title: Errors of omission in the treatment of prehospital chest pain patients.
abstract: OBJECTIVE
  Despite the widespread use of standard treatment protocols, there are few published data regarding paramedic protocol adherence. In this descriptive study, the authors sought to assess the frequency and nature of deviations from a standardized treatment protocol for the chief complaint of chest pain. They also sought to quantify any time delays in treatment of potential ischemic cardiac chest pain.
  
  
  METHODS
  A retrospective review of written documentation obtained from four ambulance services in a mid-Atlantic state was completed. A convenience sample of consecutive emergency medical services (EMS) records was obtained from January 2001 to May 2002, and 75 calls were selected from each service (N = 300).
  
  
  RESULTS
  Neither the median scene times nor the response times varied among the four services in the study. However, the suburban ambulance service (service 1) did have a significantly longer transport time (19 minutes) than the rural (14 minutes) and the urban (11 and 10 minutes) services (p < 0.05). Documentation of history and physical characteristics varied widely for each service. The patient took aspirin 10% of the time prior to EMS arrival, yet paramedics gave it additionally 50% of the time, while nitroglycerin was given in 73% of cases of suspected cardiac ischemia. Posttreatment vital signs for nitroglycerin were documented 30% of the time for three of the four services, while the other service documented these 75% of the time. Medical command contact varied by agency (80-100%), as did the receipt and completion of medical orders.
  
  
  CONCLUSIONS
  Paramedics may delay transport of patients with potential cardiac ischemia. Deviations from protocol occur frequently and the care documented for prehospital patients with chest pain is variable. The expected care described by written protocols does not correlate with the treatment documented.
authors.affiliation: University of Pittsburgh Affiliated Residency in Emergency Medicine and the Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA. rittenbergerjc@upmc.edu
authors.forename: Jon C
authors.initials: JC
authors.lastname: Rittenberger
authors.forename: Paul W
authors.initials: PW
authors.lastname: Beck
authors.forename: Paul M
authors.initials: PM
authors.lastname: Paris
mesh_terms: D000552:Ambulances / Q000592:standards*; D002637:Chest Pain / Q000175:diagnosis / Q000628:therapy*; D002983:Clinical Competence; D002985:Clinical Protocols / Q000592:standards*; D004631:Emergency Medical Service Communication Systems; D004634:Emergency Medical Technicians / Q000592:standards*; D004638:Emergency Treatment / Q000592:standards*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D019538:Health Care Surveys; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000706:statistics & numerical data*; D010043:Outcome and Process Assessment, Health Care; D010414:Pennsylvania; D017410:Practice Guidelines as Topic; D011336:Probability; D012189:Retrospective Studies; D013996:Time and Motion Studies