Appropriateness of ambulance transportation to a suburban pediatric emergency department

Emergency medical services utilisation among febrile children attending emergency departments across Europe: an observational multicentre study

Children constitute 6-10% of all patients attending the emergency department (ED) by emergency medical services (EMS). However, discordant EMS use in children occurs in 37-61% with fever as an important risk factor. We aimed to describe EMS utilisation among febrile children attending European EDs. This study is part of an observational multicentre study assessing management and outcome in febrile children up to 18 years (MOFICHE) attending twelve EDs in eight European countries. Discordant EMS use was defined as the absence of markers of urgency including intermediate/high triage urgency, advanced diagnostics, treatment, and admission in children transferred by EMS. Multivariable logistic regression analyses were performed for the association between (1) EMS use and markers of urgency, and (2) patient characteristics and discordant EMS use after adjusting all analyses for the covariates age, gender, visiting hours, presenting symptoms, and ED setting. A total of 5464 (15%, range 0.1-42%) children attended the ED by EMS. Markers of urgency were more frequently present in the EMS group compared with the non-EMS group. Discordant EMS use occurred in 1601 children (29%, range 1-59%). Age and gender were not associated with discordant EMS use, whereas neurological symptoms were associated with less discordant EMS use (aOR 0.2, 95%CI 0.1-0.2), and attendance out of office hours was associated with more discordant EMS use (aOR 1.6, 95%CI 1.4-1.9). Settings with higher percentage of self-referrals to the ED had more discordant EMS use (p < 0.05).  Conclusion: There is large practice variation in EMS use in febrile children attending European EDs. Markers of urgency were more frequently present in children in the EMS group. However, discordant EMS use occurred in 29%. Further research is needed on non-medical factors influencing discordant EMS use in febrile children across Europe, so that pre-emptive strategies can be implemented. What is Known: •Children constitute around 6-10% of all patients attending the emergency department by emergency medical services. •Discordant EMS use occurs in 37-61% of all children, with fever as most common presenting symptom for discordant EMS use in children. What is New: •There is large practice variation in EMS use among febrile children across Europe with discordance EMS use occurring in 29% (range 1-59%), which was associated with attendance during out of office hours and with settings with higher percentage of self-referrals to the ED. •Future research is needed focusing on non-medical factors (socioeconomic status, parental preferences and past experience, healthcare systems, referral pathways, out of hours services provision) that influence discordant EMS use in febrile children across Europe.

What factors are associated with ambulance use for non-emergency problems in children? A systematic mapping review and qualitative synthesis

OBJECTIVE

To explore what factors are associated with ambulance use for non-emergency problems in children.

METHODS

This study is a systematic mapping review and qualitative synthesis of published journal articles and grey literature. Searches were conducted on the following databases, for articles published between January 1980 and July 2020: MEDLINE, EMBASE, PsycINFO, CINAHL and AMED. A Google Scholar and a Web of Science search were undertaken to identify reports or proceedings not indexed in the above. Book chapters and theses were searched via the OpenSigle, EThOS and DART databases. A literature advisory group, including experts in the field, were contacted for relevant grey literature and unpublished reports. The inclusion criteria incorporated articles published in the English language reporting findings for the reasons behind why there are so many calls to the ambulance service for non-urgent problems in children. Data extraction was divided into two stages: extraction of data to generate a broad systematic literature 'map', and extraction of data from highly relevant papers using qualitative methods to undertake a focused qualitative synthesis. An initial table of themes associated with reasons for non-emergency calls to the ambulance for children formed the 'thematic map' element. The uniting feature running through all of the identified themes was the determination of 'inappropriateness' or 'appropriateness' of an ambulance call out, which was then adopted as the concept of focus for our qualitative synthesis.

RESULTS

There were 27 articles used in the systematic mapping review and 17 in the qualitative synthesis stage of the review. Four themes were developed in the systematic mapping stage: socioeconomic status/geographical location, practical reasons, fear of consequences and parental education. Three analytical themes were developed in the qualitative synthesis stage including practicalities and logistics of obtaining care, arbitrary scoring system and retrospection.

CONCLUSIONS

There is a lack of public and caregiver understanding about the use of ambulances for paediatrics. There are factors that appear specific to choosing ambulance care for children that are not so prominent in adults (fever, reassurance, fear of consequences). Future areas for attention to decrease ambulance activation for paediatric low-acuity reports were highlighted as: identifying strategies for helping caregivers to mitigate perceived risk, increasing availability of primary care, targeted education to particular geographical areas, education to first-time parents with infants and providing alternate means of transportation.

PROSPERO REGISTRATION NUMBER

CRD42019160395.

Impact of the COVID-19 pandemic on the Emergency Department of a tertiary children's hospital

BACKGROUND

Italy was the first country in Europe affected by COVID-19: the emergency started on February 20, 2020, culminating with national lockdown on March 11, which terminated on May 4, 2020. We describe how the pandemic affected Emergency Department (ED) accesses in a tertiary children's hospital, composed by two different pediatric centers, one located in Rome's city center and the second, Palidoro (regional COVID-19 center), in its surrounding metropolitan area, both in the Lazio region, analyzing the profile of admitted patients during the pandemic period in terms of their general characteristics (at presentation in the ED's) and urgent hospitalizations compared to prepandemic period.

METHODS

The study compare the period between the 21st of February and the 30th of April 2020, covering the three phases of the national responses (this period will be referred to as the pandemic period) with the same period of 2019 (prepandemic period). The study analyzes the number of ED visits and urgent hospitalizations and their distribution according to selected characteristics.

RESULTS

The reduction of ED visits was 56 and 62%, respectively in Rome and Palidoro centers. The higher relative decline was encountered for Diseases of Respiratory System, and for Diseases of the Nervous System and Sense Organs. A doubling of the relative frequency of hospitalizations was observed, going from 14.2 to 24.4% in Rome and from 6.4 to 10.3% in Palidoro. In terms of absolute daily numbers the decrease of urgent hospitalizations was less sharp than ED visits. For pathologies such as peritonitis, tumors or other possible life-treathening conditions we did not observe a significative increase due to delayed access.

CONCLUSIONS

In the pandemic period there was a general reduction in the number of children referred to ED, such reduction was greater in low-acuity levels. The reduction for respiratory tract infections and other communicable diseases during school closure and the national lockdown must make us reflect on the possible impact that these conditions may have on the health system, in particular the ED, at the reopening of schools. The major problem remains the fear for possible diagnostic delays in life-threatening or crippling diseases; our study doesn't demonstrate an increase in number or significant delay in some serious conditions such as tumors, peritonitis, diabetic ketoacidosis, ileo-colic intussusception and testis/ovary torsion. A continuous, deep re-organizational process step by step of the ED is nececessary in the present and upcoming pandemic situation.

Association of Insurance With Use of Emergency Medical Services Among Children

OBJECTIVE

The use of emergency medical services (EMS) can be lifesaving for critically ill children and should be defined by the child's clinical need. Our objective was to determine whether nonclinical demographic factors and insurance status are associated with EMS use among children presenting to the emergency department (ED).

METHODS

In this cross-sectional study using the National Hospital Ambulatory Medical Care Survey, we included children presenting to EDs from 2009 to 2014. We evaluated the association between EMS use and patients' insurance status using multivariable logistic regressions, adjusting for demographic, socioeconomic, and clinical factors such as illness severity as measured by a modified and recalibrated version of the Revised Pediatric Emergency Assessment Tool (mRePEAT) and the presence of comorbidities or chronic conditions. A propensity score analysis was performed to validate our findings.

RESULTS

Of the estimated 191,299,454 children presenting to EDs, 11,178,576 (5.8%) arrived by EMS and 171,145,895 (89.5%) arrived by other means. Children arriving by EMS were more ill [mRePEAT score, 1.13; 95% confidence interval (CI), 1.12-1.14 vs mRePEAT score, 1.01; 95% CI: 1.01-1.02] and more likely to have a comorbidity or chronic condition (OR: 3.17, 95% CI: 2.80-3.59). In the adjusted analyses, the odds of EMS use were higher for uninsured children and lower for children with public insurance compared with children with private insurance [OR (95% CI): uninsured, 1.41 (1.12-1.78); public, 0.77 (0.65-0.90)]. The propensity score analysis showed similar results.

CONCLUSIONS

In contrast to adult patients, children with public insurance are less likely to use EMS than children with private insurance, even after adjustment for illness severity and other confounders.

Emergency Medical Services Utilization by Children

OBJECTIVE

The aim of this study was to compare demographic and clinical features of children (0-14 years old) who arrived at general emergency departments (EDs) by emergency medical services (EMS) to those who arrived by private vehicles and other means in a rural, 3-county region of northern California.

METHODS

We reviewed 507 ED records of children who arrived at EDs by EMS and those who arrived by other means in 2013. We also analyzed prehospital procedures performed on all children transported to an area hospital by EMS.

RESULTS

Children arriving by EMS were older (9.0 vs 6.0 years; P < 0.001), more ill (mean Severity Classification Score, 2.9 vs 2.4; P < 0.001), and had longer lengths of stay (3.6 vs 2.1 hours; P < 0.001) compared with children who were transported to the EDs by other means. Children transported by EMS received more subspecialty consultations (18.7% vs 6.9%; P < 0.05) and had more diagnostic testing, including laboratory testing (22.9% vs 10.6%; P < 0.001), radiography (39.7% vs 20.8%; P < 0.001), and computed tomography scans (16.8% vs 2.9%; P < 0.001). Children arriving by EMS were transferred more frequently (8.8% vs 1.6%; P < 0.001) and had higher mean Severity Classification Scores compared with children arriving by other transportation even after adjusting for age and sex (β = 0.48; 95% confidence interval, 0.35-0.61; P < 0.001). Older children received more prehospital procedures compared with younger children, and these were of greater complexity and a wider spectrum.

CONCLUSIONS

Children transported to rural EDs via EMS are more ill and use more medical resources compared with those who arrive to the ED by other means of transportation.

Parental factors predicting unnecessary ambulance use for their child with acute illness: A cross-sectional study

AIMS

To examine characteristics of parents of children with acute, albeit mild, illnesses who used ambulance transport unnecessarily.

DESIGN

A cross-sectional study.

METHODS

From 2016 - 2017, we recruited parents who visited the emergency room of a Japanese paediatric hospital and whose children were discharged without hospitalization. Participants whose children arrived by ambulance were classified as using ambulance services unnecessarily. Participants answered a questionnaire consisting of parents' characteristics, including health literacy scales and the Parents' Uncertainty regarding their Children with Acute Illness Scale. We conducted a receiver operating characteristic analysis to convert the Parents' Uncertainty regarding their Children with Acute Illness Scale results to binary scores. We analysed questionnaire responses using logistic regression analysis.

RESULTS

Analysed data were from 171 participants. The cut-off score was 59 for the Parents' Uncertainty regarding their Children with Acute Illness Scale. Results of the logistic regression indicated that parents who did not use resources to obtain information regarding their child's illness, had low health literacy, were observing presenting symptoms for the first time in their child, or had high uncertainty, were significantly more likely to unnecessarily use ambulances.

CONCLUSION

Publicizing available resources regarding child health information, social healthcare activities to raise parents' health literacy and providing explanations in accordance with parents' uncertainty, especially when confronting new symptoms in their child, might reduce unnecessary ambulance use.

IMPACT

Of patients transported to hospitals by ambulance, the rate of paediatric parents with mild conditions has been found to be high. The study findings could contribute to the appropriateness of using ambulances and have implications for policymakers and healthcare providers, particularly in the Japanese paediatric emergency system. In particular, parental uncertainty, one of four significant characteristics, could be resolved in clinical settings. Generalization for global health services requires further research.

Assessment of Inadequate Use of Pediatric Emergency Medical Transport Services: The Pediatric Emergency and Ambulance Critical Evaluation (PEACE) Study

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.

Initial assessment, level of care and outcome among children who were seen by emergency medical services: a prospective observational study

Background

The assessment of children in the Emergency Medical Service (EMS) is infrequent representing 5.4% of the patients in an urban area in the western part of Sweden. In Sweden, patients are assessed on scene by an EMS nurse whom independently decides on interventions and level of care. To aid the EMS nurse in the assessment a triage instrument, Rapid Emergency Triage and Treatment System-paediatrics (RETTS-p) developed for Emergency Department (ED) purpose has been in use the last 5 years. The aim of this study was to evaluate the EMS nurse assessment, management, the utilisation of RETTS-p and patient outcome.

Methods

A prospective, observational study was performed on 651 children aged < 16 years from January to December 2016. Statistical tests used in the study were Mann-Whitney U test, Fisher’s exact test and Spearman’s rank statistics.

Results

The dispatch centre indexed life-threatening priority in 69% of the missions but, of all children, only 6.1% were given a life threatening RETTS-p red colour by the EMS nurse. A total of 69.7% of the children were transported to the ED and, of these, 31.7% were discharged without any interventions. Among the non-conveyed patients, 16 of 197 (8.1%) visited the ED within 72 h but only two were hospitalised. Full triage, including five out of five vital signs measurements and an emergency severity index, was conducted in 37.6% of all children. A triage colour was not present in 146 children (22.4%), of which the majority were non-conveyed. The overall 30-day mortality rate was 0.8% (n = 5) in children 0–15 years.

Conclusions

Despite the incomplete use of all vital signs according to the RETTS-p, the EMS nurse assessment of children appears to be adapted to the clinical situation in most cases and the patients appear to be assessed to the appropriate level of care but indicating an over triage. It seems that the RETTS-p with full triage is used selectively in the pre-hospital assessment of children with a risk of death during the first 30 days of less than 1%.

Risk factors related to unnecessary emergency medical services transport for pediatric patients

OBJECTIVES

This study evaluated unnecessary emergency medical services (EMS) transport for pediatric patients depending on whether they received emergency department (ED) treatment after EMS transport.

METHODS

Pediatric patients were divided into two groups according to whether they received treatment at the ED (ED treatment) or did not receive treatment at the ED (non-ED treatment).

RESULTS

The non-ED treatment group comprised 65 of the total 794 patients. The elapsed time from scene to arrival at the ED was longer in the non-ED treatment group than in the ED treatment group. Weekdays as the days of EMS transport, ground falls rather than traffic accidents as the reason for non-disease-related symptoms, and no immobilization for prehospital treatment were risk factors for non-ED treatment in EMS-transported patients. Causes of not receiving ED treatment for the non-ED treatment group were the patient's or caregiver's decision (12%) and the doctor's suggestion (88%).

CONCLUSIONS

Weekdays rather than weekends, ground falls rather than traffic accidents, and no immobilization before hospital are risk factors for not receiving ED treatment. The most common cause of not receiving ED treatment is the doctor's suggestion.

Emergency Medical Services Utilization Is Associated With Community Deprivation in Children

BACKGROUND

Pediatric emergency medical services (EMS) utilization is costly and resource intensive; significant variation exists across large-scale geographies. Less is known about variation at smaller geographic levels where factors including lack of transportation, low health literacy, and decreased access to medical homes may be more relevant. Our objective was to determine whether pediatric EMS utilization varied across Hamilton County, Ohio, census tracts and whether such utilization was associated with socioeconomic deprivation.

METHODS

This was a retrospective analysis of children living in Hamilton County, Ohio, transported by EMS to the Cincinnati Children's emergency department between July 1, 2014, and July 31, 2016. Participants' addresses were assigned to census tracts and an EMS utilization rate and deprivation index were calculated for each. Pearson's correlation coefficients evaluated relationships between tract-level EMS utilization and deprivation. Tract-level deprivation was used as a predictor in patient-level evaluations of acuity.

RESULTS

During the study period, there were 4,877 pediatric EMS transports from 219 of the 222 county census tracts. The county EMS utilization rate during the study period was 2.4 transports per 100 children (range 0.2-11). EMS utilization rates were positively correlated with increasing deprivation (r = 0.72, 95% confidence interval [CI], 0.65-0.77). Deprivation was associated with lower illness severity at triage, fewer transports resulting in resuscitation suite use, and fewer transports resulting in hospitalizations (all p < 0.05).

CONCLUSIONS

EMS utilization varied substantially across census tracts in Hamilton County, Ohio. A deeper understanding into why certain socioeconomically deprived areas contribute to disproportionately high rates of EMS utilization could support development of targeted interventions to improve use.

Emergency Ambulance Dispatch: Is there a Case for Triage?

Emergency telephone calls for an ambulance (999 calls) are usually dealt with first-come first-served. We have devised and assessed criteria that ambulance dispatch might use to prioritize responses. Data were collected retrospectively on consecutive patients presenting to an accident and emergency (A&E) department after a 999 call. An unblinded researcher abstracted data including age, date, time, caller, location, reason for call and A&E diagnosis and each case was examined for ten predetermined criteria necessitating an immediate ambulance response--namely, cardiac arrest; chest pain; shortness of breath; altered mental status/seizure; abdominal/loin pain >65 years old; fresh haematemesis; fall >2m; stabbing; major burns. 471 patients were recruited, 55% male, median age 50 years. 406 calls came from bystanders or the patients themselves, 36 from general practitioners, 8 from other hospitals and 21 from the police. 52% of patients were admitted. 44% met at least one of the above criteria. Most patients did not meet the criteria for an immediate ambulance response but might nonetheless be suitable for an urgent response. The criteria used in this study have the advantage of being based on the history provided by the caller. The introduction of a priority-based dispatch system could reduce response times to those who are seriously ill, and also improve road safety.

Epidemiology of prehospital emergency medical service use in Korean children

Objective

The aim of this study was to elucidate the epidemiology of pediatric patients transported by the National 119 Rescue Services in Korea.

Methods

We enrolled all pediatric patients (<16 years old) who used the National 119 Rescue Services in Korea between January 2006 and December 2008, and analyzed the 119 ambulance patient care record databases.

Results

The total number of the cases was 238,644 for 3 years. The median age was 6 years old and 59.0% were male, and the 2- to 5-year-old group was the largest (31.0%). The peak transport times were in the afternoon (from 12:00 p.m. to 17:59 p.m., 36.3%), on Saturday and Sunday (15.9% and 15.7%), and in summer (June to August, 27.3%). The ratio of disease versus injury as the cause of the transports was 42.3% vs. 57.7%. Among the 16 metropolitan cities and provinces, Gyeonggi (25.7%), Seoul (17.6%), and Incheon (7.0%) account for almost half of the all transported children. Regarding the annual transport rates per 100,000 children standardized by age, and gender to the Korean child population, Jeju was the largest (1,650.2) followed by Gangwon (1,201.3), and Jeonnam (1,178.1).

Conclusion

This report presents comprehensive epidemiologic data of pediatric patients transported by 119 rescue services in Korea.

Unnecessary emergency medical services transport associated with alcohol intoxication

Objective

This study investigated medically unnecessary emergency medical services (EMS) transportation by comparing non-intoxicated versus intoxicated patients who did not receive emergency department (ED) treatment but utilized EMS transport.

Methods

Patients who used EMS but did not receive ED treatment were classified into non-intoxicated and intoxicated groups. Reasons for not receiving ED treatment were categorized according to whether the decision was made by the patient against medical advice or if the decision was based on a physician’s evaluation and their recommendations.

Results

There were 212 patients reviewed; 120 in the non-intoxicated group and 92 in the intoxicated group. The intoxicated group had a higher proportion of males than the non-intoxicated group. The most common cause of non-disease symptoms in the intoxicated group was assault. In the non-intoxicated group, the most common reason for the lack of ED treatment was that treatment could take place on an outpatient basis, while in the intoxicated group, the reason was lack of patient cooperation.

Conclusions

The intoxicated group was older, male and more likely to present with symptoms not related to a disease process than those in the non-intoxicated group when using unnecessary EMS transport.

Challenges and Opportunities to Engaging Emergency Medical Service Providers in Substance Use Research: A Qualitative Study

Introduction Research suggests Emergency Medical Services (EMS) over-use in urban cities is partly due to substance users with limited access to medical/social services. Recent efforts to deliver brief, motivational messages to encourage these individuals to enter treatment have not considered EMS providers. Problem Little research has been done with EMS providers who serve substance-using patients. The EMS providers were interviewed about participating in a pilot program where they would be trained to screen their patients for substance abuse and encourage them to enter drug treatment.

METHODS

Qualitative interviews were conducted with Baltimore City Fire Department (BCFD; Baltimore, Maryland USA) EMS providers (N=22). Topics included EMS misuse, work demands, and views on participating in the pilot program. Interviews were transcribed and analyzed using grounded theory and constant-comparison.

RESULTS

Participants were mostly white (68.1%); male (68.2%); with Advanced Life Skills training (90.9%). Mean age was 37.5 years. Providers described the "frequent flyer problem" (eg, EMS over-use by a few repeat non-emergent cases). Providers expressed disappointment with local health delivery due to resource limitations and being excluded from decision making within their administration, leading to reduced team morale and burnout. Nonetheless, providers acknowledged they are well-positioned to intervene with substance-using patients because they are in direct contact and have built rapport with them. They noted patients might be most receptive to motivational messages immediately after overdose revival, which several called "hitting their bottom." Several stated that involvement with the proposed study would be facilitated by direct incorporation into EMS providers' current workflow. Many recommended that research team members accompany EMS providers while on-call to observe their day-to-day work. Barriers identified by the providers included time constraints to intervene, limited knowledge of substance abuse treatment modalities, and fearing negative repercussions from supervisors and/or patients. Despite reservations, several EMS providers expressed inclination to deliver brief motivational messages to encourage substance-using patients to consider treatment, given adequate training and skill-building.

CONCLUSIONS

Emergency Medical Service providers may have many demands, including difficult case time/resource limitations. Even so, participants recognized their unique position as first responders to deliver motivational, harm-reduction messages to substance-using patients during transport. With incentivized training, implementing this program could be life- and cost-saving, improving emergency and behavioral health services. Findings will inform future efforts to connect substance users with drug treatment, potentially reducing EMS over-use in Baltimore. Maragh-Bass AC , Fields JC , McWilliams J , Knowlton AR . Challenges and opportunities to engaging Emergency Medical Service providers in substance use research: a qualitative study. Prehosp Disaster Med. 2017;32(2):148-155.

Pediatric Use of Emergency Medical Services: The Role of Chronic Illnesses and Behavioral Health Problems

OBJECTIVE

The increasing use of prehospital emergency medical services (EMS) and its contribution to rising emergency department use and healthcare costs point to the need for better understanding factors associated with EMS use to inform preventive interventions. Understanding patient factors associated with pediatric use of EMS will inform pediatric-specific intervention. We examined pediatric patient demographic and health factors associated with one-time and repeat use of EMS.

METHODS

We reviewed data from Baltimore City Fire Department EMS patient records over a 23-month period (2008-10) for patients under 21 years of age (n = 24,760). Repeat use was defined as involvement in more than one EMS incident during the observation period. Analyses compared demographics of EMS users to the city population and demographics and health problems of repeat and one-time EMS users. Health comparisons were conducted at the patient and incident levels of analysis.

RESULTS

Repeat users (n = 1,931) accounted for 9.0% of pediatric users and 20.8% of pediatric incidents, and were over-represented among the 18-20 year age group and among females. While trauma accounted for approximately one-quarter of incidents, repeat versus one-time users had a lower proportion of trauma-related incidents (7.2% vs. 26.7%) and higher proportion of medical-related incidents (92.6% vs. 71.4%), including higher proportions of incidents related to asthma, seizures, and obstetric/gynecologic issues. In patient-level analysis, based on provider or patient reports, greater proportions of repeat compared to one-time users had asthma, behavioral health problems (mental, conduct and substance use problems), seizures, and diabetes.

CONCLUSIONS

Chronic somatic conditions and behavioral health problems appear to contribute to a large proportion of the repeat pediatric use of this EMS system. Interventions may be needed to engage repeat users in primary care and behavioral health services, to train EMS providers on the recognition and management of behavioral health emergencies, and to improve family care and self-management of pediatric asthma and other chronic conditions.

Epidemiology of Pediatric Prehospital Basic Life Support Care in the United States

Children have unique medical needs compared to adults. Emergency medical services personnel need proper equipment and training to care for children. The purpose of this study is to characterize emergency medical services pediatric basic life support to help better understand the needs of children transported by ambulance. Pediatric basic life support patients were identified in this retrospective descriptive study. Descriptive statistics were used to examine incident location, possible injury, cardiac arrest, resuscitation attempted, chief complaint, primary symptom, provider's primary impression, cause of injury, and procedures performed during pediatric basic life support calls using the largest aggregate of emergency medical services data available, the 2013 National Emergency Medical Services Information System (NEMSIS) Public Release Research Data Set. Pediatric calls represented 7.4% of emergency medical services activations. Most pediatric patients were male (49.8%), White (40.0%), and of non-Hispanic origin (56.5%). Most incidents occurred in the home. Injury, cardiac arrest, and resuscitation attempts were highest in the 15 to 19 year old age group. Global complaints (37.1%) predominated by anatomic location and musculoskeletal complaints (26.9%) by organ system. The most common primary symptom was pain (30.3%) followed by mental/psychiatric (13.4%). Provider's top primary impression was traumatic injury (35.7%). The most common cause of injury was motor vehicle accident (32.3%). The most common procedure performed was patient assessment (27.4%). Median EMS system response time was 7 minutes (IQR: 5-12). Median EMS scene time was 12 minutes (IQR: 8-19). Median transport time was 14 minutes (IQR: 8-24). Median EMS total call time was 51 minutes (IQR: 33-77). The epidemiology of pediatric basic life support can help to guide efforts in both emergency medical services operations and training.

Patient safety in ambulance services: a scoping review

Background

The role of ambulance services has changed dramatically over the last few decades with the introduction of paramedics able to provide life-saving interventions, thanks to sophisticated equipment and treatments available. The number of 999 calls continues to increase, with adverse events theoretically possible with each one. Most patient safety research is based on hospital data, but little is known concerning patient safety when using ambulance services, when things can be very different. There is an urgent need to characterise the evidence base for patient safety in NHS ambulance services.

Objective

To identify and map available evidence relating to patient safety when using ambulance services.

Design

Mixed-methods design including systematic review and review of ambulance service documentation, with areas for future research prioritised using a Delphi process.

Setting and participants

Ambulance services, their staff and service users in UK.

Data sources

A wide range of data sources were explored. Multiple databases, reference lists from key papers and citations, Google and the NHS Confederation website were searched, and experts contacted to ensure that new data were included in the review. The databases MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Science Direct, Emerald, Education Resources Information Center (ERIC), Applied Social Sciences Index and Abstracts, Social Services Abstracts, Sociological Abstracts, International Bibliography of the Social Sciences (IBSS), PsycINFO, PsycARTICLES, Health Management Information Consortium (HMIC), NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED),Health Technology Assessment, the FADE library, Current Awareness Service for Health (CASH), OpenDOAR (Directory of Open Access Repositories) and Open System for Information on Grey Literature in Europe (OpenSIGLE) and Zetoc (The British Library's Electronic Table of Contents) were searched from 1 January 1980 to 12 October 2011. Publicly available documents and issues identified by National Patient Safety Agency (NPSA), NHS Litigation Authority (NHSLA) and coroners’ reports were considered. Opinions and perceptions of senior managers, ambulance staff and service users were solicited.

Review methods

Data were extracted from annual reports using two-stage thematic analysis, data from quality accounts were collated with safety priorities tabulated and considered using thematic analysis, NPSA incident report data were collated and displayed comparatively using descriptive statistics, claims reported to NHSLA were analysed to identify number and cost of claims from mistakes and/or poor service, and summaries of coroners’ reports were assessed using thematic analysis to identify underlying safety issues. The depth of analysis is limited by the remit of a scoping exercise and availability of data.

Results

We identified studies exploring different aspects of safety, which were of variable quality and with little evidence to support activities currently undertaken by ambulance services. Adequately powered studies are required to address issues of patient safety in this service, and it appeared that national priorities were what determined safety activities, rather than patient need. There was inconsistency of information on attitudes and approaches to patient safety, exacerbated by a lack of common terminology.

Conclusion

Patient safety needs to become a more prominent consideration for ambulance services, rather than operational pressures, including targets and driving the service. Development of new models of working must include adequate training and monitoring of clinical risks. Providers and commissioners need a full understanding of the safety implications of introducing new models of care, particularly to a mobile workforce often isolated from colleagues, which requires a body of supportive evidence and an inherent critical evaluation culture. It is difficult to extrapolate findings of clinical studies undertaken in secondary care to ambulance service practice and current national guidelines often rely on consensus opinion regarding applicability to the pre-hospital environment. Areas requiring further work include the safety surrounding discharging patients, patient accidents, equipment and treatment, delays in transfer/admission to hospital, and treatment and diagnosis, with a clear need for increased reliability and training for improving handover to hospital.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Emergency medical services system utilization over the last 10 years: what predicts transport of children?

OBJECTIVE

The aim of this study was to determine the predictors of pediatric ambulance transport and evaluate changes in utilization over a 10-year period.

METHODS

The National Health Ambulatory Medical Care Survey emergency department (ED) data for visits by children aged younger than 19 years from 2000 to 2009 were analyzed using logistic regression. Age, ethnicity, race, sex, triage level, time of arrival, injury/poisoning, insurance, disposition, critical patient status, metropolitan statistical area (MSA), region, and hospital type were used to predict the mode of arrival (ambulance or nonambulance). Significant variables were evaluated for trends over time.

RESULTS

Representing 209 million ED visits, 60,761 records were analyzed. Ambulance transport was more likely among children who were aged 12 to 18 years (P < 0.05), black (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.06-1.38), evaluated for an injury/poisoning (OR, 3.03; 95% CI, 2.75-3.34), publicly insured (OR, 1.16; 95% CI, 1.03-1.31), living in an MSA (OR, 1.73; 95% CI, 1.34-2.23), living in the northeast (P < 0.05), and overnight arrivals (OR, 1.47; 95% CI, 1.26-1.7). They were more likely to have an urgency of less than 15 minutes (OR, 4.46; 95% CI, 3.56-5.59), require admission (OR, 2.82; 95% CI, 2.33-3.41), and considered critical (OR, 5.15; 95% CI, 3.43-7.73). There was no significant change in ambulance utilization in children; however, about half of critical patients and over 80% of those with a high triage level did not arrive by ambulance.

CONCLUSIONS

Ambulance transport to the ED is used more often by teens, blacks, publicly insured, overnight arrivals, and those living in an MSA or the northeast. It is concerning that many children triaged with a high urgency or requiring critical care did not arrive by ambulance.

Route less travelled? Ambulance use for children with high-acuity acute illness

AIM

Ambulance transportation offers important supportive care and treatment en route to definitive treatment. However, children may be at risk of under-utilising ambulance transportation, where private vehicle is possible. This study aims to determine how many of the sickest children present to hospitals in Auckland via ambulance and whether certain population groups are lower users of ambulance services.

METHODS

Transportation, demographic and outcome data were collected and analysed for children presenting to Starship Children's Health (Starship) from 1 January to 31 December 2011), who were 'self referrals' to hospital, less than 15 years of age, and assigned triage category 1 and 2 on presentation.

RESULTS

There were 1047 presentations to Starship identified that met inclusion criteria. Of these, 256 of the 341 triage one presentations (75.1%) and 217 of the 706 triage two presentations (30.7%) were transported by ambulance.Ambulance use was higher among older children (P < 0.001). Severity of illness or injury, as estimated by admission rates (56.7% vs. 43.3%, P = 0.21) and length of hospital stay (median = 1 day, P = 0.92), did not differ significantly by mode of transportation. There was no observed relationship with gender, ethnicity or area deprivation index score.

CONCLUSION

A significant proportion of acutely unwell children presenting to hospital were not transported by ambulance, particularly those aged less than 1 year. This has the potential to result in worse health outcomes. There were no identified associations with patient demographics, and further research is required to better understand this problem and develop solutions.

How well do General EMS 911 dispatch protocols predict ED resource utilization for pediatric patients?

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.

Judging a patient's decision to seek emergency healthcare: clues for managing increasing patient demand

OBJECTIVE

In recent years, the concept of an 'inappropriate' emergency department or ambulance user has arisen. This discussion paper explores definition and measurement of inappropriate emergency healthcare utilisation, and the effect on demand.

METHOD

A comprehensive literature review of published articles was conducted.

RESULTS

Exploration of the definitions of 'inappropriate' emergency healthcare utilisation identified two patient cohorts; emergency healthcare utilisation by those who are not experiencing a health emergency, and those who do not seek emergency healthcare who should. Several position papers from Australian and international sources emphasised the patient's right to access emergency healthcare when they feel the need, and the responsibility of emergency healthcare workers to provide treatment to all patients. Differences between medical classifications of urgency based on physiological measures are contrasted with patient-based determination of urgency, which is defined by psychosocial factors.

CONCLUSIONS

This literature review raises questions about patients' understanding of the role of emergency healthcare services in an emergency. This has implications for determining the patient's point of access to the health system in an acute health event, and offers an opportunity to selectively educate patients and carers to change help-seeking behaviours to suit the health system resources and moderate patient demand.

Medical necessity in emergency medical services transports

The purpose of this study was to generate national estimates of the prevalence of medically unnecessary emergency medical services (EMS) transports to emergency departments (EDs) over time and to identify characteristics that may be associated with medically unnecessary transports. A previously published algorithm was applied to operationalize medical necessity based on ED diagnosis to 10 years of data from the National Hospital Ambulatory Medical Care Survey. The trend over time was reported using descriptive statistics weighted to produce national estimates. Nationally, the proportion of EMS transports that were medically unnecessary increased from 13% to 17% over the 10-year study period. Individual demographic characteristics, including insurance status, were not predictive of inappropriate utilization. EMS transports for medically unnecessary complaints increased from 1997 to 2007. Our findings from a nationally representative sample highlight the opportunity for alternative patient delivery strategies for select patients seeking EMS services.

"Inappropriate" pediatric emergency medical services utilization redefined

OBJECTIVES

Previous reports on emergency medical services (EMS) transportation of pediatric patients have demonstrated a high rate of overutilization. However, there is also a concern that pediatric patients may underutilize EMS for emergencies that might benefit from EMS. This article compares EMS utilization rate between adult and pediatric patients for high-acuity patients and for the most common reasons for transport.

METHODS

This study was a secondary analysis of the National Hospital Ambulatory Medical Care Survey to compare hospital arrival by EMS to walk-in arrivals. Primary variables were age category, mode of arrival, immediacy to be seen (triage category), reason for visit, and disposition.

RESULTS

There were 253,898 records, weighted to represent 914.4 million emergency department visits, included. Emergency medical services mode of arrival was significantly higher for adult patients at 19.1% as compared with pediatric patients at 6.5% (odds ratio, 3.38). For the subgroup of patients requiring critical care interventions, adult patient arrival by EMS was 87.3% as compared with pediatric patients at 66.3% (odds ratio, 3.50). When considering the top 20 most common medical complaints in which pediatric patients used EMS transport, adult patients utilized EMS more frequently in 85% (17/20) of those complaints.

CONCLUSIONS

As compared with adults, pediatric patients are less likely to utilize EMS for transport to the hospital for both routine and emergent complaints. The definition of inappropriate utilization of EMS for pediatric transport, which has largely focused on inappropriate overutilization, should also incorporate the potential of underutilization for critical patients.

Using genetic algorithms to optimise current and future health planning--the example of ambulance locations

Background

Ambulance response time is a crucial factor in patient survival. The number of emergency cases (EMS cases) requiring an ambulance is increasing due to changes in population demographics. This is decreasing ambulance response times to the emergency scene. This paper predicts EMS cases for 5-year intervals from 2020, to 2050 by correlating current EMS cases with demographic factors at the level of the census area and predicted population changes. It then applies a modified grouping genetic algorithm to compare current and future optimal locations and numbers of ambulances. Sets of potential locations were evaluated in terms of the (current and predicted) EMS case distances to those locations.

Results

Future EMS demands were predicted to increase by 2030 using the model (R² = 0.71). The optimal locations of ambulances based on future EMS cases were compared with current locations and with optimal locations modelled on current EMS case data. Optimising the location of ambulance stations locations reduced the average response times by 57 seconds. Current and predicted future EMS demand at modelled locations were calculated and compared.

Conclusions

The reallocation of ambulances to optimal locations improved response times and could contribute to higher survival rates from life-threatening medical events. Modelling EMS case 'demand' over census areas allows the data to be correlated to population characteristics and optimal 'supply' locations to be identified. Comparing current and future optimal scenarios allows more nuanced planning decisions to be made. This is a generic methodology that could be used to provide evidence in support of public health planning and decision making.

D ERIVATION OF E MERGENCY M EDICAL S ERVICES D ISPATCH C ODES A SSOCIATED WITH L OW - ACUITY P ATIENTS

OBJECTIVE

To identify emergency medical services (EMS) dispatch codes associated with basic life support (BLS) level of prehospital care, a proxy for low illness acuity.

METHODS

This retrospective cohort study was conducted in an urban city with a single advanced life support level EMS provider. The 911 center was certified in using dispatch protocols from Priority Dispatch Corporation (Salt Lake City, UT). Dispatch data on all transported EMS patients from August 2001 to April 2002 were abstracted. The authors prospectively defined a low-acuity patient as one who received BLS-level care and defined a low-acuity dispatch code as one in which at least 90% of coded patients required only BLS care. For each dispatch code or code group, the authors calculated the fraction of patients who received BLS-level care. For each "A"-level (lowest category) dispatch code group, the fraction of patients receiving BLS-level care was also evaluated.

RESULTS

A total of 19,332 calls met inclusion criteria and were categorized into 118 dispatch codes or code groups. Twenty-eight codes or code groups with 7,801 patients met the authors' definition of low acuity. Overall, 7,394 patients received only BLS care (94.8%, 95% confidence interval: 94.3%-95.3%). Analysis of "A"-level dispatch code groups found BLS use rates of 52.8% to 99.3%.

CONCLUSIONS

Certain dispatch codes are associated with the delivery of BLS-level care, indicating identification of patients likely to be low acuity. These codes are not necessarily "A"-level dispatch codes, which are commonly considered to represent the lowest-acuity patients. Future studies are needed to prospectively validate that these codes do represent low-acuity patients.

Path Analysis Modeling Indicates Free Transport Increases Ambulance Use for Minor Indications

INTRODUCTION

Clinically unnecessary ambulance transport is increasing, diverting limited resources from patients needing ambulance transport. It was anecdotally observed that inappropriate ambulance use increased after abolition of a direct patient cost for ambulance transport.

HYPOTHESIS

In July 2003, direct patient fees were abolished in favor of a universally applied ambulance levy, potentially leading to increased ambulance use by patients with low illness acuity and admission rates.

METHODS

The influence of age, illness acuity, and need for admission on ambulance use was assessed for 55,397 emergency department attendances in 2002 and 2004. Ambulance users were compared with nonusers in both years and attendances for 2002 compared with 2004 using chi-square test for two groups. Logistic regression provided a multivariate model leading to ambulance use. Path analysis modeling to assess interrelationships between factors associated with ambulance use was developed.

RESULTS

Ambulance users in both years were older, had more acute illness, and had greater need for admission compared with nonusers. The odds ratio (OR) of arrival by ambulance in 2004 compared with 2002 was 1.14 (95% confidence interval, [CI], 1.12 to 1.17). In 2002, ambulance users were older (OR, 1.42; 95% CI, 1.40 to 1.43), were more likely to need admission (OR, 2.28; 95% CI, 2.16 to 2.4) and had higher illness acuity (OR, 2.02; 95% CI, 1.94 to 2.09). There was a negative correlation between 2004 and illness acuity.

CONCLUSIONS

Ambulance use increased in 2004 after patient transport fees were abolished. Increased use was associated with decreased age, clinical acuity, and admission need. Abolishing direct patient cost stimulates ambulance use, potentially including inappropriate transport. Path analysis to assess the effect of changed funding on ambulance use could be used to the influence of other locally relevant factors contributing to ambulance use.

VALIDATION OF USING EMS DISPATCH CODES TO IDENTIFY LOW-ACUITY PATIENTS

OBJECTIVE

To validate the predictive ability of previously derived emergency medical services (EMS) dispatch codes to identify patients with low-acuity illnesses.

METHODS

This prospective descriptive study was conducted in Rochester, New York. An expert panel reviewed and modified a previously derived set of low-priority EMS dispatch codes. Patients assigned these 21 codes between July 2002 and June 2003 were included for further analysis. Dispatch data and level of EMS care were recorded for each dispatch code. The proportion of low-acuity patients (i.e., those who received only basic life support (BLS) care or those who were not transported using lights and sirens) was determined using previously established definitions. Codes were defined as associated with low-acuity patients if the lower bound of the 95% confidence interval (CI) exceeded 90%. Medical records for patients identified as high-acuity were reviewed to evaluate whether the advanced life support (ALS) level care that was provided had a clinical impact.

RESULTS

Emergency medical services cared for 43,602 patients during the study, and 7,540 were dispatched as low-priority. We found that 7,197 (95%; 95% CI: 95-96%) of these patients met low-acuity criteria and that 11 of the evaluated codes were validated, with low-acuity care provided at least 90% of the time. Of the 343 patients identified as high-acuity, 62 (18%; 95% CI: 14-23%) were determined to have received interventions that had a clinical impact.

CONCLUSIONS

This study prospectively validates 11 EMS dispatch codes as being associated with low-acuity patients. These codes could be used to triage EMS patients based on dispatch information.

The epidemiology of emergency medical services use by children: an analysis of the National Hospital Ambulatory Medical Care Survey

OBJECTIVE

There is an absence of nationally representative data describing pediatric patients who use emergency medical services (EMS) and the factors associated with EMS use by children. This study characterizes pediatric emergency department (ED) visits for which the patient arrived by EMS and identifies factors associated with those visits using a nationally representative database.

METHODS

A secondary analysis of the ED component of the 1997-2000 National Hospital Ambulatory Medical Care Survey was performed. The dependent variable was the mode of arrival to the ED (EMS vs. not EMS), and independent variables were grouped into four domains: demographic, clinical, system, and service characteristics. Bivariate analyses and multivariate logistic regression analyses were conducted.

RESULTS

There were 110.9 million ED visits by children aged<19 years between 1997 and 2000. Pediatric patients constituted 27.3% of all ED visits during this time, and 7.9 million (7.1%) of these patients arrived via EMS. Pediatric patients represented 13% of all EMS transports. The annual EMS utilization rate by children was 26 per 1,000, compared with 66 per 1,000 in the adult population (p<0.001). Sixteen percent of children transported by EMS were admitted to the hospital. Sixty-two percent of pediatric patients arriving at the ED by EMS were transported as a result of injury or poisoning. Characteristics significantly associated with arrival by EMS in the final multivariate model included demographic (age, African American race, urban residence), clinical (need for greater immediacy of care, illnesses associated with certain diagnoses), and service (greater number of diagnostic services) variables.

CONCLUSIONS

Pediatric patients transported by EMS are more likely to have injuries and poisoning, and have higher-acuity illness than those arriving at the ED by other means. The epidemiology of pediatric EMS use may have important operational, training, and public health implications and requires further study.

Why are people without medical needs transported by ambulance? A study of indications for pre-hospital care

OBJECTIVE

The purpose of this report was to describe the characteristics of patients transported by ambulance, in spite of being evaluated by the ambulance staff at the scene as not requiring prehospital care. A second aim was to compare these patients with those judged as being in need of this care.

METHODS

Three ambulance service districts located in different rural and metropolitan geographical areas were included in the study and all three were covered by a single emergency dispatch centre. Following the dispatch of ambulances, the staff assessed and recorded the medical needs of the patients at the scene, according to a questionnaire developed for the study. In addition to the questionnaire, data were extracted from the ambulance medical records database for each patient. If the patients were just transported by ambulance without receiving any other prehospital intervention, they were assessed as not being in need of the emergency service. The evaluation included events at the scene and during transportation. The ambulance staff making the needs assessments were emergency medical technicians and registered nurses. In this report, 604 patients who did not require prehospital care are described and compared with the remaining group of patients who required this care (1373). For analysis, descriptive statistics were used to analyse the data.

RESULTS

The ambulance staff assessed that, among patients reported by the emergency medical dispatch centre as having abdominal or urinary problems, 42% did not need the ambulance service. Even among intrahospital transports (patients for whom medical personnel made the request for an ambulance), 45% did not require ambulance transport, as judged by the ambulance staff. Among patients reported by the emergency medical dispatch centre as having chest pain or other heart symptoms or trauma/accidents, respectively, only small percentages (18%) and (17%) did not require the ambulance service, as assessed by the ambulance staff. Most of the patients without obvious medical needs had been allocated an ambulance response for nonurgent conditions, that is priority level 2 or 3, but patients without medical needs were even found at the highest priority level 1. Of the patients who did not require an ambulance, more than half (55%) would have been able to get to a hospital in their own car or by taxi, whereas the remainder of the patients needed a transport vehicle in which they could lie down, but which was not equipped and staffed like an ambulance.

CONCLUSION

Among the patients transported by the emergency medical service system in the study areas, a significant percentage were judged by the ambulance staff as not being in need of prehospital interventions. The majority were transported by a fully equipped emergency medical ambulance to an emergency medical department at a hospital, without requiring any prehospital interventions either at the scene or during transportation. The emergency medical service organization has to develop clear criteria for the utilization of ambulance services that can be accepted and implemented by the dispatch centres and by healthcare personnel. These criteria need to include safety margins and at the same time enable the appropriate use of resources.

Management and outcomes of pediatric patients transported by emergency medical services in a Canadian prehospital system

OBJECTIVES

There is uncertainty around the types of interventions that are provided by emergency medical services (EMS) to children during prehospital transport. We describe the patient characteristics, events, interventions provided and outcomes of a cohort of children transported by EMS.

METHODS

This prospective cohort study was conducted in a city of 750 000 people with a 2-tiered EMS system. All children <16 years of age who were attended by EMS during a 6-month period were enrolled. Data were extracted from ambulance call reports and hospital charts, and analyzed using descriptive statistics.

RESULTS

During the study period there were 1377 pediatric EMS calls. Mean age was 8.2 years (standard deviation 5.4), and the most Common diagnoses were trauma (44.9%), seizure (11.8%) and respiratory distress (8.8%). The ambulance return code was Urgent in 7%, Prompt in 57%, Deferrable in 8% and Not Transported in 28%. Fifty-six percent received either an Advanced Life Support or Basic Life Support prehospital intervention. Common procedures included cardiac monitoring (20.0%), oxygen administration (19.8%), blood glucose monitoring (16.3%), spine board (12.2%), limb immobilization (11.1%) and cervical collar (10.0%). Uncommon procedures included administering medications intravenously (IV) (1.4%), bag-valve-mask ventilation (0.3%) and endotracheal intubation (0.1%). Seventy-eight percent of attempted IV lines were successful. Only 9.0% of EMS-transported children were admitted to hospital, and 2.2% were admitted to the intensive care unit.

CONCLUSIONS

This first study of Canadian pediatric prehospital interventions shows a high rate of non-transport, and a low rate of Urgent transports and hospital admissions for children. Very few children receive prehospital airway management, ventilation or IV medications; consequently EMS personnel have little opportunity to maintain these pediatric skills in the field.

Paramedic initiated non-transport of pediatric patients

INTRODUCTION

In a time of emergency department overcrowding and increased utilization of emergency medical services, a highly functional prehospital system will balance the needs of the individual patient with the global needs of the community. Our community addressed these issues through the development of a multitiered prehospital care system that incorporated EMS initiated non-transport of pediatric patients.

OBJECTIVE

To describe the outcome of pediatric patients accessing a progressive prehospital system that employed EMS initiated non-transport.

METHODS

A prospective observational case series was performed on pediatric patients (< 21 years old) designated EMS initiated non-transport. Patients were designated non-transport after an initial EMS protocol driven, complaint-specific clinical assessment in conjunction with medical oversight affirmation. Telephone follow-up was completed on all consecutively enrolled non-transport patients to collect information about outcome (safety) as well as overall satisfaction with the system. A five-point Likert scale was utilized to rate satisfaction.

RESULTS

There were 5,336 EMS requests during the study period. Seven hundred and four were designated non-transport, of which 74.8% completed phone follow-up. Categories of EMS request included minor; medical illness 43.4%, trauma 55.9%, and other 1.1%. There were 13 admissions (2.4%) to the hospital after EMS initiated non-transport designation. Admissions after non-transport had trends toward younger age (p = 0.002) and medical etiology (p = 0.006). There were no PICU admissions or deaths.

CONCLUSION

Our EMS system provides an alternative to traditional protocols, allowing EMS initiated non-transport of pediatric patients, resulting in effective resource utilization with a high level of patient safety and family satisfaction.

Medically unnecessary emergency medical services (EMS) transports among children ages 0 to 17 years

OBJECTIVES

Estimate the prevalence of medically unnecessary Emergency Medical Services (EMS) transports among children.

METHODS

We linked EMS and emergency department (ED) billing records for all EMS-to-hospital transports of children originating in three counties in South Carolina between January 1, 2001 and March 31, 2003. EMS responses resulting in no transport, transports to destinations other than the ED, or multiple trips for the same child in a single day could not be linked to ED data and were excluded. Medically unnecessary transports were identified with an algorithm using pre-hospital impressions, ED diagnoses and ED procedures. After exclusions, 5,693 transports of children between 0 and 17 years were available for study.

RESULTS

Sixteen percent (16.4%) of all transports were medically unnecessary. Among children through age 12, upper respiratory and viral problems were the most common diagnoses associated with medically unnecessary transports; among older children, behavioral problems such as conduct disturbance or drug abuse were common. In multivariable analysis, the odds of an unnecessary transport were higher among younger children, non-white children, rural children, and children insured by Medicaid.

CONCLUSIONS

The proportion of EMS transports which may be medically unnecessary is relatively modest compared to previous studies. However, many questions remain for future research. Further investigation should include examination of primary care availability and occurrence of unnecessary EMS use, existence of race-based disparities, and transports involving conduct disturbance and other behavioral conditions among children.

Prospective determination of medical necessity for ambulance transport by paramedics

OBJECTIVE

It has been estimated that between 11% and 61% of ambulance transports to emergency departments are not medically necessary. This study's objective was to analyze paramedic ability to determine the medical necessity of ambulance transport to the emergency department.

METHODS

Paramedics prospectively assessed adult patients transported to an emergency department during a six-week period. The setting was an urban, all advanced life support, public utility model emergency medical services (EMS) system with 58,000 transports per year. Paramedics determined medical necessity of patient transport based on the following five criteria: 1) need for out-of-hospital intervention; 2) need for expedient transport; 3) potential for self-harm; 4) severe pain; or 5) other. On arrival in the emergency department, the emergency physician made a blinded determination based on the same criteria. Kappa statistics were used to assess agreement.

RESULTS

Data forms were completed on 825 of 1,420 (58%) patients transported. Emergency physicians determined 248 (30%) transports were not necessary, paramedics 236 (29%), with agreement in 76.2% (K=0.42) of cases. Paramedics undertriaged 92 patients (11%). Rates of agreement on the five criteria were: 1) 71.9% (K=0.43); 2) 77.7% (K=0.22); 3) 89.6% (K=0.40); 4) 89.6 (K=0.32); and 5) 82.2% (K=0.29).

CONCLUSIONS

Paramedics and emergency physicians agreed that a significant percentage of patients did not require ambulance transport to the emergency department. Despite only moderate agreement regarding which patients needed transport, the undertriage rate was low.

Is it possible to safely triage callers to EMS dispatch centers to alternative resources?

OBJECTIVES

To develop guidelines allowing emergency medical services (EMS) dispatchers to safely match callers to an EMS response or, alternatively, to a nontraditional resource.

METHODS

This was a prospective cohort study of callers to an urban EMS dispatch center and an associated review of EMS patient care forms and emergency department (ED) patient care records. The following five "nature codes" (patient chief complaints) were included: back pain, fall, bleeding or laceration, sick, and trauma. Callers included in the study had been assigned the lowest severity level (Alpha), according to existing dispatch criteria. An a priori list of EMS and ED "important findings," indicating need for an EMS response, was used as the outcome variable. Classification and regression tree (CART) analysis was used to develop a decision rule to further identify a low-risk subgroup of patients who could potentially be served by alternative resources.

RESULTS

From November 1, 1998, to May 31, 1999, 656 subjects were entered into the study, including 263 males (40%) and 389 females (59%). The mean age was 51 years (range, 0-101 years). One hundred twenty-five (19%) callers had an important EMS finding, including the administration of comfort medications, morphine, benzodiazepines, and droperidol. Forty-six subjects (7%) had an important ED finding. When EMS and ED findings were combined, 158 subjects (24%) had an "important finding." Using CART analysis, having an age <12 years predicted a subset of patients who did not have an important finding suggesting the need for an EMS response. Using cross-validation, this decision rule had a 99% sensitivity, 13% specificity, and 98% negative predictive value.

CONCLUSION

The authors were able to use a demographic variable (age) to predict a population of callers to a 911 dispatch center triaged to the lowest acuity category, who have a very low risk of having an EMS or ED important finding. The decision rule developed here is preliminary, requiring further validation.

Predicted utilization of emergency medical services telemedicine in decreasing ambulance transports

OBJECTIVE

To determine predicted utilization, decrease in ambulance transports, and target population for emergency medical services (EMS) if telemedicine capabilities were available to the medic units in the field.

METHODS

A retrospective chart review of 345 consecutive ambulance transports to four hospitals (Level I urban trauma center, urban tertiary care center, children's hospital and suburban community hospital) was performed by a panel of three board-certified emergency medicine physicians experienced and credentialed in emergency telemedicine. They independently reviewed the emergency department (ED) and EMS records and were asked to determine whether patients required ambulance transport for evaluation or whether disposition could be made following paramedic and emergency physician assessment via telemedicine. A five-point Likert scale was used to grade feasibility of telemedicine disposition (definitely yes, probably yes, maybe, probably no, definitely no). Other variables analyzed included age, sex, race, chief complaint, phone, private medical doctor, and call location by patient zip code, call site, and receiving hospital.

RESULTS

In 14.7% of cases (6% definitely yes and 8.7% probably yes), disposition could be made without transport using telemedicine. The age range for eliminating transport was 2 weeks through 92 years, with mean age of 26.6 years. Under the age of 50 years, 46 out of 238 patients (19.3%) could have possibly been managed by telemedicine.

CONCLUSION

Use of EMS telemedicine could result in an approximately 15% decrease in ambulance transports when it alone is added to the prehospital care provider's armamentarium. Emphasis for implementation should be placed on younger patients and an identified subset of chief complaints conducive to management using telemedicine.

Emergency ambulance dispatch: is there a case for triage?

Emergency telephone calls for an ambulance (999 calls) are usually dealt with first-come first-served. We have devised and assessed criteria that ambulance dispatch might use to prioritize responses. Data were collected retrospectively on consecutive patients presenting to an accident and emergency (A&E) department after a 999 call. An unblinded researcher abstracted data including age, date, time, caller, location, reason for call and A&E diagnosis and each case was examined for ten predetermined criteria necessitating an immediate ambulance response--namely, cardiac arrest; chest pain; shortness of breath; altered mental status/seizure; abdominal/loin pain >65 years old; fresh haematemesis; fall >2m; stabbing; major burns. 471 patients were recruited, 55% male, median age 50 years. 406 calls came from bystanders or the patients themselves, 36 from general practitioners, 8 from other hospitals and 21 from the police. 52% of patients were admitted. 44% met at least one of the above criteria. Most patients did not meet the criteria for an immediate ambulance response but might nonetheless be suitable for an urgent response. The criteria used in this study have the advantage of being based on the history provided by the caller. The introduction of a priority-based dispatch system could reduce response times to those who are seriously ill, and also improve road safety.