Which patients should be transported to the emergency department? A perpetual prehospital dilemma.
OBJECTIVE
To examine the ability of paramedics to identify patients who could be managed in the community and to identify predictors that could be used to accurately identify patients who should be transported to EDs.


METHODS
Lower acuity patients who were assessed by paramedics in the Perth metropolitan area in 2013 were studied. Paramedics prospectively indicated on the patient care record if they considered that the patient could be treated in the community. The paramedic decisions were compared with actual disposition from the ED (discharge and admission), and the occurrence of subsequent events (ambulance request, ED visit, admission and death) for discharged patients at the scene was investigated. Decision tree analysis was used to identify predictors that were associated with hospital admission.


RESULTS
In total, 57 183 patients were transported to the ED, and 10 204 patients were discharged at the scene by paramedics. Paramedics identified 2717 patients who could potentially be treated in the community among those who were transported to the ED. Of these, 1455 patients (53.6%) were admitted to hospital. For patients discharged at the scene, those who were indicated as suitable for community care were more likely to experience subsequent events than those who were not. The decision tree found that two predictors (age and aetiology) were associated with hospital admission. Overall discriminative power of the decision tree was poor; the area under the receiver operating characteristic curve was 0.686.


CONCLUSIONS
Lower acuity patients who could be treated in the community were not accurately identified by paramedics. This process requires further evaluation.
Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.|Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Perth, Western Australia, Australia.
Hideo
H
Tohira
Emergency Medicine, Royal Perth Hospital, The University of Western Australia, Perth, Western Australia, Australia.|Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia.
Daniel
http://orcid.org/0000-0001-9414-6905
D
Fatovich
Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.|Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Perth, Western Australia, Australia.|St John Ambulance, Perth, Western Australia, Australia.|Emergency Department, Royal Perth Hospital, Perth, Western Australia, Australia.
Teresa A
TA
Williams
School of Population Health, The University of Western Australia, Perth, Western Australia, Australia.
Alexandra
A
Bremner
Emergency Medicine, Royal Perth Hospital, The University of Western Australia, Perth, Western Australia, Australia.|Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia.
Glenn
G
Arendts
Emergency Department, St John of God Murdoch Hospital, Perth, Western Australia, Australia.|University of Notre Dame Australia, Fremantle, Western Australia, Australia.
Ian R
IR
Rogers
Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Perth, Western Australia, Australia.|Emergency Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
Antonio
A
Celenza
Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Perth, Western Australia, Australia.|Emergency Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
David
D
Mountain
School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
Peter
P
Cameron
Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Perth, Western Australia, Australia.|Emergency Department, Fiona Stanley Hospital, Perth, Western Australia, Australia.
Peter
P
Sprivulis
St John Ambulance, Perth, Western Australia, Australia.
Tony
T
Ahern
Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.|Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Perth, Western Australia, Australia.|St John Ambulance, Perth, Western Australia, Australia.|School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
Judith
J
Finn
D000293:Adolescent; D000328:Adult; D000368:Aged; D001315:Australia; D002983:Clinical Competence; D003657:Decision Making; D003661:Decision Support Techniques; D003663:Decision Trees; D004634:Emergency Medical Technicians; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D062072:Patient Acuity; D011446:Prospective Studies; D014187:Transportation of Patients; D014218:Triage / Q000592:standards*; D055815:Young Adult
clinical practice guideline; decision trees; emergency medicine; prehospital emergency care