Can paramedics using guidelines accurately triage patients?

doi:10.1067/mem.2001.117198

Annals of Emergency Medicine

Volume 38, Issue 3, September 2001, Pages 268-277

Presented at the Society for Academic Emergency Medicine annual meeting, San Francisco, CA, May 2000.

https://doi.org/10.1067/mem.2001.117198 Get rights and content

Abstract

Study Objective: We determine whether paramedics, using written guidelines, can accurately triage patients in the field. Methods: This prospective, descriptive study was conducted at an urban county emergency medical services (EMS) system and county hospital. Paramedics triaged patients, for study purposes only, according to 4 categories: (1) needing to come to the emergency department by advanced life support (ALS) transport, (2) needing to come to the ED by any transport, (3) needing to see a physician within 24 hours, or (4) not needing any further physician evaluation. Medical records that provided patient treatment information to the point of ED disposition were subsequently reviewed (blinded to the paramedic rating) to determine which of the categories was appropriate. The protocol of the EMS system of the study site dictates that all patients should be transported except for those who refuse care and leave against medical advice. Only transported patients were included in the present study. Fifty-four paramedics triaged 1,180 patients. Results: Mean patient age was 43.4±17 years; 62.0% were male. Paramedics rated 1,000 (84.7%) of the patients as needing to come to the ED and 180 (15.3%) as not needing to come to the ED. Ratings according to triage category were as follows: 804 (68.1%) category 1, 196 (16.6%) category 2, 148 (12.5%) category 3, and 32 (2.7%) category 4. Seven hundred thirty-six (62.4%) patients were discharged, 298 (25.3%) were admitted, 90 (7.6%) were transferred, 36 (3.1%) left against medical advice, and 20 (1.7%) died. The review panel determined that 113 (9.6%) patients were undertriaged; 55 (48.7%) of these patients were misclassified because the paramedics misused the guidelines. Ninety-nine patients (8.4% of the total sample) were incorrectly classified as not needing to come to the ED. This represented 55% of the patients (99/180) categorized as 3 or 4 by the paramedics. Fourteen patients (1.2% of total) were incorrectly classified as category 4 instead of 3. Of the 113 undertriaged patients, 22 (19.6%) were admitted, 86 (76.1%) were discharged, and 4 (3.5%) were transferred. Conclusion: Paramedics using written guidelines fall short of an acceptable level of triage accuracy to determine disposition of patients in the field. [Pointer JE, Levitt MA, Young JC, Promes SB, Messana BJ, Adèr MEJ. Can paramedics using guidelines accurately triage patients? Ann Emerg Med. September 2001;38:268-277.]

Introduction

The National Highway Traffic Safety Administration has called for emergency medical services (EMS) to increasingly become the intersection of public safety, public health, and health care.¹ EMS systems are undergoing profound operational changes. An increasing number of emergency medical dispatch (EMD) centers subscribe to organized certification and provide prearrival instructions and priority dispatch. Several systems are using or are proposing nonemergency triage (NET) centers. These NET centers provide information and an assessment to a patient who has been “triaged out” of the 911 system. Managed care organizations are continually seeking approaches to make out-of-hospital care more cost-effective.²

These operational decisions often depend on the ability of field personnel to make at least some triage decisions. In the future, if EMS systems choose to implement protocols in which patients would either be transported to a nonemergency venue, or not be transported at all, paramedics might be required to make patient triage decisions. Several investigators have compared out-of-hospital personnel's triage decisions with those made by scoring systems.3, 4 Several other studies have compared paramedics' emergency department triage decisions with those made by emergency physicians after an initial examination and before final disposition.5, 6 This study is the first to compare paramedics' triage decisions with those made by an emergency physician review panel after a completed ED evaluation. This study tests the hypothesis that paramedics can use written guidelines to accurately and safely triage patients in the field.

Section snippets

Materials and methods

The study center is a county teaching hospital with 64,000 ED visits annually and serves as a base hospital for the county EMS system. Patients for whom the 911 system was activated, and who were subsequently transported to the study center by a paramedic participating in the study, were entered into the research database. The all–advanced life support (ALS) county EMS system receives approximately 98,000 calls per year, of which approximately 20,000 are nontransports. The large majority of the

Results

The study was conducted over a 6-month period from July 1998 to January 1999. A total of 1,180 patient transports were studied. The mean age for the patient study population was 43.4±17 years (range 2 to 96 years). The gender distribution was 62.0% (732) male. Racial distribution was 58.8% (694) black, 17.8% (210) white, 12.5% (147) Hispanic/Latino, 5.8% (69) Asian, and 5.1% (60) other.

Patients were categorized by the physician panel into 1 of 5 mutually exclusive presenting complaint groups.

Discussion

The “science” of triage has been discussed by many authors and in many contexts.7, 8 Some form of triage is used in nearly every hospital ED. Increasingly, triage is an important mechanism in the out-of-hospital arena. Although some degree of paramedic judgment in triage decisions has been a component of EMS for many years (routing patients to specialty hospitals, selective use of basic life support [BLS] protocols for patients transported by ALS vehicles), triage has become even more important

Acknowledgements

Author contributions: JEP, JCY, MAL, and MEJA conceived and designed the study. JCY, MAL, and MEJA supervised and participated in the collection of data. JEP, JCY, and BJM recruited and trained the paramedics. MAL and JCY analyzed the data and MAL provided statistical advice. JEP, SBP, and BJM served as physician evaluators. JEP, MAL, and JCY prepared the manuscript. JEP, JCY, MAL, SBP, and BJM contributed substantially to its revision. JEP takes overall responsibility for the paper.

We thank

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^☆: Author contributions are provided at the end of this article.

^☆☆: Address for reprints: James E. Pointer, MD, Alameda County Emergency Medical Services Agency, 1000 Broadway, Suite 5024, Oakland, CA 94607; 510-267-3242,fax 510-465-5624; E-mail [email protected].

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Emergency Medical ServicesCan paramedics using guidelines accurately triage patients?☆,☆☆

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Comput Biol Med

Ann Emerg Med

Air Med J

Ann Emerg Med

A comparison of EMT judgment and prehospital trauma triage instruments

J Trauma

Emergency Medical Services
Can paramedics using guidelines accurately triage patients?☆,☆☆