Journal Reviews
Journal Reviews
Schmidt T, Atcheson R, Federiuk C. Evaluation of protocols allowing emergency medical technicians to determine need for treatment and transport. Acad Emerg Med 2000; 7:663-669.
Of 277 patients determined by emergency medical services not to need an ambulance, from 3% to 11% had a critical event suggesting that, in fact, they might have needed the ambulance, according to this study from the Oregon Health Sciences University in Portland, Kaiser Permanente in Salt Lake City, and the University of Utah School of Medicine, also in Salt Lake City. Emergency medical services need to determine an acceptable rate of undertriage, argue the researchers.
The emergency medical technicians (EMTS) provided ambulance transport to 1,300 patients and categorized them as follows, according to a set of protocols developed by an expert panel:
• 1,023 (79%) needed an ambulance transport;
• 200 (15%) could go to the ED by alternative means;
• 63 (5%) could contact a primary care physician;
• 14 (1%) could be treated and released.
Using the set of protocols, EMTs determined that about 21% of patients did not need ambulance transport, and 3% to 11% of those had a critical event. Twenty-three patients (11%) had events that may not have warranted advanced life support transport, and seven (3%) had critical events in the ambulance warranting ambulance transport. The researchers explain that either the protocols don’t identify all patients who might experience a critical event during transport, or the EMTs did not correctly follow the protocol.
Most of the undertriage occurred when the EMTs did not follow the protocols, except for one case that would have been missed by the protocols, the researchers say. Better adherence to the protocols might increase safety, they suggest.
Washington DL, Stevens CD, Shekelle PG, et al. Safely directing patients to appropriate levels of care: Guideline-driven triage in the emergency service. Ann Emerg Med 2000; 36:15-22.
Standardized clinical criteria can identify ED users who can be safely cared for at a later date in a nonemergency setting, says this study from the VA Greater Los Angeles (CA) Healthcare System. Using standardized criteria for deferred care, ED nurses screened 1,187 ambulatory adult patients with abdominal pain, musculoskeletal symptoms, or respiratory infection. Here are key findings:
• 226 (19%) of patients met screening criteria for deferred care. Of those patients, none was hospitalized within seven days, and none died within 30 days.
• 68 (7%) of the 961 patients who did not meet criteria for deferred care were hospitalized for related conditions, and five died.
• Patients who met the criteria for deferred care were offered the option of an appointment within one week in the ambulatory care clinic.
• The study supports the use of guidelines to triage patients for emergency care or a scheduled appointment within one week, say the researchers.
"This is a safe and timely way to approach the problem of ED overcrowding, so that explicit clinical criteria, rather than the length of the wait for care, determine which patients leave the ED," they write.
However, they caution that the deferred-care guidelines are only feasible if cost-effective alternatives to ED care exist. Patients who are safe for deferred care need to be given an appointment to be seen in a primary care setting at a later date, say the researchers.
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