Evidence-based paramedic models of care to reduce unnecessary emergency department attendance--feasibility and safety

BACKGROUND

As demand for Emergency Department (ED) services continues to exceed increases explained by population growth, strategies to reduce ED presentations are being explored. The concept of ambulance paramedics providing an alternative model of care to the current default 'see and transport to ED' has intuitive appeal and has been implemented in several locations around the world. The premise is that for certain non-critically ill patients, the Extended Care Paramedic (ECP) can either 'see and treat' or 'see and refer' to another primary or community care practitioner, rather than transport to hospital. However, there has been little rigorous investigation of which types of patients can be safely identified and managed in the community, or the impact of ECPs on ED attendance.

METHODS/DESIGN

St John Ambulance Western Australia paramedics will indicate on the electronic patient care record (e-PCR) of patients attended in the Perth metropolitan area if they consider them to be suitable to be managed in the community. 'Follow-up' will examine these patients using ED data to determine the patient's disposition from the ED. A clinical panel will then develop a protocol to identify those patients who can be safely managed in the community. Paramedics will then assess patients against the derived ECP protocols and identify those deemed suitable to 'see and treat' or 'see and refer'. The ED disposition (and other clinical outcomes) of these 'ECP protocol identified' patients will enable us to assess whether it would have been appropriate to manage these patients in the community. We will also 'track' re-presentations to EDs within seven days of the initial presentation. This is a 'virtual experiment' with no direct involvement of patients or changes in clinical practice. A systems modelling approach will be used to assess the likely impact on ED crowding.

DISCUSSION

To date the efficacy, cost-effectiveness and safety of alternative community-based models of emergency care have not been rigorously investigated. This study will inform the development of ECP protocols through the identification of types of patient presentation that can be considered both safe and appropriate for paramedics to manage in the community.

Does a standardised scoring system of clinical signs reduce variability between doctors' assessments of the potentially dehydrated child?

AIMS

Clinical assessment of dehydration in children is often inaccurate. We aimed to determine if a scoring system based on standardised clinical signs would reduce the variability between doctors' assessment of dehydration.

METHODS

A clinical scoring system was developed using seven physiological variables based on previously published research. Estimated percentage dehydration and severity scores were recorded for 100 children presenting to a Paediatric Emergency Department with symptoms of gastroenteritis and dehydration by three doctors of different seniority (resident medical officer, registrar and consultant). Agreement was measured using intra-class correlation coefficient (ICC) for percentage ratings and total clinical scores and kappa for individual characteristics.

RESULTS

Estimated percentage dehydration ranged from 0-9%, mean 2.96%, across the three groups. Total clinical scores from 0-10, mean 2.20. There was moderate agreement amongst clinicians for the percentage dehydration (ICC 0.40). The level of agreement on the clinical scoring system was identical (ICC 0.40). Consultants gave statistically lower scores than the other two groups (Consultant (Con) vs. Resident P = 0.001, Con vs. Registrar P = 0.013). There was a marked difference in agreement across characteristics comprising the scoring system, from kappa 0.02 for capillary refill time to 0.42 for neurological status.

CONCLUSION

The clinical scoring system used did not reduce the variability of assessment of dehydration compared to doctors' conventional methods. In order to reduce variability improving education may be more important than production of a scoring system as experience appears to be a key determinant in the assessment of a potentially dehydrated child.

Too long in the tooth: a descriptive study of adults presenting to a pediatric emergency department

OBJECTIVE

To describe the demographics, presenting complaints, diagnoses, and disposition of adults presenting to an Australian pediatric emergency department. It was hypothesized that most patients would be younger than 20 years, with low acuity complaints predominantly related to minor injuries resulting in a low admission rate.

METHODS

A prospective cohort of new adult patients (age, > or = 16 years) were recruited. Baseline data was recorded for all eligible patients. Consenting patients had provisional diagnoses recorded along with disposition decisions. Patients' records were reviewed at the referral destination to establish the final diagnoses and the admission rate.

RESULTS

Forty-eight patients (0.6% of all presentations) presented during the study period. The median age was 17.5 years (interquartile range, 16.3-26.1 years). Thirty-four patients (70.8%) were younger than 20 years (P = 0.003). Seven (14.6%) patients had an Australasian Triage Scale score of 2, and 19 (39.6%) had a score of 3. Injury-related complaints formed the largest proportion of presentations (mean, 37.5%; range, 23.8%-51.2%). Thirty-one patients were enrolled in the study. Twenty (mean, 48.8%; range, 33.5%-64.1%) of the provisional diagnoses in this group were injury-related. Twenty-nine patients (mean, 93.5%; range, 84.9%-100%) were advised to seek further medical attention. Injuries comprised the largest group of final diagnoses (mean, 55.2%; range, 37.1%-73.3%). Five patients (mean, 16.1%; range, 3.2%-29%) were admitted.

CONCLUSIONS

Adult presentations were not infrequent. Twenty patients (41.7%) were within 1 year of the age cutoff at Princess Margaret Hospital. Although 45.8% of presentations had a low acuity, the majority of patients had Australasian Triage Scale scores of 2 or 3. The presentations were heterogeneous in nature, with injuries accounting for a large proportion. Most patients were referred for further care, but a minority were not compliant with follow-up instructions. There was a low admission rate.

Intranasal fentanyl is an equivalent analgesic to oral morphine in paediatric burns patients for dressing changes: a randomised double blind crossover study

INTRODUCTION

The ideal analgesic agent for burns wound dressings in paediatric patients would be one that is easy to administer, well tolerated, and produces rapid onset of analgesia with a short duration of action and minimal side-effects to allow rapid resumption of activities and oral intake. We compared our current treatment of oral morphine to intranasal fentanyl in an attempt to find an agent closer to the ideal.

METHODS

A randomised double blind two-treatment crossover study comparing intranasal administration of fentanyl (INF) to orally administered morphine (OM). Children with burn injury aged up to 15 years and weighing 10-75 kg were included. Primary end-point was pain scores. Secondary end-points were time to resumption of age-appropriate activities, time to resumption of fluid intake, sedation and cooperation. Routine observations and vital signs were also recorded.

RESULTS

Twenty-four patients were studied with a median age of 4.5 years (interquartile range 1.8-9.0 years) and a median weight of 18.4 kg (interquartile range 12.9-33.2kg). Mean pain difference scores (OM-INF) ranged from -0.500 (95% CI=-1.653 to 0.653) at baseline to -0.625 (05% CI=-1.863 to 0.613) for a retrospective rating of worst pain experienced during the dressing procedure. All measurements were within a pre-defined range of equivalent efficacy. The median time to resumption of fluid intake was 108 min (range 44-175 min) with OM and 140 min (range 60-210 min) with INF. These differences were not statistically significant. Fewer patients experienced mild side-effects with INF compared to OM (n=5 versus n=10). No patients experienced depressed respirations or oxygen saturations.

SUMMARY

Intranasal fentanyl was shown to be equivalent to oral morphine in the provision of analgesia for burn wound dressing changes in this cohort of paediatric patients. It was concluded that intranasal fentanyl is a suitable analgesic agent for use in paediatric burns dressing changes either by itself or in combination with oral morphine as a top up titratable agent.

Intranasal fentanyl reduces acute pain in children in the emergency department: a safety and efficacy study

INTRODUCTION

Provision of rapid, painless and effective analgesia to children remains problematic in the prehospital and emergency setting. Intranasal fentanyl has the potential to eliminate many of the problems of narcotic administration in children. The aim of this study, conducted in a tertiary paediatric emergency department was to evaluate the safety and efficacy of intranasal fentanyl in children.

METHODS

Children in acute pain aged between three and 12 years inclusive were enrolled on presentation to the emergency department. Routine observations and pain scoring by the child and caregiver was undertaken prior to the child receiving fentanyl (20 micrograms for 3-7 year olds and 40 micrograms for 8-12 year olds) and at intervals of 5 min for 30 min Additional fentanyl at the dose of 20 micrograms was given 5 minutely as required. Caregivers and older children used a visual analogue scale (VAS) and the younger children used the Wong-Baker faces scale (WBS).

RESULTS

Forty five children were enrolled with a mean age of 8.0 years. The median dose of fentanyl administered was 1.5 micrograms/kg. Mean pain score in 32 children using the VAS was 62.3 mm (95% confidence interval 53.2-69.4 mm) at presentation and reduced at 10 min to 44.6 mm (95% confidence interval 36.2-53.1 mm). In 16 children using WBS the initial mean reading was 4.0 (95% confidence interval 3.3-4.7) and reduced to 2.2 (95% confidence interval 1.3-3.1) at 10 min. Caregiver pain scores showed a mean preintervention pain score of 64.9 mm (95% confidence interval 57.7-72.2 mm) with a significant reduction at 10 min to 41.7 mm (95% confidence interval 34.7-48.6 mm). There was no significant alteration in pulse rate, respiratory rate, and blood pressure or oxygen saturations. There were no negative side-effects.

CONCLUSIONS

Early and significant reduction in pain (compared to baseline assessments) was achieved in children using intranasal fentanyl by 10 min and sustained throughout the 30 min of observations. This raises the possibility of using intranasal fentanyl in children in the prehospital setting as well as a role for this form of analgesia as triage nurse-initiated administration in the emergency department.

Options in prehospital analgesia

BACKGROUND

Prehospital analgesia options for paramedics have been limited due to the difficulty in achieving safe and effective pain relief without compromising transportation to hospital. The present paper identifies the analgesia methods currently available in the prehospital setting so as to evaluate the various options and highlight areas for future research.

METHODS

A literature review of Medline and Embase databases from 1966 until the present was undertaken. Further hand searching of all the references identified in these papers was also performed. All current literature was analysed and categorized according to one of four levels of evidence using National Health and Medical Research Council of Australia guidelines (1999).

RESULTS

There is a paucity of randomized control trials relating to prehospital analgesia. All published literature was level III or IV prospective or retrospective studies. Drug options used included nitrous oxide/oxygen mixtures, intravenous/intramuscular nalbuphine, intravenous tramadol and intravenous pure opiate agonists.

CONCLUSIONS

The evidence supporting analgesic options in the prehospital setting is limited. There are few published data in this area despite the inadequacy of pain relief being recognized as a weakness in prehospital care. Prehospital analgesia is an area worthy of innovative methods for the administration of safe and effective analgesics without significant impact on transport times. Such methods should be prospectively evaluated in well-constructed trials.

Injury and illness in a wilderness multisport endurance event

Our objective was to identify patterns of injury and illness and develop possible preventive strategies for competitors in a wilderness multisport endurance event. Using a prospective observational cohort study during the Winter Classic, a 2-day wilderness multisport endurance event held in rugged alpine terrain in Victoria, Australia, we sought details of demographics, pre-, intra-, and postrace injuries and illness. We employed chi-squared tests and iterative multivariate analysis. There were 33 respondents with 26 (78%) aged between 26 and 35 years. Seven (21%) developed symptoms consistent with exposure, and three (9%) developed asthma during the race. Competitors in the marathon pairs class had a 50% risk of exposure vs 12% for the individual class (p = 0.031). The number of times raced, nonsteroidal anti-inflammatory drug use, and increasing age were the other independent significant predictors of exposure. Twenty-three (70%) of the competitors were injured at some time during the race. The day 1 run was more commonly associated with injuries than other stages (39% injured, p = 0.0037). Increased amounts of training, previous musculoskeletal problems, and increased number of previous race attempts were all significant independent predictors of injury. Most competitors (67%) suffered musculoskeletal problems after the race, these typically being of the thighs and calves, but only two competitors required time off from their normal activities. We concluded that injuries in wilderness multisport endurance events are common, particularly in the run stages. These injuries are usually minor, but their frequency makes major injury an ever-present risk. Both injury and illness are more frequent in those who compete while carrying injuries. These events are high risk for the development of injuries and illness and require a high level of competitor preparation and readily available medical support.