Concordance of field and emergency department assessment in the prehospital management of patients with dyspnea.
OBJECTIVE
Dyspnea is a common complaint of patients treated by emergency medical services (EMS). Few studies have examined the ability of paramedics to distinguish between etiologies of dyspnea. The authors evaluated the degree of agreement related to cardiac versus noncardiac sources of dyspnea between field and emergency department (ED) assessment of patients transported at the advanced life support level.


METHODS
This was a retrospective, cohort study of consecutive patients aged > or =35 years transported by paramedics with dyspnea. The authors compared the concordance between the EMS and ED diagnoses. They also investigated whether patients whose assessments were discordant had worse outcomes.


RESULTS
Paramedics correctly assessed the cause of dyspnea in 172 of 222 (77%) patients (kappa=0.60; 95% confidence interval [CI]=0.51, 0.69). Among single-source (i.e., cardiac or noncardiac) dyspnea patients, prehospital providers correctly assessed 70 of 84 (83%) noncardiac causes and 98 of 114 (86%) cardiac causes (kappa=0.69; 95% CI=0.59, 0.79). When the ED diagnosis included both cardiac and noncardiac etiologies, paramedics treated seven of 24 (29%) patients as noncardiac, 13 of 24 (54%) as cardiac, and four of 24 (17%) as combined-source dyspnea. The authors did not observe any statistically significant differences in in-hospital mortality, intubation frequency, or hospital length of stay in patients whose prehospital dyspnea diagnosis was discordant.


CONCLUSIONS
The authors conclude that in this EMS system, field assessment of dyspnea by paramedics is in agreement with that arrived at in the ED in a high proportion of patients with dyspnea from a single source. However, field assessment of dyspnea from multiple etiologies is less concordant.
Pozner
Charles N
CN
Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA. cpozner@partners.org
Levine
Michael
M
Shapiro
Nathan
N
Hanrahan
John P
JP
D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D016887:Cardiopulmonary Resuscitation / Q000592:standards* / Q000639:trends; D015331:Cohort Studies; D016001:Confidence Intervals; D003937:Diagnosis, Differential; D004417:Dyspnea / Q000175:diagnosis* / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D004632:Emergency Medical Services / Q000592:standards* / Q000639:trends; D004636:Emergency Service, Hospital / Q000592:standards* / Q000639:trends; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D011336:Probability; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D012737:Sex Factors; D016019:Survival Analysis; D016896:Treatment Outcome