Medically Unnecessary Pediatric Ambulance Transports: A Medical Taxi Service?

Objective : To characterize ambulance utilization in a pediatric population and pediatric emergency physicians' judgment of the medical need for ambulance transport. Methods : A convenience sample of ambulance transports were studied prospectively during a 5-week period. Exclusion criteria included transfer from another medical facility, study physician not available, need for immediate resuscitation, or trauma team activation. A questionnaire completed by the physician assessed medical need for the ambulance based on chief complaint, general appearance, vital signs, and ambulance run sheet information. A separate questionnaire was administered to the parents regarding reasons for ambulance use and other available means of transportation. Caregivers were contacted by telephone 2–3 days later to determine the mode of transportation home and the clinical outcome. Results : Of 172 eligible patients, 92 (53%) were enrolled. Most (61%; 56/92) transports were considered medically unnecessary. Interestingly, 40% (37/92) of the subjects had no other means of transportation; 86% (32/37) of ambulance transports for this group were judged medically unnecessary. Overall, 86% (79/92) of families had not called their physician. There was no association between having spoken with the physician and medical need for an ambulance. Many (82%; 46/56) Medicaid transports were judged medically unnecessary. Overall, follow-up was achieved for 91% (85/92) of the patients. No patient for whom transport was medically unnecessary had a repeat ED visit for the same complaint or required admission. Most patients (74%; 68/92) returned home without any assistance. Among the medically unnecessary transports, 52% (32/ 60) of the caregivers cited no other means of transportation, yet 34% (11/32) of these patients returned home by private car. Conclusions : Most pediatric ambulance transports in this sample, which excluded patients requiring immediate resuscitation or trauma team care, were judged to be medically unnecessary. Caregivers often use an ambulance as a convenience or as the only means of transportation. An alternate, less resource-intensive transportation system may be more appropriate for this population.     

Contributing Factors andIssues Associated with Rural Ambulance Crashes: Literature Review andAnnotated Bibliography

Ambulance crashes occur with greater frequency andseverity than crashes involving vehicles of similar size andweight characteristics. Crashes in rural areas tend to be more severe in terms of injury or death to vehicle occupants. The purpose of this article was to examine the extant literature, as well as summarize anddiscuss the overlapping findings of that body of literature. A stepwise literature search was conducted using the following MeSH search terms ambulance; accident, traffic; emergency medical technician; occupational health; andrural in descending combination. MEDLINE was used as the primary database but was augmented by searches of Academic Search Premier, Comprehensive Index of Nursing, Allied Health Literature, andProQuest Dissertation International. The search resulted in 32 article citations, andof these, 28 were included. An annotated bibliography is followed by a discussion andconclusion that identify opportunities for prevention activities in the areas of education, enforcement, andengineering.     

Relationships between Ambulance Transports for Alcohol Intoxication and Assault

Objective : To evaluate the association between ambulance transports for assault and those for alcohol intoxication.
Methods : A retrospective analysis of emergency medical services (EMS) calls was performed. The authors used logistic regression models to compare patients transported for alcohol intoxication with a control group of patients transported for respiratory distress (asthma or shortness of breath) with respect to whether they had been transported on a separate occasion for a chief complaint of assault.
Results : Patients transported for alcohol intoxication had 9 times the risk of transport for assault as compared with the control group (OR = 9.3; 95% CI = 6.4, 13.6). The odds of transport for assault among the alcohol patients increased 17.1% with each alcohol transport (OR = 1.17; 95% CI = 1.14, 1.20) but decreased for the control group (OR = 0.34; 95% CI = 0.26, 0.44). Repeat transports for assault were more common among the alcohol patients than among the control group (OR = 3.3; 95% CI = 1.1, 11.3). The mean number of assault transports was higher among the alcohol patients than among the patients never transported for alcohol intoxication (p < 0.0001).
Conclusions : Patients transported on multiple occasions for acute alcohol intoxication are at relatively high risk for assault. This risk group should be targeted for focused assault prevention interventions that include components designed to reduce incidents of repeat alcohol intoxication.     

Reasons Why Patients Choose an Ambulance and Willingness to Consider Alternatives

Objectives: To test a hypothesis that patients would accept alternatives to transport to an emergency department (ED) by ambulance and to evaluate factors related to patient willingness to consider alternatives. Concerns about resource utilization have prompted emergency medical services (EMS) systems to explore alternatives to ambulance transport to an ED, but studies have evaluated the safety of alternatives, not patient preferences.
Methods: Trained research assistants surveyed patients transported by ambulance to a university ED. Interfacility transfers, trauma patients, and critically ill patients were excluded. The primary outcome was willingness to accept one of several presented alternatives to ambulance transport to the ED for that visit. Demographic and clinical factors were evaluated for association with willingness to consider alternatives. Relative risks (RR) and 95% confidence intervals (95% CI) were determined by using Mantel-Haenszel stratified methods.
Results: Three hundred fifteen subjects completed the survey. Two hundred forty-seven (78.4%) were willing to consider at least one alternative. One hundred ninety-four (61.6%) were willing to consider transportation by car, and 177 (56.2%) were willing to consider transportation by taxi. Factors associated with willingness to consider alternatives included the following: age 18–65 years (RR, 1.25; 95% CI = 1.03 to 1.49), being unemployed (RR, 1.08; 95% CI = 1.08 to 1.33), use of the ED for routine care (RR, 1.25; 95% CI = 1.17 to 1.35), and not being admitted to the hospital (RR, 1.19; 95% CI = 1.04 to 1.40). Race, gender, health insurance status, and EMS interventions en route were not associated with willingness to consider transportation alternatives.
Conclusions: Many patients transported by ambulance to an ED would have considered an alternative, if one were offered.     

The "Vertical Response Time": Barriers to Ambulance Response in an Urban Area

Background: Ambulance response time is typically reported as the time interval from call dispatch to arrival on-scene. However, the often unmeasured "vertical response time" from arrival on-scene to arrival at the patient's side may be substantial, particularly in urban areas with high-rise buildings or other barriers to access.
Objectives: To measure the time interval from arrival on-scene to the patient in a large metropolitan area and to identify barriers to emergency medical services arrival.
Methods: This was a prospective observational study of response times for high-priority call types in the New York City 9-1-1 emergency medical services system. Research assistants riding with paramedics enrolled a convenience sample of calls between 2001 and 2003.
Results: A total of 449 paramedic calls were included, with a median time from call dispatch to arrival on-scene of 5.2 minutes. The median on-scene to patient arrival interval was 2.1 minutes, leading to an actual response interval (dispatch to patient) of 7.6 minutes. The median on-scene to patient interval was 2.8 minutes for residential buildings, 2.7 minutes for office complexes, 1.3 minutes for private homes (less than four stories), and 0.5 minutes for outdoor calls. Overall, for all calls, the on-scene to patient interval accounted for 28% of the actual response interval. When an on-scene escort provided assistance in locating and reaching the patient, the on-scene to patient interval decreased from 2.3 to 1.9 minutes. The total dispatch to patient arrival interval was less than 4 minutes in 8.7%, less than 6 minutes in 28.5%, and less than 8 minutes in 55.7% of calls.
Conclusions: The time from arrival on-scene to the patient's side is an important component of overall response time in large urban areas, particularly in multistory buildings.     

Existing Science on Human Factors and Ergonomics in the Design of Ambulances and EMS Equipment

Background: Emergency medical services (EMS) personnel face a disproportionally high risk for fatality and injury due to the nature of their work; and current ambulance and EMS equipment design standards do not adequately safeguard EMS personnel from sacrificing personal safety for patient care, a known human factors and ergonomic (HFE) design challenge. Despite the desire to include HFE interventions or considerations into a standard, the effectiveness of existing HFE interventions for EMS is unclear. Objective: Therefore, this study aimed to synthesize the peer-reviewed literature on the design features of patient compartments and EMS equipment that affect EMS personnel’s performance or well-being. Methods: A scoping review methodology was applied to systematically search and screen for relevant articles, and extract data. Three databases (EmBase, Scopus, and PubMed) were searched, and search results were screened for articles that pertained to the performance or well-being of EMS personnel when interacting with the patient compartment or its associated equipment. Results and Discussion: Of the 4,125 search results, 48 relevant articles were retained, and then sorted into one of 3 categories: general design, patient handling, and patient transport. It was concluded that, although research has progressed over the past 15 years, more research, development, and resources are needed. Newer generations of ambulances have not been shown to be safer during collisions and there is a knowledge gap in how occupants and contents of a patient compartment behave during a collision. Crash-tests have been performed with restrained occupants and supplies; however, that scenario is unrealistic in the field. While the existing literature provided initial ideas and innovations for improving the HFE of patient handling and patient transport, it is important for future research to convey findings in a manner that can be used to inform design standards.     

The Effects of Ambulance Diversion: A Comprehensive Review

Objectives
To review the current literature on the effects of ambulance diversion (AD).
Methods
The authors performed a systematic review of AD and its effects. PubMed, EMBASE, the Cochrane database, societal meeting abstracts, and references from relevant articles were searched. All articles were screened for relevance to AD.
Results
The authors examined 600 citations and reviewed the 107 articles relevant to AD. AD is a common occurrence that is increasing in frequency. AD is associated with periods of emergency department (ED) crowding (Mondays, mid-afternoon to early evening, influenza season, and when hospitals are at capacity). Interventions that redesign the AD process or that provide additional hospital or ED resources reduce diversion frequency. AD is associated with increased patient transport times and time to thrombolytics but not with mortality. AD is associated with loss of estimated hospital revenues. Short of anecdotal or case reports, no studies measured the effect of AD on ED crowding, morbidity, patient and provider satisfaction, or EMS resource utilization.
Conclusions
Despite its common use, there is a relative paucity of studies on the effects of AD. Further research into these effects should be performed so that we may understand the role of AD in the health system.     

Neighborhood Poverty and 9-1-1 Ambulance Contacts

Background: Neighborhood poverty is positively associated with frequency of 9-1-1 ambulance utilization, but it is unclear whether this association remains significant when accounting for variations in the severities and types of ambulance contacts. Methods: We merged EMS ambulance contact records in a single California county (n = 88,027) with data from the American Community Survey at the census tract level (n = 300). Using tract as a proxy for neighborhood and negative binomial regression as an analytical tool, we predicted 16 outcomes: any ambulance contacts, ambulance contacts stratified by three intervention severities, and ambulance contacts varied by 12 primary impression categories. For each model, we estimated the incident rate ratios for 10 percentage point increases in tract-level poverty while controlling for geographic patterns in race, citizenship, gender, age, emergency department proximity, population density, and population size. Results: Our study produced three major findings. First, tract-level poverty was positively associated with ambulance contacts (incident rate ratio [IRR] 1.45; 95% confidence interval [CI] 1.34 to 1.57). Second, poverty was positively associated with low severity contacts (IRR 1.48; 95% CI 1.35 to 1.61), medium severity contacts (IRR 1.38; 95% CI 1.28 to 1.49), and high severity contacts (IRR 1.40; 95% CI 1.30 to 1.51). Third, poverty was positively associated with 12 primary impression categories: abdominal (IRR 1.48; 95% CI 1.36 to 1.61), altered level of consciousness (IRR 1.37; 95% CI 1.25 to 1.50), cardiac (IRR 1.28; 95% CI 1.14 to 1.42), overdose/intoxication (IRR 1.59; 95% CI 1.40 to 1.81), pain (IRR 1.56; 95% CI 1.41 to 1.73), psych/behavioral (IRR 1.50; 95% CI 1.34 to 1.67), respiratory (IRR 1.42; 95% CI 1.29 to 1.56) seizure (IRR 1.52; 95% CI 1.38 to 1.68), stroke (IRR 1.14; 95% CI 1.01 to 1.28), syncope/near syncope (IRR 1.23; 95% CI 1.12 to 1.36), trauma (IRR 1.44; 95% CI 1.31 to 1.58), and general weakness (IRR 1.31; 95% CI 1.20 to 1.42). Conclusion: Our study suggests poverty is a positive, strong, and enduring predictor of ambulance contacts at the neighborhood level. The relationship between neighborhood poverty and ambulance utilization should be considered at multiple levels of EMS decision making     

Neighborhood Poverty and 9-1-1 Ambulance Response Time

Background: Are 9-1-1 ambulances relatively late to poorer neighborhoods? Studies suggesting so often rely on weak measures of neighborhood (e.g., postal zip code), limit the analysis to particular ambulance encounters (e.g., cardiac arrest responses), and do little to account for variations in dispatch priority or intervention severity. Methods: We merged EMS ambulance contact records in a single California county (n = 87,554) with tract-level data from the American Community Survey (n = 300). After calculating tract-level median ambulance response time (MART), we used ordinary least squares (OLS) regression to estimate a conditional average relationship between neighborhood poverty and MART and quantile regression to condition this relationship on 25th, 50th, and 75th percentiles of MART. We also specified each of these outcomes by five dispatch priorities and by three intervention severities. For each model, we estimated the associated changes in MART per 10 percentage point increase in tract-level poverty while adjusting for emergency department proximity, population density, and population size. Results: Our study produced three major findings. First, most of our tests suggested tract-level poverty was negatively associated with MART. Our baseline OLS model estimates that a 10 percentage point increase in tract-level poverty is associated with almost a 24 s decrease in MART (?23.55 s, 95% confidence interval [CI] ?33.13 to ?13.98). Results from our quantile regression models provided further evidence for this association. Second, we did not find evidence that ambulances are relatively late to poorer neighborhoods when specifying MART by dispatch priority. Third, we were also unable to identify a positive association between tract-level poverty and MART when we specified our outcomes by three intervention severities. Across each of our 36 models, tract-level poverty was either not significantly associated with MART or was negatively associated with MART by a magnitude smaller than a full minute per estimated 10 percentage point increase in poverty concentration. Conclusion: Our study challenges the commonly held assumption that ambulances are later to poor neighborhoods. We scrutinize our findings before cautiously considering their relevance for ambulance response time research and for ongoing conversations on the relationship between neighborhood poverty and prehospital care.     

Tourniquets: A Review of Current Use with Proposals for Expanded Prehospital Use

Objective. To perform an initial screening study of methicillin-resistant Staphylococcus aureus (MRSA) contamination in an ambulance fleet. Methods. This was a cross-sectional study of MRSA contamination in an ambulance fleet operating in the western United States in June 2006. Five specific areas within each of 21 ambulances (n = 105) were tested for MRSA contamination using dacron swabs moistened with a 0.85% sterile saline solution. These samples were then plated onto a screening media of mannitol salt agar containing 6.5% NaCl and4 mcg/mL oxacillin. Results. Thirteen samples isolated from 10 of the 21 ambulances (47.6%) in the sample group tested positive for MRSA. Conclusions. The results of this preliminary study suggest that ambulances operating in the emergency medical services (EMS) system may have a significant degree of MRSA contamination andmay represent an important reservoir in the transmission of potentially serious infections to patients.     

E MERGENCY M EDICAL S ERVICES AND C ULTURAL D ETERMINANTS OF AN E MERGENCY IN K ARACHI,P AKISTAN

Objectives. The study was conducted to understand the prehospital system in Karachi, the mode of transport that adult inpatients use to reach the emergency departments (EDs), and the barriers to the use of ambulances. Methods. The study consisted of two parts. The first part involved interviewing the administrators of major ambulance services in Karachi. The second part consisted of a structured interview of randomly selected adult inpatients admitted to one government and one private hospital. Results. Seven ambulance service administrators were interviewed. The interviews revealed that ambulances in Karachi are mainly involved in transporting patients from hospital to hospital or to home. A large number of calls are for transporting dead bodies. A total of 92 patients were interviewed (58 male, 34 female). Admission complaints included abdominal pain (22), blunt trauma (11), penetrating trauma (3), chest pain (6), shortness of breath (4), hematemesis (3), acute focal weakness (4), high fever (4), and other (32). The most common mode of transport to the ED was taxi (53, 58%), followed by private car (21, 23%). Specific reasons for not using ambulances included a perception that the patient was not sick enough (34, 45%), slow response of the ambulance services (17, 23%), not knowing how to find one (8, 11%), and the high cost (6, 8%). Conclusion. In case of a medical emergency, most people in Karachi do not use ambulances. The reasons for this low usage include not only poor accessibility, but also cultural barriers and lack of education in recognition of danger signs.     

Advanced Life Support vs Basic Life Support Field Care: An Outcome Study

Abstract. Objective : To determine whether the provision of advanced life support (ALS) field care has any impact on patient outcome in the urban Canadian environment. Methods : A convenience cohort study was conducted of all emergent ambulance transfers of adults to an urban Canadian hospital from May 22 to July 31, 1996. Data were collected from ambulance call reports regarding presenting complaint and field interventions applied, and from hospital records regarding time in the ED, hospital length of stay (LOS), and discharge disposition. Patient outcomes were compared within 7 presenting complaint groups (chest pain, altered level of consciousness, shortness of breath, abdominal pain, motor vehicle crash, falls, and other) by field care level: level 1—BLS (basic life support) vs levels 2 and 3— ALS. Results : The study population consisted of 1,397 patients. No significant differences were seen between BLS and ALS patients on baseline demographics. ED triage score did not depend on field care level for any group, implying that those in the ALS group were not inherently sicker. Outcome measures (ED LOS, admission rates, and hospital LOS) showed no significant differences between BLS and ALS for each presenting complaint group. Discharge dispositions were analyzed by x² but were not varied enough to allow reliable analysis. Observation of trends suggested no difference between BLS and ALS. Conclusions: There was no beneficial impact on the measured patient outcomes found in association with the provision of ALS vs BLS field care in Metropolitan Toronto for patients who were brought to a non-trauma center.     

A Randomized Controlled Trial to Assess Decay in Acquired Knowledge among Paramedics Completing a Pediatric Resuscitation Course

BACKGROUND: Critical pediatric illness or injury occurs infrequently in out-of-hospital settings, making it difficult for paramedics to maintain physical assessment, treatment, and procedure skills. OBJECTIVES: To document the ability of paramedics to retain clinical knowledge over a one-year interval after completing a pediatric resuscitation course and to determine whether clinical experience or retesting improves retention. METHODS: This was a randomized controlled study assessing retention of knowledge in pediatric resuscitation soon after, six months after, and 12 months following completion of a pediatric advanced life support course. Forty-three paramedics participated in pre- and post-pediatric resuscitation course testing and were randomly assigned to one of four groups. Group 1 received a knowledge examination (KE) and mock resuscitation scenarios (MR) at six months. Group 2 received only the KE at six months. Group 3 received the MR only at six months. Group 4 received no intermediate testing. All groups were reassessed at 12 months. RESULTS: Pediatric clinical knowledge (as measured by KE) rose sharply immediately after the course but returned to baseline levels within six months. There was no difference between the groups in knowledge scores at 12 months, despite the interventions at six months. CONCLUSIONS: Although intensive out-of-hospital pediatric education enhances knowledge, that knowledge rapidly decays. Emergency medical services programs need to find novel ways to increase retention and ensure paramedic readiness.