title: Paramedic Checklists do not Accurately Identify Post-ictal or Hypoglycaemic Patients Suitable for Discharge at the Scene.
abstract: OBJECTIVE
  The objective of this study was to assess the accuracy and safety of two pre-defined checklists to identify prehospital post-ictal or hypoglycemic patients who could be discharged at the scene.
  
  
  METHODS
  A retrospective cohort study of lower acuity, adult patients attended by paramedics in 2013, and who were either post-ictal or hypoglycemic, was conducted. Two self-care pathway assessment checklists (one each for post-ictal and hypoglycemia) designed as clinical decision tools for paramedics to identify patients suitable for discharge at the scene were used. The intention of the checklists was to provide paramedics with justification to not transport a patient if all checklist criteria were met. Actual patient destination (emergency department [ED] or discharge at the scene) and subsequent events (eg, ambulance requests) were compared between patients who did and did not fulfill the checklists. The performance of the checklists against the destination determined by paramedics was also assessed.
  
  
  RESULTS
  Totals of 629 post-ictal and 609 hypoglycemic patients were identified. Of these, 91 (14.5%) and 37 (6.1%) patients fulfilled the respective checklist. Among those who fulfilled the checklist, 25 (27.5%) post-ictal and 18 (48.6%) hypoglycemic patients were discharged at the scene, and 21 (23.1%) and seven (18.9%) were admitted to hospital after ED assessment. Amongst post-ictal patients, those fulfilling the checklist had more subsequent ambulance requests (P=.01) and ED attendances with seizure-related conditions (P=.04) within three days than those who did not. Amongst hypoglycemic patients, there were no significant differences in subsequent events between those who did and did not meet the criteria. Paramedics discharged five times more hypoglycemic patients at the scene than the checklist predicted with no significant differences in the rate of subsequent events. Four deaths (0.66%) occurred within seven days in the hypoglycemic cohort, and none of them were attributed directly to hypoglycemia.
  
  
  CONCLUSIONS
  The checklists did not accurately identify patients suitable for discharge at the scene within the Emergency Medical Service. Patients who fulfilled the post-ictal checklist made more subsequent health care service requests within three days than those who did not. Both checklists showed similar occurrence of subsequent events to paramedics' decision, but the hypoglycemia checklist identified fewer patients who could be discharged at the scene than paramedics actually discharged. Reliance on these checklists may increase transportations to ED and delay initiation of appropriate treatment at a hospital. Tohira H , Fatovich D , Williams TA , Bremner A , Arendts G , Rogers IR , Celenza A , Mountain D , Cameron P , Sprivulis P , Ahern T , Finn J . Paramedic checklists do not accurately identify post-ictal or hypoglycaemic patients suitable for discharge at the scene. Prehosp Disaster Med. 2016;31(3):282-293.
authors.affiliation: 1Prehospital, Resuscitation, and Emergency Care Research Unit,School of Nursing,Midwifery, and Paramedicine,Curtin University,Bentley,Western Australia,Australia.
authors.forename: Hideo
authors.initials: H
authors.lastname: Tohira
authors.affiliation: 2Emergency Medicine,Royal Perth Hospital,The University of Western Australia,Perth,Western Australia,Australia.
authors.forename: Daniel
authors.initials: D
authors.lastname: Fatovich
authors.affiliation: 1Prehospital, Resuscitation, and Emergency Care Research Unit,School of Nursing,Midwifery, and Paramedicine,Curtin University,Bentley,Western Australia,Australia.
authors.forename: Teresa A
authors.initials: TA
authors.lastname: Williams
authors.affiliation: 7School of Population Health,The University of Western Australia,Crawley,Western Australia,Australia.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Bremner
authors.affiliation: 4Discipline of Emergency Medicine,School of Primary,Aboriginal and Rural Health Care,The University of Western Australia,Crawley,Western Australia,Australia.
authors.forename: Glenn
authors.initials: G
authors.lastname: Arendts
authors.affiliation: 8St John of God Murdoch Hospital,Murdoch,Western Australia,Australia.
authors.forename: Ian R
authors.initials: IR
authors.lastname: Rogers
authors.affiliation: 4Discipline of Emergency Medicine,School of Primary,Aboriginal and Rural Health Care,The University of Western Australia,Crawley,Western Australia,Australia.
authors.forename: Antonio
authors.initials: A
authors.lastname: Celenza
authors.affiliation: 4Discipline of Emergency Medicine,School of Primary,Aboriginal and Rural Health Care,The University of Western Australia,Crawley,Western Australia,Australia.
authors.forename: David
authors.initials: D
authors.lastname: Mountain
authors.affiliation: 11School of Public Health and Preventive Medicine,Monash University,Melbourne,Victoria,Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Cameron
authors.affiliation: 4Discipline of Emergency Medicine,School of Primary,Aboriginal and Rural Health Care,The University of Western Australia,Crawley,Western Australia,Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Sprivulis
authors.affiliation: 5St John Ambulance Western Australia,Belmont,Western Australia,Australia.
authors.forename: Tony
authors.initials: T
authors.lastname: Ahern
authors.affiliation: 1Prehospital, Resuscitation, and Emergency Care Research Unit,School of Nursing,Midwifery, and Paramedicine,Curtin University,Bentley,Western Australia,Australia.
authors.forename: Judith
authors.initials: J
authors.lastname: Finn
mesh_terms: D000328:Adult; D057189:Checklist / Q000592:standards*; D003657:Decision Making; D004634:Emergency Medical Technicians; D005260:Female; D006801:Humans; D007003:Hypoglycemia / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge; D012189:Retrospective Studies; D014904:Western Australia
keywords: Australian Modification; BSL blood sugar level; DM diabetes mellitus; ECP Extended Care Paramedic; ED emergency department; EDIS emergency department information system; Emergency Medical Services; GCS Glasgow Coma Scale; ICD-10-AM International Classification of Diseases; JRCALC Joint Royal Colleges Ambulance Liaison Committee; SCP self-care pathway; SJA-WA St John Ambulance Western Australia; Tenth Revision; WA Western Australia; clinical practice guideline; e-PCR electronic patient care record; hypoglycemia; seizures