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Ward CE, Badolato GM, Taylor MF, Brown KM, Simpson JN, Chamberlain JM. Clinician and Caregiver Determinations of Acuity for Children Transported by Emergency Medical Services: A Prospective Observational Study. Ann Emerg Med 2023; 81:343-352. [PMID: 36334958 PMCID: PMC9974545 DOI: 10.1016/j.annemergmed.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/24/2022] [Accepted: 09/02/2022] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVE Many Emergency Medical Services (EMS) agencies have developed alternative disposition processes for patients with nonemergency problems, but there is a lack of evidence demonstrating EMS clinicians can accurately determine acuity in pediatric patients. Our study objective was to determine EMS and other stakeholders' ability to identify low acuity pediatric EMS patients. METHODS We conducted a prospective, observational study of children transported to a pediatric emergency department (ED) by EMS. Acuity was defined using a composite measure that included data from the patient's vital signs and examination, resources used (laboratory results, radiographs, etc), and disposition. For each patient, an EMS clinician, patient caregiver, ED nurse, and ED provider completed a survey as soon as possible after the patient's arrival at the ED. The survey asked respondents 2 questions: to state their level of agreement that a patient was low acuity and could the patient have been managed by various alternative dispositions. For each respondent group, we calculated the sensitivity, specificity, and positive and negative predictive values for low acuity versus the composite measure. RESULTS From August 2020 through September 2021, we approached 1,015 caregivers, of whom 996 (99.8%) agreed to participate and completed the survey. Survey completion varied between 78.7% and 84.1% for EMS and ED nurses and providers. The mean patient age was 7 years, 62.6% were non-Hispanic Black, and 60% were enrolled in public insurance programs. Of the 996 patient encounters, 33% were determined to be low acuity by the composite measure. The positive predictive value for EMS clinicians when identifying low acuity children was 0.60 (95% confidence intervals [CI], 0.58 to 0.67). The positive predictive value for ED nurses and providers was 0.67 (95% CI, 0.61 to 0.72) and 0.68 (95% CI, 0.63 to 0.74) respectively. The negative predictive value for EMS clinicians when identifying not low acuity children was 0.62 (95% CI, 0.58 to 0.67). The negative predictive value for ED nurses and providers was 0.72 (95% CI, 0.68 to 0.76) and 0.73 (95% CI, 0.70 to 0.77) respectively. Caregivers had the lowest positive predictive value 0.34 (95% CI, 0.30 to 0.40) but the highest negative predictive value 0.82 (95% CI, 0.79 to 0.85). The EMS clinicians, ED nurses and providers were more likely than caregivers to think that a child with a low acuity complaint could have been safely managed by alternative disposition. CONCLUSION All 4 groups studied had a limited ability to identify which children transported by EMS would have no emergency resource needs, and support for alternative disposition was limited. For children to be included in alternative disposition processes, novel triage tools, training, and oversight will be required to prevent undertriage.
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Affiliation(s)
- Caleb E Ward
- Division of Emergency Medicine, Children's National Hospital, Washington DC; George Washington University School of Medicine and Health Sciences, Washington DC.
| | - Gia M Badolato
- Division of Emergency Medicine, Children's National Hospital, Washington DC
| | - Michael F Taylor
- Division of Emergency Medicine, Children's National Hospital, Washington DC
| | - Kathleen M Brown
- Division of Emergency Medicine, Children's National Hospital, Washington DC; George Washington University School of Medicine and Health Sciences, Washington DC
| | - Joelle N Simpson
- Division of Emergency Medicine, Children's National Hospital, Washington DC; George Washington University School of Medicine and Health Sciences, Washington DC
| | - James M Chamberlain
- Division of Emergency Medicine, Children's National Hospital, Washington DC; George Washington University School of Medicine and Health Sciences, Washington DC
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Choice of Transport to Hospital in Nonurban Areas in Life-Threatening Situations: A Qualitative Research. J Ambul Care Manage 2021; 44:155-165. [PMID: 33591130 DOI: 10.1097/jac.0000000000000375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The time it takes to begin treatment in life-threatening situations is critical. Ambulance transport to the hospital in such situations ensures quick and effective treatment but is not always readily available in nonurban areas, or not preferred by the public, for various reasons. The purpose of this qualitative study was to examine the factors that deter or encourage ambulance use in life-threatening situations in the geographic periphery from clients' perspectives. We conducted interviews with 71 patients in 3 medical centers who had arrived by ambulance or by private transport, and with the 3 emergency department directors. The findings revealed that awareness of the clinical situation and health literacy, accessibility of emergency services, geographical conditions, and social and economic factors are central in the decision to utilize this service. We detail research recommendations for strengthening public health literacy and access to services.
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Pearson C, Kim DS, Mika VH, Imran Ayaz S, Millis SR, Dunne R, Levy PD. Emergency department visits in patients with low acuity conditions: Factors associated with resource utilization. Am J Emerg Med 2018; 36:1327-1331. [DOI: 10.1016/j.ajem.2017.12.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/30/2017] [Accepted: 12/13/2017] [Indexed: 10/18/2022] Open
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Munjal KG, Shastry S, Loo GT, Reid D, Grudzen C, Shah MN, Chapin HH, First B, Sirirungruang S, Alpert E, Chason K, Richardson LD. Patient Perspectives on EMS Alternate Destination Models. PREHOSP EMERG CARE 2016; 20:705-711. [DOI: 10.1080/10903127.2016.1182604] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Rantala A, Ekwall A, Forsberg A. The meaning of being triaged to non-emergency ambulance care as experienced by patients. Int Emerg Nurs 2016; 25:65-70. [DOI: 10.1016/j.ienj.2015.08.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 06/30/2015] [Accepted: 08/03/2015] [Indexed: 11/25/2022]
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Turner J, Coster J, Chambers D, Cantrell A, Phung VH, Knowles E, Bradbury D, Goyder E. What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03430] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundIn 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.ObjectiveThe purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.Data sourcesMEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.MethodsWe have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.ResultsThe review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.LimitationsAlthough there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.ConclusionsThe evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.FundingThe National Institute for Health Research Health Services and Delivery Research Programme.
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Affiliation(s)
- Janette Turner
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Joanne Coster
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Duncan Chambers
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Viet-Hai Phung
- College of Social Science, University of Lincoln, Lincoln, UK
| | - Emma Knowles
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Bradbury
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Kang K. Unmet Need and Inappropriate Use in Emergency Ambulance Service. HEALTH POLICY AND MANAGEMENT 2014. [DOI: 10.4332/kjhpa.2014.24.4.357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Toloo GS, FitzGerald GJ, Aitken PJ, Ting JYS, McKenzie K, Rego J, Enraght-Moony E. Ambulance use is associated with higher self-rated illness seriousness: user attitudes and perceptions. Acad Emerg Med 2013; 20:576-83. [PMID: 23758304 DOI: 10.1111/acem.12149] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 10/29/2012] [Accepted: 12/14/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to study the role and effect of patients' perceptions on reasons for using ambulance services in Queensland, Australia. METHODS A cross-sectional survey was conducted of patients (n = 911) presenting via ambulance or self-transport at eight public hospital emergency departments (EDs). The survey included perceived illness severity, attitudes toward ambulance, and reasons for using ambulance. A theoretical framework was developed to inform this study. RESULTS Ambulance users had significantly higher self-rated perceived seriousness, urgency, and pain than self-transports. They were also more likely to agree that ambulance services are for everyone to use, regardless of the severity of their conditions. In compared to self-transports, likelihood of using an ambulance increased by 26% for every unit increase in perceived seriousness; and patients who had not used an ambulance in the 6 months prior to the survey were 66% less likely to arrive by ambulance. Patients who had presented via ambulance stated they considered the urgency (87%) or severity (84%) of their conditions as reasons for calling the ambulance. Other reasons included requiring special care (76%), getting higher priority at the ED (34%), not having a car (34%), and financial concerns (17%). CONCLUSIONS Understanding patients' perceptions is essential in explaining their actions and developing safe and effective health promotion programs. Individuals use ambulances for various reasons and justifications according to their beliefs, attitudes, and sociodemographic conditions. Policies to reduce and manage demand for such services need to address both general opinions and specific attitudes toward emergency health services to be effective.
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Affiliation(s)
- Ghasem Sam Toloo
- School of Public Health and Social Work; Queensland University of Technology; Brisbane; QLD
| | - Gerry J. FitzGerald
- School of Public Health and Social Work; Queensland University of Technology; Brisbane; QLD
| | - Peter J. Aitken
- Emergency Department; The Townsville Hospital, and Anton Breinl Centre for Public Health and Tropical Medicine; James Cook University; Townsville; QLD
| | - Joseph Y. S. Ting
- Mater Health Services; Careflight Medical Services Qld, and University of Queensland Medical School; Brisbane; QLD
| | - Kirsten McKenzie
- Centre for Accident Research and Road Safety Queensland; School of Psychology and Counseling, and National Centre for Health Information Research and Training; School of Public Health; Queensland University of Technology; Brisbane; QLD
| | - Joanna Rego
- School of Public Health and Social Work; Queensland University of Technology; Brisbane; QLD
| | - Emma Enraght-Moony
- Clinical Performance & Service Improvement Unit; Queensland Ambulance Service; Brisbane; QLD; Australia
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Millin MG, Brown LH, Schwartz B. EMS provider determinations of necessity for transport and reimbursement for EMS response, medical care, and transport: combined resource document for the National Association of EMS Physicians position statements. PREHOSP EMERG CARE 2011; 15:562-9. [PMID: 21797787 DOI: 10.3109/10903127.2011.598625] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
With increasing demands for emergency medical services (EMS), many EMS jurisdictions are utilizing EMS provider-initiated nontransport policies as a method to offload potentially nonemergent patients from the EMS system. EMS provider determination of medical necessity, resulting in nontransport of patients, has the potential to avert unnecessary emergency department visits. However, EMS systems that utilize these policies must have additional education for the providers, a quality improvement process, and active physician oversight. In addition, EMS provider determination of nontransport for a specific situation should be supported by evidence in the peer-reviewed literature that the practice is safe. Further, EMS systems that do not utilize these programs should not be financially penalized. Payment for EMS services should be based on the prudent layperson standard. EMS systems that do utilize nontransport policies should be appropriately reimbursed, as this represents potential cost savings to the health care system.
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Affiliation(s)
- Michael G Millin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21209, USA.
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The ambulance services in northern Norway 2004-2008: improved competence, more tasks, better logistics and increased costs. Int J Emerg Med 2010; 3:69-74. [PMID: 20606813 PMCID: PMC2885266 DOI: 10.1007/s12245-010-0166-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2009] [Accepted: 01/22/2010] [Indexed: 11/23/2022] Open
Abstract
Background The ambulance services in northern Norway have undergone significant development during recent years. Aims The objective of this study was to describe these changes in terms of tasks performed, distance driven, resources spent and level of competence in terms of education. Methods A retrospective analysis was performed. The ambulance fleet’s activity during the time period 2004–2008 was analysed. The subject was the ambulance fleet in northern Norway and its crew members. Tasks done, kilometres driven, resources spent per thousand inhabitants and level of competence were the main outcome measures. Results The major findings were almost doubled costs (92%), increasing number of tasks performed (13%) and a stable situation concerning kilometres driven. We also revealed improving competence in terms of education. A 20% absolute increase in crew members having a certificate of competence (fagbrev) was observed. Conclusions Significant economic resources have been invested in the fleet. Improved level of competence and an upgraded coordination system have improved logistics and hopefully treatment outcome. The latter should be further elucidated when the electronic patient record (EPR) system has been implemented.
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Brown LH, Hubble MW, Cone DC, Millin MG, Schwartz B, Patterson PD, Greenberg B, Richards ME. Paramedic determinations of medical necessity: a meta-analysis. PREHOSP EMERG CARE 2010; 13:516-27. [PMID: 19731166 DOI: 10.1080/10903120903144809] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Reducing unnecessary ambulance transports may have operational and economic benefits for emergency medical services (EMS) agencies and receiving emergency departments. However, no consensus exists on the ability of paramedics to accurately and safely identify patients who do not require ambulance transport. Objective. This systematic review and meta-analysis evaluated studies reporting U.S. paramedics' ability to determine medical necessity of ambulance transport. METHODS PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library databases were searched using Cochrane Prehospital and Emergency Care Field search terms combined with the Medical Subject Headings (MeSH) terms "triage"; "utilization review"; "health services misuse"; "severity of illness index," and "trauma severity indices." Two reviewers independently evaluated each title to identify relevant studies; each abstract then underwent independent review to identify studies requiring full appraisal. Inclusion criteria were original research; emergency responses; determinations of medical necessity by U.S. paramedics; and a reference standard comparison. The primary outcome measure of interest was the negative predictive value (NPV) of paramedic determinations. For studies reporting sufficient data, agreement between paramedic and reference standard determinations was measured using kappa; sensitivity, specificity, and positive predictive value (PPV) were also calculated. RESULTS From 9,752 identified titles, 214 abstracts were evaluated, with 61 studies selected for full review. Five studies met the inclusion criteria (interrater reliability, kappa = 0.75). Reference standards included physician opinion (n = 3), hospital admission (n = 1), and a composite of physician opinion and patient clinical circumstances (n = 1). The NPV ranged from 0.610 to 0.997. Results lacked homogeneity across studies; meta-analysis using a random-effects model produced an aggregate NPV of 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported complete 2 x 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823. CONCLUSION The results of the few studies evaluating U.S. paramedic determinations of medical necessity for ambulance transport vary considerably, and only two studies report complete data. The aggregate NPV of the paramedic determinations is 0.91, with a lower confidence limit of 0.71. These data do not support the practice of paramedics' determining whether patients require ambulance transport. These findings have implications for EMS systems, emergency departments, and third-party payers.
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Affiliation(s)
- Lawrence H Brown
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA.
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