Original contributionHow well do paramedics predict admission to the hospital? A prospective study
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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Cited by (66)
Clinician and Caregiver Determinations of Acuity for Children Transported by Emergency Medical Services: A Prospective Observational Study
2023, Annals of Emergency MedicineCitation Excerpt :The National Association of EMS Physicians has noted a paucity of peer-reviewed literature showing that EMS clinicians can reliably determine the necessity for emergency transportation.3 Furthermore, most previous studies have been restricted to adult patients, used an inadequate reference standard (such as physician opinion or hospital admission), or focused on predicting patients with critical care needs.8–20 The only study measuring the accuracy of paramedic determinations of medical necessity in children compared paramedic accuracy to a base station physician, whose assessment was based only on the EMS report.21
Provider-in-triage prediction of hospital admission after brief patient interaction
2021, American Journal of Emergency MedicineCitation Excerpt :Other studies have shown similar results for physicians' prediction accuracy [16]. Many studies evaluating prediction have been limited by the evaluation only of specific study patient populations - evaluating only pediatric, psychiatric or elderly patients or excluding patients with specific complaints such as chest pain [17-21]. In recent years, EDs have utilized a provider-in-triage (PIT) model in which providers (physicians or advanced practice providers) work in triage and place various orders to help facilitate patient throughput.
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2019, American Journal of Emergency MedicineParamedic determination of appropriate emergency department destination
2019, American Journal of Emergency MedicineCitation Excerpt :Previous studies evaluating paramedic medical decision-making have yielded equivocal results. Some studies have demonstrated paramedics are able to accurately triage patients [14-18], while others have found their triage accuracy to be unacceptable [19-23]. Several studies have found that paramedics were unable to determine whether a patient needs transport at all [19, 21, 24].
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Original Contributions is coordinated by John Marx, md, of Carolinas Medical Center, Charlotte, North Carolina