Alternative Destination Transport? The Role of Paramedics in Optimal Use of the Emergency Department.
BACKGROUND
Alternative destination transportation by emergency medical services (EMS) is a subject of hot debate between those favoring all patients being evaluated by an emergency physician (EP) and those recognizing the need to reduce emergency department (ED) crowding. This study aimed to determine whether paramedics could accurately assess a patient's acuity level to determine the need to transport to an ED.


METHODS
We performed a prospective double-blinded analysis of responses recorded by paramedics and EPs of arriving patients' acuity level in a large Level II trauma center between April 2015 and November 2015. Under-triage was defined as lower acuity assessed by paramedics but higher acuity by EPs. Over-triage was defined as higher acuity assessed by paramedics but lower acuity by EPs. The degree of agreement between the paramedics and EPs' evaluations of patient's acuity level was compared using Chi-square test.


RESULTS
We included a total of 503 patients in the final analysis. For paramedics, 2 51 (49.9%) patients were assessed to be emergent, 178 (35.4%) assessed as urgent, and 74 (14.7%) assessed as non-emergent/non-urgent. In comparison, the EPs assessed 296 (58.9%) patients as emergent, 148 (29.4%) assessed as urgent, and 59 (11.7%) assessed as non-emergent/non-urgent. Paramedics agreed with EPs regarding the acuity level assessment on 71.8% of the cases. The overall under- and over-triage were 19.3% and 8.9%, respectively. A moderate Kappa=0.5174 indicated moderate inter-rater agreement between paramedics' and EPs' assessment on the same cohort of patients.


CONCLUSIONS
There is a significant difference in paramedic and physician assessment of patients into emergent, urgent, or non-emergent/non-urgent categories. The field triage of a patient to an alternative destination by paramedics under their current scope of practice and training cannot be supported.
Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.
Michael M
MM
Neeki
Western University of Health Sciences, Graduate College of Biomedical Sciences, Pomona, California.
Fanglong
F
Dong
Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.
Leigh
L
Avera
Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.
Tan
T
Than
Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.
Rodney
R
Borger
City of Rialto Fire Department, Rialto, California.
Joe
J
Powell
Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.
Reza
R
Vaezazizi
Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.
Richard
R
Pitts
D002983:Clinical Competence; D003441:Crowding; D004632:Emergency Medical Services; D004634:Emergency Medical Technicians / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D010820:Physicians / Q000592:standards* / Q000706:statistics & numerical data; D011446:Prospective Studies; D011795:Surveys and Questionnaires; D014187:Transportation of Patients; D014218:Triage / Q000592:standards* / Q000706:statistics & numerical data