Examining the association between paramedic transport to the emergency department and hospital admission: a population-based cohort study

Abstract

Background Increasing hospitalization rates present unique challenges to manage limited inpatient bed capacity and services. Transport by paramedics to the emergency department (ED) may influence hospital admission decisions independent of patient need/acuity, though this relationship has not been established. We examined whether mode of transportation to the ED was independently associated with hospital admission. Methods We conducted a retrospective cohort study using the National Ambulatory Care Reporting System (NACRS) from April 1, 2015 to March 31, 2020 in Ontario, Canada. We included all adult patients (≥18 years) who received a triage score in the ED and presented via paramedic transport or self-referral (walk-in). Multivariable binary logistic regression was used to determine the association of mode of transportation between hospital admission, after adjusting for important patient and visit characteristics. Results During the study period, 21,764,640 ED visits were eligible for study inclusion. Approximately one-fifth (18.5%) of all ED visits were transported by paramedics. All-cause hospital admission incidence was greater when transported by paramedics (35.0% vs. 7.5%) and with each decreasing Canadian Triage and Acuity Scale level. Paramedic transport was independently associated with hospital admission (OR = 3.76; 95%CI = 3.74–3.77), in addition to higher medical acuity, older age, male sex, greater than two comorbidities, treatment in an urban setting and discharge diagnoses specific to the circulatory or digestive systems. Conclusions Transport by paramedics to an ED was independently associated with hospital admission as the disposition outcome, when compared against self-referred visits. Our findings highlight patient and visit characteristics associated with hospital admission, and can be used to inform proactive healthcare strategizing for in-patient bed management.

Increased demand for paramedic transports to the emergency department in Ontario, Canada: a population-level descriptive study from 2010 to 2019

“…We speculate some of the contributing factors include: difficulty in accessing primary healthcare, a lack of timely access to care, perceived situation by the patient, a sense of superior in-hospital care, and a lack of awareness of other healthcare services [24][25][26]. Consistent with previous literature, we found that older age groups and increasing comorbidities may be contributing factors to increased paramedic utilization [6,27,28].…”

“…Contrary to traditional conceptualizations of paramedicine as an emergency service, the majority of paramedic transported patients have non-emergent medical complaints and conditions [1,6]. Expanding and aligning paramedic scope of practice, clinical decision-making, and models of care with primary care skills and service accessibility may support efforts to improve patient-centered care and lessen the burden of ED workload [1,31].…”

“…Demand for paramedic response and transportation to the emergency department (ED) has increased across Canada [1]. Particular growth in paramedic transports and workload has been reported in Alberta, Nova Scotia, Prince Edward Island and New Brunswick, though little is known about Ontario [2][3][4][5][6][7]. Ontario's annual incidence of paramedic transports have yet to be investigated on a population level, despite comprising the largest population (39% of Canada; 14,789,778 persons), second highest provincial growth rate and highest provincial ED visitation rate of all provinces [7,8].…”

Validation of a classification to identify emergency department visits suitable for subacute and virtual care models: a randomised single-blinded agreement study protocol

“…3 6-9 In Ontario, ED utilisation by patients with non-emergent conditions has doubled population growth (13.4% vs 6.2%) in the past decade. 6 10 With Ontario's continued population growth, the demand for ED healthcare may continue to increase, further challenging departments to manage already overburdened workloads. [11][12][13] Challenges of ED overcrowding extend beyond Canada; international research reports similar increases in patient volumes and longer admission times.…”

Predicting Hospital Admission among High Acuity Triaged Patients Transported to the Emergency Department in Ontario, Canada: A Population-Based Cohort Study using Machine Learning

“…(1) Empirically, the majority of emergent triaged paramedic transports do not receive emergency medicine in the ED, do not clinically deteriorate, are discharged home directly from the ED (56.6%) and a sizeable proportion receive physician interventions considered primary care-like (39.3%). (3,4) Paramedics transporting high-acuity triaged patients exclusively to the nearest ED constitutes an operational ine ciency; all emergently triaged patients are handled the same in the prehospital setting, independent of patient repatriation for continuity of care, patient preference, ED workload, sta ng, or bed availability. (1) In circumstances where emergently triaged conditions do not require emergency or time-sensitive care, transport to an alternative ED could bene t both the patient and overwhelmed EDs.…”