Differences in Accuracy Between Paramedics and Emergency Medical Technicians (EMTs) When Identifying Low-Acuity Pediatric Patients
Article Sidebar
Main Article Content
Abstract
Background
Alternative emergency medical services (EMS) disposition programs have been developed for adults with low-acuity complaints. One barrier to including children in such programs is a lack of evidence regarding whether paramedics and emergency medical technicians (EMTs) can accurately identify children with low-acuity complaints. Our primary objective was to compare the accuracy of EMTs to that of paramedics in identifying low-acuity pediatric encounters. Our secondary objective was to determine whether support for alternative EMS dispositions differed between paramedics and EMTs.
Methods
This was a planned secondary analysis of a cross-sectional study of children transported by EMS to an emergency department (ED). Acuity was defined using a composite measure that included physiological patient assessments, resources used (including laboratory tests and radiographs), and patient disposition. EMS clinicians rated on a Likert scale their level of agreement that a patient had a low-acuity problem and could have been transported by private vehicle, seen in clinic, or not transported. The sensitivity, specificity, and positive and negative predictive values (PPV and NPV) for paramedic and EMT acuity assessments were calculated.
Results
EMS surveys were completed for 84.0% of 996 participants (76.4% by EMTs, 22.6% by paramedics). 35.1% of participants were classified as having a low-acuity complaint. The sensitivity for identifying a child as low-acuity was 24% (95% CI 20%, 38%) for paramedics and 50% (46%, 54%) for EMTs. The PPV for identifying a child as low-acuity was 0.44 (0.28, 0.60) for paramedics and 0.62 (0.55, 0.68) for EMTs. Only 20.5% of paramedics and 22.5% of EMTs supported non-transport for children with low-acuity complaints.
Conclusions
Relying on EMS assessments of pediatric patient acuity may lead to under-triage, regardless of whether a paramedic or EMT makes this determination. Additional training and triage tools may be required before children can be safely included in alternative EMS disposition programs.
Article Details
This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
Publishing in IJOP allows authors to keep their copyright while giving IJOP unrestricted copyright permissions. Articles published in IJOP use Creative Common Attribution 4.0 International (CC BY-ND 4.0) licensing. This license requires that re-users give credit to the creator. It allows re-users to copy and distribute the material in any medium or format in unadapted form only, even for commercial purposes. Additional terms apply and can be accessed here.
Publishing in IJOP also allows authors to have contracts for non-exclusive distribution of the Journal's published version of the article, such as posting to an institutional repository or publication in a book, on the condition that the original publication in the original layout format in IJOP is retained and acknowledged.
We permit and encourage authors to post the articles they published in IJOP on their affiliated websites. This helps share the information, encourages citation in other works, and promotes scholarly discourse in the spirit of open access.
References
Alpert, A., Morganti, K. G., Margolis, G. S., Wasserman, J., & Kellermann, A. L. (2013). Giving EMS Flexibility In Transporting Low-Acuity Patients Could Generate Substantial Medicare Savings. Health Affairs, 32(12), 2142–2148. https://doi.org/10.1377/hlthaff.2013.0741
Brown, L. H., Hubble, M. W., Cone, D. C., Millin, M. G., Schwartz, B., Patterson, P. D., Greenberg, B., & Richards, M. E. (2009). Paramedic Determinations of Medical Necessity: A Meta-Analysis. Prehospital Emergency Care, 13(4), 516–527. https://doi.org/10.1080/10903120903144809
Cone, D. (2004a). Developing research criteria to define medical necessity in emergency medical services*1. Prehospital Emergency Care, 8(2), 116–125. https://doi.org/10.1016/j.prehos.2003.12.002
Cone, D. (2004b). Field triage systems: Methodologies from the literature*1. Prehospital Emergency Care, 8(2), 130–137. https://doi.org/10.1016/j.prehos.2003.12.004
Crowe, R. P., Bower, J. K., Cash, R. E., Panchal, A. R., Rodriguez, S. A., & Olivo-Marston, S. E. (2018). Association of Burnout with Workforce-Reducing Factors among EMS Professionals. Prehospital Emergency Care: Official Journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 22(2), 229–236. https://doi.org/10.1080/10903127.2017.1356411
Crowe, R. P., Fernandez, A. R., Pepe, P. E., Cash, R. E., Rivard, M. K., Wronski, R., Anderson, S. E., Hogan, T. H., Andridge, R. R., Panchal, A. R., & Ferketich, A. K. (2020). The association of job demands and resources with burnout among emergency medical services professionals. Journal of the American College of Emergency Physicians Open, 1(1), 6–16. https://doi.org/10.1002/emp2.12014
Derlet, R. W., & Richards, J. R. (2000). Overcrowding in the nation’s emergency departments: Complex causes and disturbing effects. Annals of Emergency Medicine, 35(1), 63–68. https://doi.org/10.1016/s0196-0644(00)70105-3
Duong, H. V., Herrera, L. N., Moore, J. X., Donnelly, J., Jacobson, K. E., Carlson, J. N., Mann, N. C., & Wang, H. E. (2018). National Characteristics of Emergency Medical Services Responses for Older Adults in the United States. Prehospital Emergency Care, 22(1), 7–14. https://doi.org/10.1080/10903127.2017.1347223
Gilboy, N., Tanabe, P., Travers, D., & Rosenau, A. (2011). Emergency Seveirt Index 9ESI): A Triage Tool for Emergency Department Care, Version 4. Implementation Handbook. Agency for Healthcare Research and Quality. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/esi/esihandbk.pdf
Goldman, S., Doetzer, G., Parekh, A., Carr, B., & Alley, D. (2020). Right Care, Right Place, Right Time: The CMS Innovation Center Launches the Emergency Triage, Treat, and Transport Model. Annals of Emergency Medicine, 75(5), 609–611. https://doi.org/10.1016/j.annemergmed.2019.09.006
Haines, C. J., Lutes, R. E., Blaser, M., & Christopher, N. C. (2006). Paramedic Initiated Non-Transport of Pediatric Patients. Prehospital Emergency Care, 10(2), 213–219. https://doi.org/10.1080/10903120500541308
Hansen, M., Meckler, G., Dickinson, C., Dickenson, K., Jui, J., Lambert, W., & Guise, J.-M. (2015). Children’s Safety Initiative: A National Assessment of Pediatric Educational Needs among Emergency Medical Services Providers. Prehospital Emergency Care, 19(2), 287–291. https://doi.org/10.3109/10903127.2014.959223
Jensen, J. L., Carter, A. J. E., Rose, J., Visintini, S., Bourdon, E., Brown, R., McVey, J., & Travers, A. H. (2015). Alternatives to Traditional EMS Dispatch and Transport: A Scoping Review of Reported Outcomes. CJEM, 17(5), 532–550. https://doi.org/10.1017/cem.2014.59
Jeruzal, J. N., Boland, L. L., Frazer, M. S., Kamrud, J. W., Myers, R. N., Lick, C. J., & Stevens, A. C. (2019). Emergency Medical Services Provider Perspectives on Pediatric Calls: A Qualitative Study. Prehospital Emergency Care, 23(4), 501–509. https://doi.org/10.1080/10903127.2018.1551450
Kahalé, J., Osmond, M. H., Nesbitt, L., & Stiell, I. G. (2006). What are the characteristics and outcomes of nontransported pediatric patients? Prehospital Emergency Care: Official Journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 10(1), 28–34. https://doi.org/10.1080/10903120500373322
Kamper, M., Mahoney, B. D., Nelson, S., & Peterson, J. (2001). Feasibility of Paramedic Treatment and Referral of Minor Illnesses and Injuries. Prehospital Emergency Care, 5(4), 371–378. https://doi.org/10.1080/10903120190939535
Lerner, E. B., Newgard, C. D., & Mann, N. C. (2020). Effect of the Coronavirus Disease 2019 (COVID-19) Pandemic on the U.S. Emergency Medical Services System: A Preliminary Report. Academic Emergency Medicine, 27(8), 693–699. https://doi.org/10.1111/acem.14051
Levine, S. D., Colwell, C. B., Pons, P. T., Gravitz, C., Haukoos, J. S., & McVaney, K. E. (2006). How well do paramedics predict admission to the hospital? A prospective study. The Journal of Emergency Medicine, 31(1), 1–5. https://doi.org/10.1016/j.jemermed.2005.08.007
Mann, N. (2004). Defining research criteria to characterize medical necessity in emergency medical services: A consensus among experts at the neely conference*1. Prehospital Emergency Care, 8(2), 138–153. https://doi.org/10.1016/j.prehos.2003.12.005
Martin, A., & O’Meara, P. (2019). Perspectives from the frontline of two North American community paramedicine programs: An observational, ethnographic study. Rural and Remote Health. https://doi.org/10.22605/RRH4888
Mell, H. K., Mumma, S. N., Hiestand, B., Carr, B. G., Holland, T., & Stopyra, J. (2017). Emergency Medical Services Response Times in Rural, Suburban, and Urban Areas. JAMA Surgery, 152(10), 983. https://doi.org/10.1001/jamasurg.2017.2230
Millin, M. G., Brown, L. H., & Schwartz, B. (2011). EMS Provider Determinations of Necessity for Transport and Reimbursement for EMS Response, Medical Care, and Transport: Combined Resource Document for the National Association of EMS Physicians Position Statements. Prehospital Emergency Care, 15(4), 562–569. https://doi.org/10.3109/10903127.2011.598625
Morgan, R., & Cutter, J. (2023). Prehospital use of the paediatric observation priority score. Journal of Paramedic Practice, 15(8), 330–336. https://doi.org/10.12968/jpar.2023.15.8.330
National Registry of Emergency Medical Technicians. (2023). National Registry Data, Dashboard and Maps. https://www.nremt.org/maps
O’Meara, P., Stirling, C., Ruest, M., & Martin, A. (2015). Community paramedicine model of care: An observational, ethnographic case study. BMC Health Services Research, 16(1), 39. https://doi.org/10.1186/s12913-016-1282-0
Patterson, P. D., Baxley, E. G., Probst, J. C., Hussey, J. R., & Moore, C. G. (2006). Medically Unnecessary Emergency Medical Services (EMS) Transports Among Children Ages 0 to 17 Years. Maternal and Child Health Journal, 10(6), 527–536. https://doi.org/10.1007/s10995-006-0127-6
Pointer, J. E., Levitt, M. A., Young, J. C., Promes, S. B., Messana, B. J., & Adèr, M. E. J. (2001). Can paramedics using guidelines accurately triage patients? Annals of Emergency Medicine, 38(3), 268–277. https://doi.org/10.1067/mem.2001.117198
Power, B., Bury, G., & Ryan, J. (2019). Stakeholder opinion on the proposal to introduce ‘treat and referral’ into the Irish emergency medical service. BMC Emergency Medicine, 19(1), 81. https://doi.org/10.1186/s12873-019-0295-5
Price, T. G., Hooker, E. A., & Neubauer, J. (2005). Prehospital Provider Prediction of Emergency Department Disposition: Prehospital Emergency Care, 9(3), 322–325. https://doi.org/10.1080/10903120590962012
Rahman, A., Curtis, S., DeBruyne, B., Sookram, S., Thomson, D., Lutz, S., & Ali, S. (2015). Emergency Medical Services Provider Comfort with Prehospital Analgesia Administration to Children. Prehospital and Disaster Medicine, 30(1), 66–71. https://doi.org/10.1017/S1049023X14001277
Richards, J. R., & Ferrall, S. J. (1999). Triage ability of emergency medical services providers and patient disposition: A prospective study. Prehospital and Disaster Medicine, 14(3), 174–179.
SAS/STAT 15.3 User’s Guide. (2023). [Computer software]. SAS Institute Inc.
Satty, T., Ramgopal, S., Elmer, J., Mosesso, V. N., & Martin-Gill, C. (2021). EMS responses and non-transports during the COVID-19 pandemic. The American Journal of Emergency Medicine, 42, 1–8. https://doi.org/10.1016/j.ajem.2020.12.078
Schmidt, T. (2004). Criteria currently used to evaluate dispatch triage systems: Where do they leave us?*1. Prehospital Emergency Care, 8(2), 126–129. https://doi.org/10.1016/j.prehos.2003.12.003
Seltzer, A. G., Vilke, G. M., Chan, T. C., Fisher, R., & Dunford, J. V. (2001). Outcome study of minors after parental refusal of paramedic transport. Prehospital Emergency Care: Official Journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 5(3), 278–283. https://doi.org/10.1080/10903120190939797
Totten, A. M., Cheney, T. P., O’Neil, M. E., Newgard, C. D., Daya, M., Fu, R., Wasson, N., Hart, E. L., & Chou, R. (2018). Physiologic Predictors of Severe Injury: Systematic Review. Agency for Healthcare Research and Quality (AHRQ). https://doi.org/10.23970/AHRQEPCCER205
Ward, C. E., Badolato, G. M., Taylor, M. F., Brown, K. M., Simpson, J. N., & Chamberlain, J. M. (2022). Clinician and Caregiver Determinations of Acuity for Children Transported by Emergency Medical Services: A Prospective Observational Study. Annals of Emergency Medicine, S0196-0644(22)01088-5. https://doi.org/10.1016/j.annemergmed.2022.09.002
Ward, C. E., Singletary, J., Campanella, V., Page, C., & Simpson, J. N. (2023). Caregiver Perspectives on Including Children in Alternative Emergency Medical Services Disposition Programs: A Qualitative Study. Prehospital Emergency Care, 0(ja), 1–17. https://doi.org/10.1080/10903127.2023.2206480
Ward, C. E., Singletary, J., Hatcliffe, R. E., Colson, C. D., Simpson, J. N., Brown, K. M., & Chamberlain, J. M. (2022). Emergency Medical Services Clinicians’ Perspectives on Pediatric Non-Transport. Prehospital Emergency Care, 1–22. https://doi.org/10.1080/10903127.2022.2108180
Ward, C., Zhang, A., Brown, K., Simpson, J., & Chamberlain, J. (2022). National Characteristics of Non-Transported Children by Emergency Medical Services in the United States. Prehospital Emergency Care, 26(4), 537–546. https://doi.org/10.1080/10903127.2021.1985666
Zachariah, B. S., Bryan, D., Pepe, P. E., & Griffin, M. (1992). Follow-up and Outcome of Patients Who Decline or Are Denied Transport by EMS. Prehospital and Disaster Medicine, 7(4), 359–364. https://doi.org/10.1017/S1049023X00039777
Zaritsky, A. (1994). A Statewide Evaluation of Pediatric Prehospital and Hospital Emergency Services. Archives of Pediatrics & Adolescent Medicine, 148(1), 76. https://doi.org/10.1001/archpedi.1994.02170010078019