Suboptimal prehospital decision- making for referral to alternative levels of care – frequency, measurement, acceptance rate and room for improvement

Abstract

Background The emergency medical services (EMS) have undergone dramatic changes during the past few decades. Increased utilisation, changes in care-seeking behaviour and competence among EMS clinicians have given rise to a shift in EMS strategies in many countries. From transport to the emergency department to at the scene deciding on the most appropriate level of care and mode of transport. Among the non-conveyed patients some may suffer from “time-sensitive conditions” delaying diagnosis and treatment. Thus, four questions arise: How often are time-sensitive cases referred to primary care or self-care advice? How can we measure and define the level of inappropriate clinical decision-making? What is acceptable? How to increase patient safety? Main text To what extent time-sensitive cases are non-conveyed varies. About 5–25% of referred patients visit the emergency department within 72 hours, 5% are hospitalised, 1–3% are reported to have a time-sensitive condition and seven-day mortality rates range from 0.3 to 6%. The level of inappropriate clinical decision-making can be measured using surrogate measures such as emergency department attendances, hospitalisation and short-term mortality. These measures do not reveal time-sensitive conditions. Defining a scoring system may be one alternative, where misclassifications of time-sensitive cases are rated based on how severely they affected patient outcome. In terms of what is acceptable there is no general agreement. Although a zero-vision approach does not seem to be realistic unless under-triage is split into different levels of severity with zero-vision in the most severe categories. There are several ways to reduce the risk of misclassifications. Implementation of support systems for decision-making using machine learning to improve the initial assessment is one approach. Using a trigger tool to identify adverse events is another. Conclusion A substantial number of patients are non-conveyed, including a small portion with time-sensitive conditions. This poses a threat to patient safety. No general agreement on how to define and measure the extent of such EMS referrals and no agreement of what is acceptable exists, but we conclude an overall zero-vision is not realistic. Developing specific tools supporting decision making regarding EMS referral may be one way to reduce misclassification rates.

From symptom onset to ED departure: understanding the acute care chain for patients with undifferentiated complaints: a prospective observational study

“…An example is that risk stratification can be optimised, and tools to help healthcare providers can be developed [ 21 , 22 ]. A Swedish study on the quality of prehospital decision-making for referral to alternative levels of care by EMS showed that only 1% of patients not transported by EMS were diagnosed with a time-sensitive condition, which shows that prehospital professionals contribute to optimising care efficiency, but may be in need for extra tools to help them [ 23 ]. other options might be to identify those at risk for an ED visit and increase home care, initiate treatment (e.g.…”

Organizational factors influencing clinical reasoning in a Swedish emergency medical service organization: An explorative qualitative case study

“…11,12 These decisions add to the importance of CR with a risk minimizing approach. 13 Research specifically intended to examine organizational factors (i.e. work and healthcare environment, supportive structures, in-service training, workplace culture) related to CR in EMS is lacking, while more research has been conducted within related sectors and professions in public sector service work (i.e.…”