Mental health-related cases represent one in ten EMS attendances in Victoria. A large proportion of mental health presentations receive little intervention by EMS, and could benefit from community-based services provided by mental health clinicians.
Objective
Administration of a sedative agent is required for safe transport of prehospital patients with severe agitation to EDs. Ambulance services in Australasia use ketamine, droperidol or midazolam as first line agent but the optimal agent is uncertain. In Victoria, intramuscular (IM) ketamine is used. The present study aimed to examine the prehospital characteristics and ED outcomes of patients with severe agitation after IM ketamine administration.
Methods
A retrospective review was conducted for patients who received IM ketamine for severe agitation over a 2‐year period. Data were sourced from Ambulance Victoria and linked to hospital data. The primary outcome was time to sedation. Data collected included baseline characteristics, adverse events and ED outcomes.
Results
Three hundred and fifty‐eight prehospital cases transported to 32 hospitals were included. Outcome data were available for 305 patients (21 hospitals). Median age was 31 years (IQR 23–40). 71.2% were male. Adequate sedation was achieved in 96.9% of cases in a median time of 5.0 min (IQR 3.0–7.0; range 1–31 min). Adverse events were transient hypoxia (5.0%), hyper‐salivation (4.2%) and emergence reactions (0.8%). A total of 45 (14.8%) patients were intubated; two prehospital.
Conclusion
Intramuscular ketamine is effective with a low rate of prehospital complications in severely agitated patients in the prehospital setting. Given the variation in ambulance practice in Australasia, prospective, randomised trials in the prehospital setting comparing ketamine to other sedating agents such as droperidol in patients with severe agitation are required.
Aim The Advanced Medical Priority Dispatch (AMPDS) system is used to triage emergency medical calls in Victoria, Australia. However, the level of response assigned to each AMPDS Event Type (ET), which may include triage away from an emergency medical service (EMS) attendance, is determined by Ambulance Victoria. This study aimed to increase the proportion of low-acuity calls diverted to secondary triage and onto an alternative service provider (ASP), ultimately reducing EMS demand. Methods A review of the level of EMS response assigned to AMPDS ET was conducted using research, audit and clinical expertise. Existing 'time-critical' and 'acute but not time-critical' ETs were assessed for suitability against the assigned level of EMS response and existing dispatch rules. An analysis of events occurring pre-reform (8 Feb-8 May 2016) and postreform (9 May-8 Aug 2016) was conducted. Results A total of 105 'time-critical' ETs were assessed as suitable for downgrade to an 'acute' response, while 221 'acute' and 'time-critical' ETs were deemed suitable for diversion to secondary triage. The changes were implemented using staged approach, commencing in October 2015. The proportion of cases receiving a 'time-critical' EMS response decreased from 55.1% pre-reform to 48.9% post-reform (p<0.001).The proportion of emergency calls avoiding EMS dispatch increased from 8.8% pre-reform to 14.1% post-reform (p<0.001). Of the cases diverted to secondary triage post-reform, 32.4% were referred to an ASP, 30.2% were referred to a non-emergency transport service and 41.8% were returned for EMS dispatch. Conclusion This study provides a sound methodological approach for revising EMS dispatch protocols. Ongoing monitoring of the dispatch changes aims to identify areas that may benefit from further optimisation. Conflict of interest None declared. Funding None declared.
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