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Herr D, Bhatia S, Breuer F, Poloczek S, Pommerenke C, Dahmen J. Increasing emergency number utilisation is not driven by low-acuity calls: an observational study of 1.5 million emergency calls (2018-2021) from Berlin. BMC Med 2023; 21:184. [PMID: 37193989 DOI: 10.1186/s12916-023-02879-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/24/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND The Emergency Medical Service (EMS) in Germany is increasingly challenged by strongly rising demand. Speculations about a greater utilisation for minor cases have led to intensive media coverage, but empirical evidence is lacking. We investigated the development of low-acuity calls from 2018 to 2021 in the federal state of Berlin and its correlations with sociodemographic characteristics. METHODS We analysed over 1.5 million call documentations including medical dispatch codes, age, location and time using descriptive and inferential statistics and multivariate binary logistic regression. We defined a code list to classify low-acuity calls and merged the dataset with sociodemographic indicators and data on population density. RESULTS The number of emergency calls (phone number 112 in Germany) increased by 9.1% from 2018 to 2021; however, the proportion of low-acuity calls did not increase. The regression model shows higher odds of low-acuity for young to medium age groups (especially for age 0-9, OR 1.50 [95% CI 1.45-1.55]; age 10-19, OR 1.77 [95% CI 1.71-1.83]; age 20-29, OR 1.64 [95% CI 1.59-1.68] and age 30-39, OR 1.40 [95% CI 1.37-1.44]; p < 0.001, reference group 80-89) and for females (OR 1.12 [95% CI 1.1-1.13], p < 0.001). Odds were slightly higher for calls from a neighbourhood with lower social status (OR 1.01 per index unit increase [95% CI 1.0-1.01], p < 0.05) and at the weekend (OR 1.02 [95% CI 1.0-1.04, p < 0.05]). No significant association of the call volume with population density was detected. CONCLUSIONS This analysis provides valuable new insights into pre-hospital emergency care. Low-acuity calls were not the primary driver of increased EMS utilisation in Berlin. Younger age is the strongest predictor for low-acuity calls in the model. The association with female gender is significant, while socially deprived neighbourhoods play a minor role. No statistically significant differences in call volume between densely and less densely populated regions were detected. The results can inform the EMS in future resource planning.
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Affiliation(s)
- David Herr
- Faculty of Medicine, School of Public Health, Imperial College London, South Kensington Campus, London, SW7 2 AZ, UK.
| | - Sangeeta Bhatia
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Jameel Institute, Imperial College London, London, UK
| | - Florian Breuer
- Emergency Medical Services Director, Rhine-Berg District, Office for Fire Protection and Emergency Medical Service, Bergisch Gladbach, Germany
| | - Stefan Poloczek
- Office of the Medical Director, Emergency Medical Services, Berlin, Germany
| | | | - Janosch Dahmen
- Faculty of Health, Department of Medicine, Witten/Herdecke University, Witten, Germany
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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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Carrigan S, Goldstein J, Carter A, Asada Y, Travers A. The Prevalence and Characteristics of Non-Transports in a Provincial Emergency Medical Services System: A Population-Based Study. J Emerg Med 2022; 62:534-544. [PMID: 35131130 DOI: 10.1016/j.jemermed.2021.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 11/08/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Emergency Medical Services (EMS) provide patients with out-of-hospital care, but not all patients are transported to the hospital. Non-transport represents an often undefined yet potentially significant risk for poor clinical outcomes. Few North American studies have quantified this risk. OBJECTIVE The objectives of this study were to determine the prevalence of non-transport and 48-h adverse event (composite of relapse responses that resulted in transport or death) and to identify characteristics associated with either outcome. METHODS An analysis of pooled cross-sectional, population-based administrative data from the provincial EMS electronic charting system in 2014 was conducted. Determination of non-transport was based on recorded call outcome. The data were searched by patient identifiers to determine the 48-h adverse event rate. Paramedic-documented patient, operational, and environmental characteristics were included in the logistic regression models. RESULTS Of 74,293 emergency responses, 14,072 (18.9%) were non-transport and, of those, 798 (5.6%) resulted in a 48-h adverse event. The characteristics statistically significantly and independently associated with non-transport and 48-h adverse event were younger age (odds ratio [OR] 1.72; 99.9% confidence interval [CI] 1.46-2.02), nonspecific paramedic clinical impression (OR 5; 99.9% CI 4.48-5.57), more than 7 comorbidities (OR 0.47; 99.9% CI 0.42-0.53), and incident location (jail) (OR 2.88; 99.9% CI 2.22-3.74). CONCLUSIONS This study provides an estimate of prevalence of non-transports and 48-h adverse event in a provincial mixed rural-urban EMS system. The results of this study describe the scope of non-transport and present several characteristics associated with non-transport. Future study should examine the appropriateness of EMS responses and methods to mitigate risk of adverse event after non-transport.
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Affiliation(s)
| | - Judah Goldstein
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada; Division of Emergency Medical Services, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Emergency Health Services, Nova Scotia, Canada
| | - Alix Carter
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada; Division of Emergency Medical Services, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Emergency Health Services, Nova Scotia, Canada
| | - Yukiko Asada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Andrew Travers
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada; Division of Emergency Medical Services, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Emergency Health Services, Nova Scotia, Canada
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Magnusson C, Herlitz J, Axelsson C. Patient characteristics, triage utilisation, level of care, and outcomes in an unselected adult patient population seen by the emergency medical services: a prospective observational study. BMC Emerg Med 2020; 20:7. [PMID: 32000684 PMCID: PMC6993445 DOI: 10.1186/s12873-020-0302-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 01/10/2020] [Indexed: 11/25/2022] Open
Abstract
Background Crowding in the emergency department (ED) is a safety concern, and pathways to bypass the ED have been introduced to reduce the time to definitive care. Conversely, a number of low-acuity patients in the ED could be assessed by the emergency medical services (EMS) as requiring a lower level of care. The limited access to primary care in Sweden leaves the EMS nurse to either assess the patient as requiring the ED or to stay at the scene. This study aimed to assess patient characteristics and evaluate the initial assessment by and utilisation of the ambulance triage system and the appropriateness of non-transport decisions. Methods A prospective observational study including 6712 patients aged ≥16 years was conducted. The patient records with 72 h of follow-up for non-transported patients were reviewed. Outcomes of death, time-critical conditions, complications within 48 h and final hospital assessment were evaluated. The Mann-Whitney U test, Fisher’s exact test, and Spearman’s rank correlation were used for statistical analysis. Results The median patient age was 66 years, and the most common medical history was a circulatory diagnosis. Males received a higher priority from dispatchers and were more frequently assessed at the scene as requiring hospital care. A total of 1312 patients (19.7%) were non-transported; a history of psychiatric disorders or no medical history was more commonly noted among these patients. Twelve (0.9%) of the 1312 patients not transported were later admitted with time-critical conditions. Full triage was applied in 77.4% of the cases, and older patients were triaged at the scene as an ‘unspecific condition’ more frequently than younger patients. Overall, the 30-day mortality was 4.1% (n = 274). Conclusions Age, sex, medical history, and presentation all appear to influence the initial assessment. A number of patients transported to ED could be managed at a lower level of care. A small proportion of the non-transported patients were later diagnosed with a time-critical condition, warranting improved assessment tools at the scene and education of the personnel focusing on the elderly population. These results may be useful in addressing resource allocation issues aiming at increasing patient safety.
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Affiliation(s)
- Carl Magnusson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Johan Herlitz
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Pre Hospen-Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Christer Axelsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Pre Hospen-Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
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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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Poryo M, Burger M, Wagenpfeil S, Ziegler B, Sauer H, Flotats-Bastardas M, Grundmann U, Zemlin M, Meyer S. Assessment of Inadequate Use of Pediatric Emergency Medical Transport Services: The Pediatric Emergency and Ambulance Critical Evaluation (PEACE) Study. Front Pediatr 2019; 7:442. [PMID: 31709211 PMCID: PMC6823188 DOI: 10.3389/fped.2019.00442] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 10/10/2019] [Indexed: 11/13/2022] Open
Abstract
Aim: To provide data on the inadequate use of emergency medical transports services (EMTS) in children and underlying contributing factors. Methods: This was a prospective single-center cohort study (01/2017-12/2017) performed at the Saarland University Children's Hospital, Homburg, Germany. Patients ≤20 years of age transported by EMTS for suspected acute illness/trauma were included and proportion of inadequate/adequate EMTS use, underlying contributing factors, and additional costs were analyzed. Results: Three hundred seventy-nine patients (mean age: 9.0 ± 6.3 years; 55.7% male, 44.3% female) were included in this study. The three most common reasons for EMTS use were: central nervous system (30.6%), respiratory system affection (14.0%), and traumas (13.2%). ETMS use was categorized as inadequate depending on physician's experience: senior physician (58.8%), pediatrician (54.9%), resident (52.7%). All three physicians considered 127 (33.5%) cases to be medically indicated for transportation by EMTS, and 177 (46.7%) to be medically not indicated. The following parameters were significantly associated with inadequate EMTS use: non-acute onset of symptoms (OR 2.5), parental perception as non-life-threatening (OR 1.7), and subsequent out-patient treatment (OR 4.0). Conversely, transport by an emergency physician (OR 3.5) and first time parental EMTS call (OR 1.7) were associated with adequate use of EMTS. Moreover, a significant relation existed between maternal, respectively, paternal educational status and inadequate EMTS use (each p = 0.01). Using multiple logistic regression analysis, non-acute onset of symptoms (OR 2.2) was associated with inadequate use of EMTS while first time parental EMTS call (OR 1.8), transport by an emergency physician (OR 3.3), and need for in-patient treatment (OR 4.0) were associated with adequate use of EMTS. Conclusion: A substantial number of pediatric EMTS is medically not indicated. Possibly, specific measures including multifaceted educational efforts may be helpful in reducing unnecessary EMTS use.
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Affiliation(s)
- Martin Poryo
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg, Germany
| | - Martin Burger
- Medical School, University of Saarland, Homburg, Germany
| | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University Medical Center, Homburg, Germany
| | | | - Harald Sauer
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg, Germany
| | | | - Ulrich Grundmann
- Department of Anesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center, Homburg, Germany
| | - Michael Zemlin
- Department of Pediatrics and Neonatology, Saarland University Medical Center, Homburg, Germany
| | - Sascha Meyer
- Department of Pediatrics and Neonatology, Saarland University Medical Center, Homburg, Germany
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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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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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Pekanoja S, Hoikka M, Kyngäs H, Elo S. Non-transport emergency medical service missions - a retrospective study based on medical charts. Acta Anaesthesiol Scand 2018; 62:701-708. [PMID: 29363100 DOI: 10.1111/aas.13071] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 12/16/2017] [Accepted: 12/27/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND In Finland, approximately 40% of emergency medical service (EMS) missions do not result in transport of the patient to a hospital by ambulance, and there is wide variability in the reasons underlying non-transport decisions. The aim of this study was to describe the context of these EMS non-transport missions. METHODS The data were collected retrospectively between 3 September and 20 October 2014 by investigating non-transport EMS charts (n = 1154). Event information and patients' main symptoms were extracted from information found in EMS charts and quantified using content and statistical analyses. RESULTS Patients' need for EMS were explained by various reasons. One-third of the missions were caused by organ-specific symptoms, whereas in 30.8% of cases the reason for EMS was unspecified. Sudden onset symptoms were noted for 38.4% of the cases, whereas in 14.7% of cases the symptoms had persisted for days or weeks before EMS contact. EMS personnel offered guidance instead of treatment in 79.2% of the missions. CONCLUSIONS Non-transport missions represent a significant daily work load for the EMS. Although most of the symptoms showed acute onset, the majority of these missions involved only assessment of medical necessity and/or guidance without any medical treatment. It is questionable whether this use of the EMS is cost-effective for any healthcare system.
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Affiliation(s)
- S. Pekanoja
- Research Unit of Nursing Science and Health Management; University of Oulu; Oulu Finland
| | - M. Hoikka
- Division of Intensive Care; Department of Anaesthesiology; Medical Research Centre; Research Unit of Surgery, Anaesthesia and Intensive Care; Oulu University Hospital; University of Oulu; Oulu Finland
| | - H. Kyngäs
- Research Unit of Nursing Science and Health Management; Medical Research Centre; Oulu University Hospital; University of Oulu; Oulu Finland
| | - S. Elo
- Research Unit of Nursing Science and Health Management; Medical Research Centre; Oulu University Hospital; University of Oulu; Oulu Finland
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11
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Abstract
Sporer KA . 911 patient redirection. Prehosp Disaster Med. 2017;32(6):589-592.
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12
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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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Abstract
OBJECTIVE The goal of this search was to review the current literature regarding paramedic triage of primary care patients and the safety of paramedic-initiated non-transport of non-urgent patients. METHODS A narrative literature review was conducted using the Medline (Medline Industries, Inc.; Mundelein, Illinois USA) database and a manual search of Google Scholar (Google; Mountain View, California USA). RESULTS Only 11 studies were found investigating paramedic triage and safety of non-transport of non-urgent patients. It was found that triage agreement between paramedic and emergency department staff generally is poor and that paramedics are limited in their abilities to predict the ultimate admission location of their patients. However, these triage decisions and admission predictions are much more accurate when the patient's condition is the result of trauma and when the patient requires critical care services. Furthermore, the literature provides very limited support for the safety of paramedic triage in the refusal of non-urgent patient transport, especially without physician oversight. Though many non-transported patients are satisfied with the quality of non-urgent treatment that they receive from paramedics, the rates of under-triage and subsequent hospitalization reported in the literature are too high to suggest that this practice can be adopted widely. CONCLUSION There is insufficient evidence to suggest that non-urgent patients can safely be refused transport based on paramedic triage alone. Further attempts to implement paramedic-initiated non-transport of non-urgent patients should be approached with careful triage protocol development, paramedic training, and pilot studies. Future primary research and systematic reviews also are required to build on the currently limited literature. Fraess-Phillips AJ . Can paramedics safely refuse transport of non-urgent patients? Prehosp Disaster Med. 2016;31(6):667-674.
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Lehm KK, Andersen MS, Riddervold IS. Non-urgent Emergency Callers: Characteristics and Prognosis. PREHOSP EMERG CARE 2016; 21:166-173. [PMID: 27629892 DOI: 10.1080/10903127.2016.1218981] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE In Denmark, calls to the Danish emergency number 1-1-2 concerning medical emergencies are received by an emergency medical communication center (EMCC). At the EMCC, health care professionals (nurses, paramedics, and physicians) decide the necessary response, depending on the level of emergency as indicated by the Danish Index for Emergency Care. The index states 37 main criteria (symptoms) and five levels of emergency, descending from A (life threatening) to E (not serious). An ambulance is not sent to emergency level-E patients (level-E patients), but they are given other kinds of help/advice. No prior studies focusing on Danish level-E patients exist, hence the sparse knowledge about them. This study aimed to characterize level-E patients in the Central Denmark Region and to investigate their progress in the health care system after the 1-1-2 call, regarding contacting 1-1-2 again, general practitioner and Emergency Department (ED) visits, hospital admission, and death. METHODS This is a retrospective follow-up study of callers who contacted the EMCC of the Central Denmark Region and were assessed as level-E patients from August 2013 to July 2014. The study population was identified in the EMCC dispatch software, whose data were supplemented with health care data from three national registries. RESULTS Of the 53,414 patients who called 1-1-2 over the study period, 4,962 level-E patients were included in the study. The median age was 47 years (IQR: 24.3-67.7), and 53.4% were men. The most common main criteria were extremity pain - minor wounds. Within 1 day after their 1-1-2 call, 42.1% had a subsequent contact with the health care system. Of those, 5.9% called 1-1-2 again, 24.3% contacted an ED, and 8.6% were admitted. The fatality rate was 0.1%. CONCLUSIONS Level-E patients who contacted the EMCC of the Central Denmark Region were most frequently young adults. Almost 60% of level E-patients, who could be tracked, had no further contact with the health care system within a day after their 1-1-2 call. Of those who did, a quarter contacted an ED, indicating that level-E patients needed medical attention. The low fatality rates suggest limited undertriage, that is, level-E patients do not seem to need emergency medical service transportation. Further studies on undertriage among other things are needed.
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Fessler SJ, Simon HK, Yancey AH, Colman M, Hirsh DA. How well do General EMS 911 dispatch protocols predict ED resource utilization for pediatric patients? Am J Emerg Med 2013; 32:199-202. [PMID: 24370070 DOI: 10.1016/j.ajem.2013.09.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 09/22/2013] [Accepted: 09/23/2013] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The use of Emergency Medical Services (EMS) for low-acuity pediatric problems is well documented. Attempts have been made to curb potentially unnecessary transports, including using EMS dispatch protocols, shown to predict acuity and needs of adults. However, there are limited data about this in children. The primary objective of this study is to determine the pediatric emergency department (PED) resource utilization (surrogate of acuity level) for pediatric patients categorized as "low-acuity" by initial EMS protocols. METHODS Records of all pediatric patients classified as "low acuity" and transported to a PED in winter and summer of 2010 were reviewed. Details of the PED visit were recorded. Patients were categorized and compared based on chief complaint group. Resource utilization was defined as requiring any prescription medications, labs, procedures, consults, admission or transfer. "Under-triage" was defined as a "low-acuity" EMS transport subsequently requiring emergent interventions. RESULTS Of the 876 eligible cases, 801 were included; 392/801 had no resource utilization while 409 of 801 had resource utilization. Most (737/801) were discharged to home; however, 64/801 were admitted, including 1 of 801 requiring emergent intervention (under-triage rate 0.12%). Gastroenterology and trauma groups had a significant increase in resource utilization, while infectious disease and ear-nose-throat groups had decreased resource utilization. DISCUSSION While this EMS system did not well predict overall resource utilization, it safely identified most low-acuity patients, with a low under-triage rate. This study identifies subgroups of patients that could be managed without emergent transport and can be used to further refine current protocols or establish secondary triage systems.
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Affiliation(s)
- Stephanie J Fessler
- Pediatric Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - Harold K Simon
- Pediatric Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA; Dept of Pediatrics, Emory University, Atlanta, GA, USA; Department of Emergency Medicine, Emory University
| | - Arthur H Yancey
- Grady Health Systems, Grady Emergency Medical Services, Atlanta, GA, USA; Department of Emergency Medicine, Emory University
| | - Michael Colman
- Grady Health Systems, Grady Emergency Medical Services, Atlanta, GA, USA
| | - Daniel A Hirsh
- Pediatric Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA; Dept of Pediatrics, Emory University, Atlanta, GA, USA
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The forgotten trauma patient: outcomes for injured patients evaluated by emergency medical services but not transported to the hospital. J Trauma Acute Care Surg 2012; 72:594-9; discussion 599-600. [PMID: 22491541 DOI: 10.1097/ta.0b013e31824764ef] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Injured patients who are not transported by an ambulance to the hospital are often not included in trauma registries. The outcomes of these patients have until now been unknown. Understanding what happens to nontransports is necessary to better understand triage validity, patient outcomes, and costs associated with injury. We hypothesized that a subset of patients who were not transported from the scene would later present for evaluation and that these patients would have a nonzero mortality rate. METHODS This is a population-based, retrospective cohort study of injured adults and children for three counties in California from 2006 to 2008. Prehospital data for injured patients for whom an ambulance was dispatched were probabilistically linked to trauma registry data from four trauma centers, state-level discharge data, emergency department records, and death files (1-year mortality). RESULTS A total of 69,413 injured persons who were evaluated at the scene by emergency medical services were included in the analysis. Of them, 5,865 (8.5%) were not transported. Of those not transported, 1,616 (28%) were later seen in an emergency department and discharged and 92 (2%) were admitted. Seven (0.2%) patients later died. CONCLUSION Patients evaluated by emergency medical services, but not initially transported from the field after injury, often present later to the hospital. The mortality rate in this population was not zero, and these patients may represent preventable deaths. LEVEL OF EVIDENCE III, therapeutic study.
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Bigham BL, Buick JE, Brooks SC, Morrison M, Shojania KG, Morrison LJ. Patient safety in emergency medical services: a systematic review of the literature. PREHOSP EMERG CARE 2012; 16:20-35. [PMID: 22128905 DOI: 10.3109/10903127.2011.621045] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Preventable harm from medical care has been extensively documented in the inpatient setting. Emergency medical services (EMS) providers care for patients in dynamic and challenging environments; prehospital emergency care is a field that represents an area of high risk for errors and harm, but has received relatively little attention in the patient safety literature. OBJECTIVE To identify the threats to patient safety unique to the EMS environment and interventions that mitigate those threats, we completed a systematic review of the literature. METHODS We searched MEDLINE, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) for combinations of key EMS and patient safety terms composed by a pan-canadian expert panel using a year limit of 1999 to 2011. We excluded commentaries, opinions, letters, abstracts, and non-english publications. Two investigators performed an independent hierarchical screening of titles, abstracts, and full-text articles blinded to source. We used the kappa statistic to examine interrater agreement. Any differences were resolved by consensus. RESULTS We retrieved 5,959 titles, and 88 publications met the inclusion criteria and were categorized into seven themes: adverse events and medication errors (22 articles), clinical judgment (13), communication (6), ground vehicle safety (9), aircraft safety (6), interfacility transport (16), and intubation (16). Two articles were randomized controlled trials; the remainder were systematic reviews, prospective observational studies, retrospective database/chart reviews, qualitative interviews, or surveys. The kappa statistics for titles, abstracts, and full-text articles were 0.65, 0.79, and 0.87, respectively, for the first search and 0.60, 0.74, and 0.85 for the second. CONCLUSIONS We found a paucity of scientific literature exploring patient safety in EMS. Research is needed to improve our understanding of problem magnitude and threats to patient safety and to guide interventions.
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Affiliation(s)
- Blair L Bigham
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada.
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Kannikeswaran N, Mahajan PV, Dunne RB, Compton S, Knazik SR. Epidemiology of pediatric transports and non-transports in an urban Emergency Medical Services system. PREHOSP EMERG CARE 2008; 11:403-7. [PMID: 17907024 DOI: 10.1080/10903120701536677] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This study was done to describe an urban, Emergency Medical Service (EMS) system's experiences with pediatric patients and the rate and characteristics of non-transports in this setting. METHODS A retrospective analysis of all pediatric patients responded to by the Detroit Fire Department Division of EMS between January 1, 2002 and August 30, 2002 was done. RESULTS There were 5,976 pediatric EMS cases. Children 10 years of age or older accounted for 49.4% of transports, 53.8% of all patients had medical illness, and 38.8% of the patients belonged to the non-urgent category. A large percentage of patients were not transported (27.2%), most commonly secondary to parent/caregiver/patient refusals. The median number of minutes on-scene for refusals was longer than for transports (23.5 vs. 17.3, respectively)[difference = 6.2 minutes (95% CI: 5.6-6.9)]. The odds ratios (OR) for refusal was highest for assaults (2.09; 95% CI: 1.66-2.63), difficulty in breathing (1.38; 95% CI: 1.14-1.68), and motor vehicle accidents (1.19; 95% CI: 1.04-1.37). CONCLUSIONS In this system, the majority of pediatric patients are not severely ill, and a large number are not transported. Non-transports are more likely to be young adolescents, have been involved in assaults, and have a longer on-scene time.
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Affiliation(s)
- Nirupama Kannikeswaran
- Carman and Ann Adams Department of Pediatrics, Division of Emergency Medicine, The Children's Hospital of Michigan, Detroit, MI 48201, USA.
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Halter M, Marlow T, Mohammed D, Ellison GTH. A patient survey of out-of-hours care provided by Emergency Care Practitioners. BMC Emerg Med 2007; 7:4. [PMID: 17573959 PMCID: PMC1913059 DOI: 10.1186/1471-227x-7-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Accepted: 06/15/2007] [Indexed: 11/14/2022] Open
Abstract
Background Emergency Care Practitioners (ECPs) have recently been deployed to provide out-of-hours primary care home visits – a practice development that has been supported by policy makers. The aim of the study was to evaluate the care provided to patients receiving out-of-hours home visits from ECPs in London from the patients' perspective and to assess their wellbeing following the visit. Methods A bespoke telephone-administered questionnaire was designed to survey all patients who had received out-of-hours care in Bromley Primary Care Trust from ECPs during a ten week period in 2005 (n = 174). Results Sixty three patients (36.2%) were excluded because: no telephone number was available; they had a diagnosis of dementia; or had not received a study information sheet. The remainder (n = 111) were contacted 3–5 days after the home visit, and 81 of these (73.0%) completed the survey. Of those respondents treated at home who gave unequivocal answers (n = 60), all but one (8.3%) reported that they felt that their treatment had been 'right' and/or had followed any advice given. However, overall only 86.4% reported that they had been clear about their ECP's assessment, and only 58.0% reported that their health was now 'better'. Those who reported that they were not clear about their assessment were less likely to report that their health was 'better' (p = 0.03) and more likely to have subsequently used hospital-based health services (p = 0.03). Conclusion Most patients treated at home by ECPs appeared satisfied and compliant with the care provided, according to the measures used in this study. However, it appears that a sizeable minority of patients were unclear about ECP assessments and it remains to be seen whether these patients had pre-existing health complaints which made them less likely to recover and more likely to seek hospital care, or whether the lack of clarity about their assessment undermined their subsequent recovery and necessitated hospital care. Further research is required to establish if the assessments provided by ECPs are less clear than those provided by other practitioners, and whether it is possible to ensure that all such assessments are clear to all patients. Patients hold a mainly positive view of out-of-hours home visit care provided by ECPs, although a lack of clarity about their assessment was evident, with a possible impact on their continuing health.
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Affiliation(s)
- Mary Halter
- Faculty of Health and Social Care Sciences, Kingston University and St George's, University of London, Grosvenor Wing, St George's Hospital, Cranmer Terrace, London SW17 0RE, UK
| | - Tom Marlow
- Community Services Development, 95 Beaconsfield Road, Surbiton, KG5 9AW, UK
| | - Daryl Mohammed
- London Ambulance Service NHS Trust, 8-20 Pocock Street, London, SE1 0BW, UK
| | - George TH Ellison
- Faculty of Health and Social Care Sciences, Kingston University and St George's, University of London, Grosvenor Wing, St George's Hospital, Cranmer Terrace, London SW17 0RE, UK
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