of the patient's capacity to make decisions and how this was interpreted. The second was to do with the complexity of the decision-making process, in which the patient, the crew and, in many cases, family or carers often take part in negotiation and de facto joint decision-making. Conclusions There is a mismatch between policy and practice in relation to non-conveyance decisions. Findings should be built into research and service development in this rapidly changing field of practice in emergency and/or unscheduled care. The commonly accepted perspective on shared decision-making should be extended to include the context of ‘999’ ambulance calls.
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Affiliation(s)
- Alison Porter
- Centre for Health Information, Research & Evaluation, School of Medicine, Swansea University, Swansea SA2 8PP, UK.
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Tohira H, Fatovich D, Williams TA, Bremner AP, Arendts G, Rogers IR, Celenza A, Mountain D, Cameron P, Sprivulis P, Ahern T, Finn J. Is it Appropriate for Patients to be Discharged at the Scene by Paramedics? PREHOSP EMERG CARE 2016; 20:539-49. [DOI: 10.3109/10903127.2015.1128028] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Snooks HA, Carter B, Dale J, Foster T, Humphreys I, Logan PA, Lyons RA, Mason SM, Phillips CJ, Sanchez A, Wani M, Watkins A, Wells BE, Whitfield R, Russell IT. Support and Assessment for Fall Emergency Referrals (SAFER 1): cluster randomised trial of computerised clinical decision support for paramedics. PLoS One 2014; 9:e106436. [PMID: 25216281 PMCID: PMC4162545 DOI: 10.1371/journal.pone.0106436] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 08/05/2014] [Indexed: 11/23/2022] Open
Abstract
Objective To evaluate effectiveness, safety and cost-effectiveness of Computerised Clinical Decision Support (CCDS) for paramedics attending older people who fall. Design Cluster trial randomised by paramedic; modelling. Setting 13 ambulance stations in two UK emergency ambulance services. Participants 42 of 409 eligible paramedics, who attended 779 older patients for a reported fall. Interventions Intervention paramedics received CCDS on Tablet computers to guide patient care. Control paramedics provided care as usual. One service had already installed electronic data capture. Main Outcome Measures Effectiveness: patients referred to falls service, patient reported quality of life and satisfaction, processes of care. Safety Further emergency contacts or death within one month. Cost-Effectiveness Costs and quality of life. We used findings from published Community Falls Prevention Trial to model cost-effectiveness. Results 17 intervention paramedics used CCDS for 54 (12.4%) of 436 participants. They referred 42 (9.6%) to falls services, compared with 17 (5.0%) of 343 participants seen by 19 control paramedics [Odds ratio (OR) 2.04, 95% CI 1.12 to 3.72]. No adverse events were related to the intervention. Non-significant differences between groups included: subsequent emergency contacts (34.6% versus 29.1%; OR 1.27, 95% CI 0.93 to 1.72); quality of life (mean SF12 differences: MCS −0.74, 95% CI −2.83 to +1.28; PCS −0.13, 95% CI −1.65 to +1.39) and non-conveyance (42.0% versus 36.7%; OR 1.13, 95% CI 0.84 to 1.52). However ambulance job cycle time was 8.9 minutes longer for intervention patients (95% CI 2.3 to 15.3). Average net cost of implementing CCDS was £208 per patient with existing electronic data capture, and £308 without. Modelling estimated cost per quality-adjusted life-year at £15,000 with existing electronic data capture; and £22,200 without. Conclusions Intervention paramedics referred twice as many participants to falls services with no difference in safety. CCDS is potentially cost-effective, especially with existing electronic data capture. Trial Registration ISRCTN Register ISRCTN10538608
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Affiliation(s)
- Helen Anne Snooks
- Institute of Life Science, College of Medicine, Swansea University, Singleton Park, Swansea, United Kingdom
- * E-mail:
| | - Ben Carter
- Institute of Primary Care & Public Health, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff, United Kingdom
| | - Jeremy Dale
- Warwick Medical School, Gibbet Hill Campus, University of Warwick, Coventry, United Kingdom
| | - Theresa Foster
- East of England Ambulance Service NHS Trust, Milford Service Area, Fiveways Roundabout, Barton Mills, Suffolk, United Kingdom
| | - Ioan Humphreys
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Singleton Park, Swansea, United Kingdom
| | - Philippa Anne Logan
- Division of Rehabilitation and Ageing, School of Community Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Ronan Anthony Lyons
- Institute of Life Science, College of Medicine, Swansea University, Singleton Park, Swansea, United Kingdom
| | - Suzanne Margaret Mason
- School of Health and Related Research, Sheffield University, Regent Court, Sheffield, United Kingdom
| | - Ceri James Phillips
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Singleton Park, Swansea, United Kingdom
| | - Antonio Sanchez
- Department of Medicine, Cardiff University, Academic Building, Llandough Hospital, Penarth, United Kingdom
| | - Mushtaq Wani
- Abertawe Bro Morgannwg University Health Board, Department of Stroke Medicine, Morriston Hospital, Morriston, Swansea, United Kingdom
| | - Alan Watkins
- Institute of Life Science, College of Medicine, Swansea University, Singleton Park, Swansea, United Kingdom
| | - Bridget Elizabeth Wells
- Institute of Life Science, College of Medicine, Swansea University, Singleton Park, Swansea, United Kingdom
| | - Richard Whitfield
- Prehospital Emergency Research Unit, Welsh Ambulance Services NHS Trust, Lansdowne Hospital, Canton, Cardiff, United Kingdom
| | - Ian Trevor Russell
- Institute of Life Science, College of Medicine, Swansea University, Singleton Park, Swansea, United Kingdom
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The Utilization of Bicycles in the Delivery of Emergency Medical Services: A Preliminary Report. Prehosp Disaster Med 2012. [DOI: 10.1017/s1049023x0003750x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractIntroduction:Bicycles may be useful in the delivery of out-of-hospital emergency medical services. The use of bicycles in providing emergency medical services was investigated by surveying currently existing bicycle-medic systems.Methods:Two questionnaires were developed to gain information on service areas, injuries, gear used, missions, and specific data from bicycle-medic response.Results:Of 210 surveys mailed to bicyclemedics, 21 (10%) were completed and returned by the pre-established deadline. Of 11 surveys mailed to bicycle-medic supervisors, four (36%) were returned. Preliminary results showed that 76% of respondents are career providers and the remainder serve as volunteers. Mean age for respondents was 33±7.4 years, with 96% being males. Most teams have been in existence for three to four years. Job satisfaction was greater when participating on the bicycle crews than when not performing on the bicycle crew, t = 4.15, p = 0.0002. The teams varied in size (6–100 persons) with a mean value of 31. On the average, team size represented 10% of total number of personnel for the respective organizations.The majority of bicycle teams operate all year in all conditions. Most bicycle-medic teams were initiated for special events. Nineteen percent reported injuries while on duty or in training. Ninety percent of units that responded use existing agency protocols and have no special protocols related to the bicycle team. Eighty percent of the units are dispatched through the normal agency procedures. Eighty-five percent of respondents coordinate for transport units via dispatch. Reported response times were under two minutes for special event responses. These were within established agency response times. In approximately 25% of the responses, the patients refused transport, and another 65% of the responses were for relatively minor injuries or complaints that did not require transport to a hospital.Conclusion:This survey begins to characterize the utilization of bicycles as a tool to gain patient access in specialized situations. The use of bicycle-medics may be cost-effective, may help to improve employee morale, and possibly reduce employee health-care costs. Further study is needed to determine the impact of bicycle-medics on patient outcomes and response times.
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Snooks H, Anthony R, Chatters R, Cheung WY, Dale J, Donohoe R, Gaze S, Halter M, Koniotou M, Logan P, Lyons R, Mason S, Nicholl J, Phillips C, Phillips J, Russell I, Siriwardena AN, Wani M, Watkins A, Whitfield R, Wilson L. Support and assessment for fall emergency referrals (SAFER 2) research protocol: cluster randomised trial of the clinical and cost effectiveness of new protocols for emergency ambulance paramedics to assess and refer to appropriate community-based care. BMJ Open 2012; 2:bmjopen-2012-002169. [PMID: 23148348 PMCID: PMC3533098 DOI: 10.1136/bmjopen-2012-002169] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Emergency calls to ambulance services are frequent for older people who have fallen, but ambulance crews often leave patients at the scene without ongoing care. Evidence shows that when left at home with no further support older people often experience subsequent falls which result in injury and emergency-department attendances. SAFER 2 is an evaluation of a new clinical protocol which allows paramedics to assess and refer older people who have fallen, and do not need hospital care, to community-based falls services. In this protocol paper, we report methods and progress during trial implementation. SAFER 2 is recruiting patients through three ambulance services. A successful trial will provide robust evidence about the value of this new model of care, and enable ambulance services to use resources efficiently. DESIGN Pragmatic cluster randomised trial. METHODS AND ANALYSIS We randomly allocated 25 participating ambulance stations (clusters) in three services to intervention or control group. Intervention paramedics received training and clinical protocols for assessing and referring older people who have fallen to community-based falls services when appropriate, while control paramedics deliver care as usual. Patients are eligible for the trial if they are aged 65 or over; resident in a participating falls service catchment area; and attended by a trial paramedic following an emergency call coded as a fall without priority symptoms. The principal outcome is the rate of further emergency contacts (or death), for any cause and for falls. Secondary outcomes include further falls, health-related quality of life, 'fear of falling', patient satisfaction reported by participants through postal questionnaires at 1 and 6 months, and quality and pathways of care at the index incident. We shall compare National Health Service (NHS) and patient/carer costs between intervention and control groups and estimate quality-adjusted life years (QALYs) gained from the intervention and thus incremental cost per QALY. We shall estimate wider system effects on key-performance indicators. We shall interview 60 intervention patients, and conduct focus groups with contributing NHS staff to explore their experiences of the assessment and referral service. We shall analyse quantitative trial data by 'treatment allocated'; and qualitative data using content analysis. ETHICS AND DISSEMINATION The Research Ethics Committee for Wales gave ethical approval and each participating centre gave NHS Research and Development approval. We shall disseminate study findings through peer-reviewed publications and conference presentations. TRIAL REGISTRATION ISRCTN 60481756.
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Affiliation(s)
- Helen Snooks
- Centre for Health Information Research and Evaluation, Swansea University, Swansea, UK
| | - Rebecca Anthony
- Centre for Health Information Research and Evaluation, Swansea University, Swansea, UK
| | - Robin Chatters
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Wai-Yee Cheung
- Centre for Health Information Research and Evaluation, Swansea University, Swansea, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachael Donohoe
- Clinical Audit and Research Unit, London Ambulance Service NHS Trust, London, UK
| | - Sarah Gaze
- Centre for Health Information Research and Evaluation, Swansea University, Swansea, UK
| | - Mary Halter
- Faculty of Health and Social Services, St Georges University Hospital, London, UK
| | - Marina Koniotou
- Centre for Health Information Research and Evaluation, Swansea University, Swansea, UK
| | - Phillippa Logan
- Community Health Sciences, The University of Nottingham, Nottingham, UK
| | - Ronan Lyons
- Centre for Health Information Research and Evaluation, Swansea University, Swansea, UK
| | - Suzanne Mason
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jon Nicholl
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ceri Phillips
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea, UK
| | - Judith Phillips
- Centre for Innovative Ageing, Swansea University, Swansea, UK
| | - Ian Russell
- West Wales Organisation for Rigorous Trials in Health, College of Medicine, Swansea, UK
| | | | - Mushtaq Wani
- Department of Geriatric and Stroke Medicine, Morriston Hospital, Swansea, UK
| | - Alan Watkins
- School of Business and Economics, Swansea University, Swansea, UK
| | - Richard Whitfield
- Pre-hospital Emergency Research Unit (PERU), Welsh Ambulance Services NHS Trust, Cardiff, UK
| | - Lynsey Wilson
- Centre for Health Information Research and Evaluation, Swansea University, Swansea, UK
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Evolution of the Literature Identifying Physicians' Roles in Leadership, Clinical Development, and Practice of the Subspecialty of Emergency Medical Services. Prehosp Disaster Med 2011; 26:49-64. [DOI: 10.1017/s1049023x1000004x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPurpose: The 2007 Institute of Medicine report entitled Emergency Medical Services at the Crossroads identified a need for the establishment of physician subspecialty certification in emergency medical services (EMS). The purpose of this study was to identify and explore the evolution of publications that define the role of the physician in EMS systems in the United States.Methods: Three comprehensive searches were undertaken to identify articles that define the physician's role in the leadership, clinical development, and practice of EMS. Independent reviewers then evaluated these articles to further determine whether the articles identified the physician's role in EMS. Then, identified articles were classified by the type of publication in order to evaluate the transition from a non-peer reviewed to peer-reviewed literature base and an analysis was performed on the differences in the growth between these two groups. In addition, for the peer-reviewed articles, an analysis was performed to identify the proportion of articles that were quantitative versus qualitative in nature.Results: The comprehensive review identified 1,504 articles. Ninety articles were excluded due to lack of relevance to the US. The remaining 1,414 articles were reviewed, and 194 papers that address the physician's role within EMS systems were identified; 72 additional articles were identified by hand search of references for a total of 266 articles. The percentage of peer-reviewed articles has increased steadily over the past three decades. In addition, the percentage of quantitative articles increased from the first decade to the second and third decades.Conclusions: This comprehensive review demonstrates that over the past 30 years an evidence base addressing the role of the physician in EMS has developed. This evidence base has steadily evolved to include a greater proportion of peer-reviewed, quantitative literature.
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Mears GD, Rosamond WD, Lohmeier C, Murphy C, O'Brien E, Asimos AW, Brice JH. A link to improve stroke patient care: a successful linkage between a statewide emergency medical services data system and a stroke registry. Acad Emerg Med 2010; 17:1398-404. [PMID: 21122025 DOI: 10.1111/j.1553-2712.2010.00925.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES regionalization of stroke care, including diversion to stroke centers, requires that emergency medical services (EMS) systems accurately identify acute stroke patients. A barrier to evaluating and improving EMS stroke patient identification is the inability to link EMS data with hospital data for individual patients. We sought to create and validate a linkage of the North Carolina EMS Data System (NC-EMS-DS) with data contained in the North Carolina Stroke Care Collaborative (NCSCC) Registry. METHODS all NCSCC Registry patients arriving to one of three hospitals by EMS in a 6-month period were matched against NC-EMS-DS. Records were deterministically matched on receiving hospital, hospital arrival date/time, age, and sex. We performed linkage validation by providing each site investigator with a stroke patient list derived from North Carolina Stroke Care Collaborative Registry (NC-EMS-DS), matched by individual patient to deidentified data in the NCSCCR. Each site investigator determined the set of true matches by comparing the matched list to a NCSCCR patient identifier key maintained at each site. Incorrect matches were reviewed by the research team to identify methods for future improvement in the matching logic. RESULTS for the three validation hospitals, 753 NCSCC Registry patients arrived by EMS. For these patients, 473 (63%) matches to local EMS records were identified, and 421 (89%) of the matches were verified using full patient identifiers. Most match verification failures were due to incorrect date/time stamp and inability to find a corresponding EMS record. CONCLUSIONS linking EMS records electronically to a stroke registry is feasible and leads to a large number of valid matches. This small validation is limited by EMS data quality. Matching may improve with better EMS documentation and standardized facility documentation.
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Affiliation(s)
- Greg D Mears
- Department of Emergency Medicine, University of North Carolina School of Medicine, North Carolina, USA
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Snooks H, Cheung WY, Close J, Dale J, Gaze S, Humphreys I, Lyons R, Mason S, Merali Y, Peconi J, Phillips C, Phillips J, Roberts S, Russell I, Sánchez A, Wani M, Wells B, Whitfield R. Support and Assessment for Fall Emergency Referrals (SAFER 1) trial protocol. Computerised on-scene decision support for emergency ambulance staff to assess and plan care for older people who have fallen: evaluation of costs and benefits using a pragmatic cluster randomised trial. BMC Emerg Med 2010; 10:2. [PMID: 20102616 PMCID: PMC2824628 DOI: 10.1186/1471-227x-10-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 01/26/2010] [Indexed: 11/21/2022] Open
Abstract
Background Many emergency ambulance calls are for older people who have fallen. As half of them are left at home, a community-based response may often be more appropriate than hospital attendance. The SAFER 1 trial will assess the costs and benefits of a new healthcare technology - hand-held computers with computerised clinical decision support (CCDS) software - to help paramedics decide who needs hospital attendance, and who can be safely left at home with referral to community falls services. Methods/Design Pragmatic cluster randomised trial with a qualitative component. We shall allocate 72 paramedics ('clusters') at random between receiving the intervention and a control group delivering care as usual, of whom we expect 60 to complete the trial. Patients are eligible if they are aged 65 or older, live in the study area but not in residential care, and are attended by a study paramedic following an emergency call for a fall. Seven to 10 days after the index fall we shall offer patients the opportunity to opt out of further follow up. Continuing participants will receive questionnaires after one and 6 months, and we shall monitor their routine clinical data for 6 months. We shall interview 20 of these patients in depth. We shall conduct focus groups or semi-structured interviews with paramedics and other stakeholders. The primary outcome is the interval to the first subsequent reported fall (or death). We shall analyse this and other measures of outcome, process and cost by 'intention to treat'. We shall analyse qualitative data thematically. Discussion Since the SAFER 1 trial received funding in August 2006, implementation has come to terms with ambulance service reorganisation and a new national electronic patient record in England. In response to these hurdles the research team has adapted the research design, including aspects of the intervention, to meet the needs of the ambulance services. In conclusion this complex emergency care trial will provide rigorous evidence on the clinical and cost effectiveness of CCDS for paramedics in the care of older people who have fallen. Trial Registration ISRCTN10538608
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Affiliation(s)
- Helen Snooks
- Centre for Health Information Research and Evaluation, Swansea University, Swansea UK.
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Brown LH, Hubble MW, Cone DC, Millin MG, Schwartz B, Patterson PD, Greenberg B, Richards ME. Paramedic determinations of medical necessity: a meta-analysis. PREHOSP EMERG CARE 2010; 13:516-27. [PMID: 19731166 DOI: 10.1080/10903120903144809] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Reducing unnecessary ambulance transports may have operational and economic benefits for emergency medical services (EMS) agencies and receiving emergency departments. However, no consensus exists on the ability of paramedics to accurately and safely identify patients who do not require ambulance transport. Objective. This systematic review and meta-analysis evaluated studies reporting U.S. paramedics' ability to determine medical necessity of ambulance transport. METHODS PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library databases were searched using Cochrane Prehospital and Emergency Care Field search terms combined with the Medical Subject Headings (MeSH) terms "triage"; "utilization review"; "health services misuse"; "severity of illness index," and "trauma severity indices." Two reviewers independently evaluated each title to identify relevant studies; each abstract then underwent independent review to identify studies requiring full appraisal. Inclusion criteria were original research; emergency responses; determinations of medical necessity by U.S. paramedics; and a reference standard comparison. The primary outcome measure of interest was the negative predictive value (NPV) of paramedic determinations. For studies reporting sufficient data, agreement between paramedic and reference standard determinations was measured using kappa; sensitivity, specificity, and positive predictive value (PPV) were also calculated. RESULTS From 9,752 identified titles, 214 abstracts were evaluated, with 61 studies selected for full review. Five studies met the inclusion criteria (interrater reliability, kappa = 0.75). Reference standards included physician opinion (n = 3), hospital admission (n = 1), and a composite of physician opinion and patient clinical circumstances (n = 1). The NPV ranged from 0.610 to 0.997. Results lacked homogeneity across studies; meta-analysis using a random-effects model produced an aggregate NPV of 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported complete 2 x 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823. CONCLUSION The results of the few studies evaluating U.S. paramedic determinations of medical necessity for ambulance transport vary considerably, and only two studies report complete data. The aggregate NPV of the paramedic determinations is 0.91, with a lower confidence limit of 0.71. These data do not support the practice of paramedics' determining whether patients require ambulance transport. These findings have implications for EMS systems, emergency departments, and third-party payers.
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Affiliation(s)
- Lawrence H Brown
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA.
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22
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Abstract
The objective of this study was to determine the rate of major omissions from documentation in a prehospital environment. Analysis of 251 competitor records, documented over 2 years from four consecutive UK outdoor endurance events (2006-2007), was performed. Eighty-two percent of case notes were found to be of adequate quality (n = 206), with 15% containing minor omissions (n = 37, i.e. omissions of some patient details) and 3% containing major omissions (n = 8, i.e. no details of diagnosis/treatment). Of the major omissions, first aiders and health-care professionals (doctors and nurses) made the same number of errors (n = 4 each, P = 0.7), but first aiders made significantly more minor omissions (n = 31 vs. 6, P<0.001). From 25 patients who needed medication, only one prescription error occured. In conclusion, accurate documentation is achievable at prehospital mass gathering events. First aiders made no more major documentation omissions than health-care professionals, but made more minor omissions. Standardized proformas may help reduce this rate and improve efficiency.
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Shah MN, Bazarian JJ, Mattingly AM, Davis EA, Schneider SM. Patients with head injuries refusing emergency medical services transport. Brain Inj 2009; 18:765-73. [PMID: 15204317 DOI: 10.1080/02699050410001671801] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PRIMARY OBJECTIVE To characterize patients with head injury who refuse emergency medical services (EMS) transport to an emergency department (ED). To identify predictors of patients with head injury who refuse EMS transport. RESEARCH DESIGN Retrospective chart review. METHODS Patients with a head injury cared for by EMS during 2001 were identified. Medical records were abstracted for demographic and clinical information and reasons for refusing transport. Patients accepting transport were compared to those refusing. Reasons for refusing transport were described. RESULTS Three hundred and thirty-three patients with head injuries were identified. Sixteen per cent refused EMS transport. Patients refusing transport were more likely to be male, younger and victims of assault and less likely to have lost consciousness. Patients refusing transport often felt they did not need care or could obtain care later. CONCLUSIONS Patients with head injuries frequently refuse EMS transportation. Individuals accepting care differ significantly from those refusing care. Sufficient awareness of the risk of head injury seems to be lacking among patients.
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Affiliation(s)
- Manish N Shah
- University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA.
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Brice JH, Friend KD, Delbridge TR. Accuracy of EMS-Recorded Patient Demographic Data. PREHOSP EMERG CARE 2009; 12:187-91. [DOI: 10.1080/10903120801907687] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kahalé J, Osmond MH, Nesbitt L, Stiell IG. What Are the Characteristics andOutcomes of Nontransported Pediatric Patients? PREHOSP EMERG CARE 2009; 10:28-34. [PMID: 16418088 DOI: 10.1080/10903120500373322] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The authors have demonstrated that 28% of children cared for by paramedics are not transported to hospital by ambulance. OBJECTIVE To determine the characteristics, reasons, and outcomes for this nontransported population. METHODS This was a prospective cohort study in a single city with a two-tiered emergency medical services system. Enrolled were all children aged < 16 years assessed by paramedics but not transported to hospital over a five-month period. Data were collected from ambulance call reports, phone interviews, and hospital charts. Descriptive statistics were used. RESULTS Over five months, there were 345 nontransported pediatric patients with a mean age of 6 years, and 58.3% were male. The dispatch priority was urgent in 68.1% of cases and prompt in 30.4% of cases. The primary problems were almost evenly split between trauma (50.7%) and medical (45.2%) causes. Paramedics listed the following reasons for nontransport: parent will take the child to a physician (27.8%), parent will monitor the child's condition (25.8%), and no reason documented (46.4%). Phone interview was conducted with 106 parents (30.7%): 76.4% believed there was a true emergency at the time of the 9-1-1 call, 75.5% stated that the paramedics did not recommend that the child be transported to hospital by ambulance, and 29.2% stated that the paramedics said ambulance transport was not necessary. Fifty-one children were seen in an emergency department (ED) within 48 hours of the 9-1-1 call. The majority (91.3%) were discharged home from the ED, while a small minority (8.7%) were admitted to hospital. No deaths were reported. CONCLUSIONS Most nontransported children did not require immediate or urgent medical care. Both parents and paramedics gave input into the nontransport decision, and the short-term outcome of this population appeared to be good. Paramedic documentation for the reasons for nontransport should be improved.
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Affiliation(s)
- Justin Kahalé
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Cone DC, Galante N, MacMillan DS, Perez MM, Parwani V. Is There a Role for First Responders in EMS Responses to Medical Facilities? PREHOSP EMERG CARE 2009; 11:14-8. [PMID: 17169870 DOI: 10.1080/10903120601023453] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Emergency medical dispatch (EMD) protocols should match response resources with patient needs. We tested a protocol sending only a commercial ambulance, without fire department first responders (FR), to all non-cardiac-arrest EMS calls at a physician-staffed HMO facility. Study objectives were to determine how often FR provided patient care at such facilities and whether EMD implementation could conserve FR resources without compromising patient care. METHODS All EMS dispatches to this facility in the 4 months before implementation of the EMD protocol and 4 months after implementation were identified through dispatch records, and all FR and ambulance patient care reports were reviewed. In the "after" phase, all cases needing ALS transport were reviewed to examine whether there would have been benefit to FR dispatch. RESULTS Of 242 dispatches in the "before" phase, BLS FR responded to 156 (64%), and ALS FR to 117 (48%). BLS FR provided patient care in 2 cases, and ALS FR in 17. Of 227 dispatches in the "after" phase, BLS FR responded to 10 (4%), and ALS FR to 10 (4%); all but one were protocol violations. BLS FR provided care in one case, and ALS FR in three. Review of the 93 "after" cases requiring ALS transport found none where FR presence would have been beneficial. CONCLUSIONS First responders rarely provided patient care when responding to EMS calls at a physician-staffed medical facility. Implementation of an EMD protocol can safely reduce the number of FR responses to unscheduled ambulance calls at such a facility.
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Affiliation(s)
- David C Cone
- Division of EMS, Section of Emergency Medicine, School of Medicine, Yale University, and Department of Emergency Medicine, Hospital of St. Raphael, New Haven, Connecticut 06519, USA.
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Haines CJ, Lutes RE, Blaser M, Christopher NC. Paramedic initiated non-transport of pediatric patients. PREHOSP EMERG CARE 2006; 10:213-9. [PMID: 16531379 DOI: 10.1080/10903120500541308] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION In a time of emergency department overcrowding and increased utilization of emergency medical services, a highly functional prehospital system will balance the needs of the individual patient with the global needs of the community. Our community addressed these issues through the development of a multitiered prehospital care system that incorporated EMS initiated non-transport of pediatric patients. OBJECTIVE To describe the outcome of pediatric patients accessing a progressive prehospital system that employed EMS initiated non-transport. METHODS A prospective observational case series was performed on pediatric patients (< 21 years old) designated EMS initiated non-transport. Patients were designated non-transport after an initial EMS protocol driven, complaint-specific clinical assessment in conjunction with medical oversight affirmation. Telephone follow-up was completed on all consecutively enrolled non-transport patients to collect information about outcome (safety) as well as overall satisfaction with the system. A five-point Likert scale was utilized to rate satisfaction. RESULTS There were 5,336 EMS requests during the study period. Seven hundred and four were designated non-transport, of which 74.8% completed phone follow-up. Categories of EMS request included minor; medical illness 43.4%, trauma 55.9%, and other 1.1%. There were 13 admissions (2.4%) to the hospital after EMS initiated non-transport designation. Admissions after non-transport had trends toward younger age (p = 0.002) and medical etiology (p = 0.006). There were no PICU admissions or deaths. CONCLUSION Our EMS system provides an alternative to traditional protocols, allowing EMS initiated non-transport of pediatric patients, resulting in effective resource utilization with a high level of patient safety and family satisfaction.
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Affiliation(s)
- Christopher J Haines
- Department of Emergency Medicine, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania 19134-1095, USA.
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Pringle RP, Carden DL, Xiao F, Graham DD. Outcomes of patients not transported after calling 911. J Emerg Med 2005; 28:449-54. [PMID: 15837028 DOI: 10.1016/j.jemermed.2004.11.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2004] [Revised: 10/15/2004] [Accepted: 11/29/2004] [Indexed: 11/24/2022]
Abstract
To compare the outcomes of patients who were denied transport by emergency medical services (EMS) with those who refused to be transported, all EMS non-transports were reviewed to determine who refused the transport and adherence to mandatory transport guidelines. Patients were contacted for telephone survey. Of 906 non-transported patients, 310 consented to the survey. Of these, 205 were patient refusals and 105 were EMS refusals. There was no significant difference between the patient and EMS refusal groups in reported change in medical care, hospitalization, or death. One hundred ten non-transported patients met mandatory transport criteria (85 patient refusals vs. 25 EMS refusals, p = 0.002). In conclusion, patient non-transport may result in adverse outcomes that are as likely to occur in patients who are denied transport by EMS as those who refuse to be transported. Patients who refuse transport are more likely to meet mandatory transport guidelines.
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Affiliation(s)
- Robert P Pringle
- Department of Emergency Medicine, University of Louisville, Louisville, Kentucky, USA
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Riley J, Burgess R, Schwartz B. Evaluating the impact of an educational intervention on documentation of decision-making capacity in an emergency medical services system. Acad Emerg Med 2004; 11:790-3. [PMID: 15231474 DOI: 10.1197/j.aem.2004.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To compare the documentation of decision-making capacity by advanced life support (ALS) providers and signature acquisition before, one month after, and one year after an educational intervention. METHODS The intervention comprised a one-and-a-half-hour module on assessment and documentation of decision-making capacity. Ambulance call reports were reviewed for all ALS calls occurring during three two-month periods, and refusals of transport were recorded. Provider compliance with documentation of decision-making capacity and signature acquisition were determined from a convenience sample of 75 reports from each period. Reviewers were blinded to study period. Twenty-percent double data entry was undertaken to evaluate accuracy. Ninety-five percent confidence intervals were calculated to compare frequencies of cancelled calls and documentation. RESULTS From the emergency medical services database, 7,744 calls before the intervention, 7,444 immediately after, and 7,604 one year later were identified. Documentation rates in the second and third periods did not differ from that prior to the intervention (1.3% vs. 0.0% and 0.0% in subsequent periods), nor did the rates of signature acquisition differ (85.3% vs. 85.3% and 78.6%). The accuracy of data entry was 92.6%. However, the frequency of call refusals decreased significantly after the intervention (from 9.0% to 2.0% and 6.6% in the respective periods). CONCLUSIONS An educational intervention resulted in no change in the rate of decision-making capacity documentation or signature acquisition by ALS providers for refusal of transport. There was a temporary increase in the number of transported patients.
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Affiliation(s)
- Jennifer Riley
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Lerner EB, Billittier AJ, Lance DR, Janicke DM, Teuscher JA. Can paramedics safely treat and discharge hypoglycemic patients in the field? Am J Emerg Med 2003; 21:115-20. [PMID: 12671811 DOI: 10.1053/ajem.2003.50014] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
To determine whether paramedics can safely treat and discharge insulin-dependent diabetic patients experiencing uncomplicated hypoglycemic events, we conducted a prospective, observational study with a convenience sample of diabetic patients whose hypoglycemia resolved after intravenous administration of dextrose and before they were transported by paramedics. On-line medical control was contacted to obtain approval and informed consent for participation from interested patients who met all eligibility criteria for the study. Participating patients were given instructions upon discharge from the study and were contacted by telephone 24 hours later to ascertain their medical outcomes and their opinions of the study protocol. We enrolled a total of 36 patients with 38 incidents of hypoglycemia. Of these, 91% reported no complications after discharge. Two patients developed recurrent hypoglycemia but treated themselves and did not require further emergency care. One further patient was found unresponsive on the morning following discharge and was subsequently admitted to a long-term care facility with hypoglycemic encephalopathy. Of the study participants, 85% were very satisfied with not being transported to an emergency department (ED) and 91% were very satisfied with the care they had received. All (100%) of the patients surveyed favored a permanent protocol allowing discharge of hypoglycemic patients without admission to an ED. We conclude that paramedics successfully treated, without complication, most of the patients with uncomplicated hypoglycemic events who were examined in our study. These patients generally preferred discharge without transportation to an ED.
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Affiliation(s)
- E Brooke Lerner
- Department of Emergency Medicine, School of Medicine and Biomedical Science, State University of New York at Buffalo, NY, USA.
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Snooks H, Williams S, Crouch R, Foster T, Hartley-Sharpe C, Dale J. NHS emergency response to 999 calls: alternatives for cases that are neither life threatening nor serious. BMJ 2002; 325:330-3. [PMID: 12169513 PMCID: PMC1123835 DOI: 10.1136/bmj.325.7359.330] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Helen Snooks
- Centre for Postgraduate Studies, Swansea Clinical School, University of Wales, Swansea SA2 8PP.
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Garrison HG, Maio RF, Spaite DW, Desmond JS, Gregor MA, O'Malley PJ, Stiell IG, Cayten CG, Chew JL, Mackenzie EJ, Miller DR. Emergency Medical Services Outcomes Project III (EMSOP III): the role of risk adjustment in out-of-hospital outcomes research. Ann Emerg Med 2002; 40:79-88. [PMID: 12085077 DOI: 10.1067/mem.2002.124758] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The purpose of the Emergency Medical Services Outcomes Project (EMSOP) is to develop a foundation and framework for out-of-hospital outcomes research. Fundamental to that purpose is the identification of priority conditions, risk-adjustment measures (RAMs), and outcome measures. In this third EMSOP article, we examine the topic of risk adjustment, discuss the relevance of risk adjustment for out-of-hospital outcomes research, and recommend RAMs that should be evaluated for potential use in emergency medical services (EMS) research. Risk adjustment allows better judgment about the effectiveness and quality of alternative therapies; it fosters a better comparison of potentially dissimilar groups of patients. By measuring RAMs, researchers account for an important source of variation in their studies. Core RAMs are those measures that might be necessary for out-of-hospital outcomes research involving any EMS condition. Potential core RAMs that should be evaluated for their feasibility, validity, and utility in out-of-hospital research include patient age and sex, race and ethnicity, vital signs, level of responsiveness, Glasgow Coma Scale, standardized time intervals, and EMS provider impression of the presenting condition. Potential core RAMs that could be obtained through linkage to other data sources and that should be evaluated for their feasibility, validity, and utility include principal diagnosis and patient comorbidity. We recommend that these potential core RAMs be systematically evaluated for use in risk adjustment of out-of-hospital patient groups that might be used for outcomes research
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Affiliation(s)
- Herbert G Garrison
- Department of Emergency Medicine, The Brody School of Medicine at East Carolina University, Greenville, NC 27858-4354, USA.
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Gerlacher GR, Sirbaugh PE, Macias CG. Prehospital evaluation of non-transported pediatric patients by a large emergency medical services system. Pediatr Emerg Care 2001; 17:421-4. [PMID: 11753185 DOI: 10.1097/00006565-200112000-00005] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES 1) To determine whether demographic characteristics of prehospital pediatric patients evaluated, but not transported, by emergency medical services (EMS) personnel were different than those of transported patients in a large metropolitan area, 2) to determine whether chart documentation for non-transported (NT) patients by EMS personnel varied among paramedic and ambulance units, and 3) to describe the most common complaints of pediatric non-transported patients. METHODS We conducted a cross-sectional study of children 12 years of age and less who were evaluated, but not transported, by EMS personnel over a 1-year period. We incorporated a nested case control study, comparing the demographic and presenting characteristics of the NT and transported children (eg, age, gender, ethnicity, and time of day). Among NT patients, significant elements of chart documentation as completed by personnel on paramedic versus ambulance units were compared. Chief complaints of the NT children were described. RESULTS During the study period, 3057 patients met inclusion criteria for cases, and 12,302 met the criteria for controls. Non-transport was less common in the first two years of life, among Hispanic patients, and during the hours of midnight to 6 am. Among NT patients, personnel of paramedic units had significantly better documentation of contact with on-line medical command (OLMC) (52% vs. 33%) than did personnel of ambulance units. Injuries (27.7%), motor vehicle accidents (20.4%), and choking episodes (10.2%) were the most common complaints among NT patients. CONCLUSIONS In this large metropolitan population, non-transport was less common in children under 2 years of age and during the early morning hours. Hispanic children were more likely to be transported. Ambulance units were significantly less likely than paramedic units to document contact with OLMC. Injuries were the most common complaints of pediatric NT patients.
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Affiliation(s)
- G R Gerlacher
- Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas 77030-2399, USA.
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Mechem CC, Barger J, Shofer FS, Dickinson ET. Short-term outcome of seizure patients who refuse transport after out-of-hospital evaluation. Acad Emerg Med 2001; 8:231-6. [PMID: 11229944 DOI: 10.1111/j.1553-2712.2001.tb01298.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the short-term outcome of patients with a known seizure disorder who have a seizure, are evaluated by out-of-hospital care providers, and refuse transport. METHODS This was a prospective study conducted over a 15-month period. Philadelphia Fire Department paramedics contacted a medical command physician whenever they encountered a patient with a known seizure disorder who had had another seizure and was refusing transport. After confirming that the patient had the mental capacity to refuse care and understood the associated risks, the physician recorded the patient's name, address, and telephone number. Beginning three days later, a registered nurse attempted to reach the patient by telephone and administer a brief questionnaire about his or her medical outcome. Patients not reached by telephone were sent a certified letter. The names of patients lost to follow-up were compared with medical examiner records to confirm that they had not died during the follow-up period. RESULTS Of 63 patients enrolled in the study, 52 (82.5%) were reached in follow-up. Of these, three (5.8%) had another seizure within 72 hours and recontacted 911. One of these patients (1.9%) was hospitalized. Twenty (38.5%) patients contacted their primary care physicians. There were no deaths, including patients lost to follow-up. CONCLUSIONS Most patients (94.2%) who were evaluated by out-of-hospital care providers for a seizure and refused transport had no further seizure activity in the subsequent 72 hours. However, because there is a risk of recurrence, out-of-hospital care providers and medical command physicians should ensure that patients understand the risks of refusal.
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Affiliation(s)
- C C Mechem
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4283, USA.
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Schmidt T, Atcheson R, Federiuk C, Mann NC, Pinney T, Fuller D, Colbry K. Evaluation of protocols allowing emergency medical technicians to determine need for treatment and transport. Acad Emerg Med 2000; 7:663-9. [PMID: 10905645 DOI: 10.1111/j.1553-2712.2000.tb02041.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine whether emergency medical technicians (EMTs) can safely apply protocols to assign transport options and to assess agreement between groups of providers on application of the protocols. METHODS Developed protocols categorized patients as: 1) needs ambulance; 2) go to the emergency department (ED) by alternative means; 3) contact primary care provider (PCP); or 4) treat and release. After education on the application of the protocols, first responders and ambulance EMTs categorized patients at the scene prior to transport but did not change current practice. Ambulance reports were reviewed using a predetermined list of critical events that signified the need for an ambulance. RESULTS The EMTs categorized 1,300 study patients as follows: 1,023 (79%) needed ambulance transport, 200 (15%) could go to the ED by alternative means, 63 (5%) could contact a PCP, 14 (1%) could be treated and released. Categorizations by a first responder and the transporting EMT were compared for 209 patients. Collapsing categories to "need ambulance/do not need ambulance" showed fair concordance (kappa = 0.51). Initially, 30 of 277 (11%) patients determined not to need an ambulance appeared to experience a critical event. After review, 23 patients had events that may not warrant advanced life support transport. Seven (3%) had critical events in the ambulance warranting ambulance transport. Most were miscategorized by the EMT. Overall sensitivity and specificity for identifying patients needing ambulance transport were 94.5% and 32.8%, respectively. CONCLUSIONS From 3% to 11% of patients determined on scene not to need an ambulance had a critical event. Emergency medical services systems need to determine an acceptable rate of undertriage. Further study is needed to determine whether better adherence to the protocols might increase safety.
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Affiliation(s)
- T Schmidt
- Oregon Health Sciences University, School of Medicine, Department of Emergency Medicine, Portland 97201-3098, USA.
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Socransky SJ, Pirrallo RG, Rubin JM. Out-of-hospital treatment of hypoglycemia: refusal of transport and patient outcome. Acad Emerg Med 1998; 5:1080-5. [PMID: 9835470 DOI: 10.1111/j.1553-2712.1998.tb02666.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Patient refusal of transport after treatment of hypoglycemia is common in urban emergency medical services (EMS) systems. The rate of relapse is unknown. The goal of this study was to compare the outcomes of diabetic patients initially refusing transport (refusers) and those transported to an ED. METHODS All paramedic runs from January to July 1995 were retrospectively reviewed. Inclusion criteria were adult patients with a field assessment of hypoglycemic signs/symptoms, and a fingerstick glucose <80 mg/dL. Data for analysis included paramedic run duration, patient demographics, and refusal or acceptance of transport. Patient outcome was obtained from a review of hospital and medical examiner records. Relapse was defined as hypoglycemia necessitating EMS activation or an ED visit within 48 hours of the initial episode. Student's t-test and chi2 analysis were used to compare means and rates, respectively. RESULTS Over the 7 months, 374 patients made 571 calls to 9-1-1 that met inclusion criteria (5.2% of all paramedic runs). Of these, 412 were refusers (72.2%) and 159 were transported patients (27.8%). The hospital records of 4 transported patients were unavailable. Sixty-three transported patients were admitted (11.2%), with 1 death from prolonged hypoglycemia. The rates of relapse did not differ between the refusers and the transported patients (p > 0.05). Twenty-five relapses occurred among the refusers (6.1%), with 14 repeat refusals, 11 transports, 5 admissions, and no deaths. There were 7 relapses among the transported patients (4.4%), with 2 refusals, 5 transports, 2 admissions, and no deaths. The paramedic run time was significantly shorter for the refusers than for the transported patients (p < 0.05). CONCLUSIONS The out-of-hospital treatment of hypoglycemic diabetic patients appears to be effective and efficient. Independent of the patient's refusal or acceptance of transport, the out-of-hospital treatment of hypoglycemic patients in this system appears to be safe.
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Affiliation(s)
- S J Socransky
- Department of Emergency Medicine, Sudbury Regional Hospital, ON, Canada
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Mechem CC, Kreshak AA, Barger J, Shofer FS. The short-term outcome of hypoglycemic diabetic patients who refuse ambulance transport after out-of-hospital therapy. Acad Emerg Med 1998; 5:768-72. [PMID: 9715237 DOI: 10.1111/j.1553-2712.1998.tb02502.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the short-term medical outcome of hypoglycemic insulin-dependent diabetic patients who refuse transport after out-of-hospital therapy and return to baseline mental status. METHODS Prospective, descriptive, short-term medical outcome data for adult patients were collected between May 1996 and December 1996. Paramedics responding to the aid of hypoglycemic insulin-dependent diabetic patients who refused transport after administration of dextrose solution (D50W) contacted a medical command physician at the University of Pennsylvania. The patients' medical histories, names, addresses, and telephone numbers were recorded. Three days after their hypoglycemic episodes, these patients were contacted by telephone by a registered nurse to determine their medical conditions. RESULTS Of 132 patients enrolled in the study, 103 (78%) could be contacted by telephone follow-up. Ninety-four (91%) of these patients had no recurrence of symptoms. Nine patients (9%) had recurrence of hypoglycemia and recontacted 911. Eight of these (8%) were transported to a hospital via ambulance and 3 (3%) were admitted, 1 (1%) for a cancer-related illness and 2 (2%) for hypoglycemia, 1 of whom died (1%). The remaining patient refused transport a second time after being treated, despite having the risks of refusal explained to him by a medical command physician. CONCLUSIONS The practice of treating and releasing most hypoglycemic insulin-dependent diabetic patients who return to normal mental status after D50W administration appears in general to be safe. Patients should be advised of the risks of recurrent hypoglycemia.
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Affiliation(s)
- C C Mechem
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia 19104, USA.
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Schmidt TA, Mann NC, Federiuk CS, Atcheson RR, Fuller D, Christie MJ. Do patients refusing transport remember descriptions of risks after initial advanced life support assessment? Acad Emerg Med 1998; 5:796-801. [PMID: 9715241 DOI: 10.1111/j.1553-2712.1998.tb02506.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine patient recall and understanding of instructions given to patients who refuse transport after initial paramedic assessment and medical treatment. METHODS Following patient consent, a phone interview was completed for consecutive persons living in a large urban area for whom 9-1-1 was contacted but who subsequently refused transport after advanced life support (ALS) assessment. Subjects were asked about their recall of explained risks and benefits of transport, their understanding of those risks at the time of assessment, and subsequent use of medical care, including hospitalization. RESULTS From October 1, 1996, to February 23, 1997, 324 people refused transport after ALS arrival. Sixty-eight people could not be contacted, providing a response rate of 79% (256/324). Six percent were subsequently admitted to the hospital for the same problem and an additional 59% sought care from a health care provider (66 ED visits, 63 personal physician, 16 urgent care, 5 other). There were no unexpected deaths. Ninety (35%) respondents were still experiencing symptoms at the time of phone contact. Despite the routine practice of providing a verbal explanation of risks and written instructions, only 141 (55%) recalled receiving written instructions and 56 (22%) recalled an explanation of risks. Twenty-six percent believed they did not fully understand their conditions or circumstances surrounding the 9-1-1 call when they refused transport and 18% would now take an ambulance if the same incident were to recur. CONCLUSION A substantial proportion of patients refusing transport do not recall receiving verbal or written instructions and would reconsider their transport decision, raising doubts about people's ability to make informed decisions at a time of great vulnerability. The majority of patients accessed health care after refusing transport and 6% were hospitalized.
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Affiliation(s)
- T A Schmidt
- Department of Emergency Medicine, Oregon Health Sciences University, School of Medicine, Portland 97201, USA.
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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. [PMID: 9472189 DOI: 10.1016/s0196-0644(98)70315-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE To describe the incidence and demographic data of prehospital patients who contact paramedics by way of the 911 system, refuse transport against medical advice (AMA), then call 911 and are subsequently reevaluated by paramedics in the following 48 hours. METHODS We conducted a retrospective observational review of records using the San Diego County Quality Assurance Network database for prehospital providers. All paramedic 911 responses that made base hospital contact over a 3-month period were reviewed to identify patients who signed out AMA. The main outcome measure was to identify patients who signed out AMA and then called 911 again within 48 hours. The demographics, complaints, treatments, and dispositions of these patients are described. RESULTS Of 6,512 total 911 responses reviewed, 443 (7%) involved patients who signed out AMA. Of these patients, 156 cases (35.2%) were listed as trauma and 287 (64.8%) were medical, with cardiac chest pain, seizure, and respiratory distress/shortness of breath the most frequently noted medical subcategories. Fifty-one (11.5%) such patients received treatment; 34 received dextrose, 12 naloxone, 4 albuterol, and 1 a splint. Patient names were available in 5,515, of the total 6,512 responses and 431 of the 443 AMA cases, permitting computer searching of reevaluations by paramedics. Of the 431 AMA patients for whom a name was available, 10 (2%) called 911 again within 48 hours. All 10 callbacks were made for a related chief compliant, and all 10 of these patients were transported (4 admitted to hospital, 1 died en route, 1 transferred to another facility, 4 discharged from the ED). Of these 10 patients, 7 (70%) were older than 65 years, compared with 17% of all AMA patients older than 65 years. CONCLUSION On the basis of our findings, patients over the age of 65 years have a propensity to recontact paramedics and should be aggressively encouraged to seek emergency medical treatment. Future prospective studies should be mounted to examine at patient outcome and to assess why patients sign out AMA after making contact with paramedics.
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Affiliation(s)
- S T Moss
- Department of Emergency Medicine University of California, San Diego, Medical Center 92103, USA
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Burstein JL, Hollander JE, Delagi R, Gold M, Henry MC, Alicandro JM. Refusal of out-of-hospital medical care: effect of medical-control physician assertiveness on transport rate. Acad Emerg Med 1998; 5:4-8. [PMID: 9444335 DOI: 10.1111/j.1553-2712.1998.tb02566.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Previous studies have shown that contacting an on-line medical-control physician increases the transport rate of patients who attempt to refuse medical assistance. The authors studied the physician-patient interaction to determine the type of interaction that was more likely to result in patient transport. METHODS A prospective, observational study of patient-initiated refusals of medical assistance (RMAs) was performed in a suburban volunteer emergency medical services (EMS) system, with 12 receiving hospitals county-wide. Medical-control contact was required for all patient-initiated RMAs. Consecutive patients who attempted out-of-hospital RMA over a 3-month period were monitored. Structured data instruments were completed by the medical-control operator and medical-control physician for all patients who attempted RMA. Data collected included patient demographics and contact information, scene characteristics, history and physical examination data, length of time of interaction, and the physician's assessment of the need for transport and the patient's capacity to refuse transport. The operator and physician independently graded the physician's assertiveness in talking to the patient on a continuous 10-point scale. RESULTS There were 130 patients who attempted RMA; 69 (53%) refused transport even after discussion with the medical-control physician, while 61 (47%) were transported to a hospital. The patients who were transported did not differ from those not transported with respect to age, chief complaint, vital signs, or presence of police on scene. Using the operators' independent assessments, the physicians were more assertive when they graded the patient as being more ill (needs transport, 8.8; may need transport, 7.7; doesn't need transport, 4.1; p < 0.01). When the physicians were more assertive, the patients were more likely to agree to transport (assertiveness > 8, 81% transport; assertiveness < 8, 19% transport; p < 0.01). CONCLUSIONS Contact with a medical-control physician appears to markedly improve the transport rate for patients who initially attempt to refuse out-of-hospital medical care. This is especially so when physicians are more assertive in recommending transport.
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Affiliation(s)
- J L Burstein
- University Medical Center, State University of New York at Stony Brook, Stony Brook, NY, USA
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Burstein JL, Henry MC, Alicandro J, Gentile D, Thode HC, Hollander JE. Outcome of patients who refused out-of-hospital medical assistance. Am J Emerg Med 1996; 14:23-6. [PMID: 8630149 DOI: 10.1016/s0735-6757(96)90007-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Activation of the emergency medical services (EMS) system does not always result in transport of a patient to the hospital. This study assessed the outcomes of patients who refused medical assistance in the field, to determine if refusal of medical assistance (RMA) is associated with poor outcomes. Four high-volume suburban volunteer ambulance corps participated in the study. Consecutive patients who refused medical assistance were prospectively enrolled. Medical and identifying data were collected for each patient. Telephone follow-up was conducted to determine the patient's condition and if the patient sought further care after RMA. Primary endpoints were whether the patient sought further care, was admitted to a hospital, or died subsequent to RMA. Follow-up was successfully obtained for 199 of 321 patients enrolled (62%). Of these 199 patients, 95 (48%) sought further medical care within 1 week for the same complaint, with 13 being admitted to the hospital. Six of the 13 admitted patients had chief complaints of a cardiac or respiratory nature. One patient died during hospital admission. Even if none of the patients lost to follow-up had sought further care, a substantial number of patients who refuse out-of-hospital medical assistance seek further care. Some of these patients require hospital admission, especially those with cardiac or respiratory complaints. Efforts to minimize RMA should be especially focused on patients with such complaints.
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Affiliation(s)
- J L Burstein
- Department of Emergency Medicine, University Medical Center, State University of New York, Stony Brook 11794-7400, USA
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Editorial Comment. Prehosp Disaster Med 1995. [DOI: 10.1017/s1049023x0005202x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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