Original contribution
How well do paramedics predict admission to the hospital? A prospective study

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Abstract

A study was designed to determine whether paramedics accurately predict which patients will require admission to the hospital, and in those requiring admission, whether they will need a ward bed or intensive care unit (ICU) monitoring. This prospective, cross-sectional study of consecutive Emergency Medical Service (EMS) transport patients was conducted at an urban city hospital. Paramedics were asked to predict if the patient they were transporting would require admission to the hospital, and if so, whether that patient would be admitted to a ward bed or require an ICU bed. Predictions were compared to actual patient disposition. During the study period, 1349 patients were transported to our hospital. Questionnaires were submitted in 985 cases (73%) and complete data were available for 952 (97%) of these patients. Paramedics predicted 202 (22%) patients would be admitted to the hospital, of whom 124 (61%) would go the ward and 78 (39%) would require intensive care. The actual overall admission rate was 21%, although the sensitivity of predicting any admission was 62% with a positive prediction value (PPV) of 59%. Further, the paramedics were able to predict admission to intensive care with a sensitivity of 68% and PPV of 50%. It is concluded that paramedics have very limited ability to predict whether transported patients require admission and the level of required care. In our EMS system, the prehospital diversion policies should not be based solely on paramedic determination.

Introduction

The nationwide problem of Emergency Department (ED) and hospital overcrowding has brought the practice of ambulance diversion to the forefront. Diversion has grown increasingly complex and many hospitals now have numerous different categories of diversion, such as ED, intensive care unit (ICU), trauma, obstetric, pediatric ICU, ward, and psychiatric diversions. In order for a particular type of diversion category to be effectively acted upon, an implied assumption is made that when a hospital declares a diversion, the prehospital caregiver is able to accurately triage patients and predict the need for admission and level of care.

Several studies have evaluated the role of prehospital providers in Emergency Medical Services (EMS) systems and the ability of paramedics to determine clinical diagnosis and prognosis (1). Some investigators have found EMS providers to be accurate in their ability to triage patients, whereas others have found accuracy rates to be unacceptable (2, 3, 4, 5, 6, 7, 8, 9). A number of publications have raised the question of whether paramedics can safely predict if a patient needs transport at all (4, 10, 11). If field personnel are able to accurately predict which patients will require admission, and particularly the need for intensive care, specific EMS diversion categories may be possible.

The purpose of this study was to determine whether paramedics can accurately determine which patients will require admission to the hospital, and in those who are admitted, whether they will require admission to a ward bed or an ICU.

Section snippets

Methods

Denver Health Medical Center (DHMC) is an urban county hospital and level I trauma center that accepts both medical and trauma EMS transports. The annual ED census at DHMC is approximately 55,000. The overall admission rate from the ED is approximately 18% and, of those, approximately 25% are admitted to the operating room (OR) or ICU. The Denver Health and Hospital Authority is the agency contracted to provide 911 emergency medical service to the City and County of Denver using a two-tier

Results

According to computer-assisted dispatch records, 1349 patients were transported to DHMC during the 1-month study period. This accounted for 55% of all EMS transports performed in the City and County of Denver by the Paramedic Division during the same time period. Research forms were completed on 985 patients (73%) and complete data were available for 952 (97%) of these. Of the 952 patients, 533 (56%) were men and 847 (89%) were over the age of 17 years. Twenty patients (2%) who were triaged

Discussion

The problem of ED overcrowding is well documented (12, 13, 14, 15). One result of overcrowding is for hospitals to declare a diversion status in an effort to direct patients being transported by ambulance to other hospitals. This places a greater burden on EMS crews to determine which patients are appropriate for particular or specific hospitals. Some categories of hospital diversion appear straight forward (ED divert) whereas others are less well defined (ICU, ward, psychiatry, CT, etc.).

Conclusion

Based on our investigation, paramedics have limited ability to predict whether transported patients need admission to the hospital and, more specifically, whether they require intensive care or ward admission. This has important implications about the limitations of diversion strategies that rely on paramedic prediction, and whether prehospital diversion policies should be based on paramedic determination. Further work to develop, assess and utilize hospital diversion guidelines and categories

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Original Contributions is coordinated by John Marx, md, of Carolinas Medical Center, Charlotte, North Carolina

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