Triage, transportation, and destination decisions by out-of-hospital emergency care providers.

INTRODUCTION: The effectiveness of a tiered emergency medical services system often hinges upon the ability of initial care providers with little or no formal training to identify emergent patient needs and determine the best means to meet those needs. OBJECTIVES: To determine if out-of-hospital emergency care providers consistently make appropriate triage, transportation, and destination decisions; and to determine if experience and training have an effect on these decisions. METHODS: A survey consisting of 14 patient-care scenarios was administered to certified and non-certified out-of-hospital emergency-care providers (n = 311) from 20 randomly selected EMS agencies. These agencies were part of EMS systems that utilize one, two, and three tiered responses by ambulance and fire-based commercial, municipal, and volunteer agencies. Participants were asked to select the most appropriate mode of transport and destination facility using the assumption that they had responded to each scenario in a basic life support ambulance. Answers included transporting the patient to various receiving facilities or requesting a more advanced-level unit to respond to the scene. Transport times to receiving facilities and estimated times of arrival for advanced-level units were provided with each choice. Eight emergency physicians unanimously had agreed upon the most appropriate answer for each scenario. A two-tailed t-test was used to compare the scores of the certified and non-certified groups; and Spearman's Correlation Coefficients were used to test the effects of experience and training. RESULTS: Non-certified providers (n = 108) had a mean score of 32.6% or 4.6 (SD = 1.84) correct answers; certified providers (n = 203) had a mean score of 41.1% or 5.76 (SD = 2.12) correct answers (p < 0.000001). Spearman's Correlation Coefficients were: 1) individual provider level--(0.3978); 2) agency provider level--(0.2741); 3) hours worked per week--(0.2505); 4) years in EMS--(-0.0821); 5) commercial or volunteer provider--(0.2398); 6) agency call volume--(0.2012); 7) agency location--(0.0685), and 8) transporting versus non-transporting agency--(0.2523). CONCLUSIONS: A need exists for further education of out-of-hospital emergency care providers with respect to triage, transportation, and destination decisions. Provider experience and level of certification do not appear to affect these critical patient-care decisions.     

FIELD TRIAGE SYSTEMS: METHODOLOGIES FROM THE LITERATURE

The primary goal of the Neely Conference project is to work toward defining a set of research criteria for medical necessity in emergency medical services (EMS). This paper reviews the extant literature on triage and non-transport decisions made in the field by EMS personnel, with emphasis on the methodologies that have been used to date. Two types of medical necessity standards are considered. First, there are triage criteria for determining whether a given patient requires EMS transport to the hospital, or whether an alternative might be appropriate. These triage criteria might be incorporated into protocols that field personnel could apply on scene to determine the best disposition for a given patient. Second, there are the outcome measures against which the decisions made by the field personnel are judged. In some cases, the outcome measure is the judgment of a reviewing emergency physician or nurse, while in others specific outcome measures are used to judge the performance of the criteria and the decision making of the field providers. While review of the literature shows that no “standard” set of triage criteria have been generated or validated in determining medical necessity in EMS, there are certain themes that emerge from the literature, and these themes can likely form the basis of a consensus on elements of a medical necessity criteria that need to be validated and refined. These may include (for triage criteria) vital signs, chief complaints, and physical exam findings, and (for outcome measures) hospital admission, critical events, death, and diagnosis.     

Field triage systems: Methodologies from the literature

The primary goal of the Neely Conference project is to work toward defining a set of research criteria for medical necessity in emergency medical services (EMS). This paper reviews the extant literature on triage and nontransport decisions made in the field by EMS personnel, with emphasis on the methodologies that have been used to date. Two types of medical necessity standards are considered. First, there are triage criteria for determining whether a given patient requires EMS transport to the hospital, or whether an alternative might be appropriate. These triage criteria might be incorporated into protocols that field personnel could apply on scene to determine the best disposition for a given patient. Second, there are the outcome measures against which the decisions made by the field personnel are judged. In some cases, the outcome measure is the judgment of a reviewing emergency physician or nurse, while in others specific outcome measures are used to judge the performance of the criteria and the decision making of the field providers. While review of the literature shows that no “standard” set of triage criteria have been generated or validated in determining medical necessity in EMS, there are certain themes that emerge from the literature, and these themes can likely form the basis of a consensus on elements of a medical necessity criteria that need to be validated and refined. These may include (for triage criteria) vital signs, chief complaints, and physical exam findings, and (for outcome measures) hospital admission, critical events, death, and diagnosis.     

A human factors analysis of an EMS crew's exposure to carbon monoxide

The safety of personnel and resources is considered to be a cornerstone of prehospital Emergency Medical Services (EMS) operations and practice. However, barriers exist that limit the comprehensive reporting of EMS safety data. To overcome these barriers, many high risk industries utilize a technique called Human Factors Analysis (HFA) as a means of error reduction. The goal of this approach is to analyze processes for the purposes of making an environment safer for patients and providers. This report describes an application of this approach to safety incident analysis following a situation during which a paramedic ambulance crew was exposed to high levels of carbon monoxide.     

Comfort level of emergency medical service providers in responding to weapons of mass destruction events: impact of training and equipment

BACKGROUND: Numerous studies have suggested that emergency medical services (EMS) providers are ill-prepared in the areas of training and equipment for response to events due to weapons of mass destruction (WMD) and other public health emergencies (epidemics, etc.). METHODS: A nationally representative sample of basic and paramedic EMS providers in the United States was surveyed to assess whether they had received training in WMD and/or public health emergencies as part of their initial provider training and as continuing medical education within the past 24 months. Providers also were surveyed as to whether their primary EMS agency had the necessary specialty equipment to respond to these specific events. RESULTS: More than half of EMS providers had some training in WMD response. Hands-on training was associated with EMS provider comfort in responding to chemical, biological, and/or radiological events and public health emergencies (odds ratio (OR) = 3.2, 95% confidence interval (CI) 3.1, 3.3). Only 18.1% of providers surveyed indicated that their agencies had the necessary equipment to respond to a WMD event. Emergency medical service providers who only received WMD training reported higher comfort levels than those who had equipment, but no training. CONCLUSIONS: Lack of training and education as well as the lack of necessary equipment to respond to WMD events is associated with decreased comfort among emergency medical services providers in responding to chemical, biological, and/or radiological incidents. Better training and access to appropriate equipment may increase provider comfort in responding to these types of incidents.     

Prehospital Trauma Triage Decision-making: A Model of What Happens between the 9-1-1 Call and the Hospital

We describe the decision-making process used by emergency medical services (EMS) providers in order to understand how 1) injured patients are evaluated in the prehospital setting; 2) field triage criteria are applied in-practice; and 3) selection of a destination hospital is determined. We conducted separate focus groups with advanced and basic life support providers from rural and urban/suburban regions. Four exploratory focus groups were conducted to identify overarching themes and five additional confirmatory focus groups were conducted to verify initial focus group findings and provide additional detail regarding trauma triage decision-making and application of field triage criteria. All focus groups were conducted by a public health researcher with formal training in qualitative research. A standardized question guide was used to facilitate discussion at all focus groups. All focus groups were audio-recorded and transcribed. Responses were coded and categorized into larger domains to describe how EMS providers approach trauma triage and apply the Field Triage Decision Scheme. We conducted 9 focus groups with 50 EMS providers. Participants highlighted that trauma triage is complex and there is often limited time to make destination decisions. Four overarching domains were identified within the context of trauma triage decision-making: 1) initial assessment; 2) importance of speed versus accuracy; 3) usability of current field triage criteria; and 4) consideration of patient and emergency care system-level factors. Field triage is a complex decision-making process which involves consideration of many patient and system-level factors. The decision model presented in this study suggests that EMS providers place significant emphasis on speed of decisions, relying on initial impressions and immediately observable information, rather than precise measurement of vital signs or systematic application of field triage criteria.     

Wipeout

When prehospital providers transported this patient to the trauma center, they felt a bit awkward, to say the least. The patient appeared to be intoxicated, and had fallen from approximately three feet. Nevertheless, upon EMS' arrival, the patient was responding only to painful stimuli and was not moving his lower extremities. This prompted EMS to activate the trauma system and treat the patient accordingly: He was immobilized on a long backboard. During transport, however, the patient became responsive to verbal stimuli and began moving his lower extremities. When he was transferred to the ED staff, he appeared to be doing fine neurologically, except for the intoxication. The EMS crew felt a bit embarrassed for the activation of trauma services. Three hours later, however, the ED physician called the providers at their station to inform them that the patient had an unstable cervical spine fracture (see x-ray above), and their care was definitely appropriate.     

The effect of pulse oximetry on emergency medical technician decision making

Objective

Relatively little is known about the use of pulse oximetry in the prehospital setting. The purpose of this study was to determine how emergency medical technicians (EMTs) use pulse oximetry information to influence their decisions regarding the involvement of advanced life support (ALS) personnel in a two-tiered emergency medical services (EMS) system.

Methods

EMTs were trained and authorized to use pulse oximetry in predefined clinical situations. The EMTs completed a questionnaire describing the influence of the oximetry information on their decision making regarding the involvement of ALS units.

Results

The EMTs reported an influence on their decisions whether to involve ALS care in 35 (12%) of 302 cases. The addition of the pulse oximetry information caused the EMTs to request ALS dispatch in 11 cases, to cancel a previously dispatched ALS response in eight cases, and not to request an ALS response from the scene when they otherwise would have requested it in 16 cases.

Conclusion

Prehospital pulse oximetry has a measurable influence on EMT decisions concerning ALS involvement in a two-tiered EMS system. It improves system efficiency by helping to match patients to an appropriate level of care.     

The Use of Epinephrine for Out-of-Hospital Treatment of Anaphylaxis: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

Anaphylaxis is a potentially life-threatening condition that requires both prompt recognition and treatment with epinephrine. All levels of emergency medical services (EMS) providers, with appropriate physician oversight, should be able to carry and properly administer epinephrine safely when caring for patients with anaphylaxis. EMS systems and EMS medical directors should develop a mechanism to review the charts of patients who received epinephrine and were not in cardiac arrest. This will help to ensure the safe and appropriate use of epinephrine in order to provide continued quality improvement. Despite the safety of epinephrine, EMS systems that carry epinephrine autoinjectors should establish protocols to deal with patients or emergency responders who have an unintentional injection of epinephrine into the hand or digit. Continued research is needed to better define the role that EMS plays in the management of anaphylaxis. This paper serves as a resource document to the National Association of EMS Physician position on the use of epinephrine for the out-of-hospital treatment of anaphylaxis.     

Informed Consent: An Ethical Dilemma

Health care today involves complex decisions. How these decisions are made and by whom are the concerns of consumers, healthcare providers, ethicists, third-party payers, and the legal community. The authors explore the question of whether hospitalized clients participate in informed decision making and they use a case study to demonstrate application of Curtin's model for ethical decision making.     

Inappropriate Use of Emergency Medical Services Transport: Comparison of Provider and Patient Perspectives

Objectives: To determine the extent of inappropriate ambulance use from the perspectives of both emergency medical services (EMS) providers and patients utilizing EMS transport, assess level of agreement, and identify variables associated with inappropriate ambulance use. Methods: A prospective cross-sectional study was done of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban university hospital ED. EMS providers and patients completed a survey with questions regarding their perceptions of whether the need for ambulance transport was an emergency or a nonemergency. Patient demographic information and availability of alternate means of transportation to the hospital were also evaluated. Results: Eight hundred eighty-seven patients were included in the study. EMS providers thought that 501 patient transports were appropriate and represented true emergencies, whereas 689 patients believed their medical problems were true emergencies. A significant number of patients (n = 415, 47%) had access to alternative transportation to the hospital. Blunt traumatic injury and altered mental status were the most common reasons for EMS transport. Patient characteristics significantly associated with EMS provider perception of a true emergency were male gender, age >51 years, higher education, chest pain/cardiac complaints, shortness of breath/respiratory complaints, and Medicare insurance. Characteristics significantly associated with patients who perceived themselves to have true emergencies were black ethnicity, higher education, shortness of breath/respiratory complaints, and Medicare insurance. There was 75% agreement between EMS providers and patients on appropriateness of ambulance transport (kappa = 0.84). Conclusion: Inappropriate ambulance use is a significant problem from both EMS provider and patient perspectives. Certain patient characteristics are associated with a higher probability of appropriate and inappropriate uses of EMS transport. A large number of patients transported by ambulance have alternative means of transportation but elect not to use them.     

Prehospital care of the stroke patient

Acute stroke care is a multidisciplinary effort. It crosses the boundaries of traditional hospital-based medicine, relying heavily on prehospital providers to obtain a significant amount of clinical information. Currently, modifications of existing EMS systems are underway to support the idea that "time is brain." Dispatchers and EMS providers are vital players in the Chain of Recovery, and are challenged to perform within this new paradigm for acute stroke care. In the near future, optimal management of the acute stroke patient may include the administration of neuroprotective medications in the prehospital setting. Educational efforts targeting high risk and elderly populations also continue to be a priority for healthcare providers and public interest groups such as the NSA. Stroke victims, family members, and caregivers must all be aware of the warning signs and symptoms of stroke. The importance of using EMS during the initial phase of acute stroke cannot be overstated. Emergency physicians must lead in coordinating the resources, placing greater emphasis on educating and assessing the performance of prehospital providers [50]. These leaders must ensure that prehospital providers understand they are integral members of the stroke team, vital to improving stroke care in the community.     

Naemsp 1999 annual meeting

The complete and irreversible cessation of life is often difficult to determine with complete confidence in the dynamic environment of out-of-hospital emergency care. As a result, resuscitation efforts often are initiated and maintained by emergency medical services (EMS) providers in many hopeless situations. Medical guidelines are reviewed here to aid EMS organizations with respect to decisions about: 1) initiating or waiving resuscitation efforts; 2) the appropriate duration of resuscitation efforts; and 3) recommended procedures for on-scene or prehospital pronouncement of death (termination of resuscitation). In cases of nontraumatic cardiac arrest, few unassailable criteria, other than certain physical signs of irreversible tissue deterioration, exist for determining medical futility at the initial encounter with the patient. Thus, the general medical recommendation is to attempt to resuscitate all patients, adult or child, in the absence of rigor mortis or dependent lividity. Conversely, well-founded guidelines now are available for decisions regarding termination of resuscitation in such patients once they have received a trial of advanced cardiac life support. In practice, however, the final decision to proceed with on-scene pronouncement of death for these patients may be determined more by family and provider comfort levels and the specific on-scene environment. For patients with posttraumatic circulatory arrest, the type of injury (blunt or penetrating), the presence of vital signs, and the electrocardiographic findings are used to determine the futility of initiating or continuing resuscitation efforts. In general, patients who are asystolic on-scene are candidates for on-scene pronouncement, regardless of mechanism. With a few exceptions, blunt trauma patients with a clearly associated mechanism of lethal injury are generally candidates for immediate cessation of efforts once they lose their pulses and respirations. Regardless of the medical futility criteria, specialized training of EMS providers and targeted related testing of operational issues need to precede field implementation of on-scene pronouncement policies. Such policies also must be modified and adapted for local issues and resources. In addition, although the current determinations of medical futility, as delineated here, are important to establish for societal needs, the individual patient's right to live must be kept in mind always as new medical advances are developed.     

Multi-criteria clinical decision support: A primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare

Current models of healthcare quality recommend that patient management decisions be evidence-based and patient-centered. Evidence-based decisions require a thorough understanding of current information regarding the natural history of disease and the anticipated outcomes of different management options. Patient-centered decisions incorporate patient preferences, values, and unique personal circumstances into the decision making process and actively involve both patients along with health care providers as much as possible. Fundamentally, therefore, evidence-based, patient-centered decisions are multi-dimensional and typically involve multiple decision makers.Advances in the decision sciences have led to the development of a number of multiple criteria decision making methods. These multi-criteria methods are designed to help people make better choices when faced with complex decisions involving several dimensions. They are especially helpful when there is a need to combine "hard data" with subjective preferences, to make trade-offs between desired outcomes, and to involve multiple decision makers. Evidence-based, patient-centered clinical decision making has all of these characteristics. This close match suggests that clinical decision support systems based on multi-criteria decision making techniques have the potential to enable patients and providers to carry out the tasks required to implement evidence-based, patient-centered care effectively and efficiently in clinical settings.The goal of this paper is to give readers a general introduction to the range of multi-criteria methods available and show how they could be used to support clinical decision-making. Methods discussed include the balance sheet, the even swap method, ordinal ranking methods, direct weighting methods, multi-attribute decision analysis, and the analytic hierarchy process (AHP).     

Can ems providers adequately assess trauma patients for cervical spinal injury?

Objective. To determine whether EMS providers can accurately apply the clinical criteria for clearing cervical spines in trauma patients. Methods. EMS providers completed a data form based on their initial assessments of all adult trauma patients for whom the mechanism of injury indicated immobilization. Data collected included the presence or absence of neck pain/tenderness; altered mental status; history of loss of consciousness; drug/alcohol use; neurologic deficit; and other painful/distracting injury. After transport to the ED, emergency physicians (EPs) completed an identical data form based on their assessments. Immobilization was considered to be indicated if any one of the six criteria was present. The El's and EMS providers were blinded to each other's assessments. Agreement between the EP and EMS assessments was analyzed using the kappa statistic. Results. Five-hundred seventy-three patients were included in the study. The El' and EMS assessments matched in 78.7% (n = 451) of the cases. There were 44 (7.7%) patients for whom EP assessment indicated immobilization, but the EMS assessment did not. The kappa for the individual components of the assessments ranged from 0.35 to 0.81, with the kappa for the decision to immobilize being 0.48. The EMS providers' assessments were generally more conservative than the EPs'. Conclusion. EMS and EP assessments to rule out cervical spinal injury have moderate to substantial agreement. However, the authors recommend that systems allowing EMS providers to decide whether to immobilize patients should follow those patients closely to ensure appropriate care and to provide immediate feedback to the EMS providers.     

Effect of vital signs on advanced life support interventions for prehospital patients

Objective. Routine vital signs assessment is considered a fundamental component of patient assessment. This study was undertaken to determine whether advanced life support (ALS) emergency medical services (EMS) providers depend on vital signs information in managing their patients.

Methods. Emergency medical technician-paramedics (EMT-Ps) and EMT-Intermediates (EMT-Is) were presented with 20 randomized patient scenarios that did not included vital signs information. The participants were asked to identify all of the interventions they would perform for each hypothetical patient. At least six weeks later the same scenarios were presented in a new order, with vital signs information, and the participants again identified the interventions they would perform. The participants' estimations of the patients' blood pressures, as well as the frequencies with which 18 specific interventions were performed, were compared for the no-vital signs and the vital signs groups using chi-square or Fisher's exact test, with an alpha value of 0.05 considered significant.

Results. Fourteen EMT-Ps and 16 EMT-Is completed both the no-vital signs and vital signs portions of the study, for a total of 1,160 hypothetical patient encounters. When vital signs were given, the EMT-Is were more likely to apply a cardiac monitor (65.2% vs 80.1%, p = 0.000), more likely to start at least one intravenous (IV) line (82.1% vs 87.8%, p = 0.038), and more likely to administer a medication (1.3% vs 5.6%, p = 0.003). The EMT-Ps were also more likely to apply a cardiac monitor (84.4% vs 90.3%, p = 0.041), more likely to run an IV at a “wide open” rate (9.5% vs 19.0%, p = 0.004), and less likely to identify patients as being hypotensive (39.9% vs 26.4%, p = 0.004).

Conclusion. The presence or absence of vital signs information does influence some of the patient care decisions of EMS providers; however, the clinical implications of these decisions are unclear. Further studies are needed to determine whether ALS providers can adequately manage actual patients without obtaining vital signs.     

A practical approach to paramedic precepting

Field-training programs allow paramedic students to train in the field with other EMS providers before they are thrust out on their own. However, paramedic trainers--better known as preceptors--are not given the same luxury of time and training to perform their jobs effectively. This article serves as a guide to ensure that the needs of the intern, preceptor and EMS agency are all well-served.