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Dr Bledsoe,

Interesting read. I do not agree though that admission to the hospital would

make the decision not to transport wrong. I would like to see a study done that

established actual harm coming to patient because the Paramedic said ambulance

not needed and sent patient POV.

Many patients could be safely treated and sent POV to the ER or their doctors

office.

I know current payment guidelines thanks to some here would not reimburse us for

that type of care though. So financially it is not feasible, but maybe with

some efforts change in payment terms could be made.

Respectfully

Renny Spencer

>

> Abstract

> Introduction. Reducing unnecessary ambulance transports may have operational

> and economic benefits for emergency medical services (EMS) agencies and

> receiving emergency departments. However, no consensus exists on the ability

> of paramedics to accurately and safely identify patients who do not require

> ambulance transport. Objective. This systematic review and meta-analysis

> evaluated studies reporting U.S. paramedics' ability to determine medical

> necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> databases were searched using Cochrane Prehospital and Emergency Care Field

> search terms combined with the Medical Subject Headings (MeSH) terms

> ³triage²; ³utilization review²; ³health services misuse²; ³severity of

> illness index,² and ³trauma severity indices.² Two reviewers independently

> evaluated each title to identify relevant studies; each abstract then

> underwent independent review to identify studies requiring full appraisal.

> Inclusion criteria were original research; emergency responses;

> determinations of medical necessity by U.S. paramedics; and a reference

> standard comparison. The primary outcome measure of interest was the

> negative predictive value (NPV) of paramedic determinations. For studies

> reporting sufficient data, agreement between paramedic and reference

> standard determinations was measured using kappa; sensitivity, specificity,

> and positive predictive value (PPV) were also calculated. Results. From

> 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> selected for full review. Five studies met the inclusion criteria

> (interrater reliability, kappa = 0.75). Reference standards included

> physician opinion (n = 3), hospital admission (n = 1), and a composite of

> physician opinion and patient clinical circumstances (n = 1). The NPV ranged

> from 0.610 to 0.997. Results lacked homogeneity across studies;

> meta-analysis using a random-effects model produced an aggregate NPV of

> 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported

> complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> Conclusion. The results of the few studies evaluating U.S. paramedic

> determinations of medical necessity for ambulance transport vary

> considerably, and only two studies report complete data. The aggregate NPV

> of the paramedic determinations is 0.91, with a lower confidence limit of

> 0.71. These data do not support the practice of paramedics' determining

> whether patients require ambulance transport. These findings have

> implications for EMS systems, emergency departments, and third-party payers.

>

> Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

>

>

>

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Guest guest

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Posted
Posted

Dr Bledsoe,

Interesting read. I do not agree though that admission to the hospital would

make the decision not to transport wrong. I would like to see a study done that

established actual harm coming to patient because the Paramedic said ambulance

not needed and sent patient POV.

Many patients could be safely treated and sent POV to the ER or their doctors

office.

I know current payment guidelines thanks to some here would not reimburse us for

that type of care though. So financially it is not feasible, but maybe with

some efforts change in payment terms could be made.

Respectfully

Renny Spencer

>

> Abstract

> Introduction. Reducing unnecessary ambulance transports may have operational

> and economic benefits for emergency medical services (EMS) agencies and

> receiving emergency departments. However, no consensus exists on the ability

> of paramedics to accurately and safely identify patients who do not require

> ambulance transport. Objective. This systematic review and meta-analysis

> evaluated studies reporting U.S. paramedics' ability to determine medical

> necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> databases were searched using Cochrane Prehospital and Emergency Care Field

> search terms combined with the Medical Subject Headings (MeSH) terms

> ³triage²; ³utilization review²; ³health services misuse²; ³severity of

> illness index,² and ³trauma severity indices.² Two reviewers independently

> evaluated each title to identify relevant studies; each abstract then

> underwent independent review to identify studies requiring full appraisal.

> Inclusion criteria were original research; emergency responses;

> determinations of medical necessity by U.S. paramedics; and a reference

> standard comparison. The primary outcome measure of interest was the

> negative predictive value (NPV) of paramedic determinations. For studies

> reporting sufficient data, agreement between paramedic and reference

> standard determinations was measured using kappa; sensitivity, specificity,

> and positive predictive value (PPV) were also calculated. Results. From

> 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> selected for full review. Five studies met the inclusion criteria

> (interrater reliability, kappa = 0.75). Reference standards included

> physician opinion (n = 3), hospital admission (n = 1), and a composite of

> physician opinion and patient clinical circumstances (n = 1). The NPV ranged

> from 0.610 to 0.997. Results lacked homogeneity across studies;

> meta-analysis using a random-effects model produced an aggregate NPV of

> 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported

> complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> Conclusion. The results of the few studies evaluating U.S. paramedic

> determinations of medical necessity for ambulance transport vary

> considerably, and only two studies report complete data. The aggregate NPV

> of the paramedic determinations is 0.91, with a lower confidence limit of

> 0.71. These data do not support the practice of paramedics' determining

> whether patients require ambulance transport. These findings have

> implications for EMS systems, emergency departments, and third-party payers.

>

> Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

>

>

>

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Posted

You would never get such a study approved by an IRB.

>

>

>

>

> Dr Bledsoe,

>

> Interesting read. I do not agree though that admission to the hospital would

> make the decision not to transport wrong. I would like to see a study done

> that established actual harm coming to patient because the Paramedic said

> ambulance not needed and sent patient POV.

>

> Many patients could be safely treated and sent POV to the ER or their doctors

> office.

>

> I know current payment guidelines thanks to some here would not reimburse us

> for that type of care though. So financially it is not feasible, but maybe

> with some efforts change in payment terms could be made.

>

> Respectfully

> Renny Spencer

>

>> >

>> > Abstract

>> > Introduction. Reducing unnecessary ambulance transports may have

>> operational

>> > and economic benefits for emergency medical services (EMS) agencies and

>> > receiving emergency departments. However, no consensus exists on the

>> ability

>> > of paramedics to accurately and safely identify patients who do not require

>> > ambulance transport. Objective. This systematic review and meta-analysis

>> > evaluated studies reporting U.S. paramedics' ability to determine medical

>> > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

>> > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

>> > databases were searched using Cochrane Prehospital and Emergency Care Field

>> > search terms combined with the Medical Subject Headings (MeSH) terms

>> > ³triage²; ³utilization review²; ³health services misuse²; ³severity of

>> > illness index,² and ³trauma severity indices.² Two reviewers independently

>> > evaluated each title to identify relevant studies; each abstract then

>> > underwent independent review to identify studies requiring full appraisal.

>> > Inclusion criteria were original research; emergency responses;

>> > determinations of medical necessity by U.S. paramedics; and a reference

>> > standard comparison. The primary outcome measure of interest was the

>> > negative predictive value (NPV) of paramedic determinations. For studies

>> > reporting sufficient data, agreement between paramedic and reference

>> > standard determinations was measured using kappa; sensitivity, specificity,

>> > and positive predictive value (PPV) were also calculated. Results. From

>> > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

>> > selected for full review. Five studies met the inclusion criteria

>> > (interrater reliability, kappa = 0.75). Reference standards included

>> > physician opinion (n = 3), hospital admission (n = 1), and a composite of

>> > physician opinion and patient clinical circumstances (n = 1). The NPV

>> ranged

>> > from 0.610 to 0.997. Results lacked homogeneity across studies;

>> > meta-analysis using a random-effects model produced an aggregate NPV of

>> > 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported

>> > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

>> > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

>> > Conclusion. The results of the few studies evaluating U.S. paramedic

>> > determinations of medical necessity for ambulance transport vary

>> > considerably, and only two studies report complete data. The aggregate NPV

>> > of the paramedic determinations is 0.91, with a lower confidence limit of

>> > 0.71. These data do not support the practice of paramedics' determining

>> > whether patients require ambulance transport. These findings have

>> > implications for EMS systems, emergency departments, and third-party

>> payers.

>> >

>> > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

>> >

>> >

>> >

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Guest guest

Posted
Posted

You would never get such a study approved by an IRB.

>

>

>

>

> Dr Bledsoe,

>

> Interesting read. I do not agree though that admission to the hospital would

> make the decision not to transport wrong. I would like to see a study done

> that established actual harm coming to patient because the Paramedic said

> ambulance not needed and sent patient POV.

>

> Many patients could be safely treated and sent POV to the ER or their doctors

> office.

>

> I know current payment guidelines thanks to some here would not reimburse us

> for that type of care though. So financially it is not feasible, but maybe

> with some efforts change in payment terms could be made.

>

> Respectfully

> Renny Spencer

>

>> >

>> > Abstract

>> > Introduction. Reducing unnecessary ambulance transports may have

>> operational

>> > and economic benefits for emergency medical services (EMS) agencies and

>> > receiving emergency departments. However, no consensus exists on the

>> ability

>> > of paramedics to accurately and safely identify patients who do not require

>> > ambulance transport. Objective. This systematic review and meta-analysis

>> > evaluated studies reporting U.S. paramedics' ability to determine medical

>> > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

>> > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

>> > databases were searched using Cochrane Prehospital and Emergency Care Field

>> > search terms combined with the Medical Subject Headings (MeSH) terms

>> > ³triage²; ³utilization review²; ³health services misuse²; ³severity of

>> > illness index,² and ³trauma severity indices.² Two reviewers independently

>> > evaluated each title to identify relevant studies; each abstract then

>> > underwent independent review to identify studies requiring full appraisal.

>> > Inclusion criteria were original research; emergency responses;

>> > determinations of medical necessity by U.S. paramedics; and a reference

>> > standard comparison. The primary outcome measure of interest was the

>> > negative predictive value (NPV) of paramedic determinations. For studies

>> > reporting sufficient data, agreement between paramedic and reference

>> > standard determinations was measured using kappa; sensitivity, specificity,

>> > and positive predictive value (PPV) were also calculated. Results. From

>> > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

>> > selected for full review. Five studies met the inclusion criteria

>> > (interrater reliability, kappa = 0.75). Reference standards included

>> > physician opinion (n = 3), hospital admission (n = 1), and a composite of

>> > physician opinion and patient clinical circumstances (n = 1). The NPV

>> ranged

>> > from 0.610 to 0.997. Results lacked homogeneity across studies;

>> > meta-analysis using a random-effects model produced an aggregate NPV of

>> > 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported

>> > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

>> > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

>> > Conclusion. The results of the few studies evaluating U.S. paramedic

>> > determinations of medical necessity for ambulance transport vary

>> > considerably, and only two studies report complete data. The aggregate NPV

>> > of the paramedic determinations is 0.91, with a lower confidence limit of

>> > 0.71. These data do not support the practice of paramedics' determining

>> > whether patients require ambulance transport. These findings have

>> > implications for EMS systems, emergency departments, and third-party

>> payers.

>> >

>> > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

>> >

>> >

>> >

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Posted
Posted

I do agree.  But, and I don't agree with this, there would be some cities,

privates, PUM's, and such that would make a SOP or Protocol that says to

transport because you make more per transport than no transport.  But, and

everybody knows, that there would that one EMT or Paramedic that would do a no

transport every time just because of laziness.  Not saying that is the case

with anyone here, but there would be somebody that would do that.  Also,

assuming you could decide whether a person should go by ambulance or not, would

you want to be the one that no rode a patient and it was detrimental to the

patient?  This in my opinion would lead to loss of respect for the field, not

to mention the loss of jobs because the number of actual transporting units

would go down.

Feemster

Re: Paramedics Cannot Determine Which Patients Require

Transport

Dr Bledsoe,

Interesting read. I do not agree though that admission to the hospital would

ake the decision not to transport wrong. I would like to see a study done that

stablished actual harm coming to patient because the Paramedic said ambulance

ot needed and sent patient POV.

Many patients could be safely treated and sent POV to the ER or their doctors

ffice.

I know current payment guidelines thanks to some here would not reimburse us for

hat type o

f care though. So financially it is not feasible, but maybe with

ome efforts change in payment terms could be made.

Respectfully

enny Spencer

-- In texasems-l , Bledsoe wrote:

Abstract

Introduction. Reducing unnecessary ambulance transports may have operational

and economic benefits for emergency medical services (EMS) agencies and

receiving emergency departments. However, no consensus exists on the ability

of paramedics to accurately and safely identify patients who do not require

ambulance transport. Objective. This systematic review and meta-analysis

evaluated studies reporting U.S. paramedics' ability to determine medical

necessity of ambulance transport. Methods. PubMed, Cumulative Index to

Nursing and Allied Health Literature (CINAHL), and Cochrane Library

databases were searched using Cochrane Prehospital and Emergency Care Field

search terms combined with the Medical Subject Headings (MeSH) terms

³triage²; ³utilization review²; ³health services misuse²; ³severity of

illness index,² and ³trauma severity indices.² Two reviewers independently

evaluated each title to identify relevant studies; each abstract then

underwent independent review to identify studies requiring full appraisal.

Inclusion criteria were original research; emergency responses;

determinations of medical necessity by U.S. paramedics; and a reference

standard comparison. The primary outcome measure of interest was the

negative predictive value (NPV) of paramedic determinations. For studies

20reporting sufficient data, agreement between paramedic and reference

standard determinations was measured using kappa; sensitivity, specificity,

and positive predictive value (PPV) were also calculated. Results. From

9,752 identified titles, 214 abstracts were evaluated, with 61 studies

selected for full review. Five studies met the inclusion criteria

(interrater reliability, kappa = 0.75). Reference standards included

physician opinion (n = 3), hospital admission (n = 1), and a composite of

physician opinion and patient clinical circumstances (n = 1). The NPV ranged

from 0.610 to 0.997. Results lacked homogeneity across studies;

meta-analysis using a random-effects model produced an aggregate NPV of

0.912 (95% confidence interval: 0.707-0.978). Only two studies reported

complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

Conclusion. The results of the few studies evaluating U.S. paramedic

determinations of medical necessity for ambulance transport vary

considerably, and only two studies report complete data. The aggregate NPV

of the paramedic determinations is 0.91, with a lower confidence limit of

0.71. These data do not support the practice of paramedics' determining

whether patients require ambulance transport. These findings have

implications for EMS systems, emergency departments, and third-party payers.

Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

[Non-text portions of this mess

age have been removed]

-----------------------------------

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Guest guest

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Posted
Posted

I do agree.  But, and I don't agree with this, there would be some cities,

privates, PUM's, and such that would make a SOP or Protocol that says to

transport because you make more per transport than no transport.  But, and

everybody knows, that there would that one EMT or Paramedic that would do a no

transport every time just because of laziness.  Not saying that is the case

with anyone here, but there would be somebody that would do that.  Also,

assuming you could decide whether a person should go by ambulance or not, would

you want to be the one that no rode a patient and it was detrimental to the

patient?  This in my opinion would lead to loss of respect for the field, not

to mention the loss of jobs because the number of actual transporting units

would go down.

Feemster

Re: Paramedics Cannot Determine Which Patients Require

Transport

Dr Bledsoe,

Interesting read. I do not agree though that admission to the hospital would

ake the decision not to transport wrong. I would like to see a study done that

stablished actual harm coming to patient because the Paramedic said ambulance

ot needed and sent patient POV.

Many patients could be safely treated and sent POV to the ER or their doctors

ffice.

I know current payment guidelines thanks to some here would not reimburse us for

hat type o

f care though. So financially it is not feasible, but maybe with

ome efforts change in payment terms could be made.

Respectfully

enny Spencer

-- In texasems-l , Bledsoe wrote:

Abstract

Introduction. Reducing unnecessary ambulance transports may have operational

and economic benefits for emergency medical services (EMS) agencies and

receiving emergency departments. However, no consensus exists on the ability

of paramedics to accurately and safely identify patients who do not require

ambulance transport. Objective. This systematic review and meta-analysis

evaluated studies reporting U.S. paramedics' ability to determine medical

necessity of ambulance transport. Methods. PubMed, Cumulative Index to

Nursing and Allied Health Literature (CINAHL), and Cochrane Library

databases were searched using Cochrane Prehospital and Emergency Care Field

search terms combined with the Medical Subject Headings (MeSH) terms

³triage²; ³utilization review²; ³health services misuse²; ³severity of

illness index,² and ³trauma severity indices.² Two reviewers independently

evaluated each title to identify relevant studies; each abstract then

underwent independent review to identify studies requiring full appraisal.

Inclusion criteria were original research; emergency responses;

determinations of medical necessity by U.S. paramedics; and a reference

standard comparison. The primary outcome measure of interest was the

negative predictive value (NPV) of paramedic determinations. For studies

20reporting sufficient data, agreement between paramedic and reference

standard determinations was measured using kappa; sensitivity, specificity,

and positive predictive value (PPV) were also calculated. Results. From

9,752 identified titles, 214 abstracts were evaluated, with 61 studies

selected for full review. Five studies met the inclusion criteria

(interrater reliability, kappa = 0.75). Reference standards included

physician opinion (n = 3), hospital admission (n = 1), and a composite of

physician opinion and patient clinical circumstances (n = 1). The NPV ranged

from 0.610 to 0.997. Results lacked homogeneity across studies;

meta-analysis using a random-effects model produced an aggregate NPV of

0.912 (95% confidence interval: 0.707-0.978). Only two studies reported

complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

Conclusion. The results of the few studies evaluating U.S. paramedic

determinations of medical necessity for ambulance transport vary

considerably, and only two studies report complete data. The aggregate NPV

of the paramedic determinations is 0.91, with a lower confidence limit of

0.71. These data do not support the practice of paramedics' determining

whether patients require ambulance transport. These findings have

implications for EMS systems, emergency departments, and third-party payers.

Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

[Non-text portions of this mess

age have been removed]

-----------------------------------

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Posted
Posted

I definitely agree with you on that. Because of that we will have a flawed way

of determining mistakes in denying transport though. Even if just the Dr saying

ambulance transport was needed would be better yet that is very subjective as

well.

> >> >

> >> > Abstract

> >> > Introduction. Reducing unnecessary ambulance transports may have

> >> operational

> >> > and economic benefits for emergency medical services (EMS) agencies and

> >> > receiving emergency departments. However, no consensus exists on the

> >> ability

> >> > of paramedics to accurately and safely identify patients who do not

require

> >> > ambulance transport. Objective. This systematic review and meta-analysis

> >> > evaluated studies reporting U.S. paramedics' ability to determine medical

> >> > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> >> > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> >> > databases were searched using Cochrane Prehospital and Emergency Care

Field

> >> > search terms combined with the Medical Subject Headings (MeSH) terms

> >> > ³triage²; ³utilization review²; ³health services misuse²; ³severity of

> >> > illness index,² and ³trauma severity indices.² Two reviewers

independently

> >> > evaluated each title to identify relevant studies; each abstract then

> >> > underwent independent review to identify studies requiring full

appraisal.

> >> > Inclusion criteria were original research; emergency responses;

> >> > determinations of medical necessity by U.S. paramedics; and a reference

> >> > standard comparison. The primary outcome measure of interest was the

> >> > negative predictive value (NPV) of paramedic determinations. For studies

> >> > reporting sufficient data, agreement between paramedic and reference

> >> > standard determinations was measured using kappa; sensitivity,

specificity,

> >> > and positive predictive value (PPV) were also calculated. Results. From

> >> > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> >> > selected for full review. Five studies met the inclusion criteria

> >> > (interrater reliability, kappa = 0.75). Reference standards included

> >> > physician opinion (n = 3), hospital admission (n = 1), and a composite of

> >> > physician opinion and patient clinical circumstances (n = 1). The NPV

> >> ranged

> >> > from 0.610 to 0.997. Results lacked homogeneity across studies;

> >> > meta-analysis using a random-effects model produced an aggregate NPV of

> >> > 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported

> >> > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> >> > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> >> > Conclusion. The results of the few studies evaluating U.S. paramedic

> >> > determinations of medical necessity for ambulance transport vary

> >> > considerably, and only two studies report complete data. The aggregate

NPV

> >> > of the paramedic determinations is 0.91, with a lower confidence limit of

> >> > 0.71. These data do not support the practice of paramedics' determining

> >> > whether patients require ambulance transport. These findings have

> >> > implications for EMS systems, emergency departments, and third-party

> >> payers.

> >> >

> >> > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> >> >

> >> >

> >> >

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Posted
Posted

I definitely agree with you on that. Because of that we will have a flawed way

of determining mistakes in denying transport though. Even if just the Dr saying

ambulance transport was needed would be better yet that is very subjective as

well.

> >> >

> >> > Abstract

> >> > Introduction. Reducing unnecessary ambulance transports may have

> >> operational

> >> > and economic benefits for emergency medical services (EMS) agencies and

> >> > receiving emergency departments. However, no consensus exists on the

> >> ability

> >> > of paramedics to accurately and safely identify patients who do not

require

> >> > ambulance transport. Objective. This systematic review and meta-analysis

> >> > evaluated studies reporting U.S. paramedics' ability to determine medical

> >> > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> >> > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> >> > databases were searched using Cochrane Prehospital and Emergency Care

Field

> >> > search terms combined with the Medical Subject Headings (MeSH) terms

> >> > ³triage²; ³utilization review²; ³health services misuse²; ³severity of

> >> > illness index,² and ³trauma severity indices.² Two reviewers

independently

> >> > evaluated each title to identify relevant studies; each abstract then

> >> > underwent independent review to identify studies requiring full

appraisal.

> >> > Inclusion criteria were original research; emergency responses;

> >> > determinations of medical necessity by U.S. paramedics; and a reference

> >> > standard comparison. The primary outcome measure of interest was the

> >> > negative predictive value (NPV) of paramedic determinations. For studies

> >> > reporting sufficient data, agreement between paramedic and reference

> >> > standard determinations was measured using kappa; sensitivity,

specificity,

> >> > and positive predictive value (PPV) were also calculated. Results. From

> >> > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> >> > selected for full review. Five studies met the inclusion criteria

> >> > (interrater reliability, kappa = 0.75). Reference standards included

> >> > physician opinion (n = 3), hospital admission (n = 1), and a composite of

> >> > physician opinion and patient clinical circumstances (n = 1). The NPV

> >> ranged

> >> > from 0.610 to 0.997. Results lacked homogeneity across studies;

> >> > meta-analysis using a random-effects model produced an aggregate NPV of

> >> > 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported

> >> > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> >> > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> >> > Conclusion. The results of the few studies evaluating U.S. paramedic

> >> > determinations of medical necessity for ambulance transport vary

> >> > considerably, and only two studies report complete data. The aggregate

NPV

> >> > of the paramedic determinations is 0.91, with a lower confidence limit of

> >> > 0.71. These data do not support the practice of paramedics' determining

> >> > whether patients require ambulance transport. These findings have

> >> > implications for EMS systems, emergency departments, and third-party

> >> payers.

> >> >

> >> > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> >> >

> >> >

> >> >

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Guest guest

Guest guest

Posted
Posted

I definitely agree with you on that. Because of that we will have a flawed way

of determining mistakes in denying transport though. Even if just the Dr saying

ambulance transport was needed would be better yet that is very subjective as

well.

> >> >

> >> > Abstract

> >> > Introduction. Reducing unnecessary ambulance transports may have

> >> operational

> >> > and economic benefits for emergency medical services (EMS) agencies and

> >> > receiving emergency departments. However, no consensus exists on the

> >> ability

> >> > of paramedics to accurately and safely identify patients who do not

require

> >> > ambulance transport. Objective. This systematic review and meta-analysis

> >> > evaluated studies reporting U.S. paramedics' ability to determine medical

> >> > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> >> > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> >> > databases were searched using Cochrane Prehospital and Emergency Care

Field

> >> > search terms combined with the Medical Subject Headings (MeSH) terms

> >> > ³triage²; ³utilization review²; ³health services misuse²; ³severity of

> >> > illness index,² and ³trauma severity indices.² Two reviewers

independently

> >> > evaluated each title to identify relevant studies; each abstract then

> >> > underwent independent review to identify studies requiring full

appraisal.

> >> > Inclusion criteria were original research; emergency responses;

> >> > determinations of medical necessity by U.S. paramedics; and a reference

> >> > standard comparison. The primary outcome measure of interest was the

> >> > negative predictive value (NPV) of paramedic determinations. For studies

> >> > reporting sufficient data, agreement between paramedic and reference

> >> > standard determinations was measured using kappa; sensitivity,

specificity,

> >> > and positive predictive value (PPV) were also calculated. Results. From

> >> > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> >> > selected for full review. Five studies met the inclusion criteria

> >> > (interrater reliability, kappa = 0.75). Reference standards included

> >> > physician opinion (n = 3), hospital admission (n = 1), and a composite of

> >> > physician opinion and patient clinical circumstances (n = 1). The NPV

> >> ranged

> >> > from 0.610 to 0.997. Results lacked homogeneity across studies;

> >> > meta-analysis using a random-effects model produced an aggregate NPV of

> >> > 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported

> >> > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> >> > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> >> > Conclusion. The results of the few studies evaluating U.S. paramedic

> >> > determinations of medical necessity for ambulance transport vary

> >> > considerably, and only two studies report complete data. The aggregate

NPV

> >> > of the paramedic determinations is 0.91, with a lower confidence limit of

> >> > 0.71. These data do not support the practice of paramedics' determining

> >> > whether patients require ambulance transport. These findings have

> >> > implications for EMS systems, emergency departments, and third-party

> >> payers.

> >> >

> >> > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> >> >

> >> >

> >> >

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Posted
Posted

This has been a question on the minds of a lot of the medical field. Yes, there

will always be the few Medics that will no ride because they're lazy, but with

proper monitoring through either Q.A./Q.I. and/or state regs. those Medics can

be weeded out. That's a good thing! Everyone knows there are calls where the

reason for the 911 call was they have no tranportation (Really, how are they

getting home? or They have 3 cars out front?), or what some of us would call

B.S. calls, but are they true emergencies? We are trained to make decisions on

proper medical care for any emergency! I've been told before that, " They call 911

and your transport! It's your job! Just deal with it! " Really, well I ask you

this, If I'm treating that fake Asthma attack because they had a fight with

their girlfriend and want attention and your husband, wife, friend, etc. has a

true life or death emergency and the next truck is 25 min. out, you still think

that I shouldn't be able to make at least at some level the decision to send

them by P.O.V. or no transport them?

Yes, Yes, I know... We can what if all day long, but not every county or city

has a second ambulance 5 min. away! In a major city I would think that this is

still an issue due to the volume of calls?

Example: 911 call for abdominal pain. AOSTF 42 y/o,M, extremely intoxicated and

complaining of right sided upper abdominal pain. Through proper assessment you

find that pt has HX of gallbladder issues and is non-compliant with doctors

request. He has had 3 attacks in the last 6 months and just wants a ride to the

ER because, " Everyone here is drunk! " You now get a 911 call for a, " Child

choking and turning blue! " Hmmmm... which is the true emergency? Don't even try

to say how often does that happen... It does and did!

This can be done with proper monitoring. Whether at a local level, regional

level, state level or combo of all three, this is possible!

>

> Abstract

> Introduction. Reducing unnecessary ambulance transports may have operational

> and economic benefits for emergency medical services (EMS) agencies and

> receiving emergency departments. However, no consensus exists on the ability

> of paramedics to accurately and safely identify patients who do not require

> ambulance transport. Objective. This systematic review and meta-analysis

> evaluated studies reporting U.S. paramedics' ability to determine medical

> necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> databases were searched using Cochrane Prehospital and Emergency Care Field

> search terms combined with the Medical Subject Headings (MeSH) terms

> ³triage²; ³utilization review²; ³health services misuse²; ³severity of

> illness index,² and ³trauma severity indices.² Two reviewers independently

> evaluated each title to identify relevant studies; each abstract then

> underwent independent review to identify studies requiring full appraisal.

> Inclusion criteria were original research; emergency responses;

> determinations of medical necessity by U.S. paramedics; and a reference

> standard comparison. The primary outcome measure of interest was the

> negative predictive value (NPV) of paramedic determinations. For studies

> 20reporting sufficient data, agreement between paramedic and reference

> standard determinations was measured using kappa; sensitivity, specificity,

> and positive predictive value (PPV) were also calculated. Results. From

> 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> selected for full review. Five studies met the inclusion criteria

> (interrater reliability, kappa = 0.75). Reference standards included

> physician opinion (n = 3), hospital admission (n = 1), and a composite of

> physician opinion and patient clinical circumstances (n = 1). The NPV ranged

> from 0.610 to 0.997. Results lacked homogeneity across studies;

> meta-analysis using a random-effects model produced an aggregate NPV of

> 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported

> complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> Conclusion. The results of the few studies evaluating U.S. paramedic

> determinations of medical necessity for ambulance transport vary

> considerably, and only two studies report complete data. The aggregate NPV

> of the paramedic determinations is 0.91, with a lower confidence limit of

> 0.71. These data do not support the practice of paramedics' determining

> whether patients require ambulance transport. These findings have

> implications for EMS systems, emergency departments, and third-party payers.

>

> Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

>

>

> [Non-text portions of this mess

> age have been removed]

>

>

>

> -----------------------------------

>

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Posted
Posted

Fast forward three months........A sheriff's deputy shows up with a Court

Citation for you, your partner, your medical director, and the service.

You're being sued for wrongful death resulting from your failure to treat and

transport the patient with a STEMI. Turns out the patient was a stock

broker with 4 children making an average of $500,000 a year. He was 42. The

total amount of economic damages that can be proved come to just over $32

million dollars when adjusted for inflation. Since you work for a private

service under 911 contract, there is no damage cap. The Plaintiffs also ask

for punitive damages, since they are alleging that your actions amounted to

wanton and reckless disregard of the patient's welfare. The next day a

representative from DSHS shows up and demands the records in the case. You're

fired. Six months later you receive a letter from Maxie Bishop saying that

you suspended and it is their intention to revoke your paramedic

certificate. You have 15 days to request a hearing.

All this is entirely possible. Now who wants to " no-ride " a patient with

abdominal pain? The facts are clear. Even physicians have trouble with

diagnosing abdominal pain. It is ludicrous to think that a paramedic should

be able to conclude that a patient with abdominal pain is just having a

recurring gallbladder attack. On top of that, there's a nasty little

condition called ascending cholangitis that presents exactly like your patient

did,

but you probably never heard of it nor of Charcot's triad, the classic

signs, much less Reynolds' pentad, which might just fit your patient to a T.

Ascending cholangitis can be seriously fatal, leading to deeply sustained and

prolonged death and dying. Yep, that most stable rhythm of them all, with

a Glasgow Coma Score of 3.

As the philosopher said, " A little knowledge can be a dangerous thing. "

When we get to thinking that we have the training and education as paramedics

to do what physicians with 25 times as much training have difficulty with,

we are flirting with disaster.

Be safe.

Gene Gandy

GG

>

>

> So...you run out the door leaving the 42 yo drunk gall bladder patient

> behind because he certainly doesn't need a ride to the ED...only to hear a

> return call to his address 45 minutes later while you are arriving at the ED

> with the choking child who was really having a febrile seizure because the

> parents didn't give Tylenol appropriately. So...you run out the door leaving

> the 42 yo drunk gall bladder patient behind because he certainly doesn't

> need a ride to the ED...only to hear a return call to his address 45 minutes

> later while you are arriving at the ED with the choking child who was

> really having a febrile seizure because the parents didn't give Tylenol

> appropriately. ..but now the return call to the address is for a cardiac

> arrest because of the 42 yo drunk'

>

> Dudley

>

> Re: Paramedics Cannot Determine Which Patients

> Require Transport

>

> This has been a question on the minds of a lot of the medical field. Yes,

> there will always be the few Medics that will no ride because they're lazy,

> but with proper monitoring through either Q.A./Q.I. and/or state regs.

> those Medics can be weeded out. That's a good thing! Everyone knows there are

> calls where the reason for the 911 call was they have no tranportation

> (Really, how are they getting home? or They have 3 cars out front?), or what

> some of us would call B.S. calls, bu

> t are they true emergencies? We are trained to make decisions on proper

> medical care for any emergency! I've been told before that, " They call 911 and

> your transport! It's your job! Just deal with it! " Really, well I ask you

> this, If I'm treating that fake Asthma attack because they had a fight with

> their girlfriend and want attention and your husband, wife, friend, etc.

> has a true life or death emergency and the next truck is 25 min. out, you

> still think that I shouldn't be able to make at least at some level the

> decision to send them by P.O.V. or no transport them?

>

> Yes, Yes, I know... We can what if all day long, but not every county or

> city has a second ambulance 5 min. away! In a major city I would think that

> this is still an issue due to the volume of calls?

>

> Example: 911 call for abdominal pain. AOSTF 42 y/o,M, extremely

> intoxicated and complaining of right sided upper abdominal pain. Through

proper

> assessment you find that pt has HX of gallbladder issues and is non-compliant

> with doctors request. He has had 3 attacks in the last 6 months and just

> wants a ride to the ER because, " Everyone here is drunk! " You now get a 911

> call for a, " Child choking and turning blue! " Hmmmm... which is the true

> emergency? Don't even try to say how often does that happen... It does and

did!

>

> This can be done with proper monitoring. Whether at a local level,

> regional level, state level or combo of all three, this is possible!

>

>

>

>

> >

> > Abstract

> > Introduction. Reducing unnecessary ambulance transports may have

> operational

> > and economic benefits for emergency medical services (EMS) agencies and

> > receiving emergency departments. However, no consensus exists on the

> ability

> > of paramedics to accurately and safely identify patients who do not

> require

> > ambulance transport. Objective. This systematic review and meta-analysis

> > evaluated studies reporting U.S. paramedics' ability to determine

> medical

> > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > databases were searched using Cochrane Prehospital and Emergency Care

> Field

> > search terms combined with the Medical Subject Headings (MeSH) terms

> > D*$¢®triageD*$¢®; D*$¢®utilization reviewD*$¢®;

D*$¢®health services misuseD*$¢®; D*$¢®

> severity of

> > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢®

Two reviewers

> independently

> > evaluated each title to identify relevant studies; each abstract then

> > underwent independent review to identify studies requiring full

> appraisal.

> > Inclusion criteria were original research; emergency responses;

> > determinations of medical=2

> 0necessity by U.S. paramedics; and a reference

> > standard comparison. The primary outcome measure of interest was the

> > negative predictive value (NPV) of paramedic determinations. For studies

> > 20reporting sufficient data, agreement between paramedic and reference

> > standard determinations was measured using kappa; sensitivity,

> specificity,

> > and positive predictive value (PPV) were also calculated. Results. From

> > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> > selected for full review. Five studies met the inclusion criteria

> > (interrater reliability, kappa = 0.75). Reference standards included

> > physician opinion (n = 3), hospital admission (n = 1), and a composite

> of

> > physician opinion and patient clinical circumstances (n = 1). The NPV

> ranged

> > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > meta-analysis using a random-effects model produced an aggregate NPV of

> > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence inte

> > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > Conclusion. The results of the few studies evaluating U.S. paramedic

> > determinations of medical necessity for ambulance transport vary

> > considerably, and only two studies report complete data. The aggregate

> NPV

> > of the paramedic determinations is 0.91, with a lower confidence limit

> of

> > 0.71. These data do not support the practice of paramedics' determining

> > whether patients require ambulance transport. These

> findings have

> > implications for EMS systems, emergency departments, and third-party

> payers.

> >

> > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> >

> >

> > [Non-text portions of this mess

> > age have been removed]

> >

> >

> >

> > ------------ -------- -------- ----

> >

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Posted
Posted

Fast forward three months........A sheriff's deputy shows up with a Court

Citation for you, your partner, your medical director, and the service.

You're being sued for wrongful death resulting from your failure to treat and

transport the patient with a STEMI. Turns out the patient was a stock

broker with 4 children making an average of $500,000 a year. He was 42. The

total amount of economic damages that can be proved come to just over $32

million dollars when adjusted for inflation. Since you work for a private

service under 911 contract, there is no damage cap. The Plaintiffs also ask

for punitive damages, since they are alleging that your actions amounted to

wanton and reckless disregard of the patient's welfare. The next day a

representative from DSHS shows up and demands the records in the case. You're

fired. Six months later you receive a letter from Maxie Bishop saying that

you suspended and it is their intention to revoke your paramedic

certificate. You have 15 days to request a hearing.

All this is entirely possible. Now who wants to " no-ride " a patient with

abdominal pain? The facts are clear. Even physicians have trouble with

diagnosing abdominal pain. It is ludicrous to think that a paramedic should

be able to conclude that a patient with abdominal pain is just having a

recurring gallbladder attack. On top of that, there's a nasty little

condition called ascending cholangitis that presents exactly like your patient

did,

but you probably never heard of it nor of Charcot's triad, the classic

signs, much less Reynolds' pentad, which might just fit your patient to a T.

Ascending cholangitis can be seriously fatal, leading to deeply sustained and

prolonged death and dying. Yep, that most stable rhythm of them all, with

a Glasgow Coma Score of 3.

As the philosopher said, " A little knowledge can be a dangerous thing. "

When we get to thinking that we have the training and education as paramedics

to do what physicians with 25 times as much training have difficulty with,

we are flirting with disaster.

Be safe.

Gene Gandy

GG

>

>

> So...you run out the door leaving the 42 yo drunk gall bladder patient

> behind because he certainly doesn't need a ride to the ED...only to hear a

> return call to his address 45 minutes later while you are arriving at the ED

> with the choking child who was really having a febrile seizure because the

> parents didn't give Tylenol appropriately. So...you run out the door leaving

> the 42 yo drunk gall bladder patient behind because he certainly doesn't

> need a ride to the ED...only to hear a return call to his address 45 minutes

> later while you are arriving at the ED with the choking child who was

> really having a febrile seizure because the parents didn't give Tylenol

> appropriately. ..but now the return call to the address is for a cardiac

> arrest because of the 42 yo drunk'

>

> Dudley

>

> Re: Paramedics Cannot Determine Which Patients

> Require Transport

>

> This has been a question on the minds of a lot of the medical field. Yes,

> there will always be the few Medics that will no ride because they're lazy,

> but with proper monitoring through either Q.A./Q.I. and/or state regs.

> those Medics can be weeded out. That's a good thing! Everyone knows there are

> calls where the reason for the 911 call was they have no tranportation

> (Really, how are they getting home? or They have 3 cars out front?), or what

> some of us would call B.S. calls, bu

> t are they true emergencies? We are trained to make decisions on proper

> medical care for any emergency! I've been told before that, " They call 911 and

> your transport! It's your job! Just deal with it! " Really, well I ask you

> this, If I'm treating that fake Asthma attack because they had a fight with

> their girlfriend and want attention and your husband, wife, friend, etc.

> has a true life or death emergency and the next truck is 25 min. out, you

> still think that I shouldn't be able to make at least at some level the

> decision to send them by P.O.V. or no transport them?

>

> Yes, Yes, I know... We can what if all day long, but not every county or

> city has a second ambulance 5 min. away! In a major city I would think that

> this is still an issue due to the volume of calls?

>

> Example: 911 call for abdominal pain. AOSTF 42 y/o,M, extremely

> intoxicated and complaining of right sided upper abdominal pain. Through

proper

> assessment you find that pt has HX of gallbladder issues and is non-compliant

> with doctors request. He has had 3 attacks in the last 6 months and just

> wants a ride to the ER because, " Everyone here is drunk! " You now get a 911

> call for a, " Child choking and turning blue! " Hmmmm... which is the true

> emergency? Don't even try to say how often does that happen... It does and

did!

>

> This can be done with proper monitoring. Whether at a local level,

> regional level, state level or combo of all three, this is possible!

>

>

>

>

> >

> > Abstract

> > Introduction. Reducing unnecessary ambulance transports may have

> operational

> > and economic benefits for emergency medical services (EMS) agencies and

> > receiving emergency departments. However, no consensus exists on the

> ability

> > of paramedics to accurately and safely identify patients who do not

> require

> > ambulance transport. Objective. This systematic review and meta-analysis

> > evaluated studies reporting U.S. paramedics' ability to determine

> medical

> > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > databases were searched using Cochrane Prehospital and Emergency Care

> Field

> > search terms combined with the Medical Subject Headings (MeSH) terms

> > D*$¢®triageD*$¢®; D*$¢®utilization reviewD*$¢®;

D*$¢®health services misuseD*$¢®; D*$¢®

> severity of

> > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢®

Two reviewers

> independently

> > evaluated each title to identify relevant studies; each abstract then

> > underwent independent review to identify studies requiring full

> appraisal.

> > Inclusion criteria were original research; emergency responses;

> > determinations of medical=2

> 0necessity by U.S. paramedics; and a reference

> > standard comparison. The primary outcome measure of interest was the

> > negative predictive value (NPV) of paramedic determinations. For studies

> > 20reporting sufficient data, agreement between paramedic and reference

> > standard determinations was measured using kappa; sensitivity,

> specificity,

> > and positive predictive value (PPV) were also calculated. Results. From

> > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> > selected for full review. Five studies met the inclusion criteria

> > (interrater reliability, kappa = 0.75). Reference standards included

> > physician opinion (n = 3), hospital admission (n = 1), and a composite

> of

> > physician opinion and patient clinical circumstances (n = 1). The NPV

> ranged

> > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > meta-analysis using a random-effects model produced an aggregate NPV of

> > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence inte

> > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > Conclusion. The results of the few studies evaluating U.S. paramedic

> > determinations of medical necessity for ambulance transport vary

> > considerably, and only two studies report complete data. The aggregate

> NPV

> > of the paramedic determinations is 0.91, with a lower confidence limit

> of

> > 0.71. These data do not support the practice of paramedics' determining

> > whether patients require ambulance transport. These

> findings have

> > implications for EMS systems, emergency departments, and third-party

> payers.

> >

> > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> >

> >

> > [Non-text portions of this mess

> > age have been removed]

> >

> >

> >

> > ------------ -------- -------- ----

> >

Link to comment
Share on other sites
Guest guest

Guest guest

Posted
Posted

Fast forward three months........A sheriff's deputy shows up with a Court

Citation for you, your partner, your medical director, and the service.

You're being sued for wrongful death resulting from your failure to treat and

transport the patient with a STEMI. Turns out the patient was a stock

broker with 4 children making an average of $500,000 a year. He was 42. The

total amount of economic damages that can be proved come to just over $32

million dollars when adjusted for inflation. Since you work for a private

service under 911 contract, there is no damage cap. The Plaintiffs also ask

for punitive damages, since they are alleging that your actions amounted to

wanton and reckless disregard of the patient's welfare. The next day a

representative from DSHS shows up and demands the records in the case. You're

fired. Six months later you receive a letter from Maxie Bishop saying that

you suspended and it is their intention to revoke your paramedic

certificate. You have 15 days to request a hearing.

All this is entirely possible. Now who wants to " no-ride " a patient with

abdominal pain? The facts are clear. Even physicians have trouble with

diagnosing abdominal pain. It is ludicrous to think that a paramedic should

be able to conclude that a patient with abdominal pain is just having a

recurring gallbladder attack. On top of that, there's a nasty little

condition called ascending cholangitis that presents exactly like your patient

did,

but you probably never heard of it nor of Charcot's triad, the classic

signs, much less Reynolds' pentad, which might just fit your patient to a T.

Ascending cholangitis can be seriously fatal, leading to deeply sustained and

prolonged death and dying. Yep, that most stable rhythm of them all, with

a Glasgow Coma Score of 3.

As the philosopher said, " A little knowledge can be a dangerous thing. "

When we get to thinking that we have the training and education as paramedics

to do what physicians with 25 times as much training have difficulty with,

we are flirting with disaster.

Be safe.

Gene Gandy

GG

>

>

> So...you run out the door leaving the 42 yo drunk gall bladder patient

> behind because he certainly doesn't need a ride to the ED...only to hear a

> return call to his address 45 minutes later while you are arriving at the ED

> with the choking child who was really having a febrile seizure because the

> parents didn't give Tylenol appropriately. So...you run out the door leaving

> the 42 yo drunk gall bladder patient behind because he certainly doesn't

> need a ride to the ED...only to hear a return call to his address 45 minutes

> later while you are arriving at the ED with the choking child who was

> really having a febrile seizure because the parents didn't give Tylenol

> appropriately. ..but now the return call to the address is for a cardiac

> arrest because of the 42 yo drunk'

>

> Dudley

>

> Re: Paramedics Cannot Determine Which Patients

> Require Transport

>

> This has been a question on the minds of a lot of the medical field. Yes,

> there will always be the few Medics that will no ride because they're lazy,

> but with proper monitoring through either Q.A./Q.I. and/or state regs.

> those Medics can be weeded out. That's a good thing! Everyone knows there are

> calls where the reason for the 911 call was they have no tranportation

> (Really, how are they getting home? or They have 3 cars out front?), or what

> some of us would call B.S. calls, bu

> t are they true emergencies? We are trained to make decisions on proper

> medical care for any emergency! I've been told before that, " They call 911 and

> your transport! It's your job! Just deal with it! " Really, well I ask you

> this, If I'm treating that fake Asthma attack because they had a fight with

> their girlfriend and want attention and your husband, wife, friend, etc.

> has a true life or death emergency and the next truck is 25 min. out, you

> still think that I shouldn't be able to make at least at some level the

> decision to send them by P.O.V. or no transport them?

>

> Yes, Yes, I know... We can what if all day long, but not every county or

> city has a second ambulance 5 min. away! In a major city I would think that

> this is still an issue due to the volume of calls?

>

> Example: 911 call for abdominal pain. AOSTF 42 y/o,M, extremely

> intoxicated and complaining of right sided upper abdominal pain. Through

proper

> assessment you find that pt has HX of gallbladder issues and is non-compliant

> with doctors request. He has had 3 attacks in the last 6 months and just

> wants a ride to the ER because, " Everyone here is drunk! " You now get a 911

> call for a, " Child choking and turning blue! " Hmmmm... which is the true

> emergency? Don't even try to say how often does that happen... It does and

did!

>

> This can be done with proper monitoring. Whether at a local level,

> regional level, state level or combo of all three, this is possible!

>

>

>

>

> >

> > Abstract

> > Introduction. Reducing unnecessary ambulance transports may have

> operational

> > and economic benefits for emergency medical services (EMS) agencies and

> > receiving emergency departments. However, no consensus exists on the

> ability

> > of paramedics to accurately and safely identify patients who do not

> require

> > ambulance transport. Objective. This systematic review and meta-analysis

> > evaluated studies reporting U.S. paramedics' ability to determine

> medical

> > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > databases were searched using Cochrane Prehospital and Emergency Care

> Field

> > search terms combined with the Medical Subject Headings (MeSH) terms

> > D*$¢®triageD*$¢®; D*$¢®utilization reviewD*$¢®;

D*$¢®health services misuseD*$¢®; D*$¢®

> severity of

> > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢®

Two reviewers

> independently

> > evaluated each title to identify relevant studies; each abstract then

> > underwent independent review to identify studies requiring full

> appraisal.

> > Inclusion criteria were original research; emergency responses;

> > determinations of medical=2

> 0necessity by U.S. paramedics; and a reference

> > standard comparison. The primary outcome measure of interest was the

> > negative predictive value (NPV) of paramedic determinations. For studies

> > 20reporting sufficient data, agreement between paramedic and reference

> > standard determinations was measured using kappa; sensitivity,

> specificity,

> > and positive predictive value (PPV) were also calculated. Results. From

> > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> > selected for full review. Five studies met the inclusion criteria

> > (interrater reliability, kappa = 0.75). Reference standards included

> > physician opinion (n = 3), hospital admission (n = 1), and a composite

> of

> > physician opinion and patient clinical circumstances (n = 1). The NPV

> ranged

> > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > meta-analysis using a random-effects model produced an aggregate NPV of

> > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence inte

> > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > Conclusion. The results of the few studies evaluating U.S. paramedic

> > determinations of medical necessity for ambulance transport vary

> > considerably, and only two studies report complete data. The aggregate

> NPV

> > of the paramedic determinations is 0.91, with a lower confidence limit

> of

> > 0.71. These data do not support the practice of paramedics' determining

> > whether patients require ambulance transport. These

> findings have

> > implications for EMS systems, emergency departments, and third-party

> payers.

> >

> > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> >

> >

> > [Non-text portions of this mess

> > age have been removed]

> >

> >

> >

> > ------------ -------- -------- ----

> >

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Posted
Posted

Ok so with comparable education to nurses and ongoing education where is the

deficit?  Was this done in California?

Danny L.

Owner/NREMT-P

PETSAR INC.

(Panhandle Emergency Training Services And Response)

Office

Fax

Subject: Paramedics Cannot Determine Which Patients Require

Transport

To: " Paramedicine " Paramedicine texasems-l " texasems-l nemsma (AT) google " nemsma (AT) google>

Date: Saturday, September 5, 2009, 11:04 AM

 

Abstract

Introduction. Reducing unnecessary ambulance transports may have operational

and economic benefits for emergency medical services (EMS) agencies and

receiving emergency departments. However, no consensus exists on the ability

of paramedics to accurately and safely identify patients who do not require

ambulance transport. Objective. This systematic review and meta-analysis

evaluated studies reporting U.S. paramedics' ability to determine medical

necessity of ambulance transport. Methods. PubMed, Cumulative Index to

Nursing and Allied Health Literature (CINAHL), and Cochrane Library

databases were searched using Cochrane Prehospital and Emergency Care Field

search terms combined with the Medical Subject Headings (MeSH) terms

³triage²; ³utilization review²; ³health services misuse²; ³severity of

illness index,² and ³trauma severity indices.² Two reviewers independently

evaluated each title to identify relevant studies; each abstract then

underwent independent review to identify studies requiring full appraisal.

Inclusion criteria were original research; emergency responses;

determinations of medical necessity by U.S. paramedics; and a reference

standard comparison. The primary outcome measure of interest was the

negative predictive value (NPV) of paramedic determinations. For studies

reporting sufficient data, agreement between paramedic and reference

standard determinations was measured using kappa; sensitivity, specificity,

and positive predictive value (PPV) were also calculated. Results. From

9,752 identified titles, 214 abstracts were evaluated, with 61 studies

selected for full review. Five studies met the inclusion criteria

(interrater reliability, kappa = 0.75). Reference standards included

physician opinion (n = 3), hospital admission (n = 1), and a composite of

physician opinion and patient clinical circumstances (n = 1). The NPV ranged

from 0.610 to 0.997. Results lacked homogeneity across studies;

meta-analysis using a random-effects model produced an aggregate NPV of

0.912 (95% confidence interval: 0.707-0.978) . Only two studies reported

complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

Conclusion. The results of the few studies evaluating U.S. paramedic

determinations of medical necessity for ambulance transport vary

considerably, and only two studies report complete data. The aggregate NPV

of the paramedic determinations is 0.91, with a lower confidence limit of

0.71. These data do not support the practice of paramedics' determining

whether patients require ambulance transport. These findings have

implications for EMS systems, emergency departments, and third-party payers.

Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

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Posted
Posted

Ok so with comparable education to nurses and ongoing education where is the

deficit?  Was this done in California?

Danny L.

Owner/NREMT-P

PETSAR INC.

(Panhandle Emergency Training Services And Response)

Office

Fax

Subject: Paramedics Cannot Determine Which Patients Require

Transport

To: " Paramedicine " Paramedicine texasems-l " texasems-l nemsma (AT) google " nemsma (AT) google>

Date: Saturday, September 5, 2009, 11:04 AM

 

Abstract

Introduction. Reducing unnecessary ambulance transports may have operational

and economic benefits for emergency medical services (EMS) agencies and

receiving emergency departments. However, no consensus exists on the ability

of paramedics to accurately and safely identify patients who do not require

ambulance transport. Objective. This systematic review and meta-analysis

evaluated studies reporting U.S. paramedics' ability to determine medical

necessity of ambulance transport. Methods. PubMed, Cumulative Index to

Nursing and Allied Health Literature (CINAHL), and Cochrane Library

databases were searched using Cochrane Prehospital and Emergency Care Field

search terms combined with the Medical Subject Headings (MeSH) terms

³triage²; ³utilization review²; ³health services misuse²; ³severity of

illness index,² and ³trauma severity indices.² Two reviewers independently

evaluated each title to identify relevant studies; each abstract then

underwent independent review to identify studies requiring full appraisal.

Inclusion criteria were original research; emergency responses;

determinations of medical necessity by U.S. paramedics; and a reference

standard comparison. The primary outcome measure of interest was the

negative predictive value (NPV) of paramedic determinations. For studies

reporting sufficient data, agreement between paramedic and reference

standard determinations was measured using kappa; sensitivity, specificity,

and positive predictive value (PPV) were also calculated. Results. From

9,752 identified titles, 214 abstracts were evaluated, with 61 studies

selected for full review. Five studies met the inclusion criteria

(interrater reliability, kappa = 0.75). Reference standards included

physician opinion (n = 3), hospital admission (n = 1), and a composite of

physician opinion and patient clinical circumstances (n = 1). The NPV ranged

from 0.610 to 0.997. Results lacked homogeneity across studies;

meta-analysis using a random-effects model produced an aggregate NPV of

0.912 (95% confidence interval: 0.707-0.978) . Only two studies reported

complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

Conclusion. The results of the few studies evaluating U.S. paramedic

determinations of medical necessity for ambulance transport vary

considerably, and only two studies report complete data. The aggregate NPV

of the paramedic determinations is 0.91, with a lower confidence limit of

0.71. These data do not support the practice of paramedics' determining

whether patients require ambulance transport. These findings have

implications for EMS systems, emergency departments, and third-party payers.

Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

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Posted
Posted

Ok so with comparable education to nurses and ongoing education where is the

deficit?  Was this done in California?

Danny L.

Owner/NREMT-P

PETSAR INC.

(Panhandle Emergency Training Services And Response)

Office

Fax

Subject: Paramedics Cannot Determine Which Patients Require

Transport

To: " Paramedicine " Paramedicine texasems-l " texasems-l nemsma (AT) google " nemsma (AT) google>

Date: Saturday, September 5, 2009, 11:04 AM

 

Abstract

Introduction. Reducing unnecessary ambulance transports may have operational

and economic benefits for emergency medical services (EMS) agencies and

receiving emergency departments. However, no consensus exists on the ability

of paramedics to accurately and safely identify patients who do not require

ambulance transport. Objective. This systematic review and meta-analysis

evaluated studies reporting U.S. paramedics' ability to determine medical

necessity of ambulance transport. Methods. PubMed, Cumulative Index to

Nursing and Allied Health Literature (CINAHL), and Cochrane Library

databases were searched using Cochrane Prehospital and Emergency Care Field

search terms combined with the Medical Subject Headings (MeSH) terms

³triage²; ³utilization review²; ³health services misuse²; ³severity of

illness index,² and ³trauma severity indices.² Two reviewers independently

evaluated each title to identify relevant studies; each abstract then

underwent independent review to identify studies requiring full appraisal.

Inclusion criteria were original research; emergency responses;

determinations of medical necessity by U.S. paramedics; and a reference

standard comparison. The primary outcome measure of interest was the

negative predictive value (NPV) of paramedic determinations. For studies

reporting sufficient data, agreement between paramedic and reference

standard determinations was measured using kappa; sensitivity, specificity,

and positive predictive value (PPV) were also calculated. Results. From

9,752 identified titles, 214 abstracts were evaluated, with 61 studies

selected for full review. Five studies met the inclusion criteria

(interrater reliability, kappa = 0.75). Reference standards included

physician opinion (n = 3), hospital admission (n = 1), and a composite of

physician opinion and patient clinical circumstances (n = 1). The NPV ranged

from 0.610 to 0.997. Results lacked homogeneity across studies;

meta-analysis using a random-effects model produced an aggregate NPV of

0.912 (95% confidence interval: 0.707-0.978) . Only two studies reported

complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

Conclusion. The results of the few studies evaluating U.S. paramedic

determinations of medical necessity for ambulance transport vary

considerably, and only two studies report complete data. The aggregate NPV

of the paramedic determinations is 0.91, with a lower confidence limit of

0.71. These data do not support the practice of paramedics' determining

whether patients require ambulance transport. These findings have

implications for EMS systems, emergency departments, and third-party payers.

Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

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Posted

So...you run out the door leaving the 42 yo drunk gall bladder patient behind

because he certainly doesn't need a ride to the ED...only to hear a return call

to his address 45 minutes later while you are arriving at the ED with the

choking child who was really having a febrile seizure because the parents didn't

give Tylenol appropriately...but now the return call to the address is for a

cardiac arrest because of the 42 yo drunk's STEMI that we didn't detect because

it had to be a gall bladder issue....  Good case to use to support the point

that paramedics aren't trained appropriately to determine what a problem is. 

We are trained to recognize life threatening issues and do something about

it...not to determine who needs to see a physician in 30 minutes or 12 hours. 

Dudley

Re: Paramedics Cannot Determine Which Patients Require

Transport

This has been a question on the minds of a lot of the medical field. Yes, there

will always be the few Medics that will no ride because they're lazy, but with

proper monitoring through either Q.A./Q.I. and/or state regs. those Medics can

be weeded out. That's a good thing! Everyone knows there are calls where the

reason for the 911 call was they have no tranportation (Really, how are they

getting home? or They have 3 cars out front?), or what some of us would call

B.S. calls, bu

t are they true emergencies? We are trained to make decisions on proper medical

care for any emergency! I've been told before that, " They call 911 and your

transport! It's your job! Just deal with it! " Really, well I ask you this, If

I'm treating that fake Asthma attack because they had a fight with their

girlfriend and want attention and your husband, wife, friend, etc. has a true

life or death emergency and the next truck is 25 min. out, you still think that

I shouldn't be able to make at least at some level the decision to send them by

P.O.V. or no transport them?

Yes, Yes, I know... We can what if all day long, but not every county or city

has a second ambulance 5 min. away! In a major city I would think that this is

still an issue due to the volume of calls?

Example: 911 call for abdominal pain. AOSTF 42 y/o,M, extremely intoxicated and

complaining of right sided upper abdominal pain. Through proper assessment you

find that pt has HX of gallbladder issues and is non-compliant with doctors

request. He has had 3 attacks in the last 6 months and just wants a ride to the

ER because, " Everyone here is drunk! " You now get a 911 call for a, " Child

choking and turning blue! " Hmmmm... which is the true emergency? Don't even try

to say how often does that happen... It does and did!

This can be done with proper monitoring. Whether at a local level, regional

level, state level or combo of all three, this is possible!

>

> Abstract

> Introduction. Reducing unnecessary ambulance transports may have operational

> and economic benefits for emergency medical services (EMS) agencies and

> receiving emergency departments. However, no consensus exists on the ability

> of paramedics to accurately and safely identify patients who do not require

> ambulance transport. Objective. This systematic review and meta-analysis

> evaluated studies reporting U.S. paramedics' ability to determine medical

> necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> databases were searched using Cochrane Prehospital and Emergency Care Field

> search terms combined with the Medical Subject Headings (MeSH) terms

> ³triage²; ³utilization review²; ³health services misuse²;

³severity of

> illness index,² and ³trauma severity indices.² Two reviewers

independently

> evaluated each title to identify relevant studies; each abstract then

> underwent independent review to identify studies requiring full appraisal.

> Inclusion criteria were original research; emergency responses;

> determinations of medical=2

0necessity by U.S. paramedics; and a reference

> standard comparison. The primary outcome measure of interest was the

> negative predictive value (NPV) of paramedic determinations. For studies

> 20reporting sufficient data, agreement between paramedic and reference

> standard determinations was measured using kappa; sensitivity, specificity,

> and positive predictive value (PPV) were also calculated. Results. From

> 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> selected for full review. Five studies met the inclusion criteria

> (interrater reliability, kappa = 0.75). Reference standards included

> physician opinion (n = 3), hospital admission (n = 1), and a composite of

> physician opinion and patient clinical circumstances (n = 1). The NPV ranged

> from 0.610 to 0.997. Results lacked homogeneity across studies;

> meta-analysis using a random-effects model produced an aggregate NPV of

> 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported

> complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> Conclusion. The results of the few studies evaluating U.S. paramedic

> determinations of medical necessity for ambulance transport vary

> considerably, and only two studies report complete data. The aggregate NPV

> of the paramedic determinations is 0.91, with a lower confidence limit of

> 0.71. These data do not support the practice of paramedics' determining

> whether patients require ambulance transport. These

findings have

> implications for EMS systems, emergency departments, and third-party payers.

>

> Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

>

>

> [Non-text portions of this mess

> age have been removed]

>

>

>

> -----------------------------------

>

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Posted
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I am not at all against moving forward. I'm commenting on the status quo.

As it is, paramedics do not have the education necessary to make some

determinations in the field. I wish they did. In fact, I just wrote my

Congresswoman about how EMS could improve basic medical care if we were allowed

to

transport to alternative locations other than hospitals and get paid for

it. I also would love to see all paramedics with a four year degree and

training comparable to a PA. There are lots of things we could do in the field

that we're not doing now. But I believe that most existing paramedic

education programs do not prepare paramedics to make many field determinations

about transport correctly.

Obviously the isolated cut finger or stubbed toe does not need ambulance

transport. We could, with the right training, even fix the cut finger right

there and release the patient. There are even some medical conditions we

could probably deal with, but at present we lack the depth of education and

training to do that reliably, as shown by the studies.

All medics are not equal in their assessment abilities; neither are all

physicians. The difference is that a physician has a license saying that s/he

has the legal power to make independent medical judgments and

determinations. We do not.

I do not believe that a 500 hour course in paramedicine is adequate to

prepare anyone to do field triage of medical problems. Even if we were given

field laboratories and x-ray machines in the truck, with our present level of

training we're not prepared to do that.

Many paramedics do not have basic college science courses under their belts

or equivalent knowledge. We allow people to become paramedics without

having the basic underlying knowledge necessary to understand pharmacology and

disease processes. We resist adding more education for many reasons, most

of which have been debated here ad infinitum.

The case of a patient with abdominal pain was used as an example. I

responded to that example. Perhaps the writer could have chosen another case

as

a better example. Abdominal pain is one of the most difficult conditions

to diagnose; the number of differential diagnoses is huge, and many of them

carry extremely serious consequences if missed.

All I am saying is that at present we are not prepared to make what amounts

to field diagnoses and no-ride patients based on our assessments. We lack

the education and tools to do that. I'm not talking about isolated minor

trauma. I'm talking about medical cases.

I have worked hard for years along with many others to improve education

requirements and standards, only to see our efforts stymied by those who have

a financial interest in keeping medics poorly educated and underpaid.

Until our system changes radically, we'll have to transport most

patients.

GG

>  

>

> If the medical field didn't make some advancements of the hundreds of

> years we would not be where we are today. By no means am I compairing myself

to

> a doctor or level of doctors knowledge, but you think doctors are 100%

> perfect? No, not by a long shot, but they still have to do a proper

> assessment, run labs, etc. to make a proper diagnoses. I'm not saying it would

be

> perfect by any means, but you take a chance every day you get on the truck.

> Non-STEMI M.I.'s, A.A.A.'s, etc... It's going to happen, but if you have been

> trained, and yes even more training would be needed, this would be a mute

> point. Like I said we can all come up with the disease that very few have

> heard of, or the what if's that we have all run into, but where do you draw

> the line and say let's move forward? We can all draw out the worse case

> scenero and make it sound sooooo bad, but what about the good cases that would

> exist too? I honestly believe the good would out weight the bad by a long

> shot. Earlier was not a personal attack on the individuals just a comment

> to open eyes and make you think about what we do on a daily basis...

>

>

> > > >

> > > > Abstract

> > > > Introduction. Reducing unnecessary ambulance transports may have

> > > operational

> > > > and economic benefits for emergency medical services (EMS) agencies

> and

> > > > receiving emergency departments. However, no consensus exists on the

> > > ability

> > > > of paramedics to accurately and safely identify patients who do not

> > > require

> > > > ambulance transport. Objective. This systematic review and

> meta-analysis

> > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > medical

> > > > necessity of ambulance transport. Methods. PubMed, Cumulative Index

> to

> > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > databases were searched using Cochrane Prehospital and Emergency

> Care

> > > Field

> > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > D*$¢®triageD*$¢® D*$¢®triageD*$¢® ; D*$¢®utilization

> reviewD*$¢®; D*$¢®health servi

> > > severity of

> > > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two

> reviewers

> > > independently

> > > > evaluated each title to identify relevant studies; each abstract

> then

> > > > underwent independent review to identify studies requiring full

> > > appraisal.

> > > > Inclusion criteria were original research; emergency responses;

> > > > determinations of medical=2

> > > 0necessity by U.S. paramedics; and a reference

> > > > standard comparison. The primary outcome measure of interest was the

> > > > negative predictive value (NPV) of paramedic determinations. For

> studies

> > > > 20reporting sufficient data, agreement between paramedic and

> reference

> > > > standard determinations was measured using kappa; sensitivity,

> > > specificity,

> > > > and positive predictive value (PPV) were also calculated. Results.

> From

> > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> studies

> > > > selected for full review. Five studies met the inclusion criteria

> > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > physician opinion (n = 3), hospital admission (n = 1), and a

> composite

> > > of

> > > > physician opinion and patient clinical circumstances (n = 1). The

> NPV

> > > ranged

> > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > meta-analysis using a random-effects model produced an aggregate NPV

> of

> > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence

> inte

> > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992

> and

> > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > determinations of medical necessity for ambulance transport vary

> > > > considerably, and only two studies report complete data. The

> aggregate

> > > NPV

> > > > of the paramedic determinations is 0.91, with a lower confidence

> limit

> > > of

> > > > 0.71. These data do not support the practice of paramedics'

> determining

> > > > whether patients require ambulance transport. These

> > > findings have

> > > > implications for EMS systems, emergency departments, and third-party

> > > payers.

> > > >

> > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > >

> > > >

> > > > [Non-text portions of this mess

> > > > age have been removed]

> > > >

> > > >

> > > >

> > > > ------------ -------- -------- ----

> > > >

Link to comment
Share on other sites
Guest guest

Guest guest

Posted
Posted

I am not at all against moving forward. I'm commenting on the status quo.

As it is, paramedics do not have the education necessary to make some

determinations in the field. I wish they did. In fact, I just wrote my

Congresswoman about how EMS could improve basic medical care if we were allowed

to

transport to alternative locations other than hospitals and get paid for

it. I also would love to see all paramedics with a four year degree and

training comparable to a PA. There are lots of things we could do in the field

that we're not doing now. But I believe that most existing paramedic

education programs do not prepare paramedics to make many field determinations

about transport correctly.

Obviously the isolated cut finger or stubbed toe does not need ambulance

transport. We could, with the right training, even fix the cut finger right

there and release the patient. There are even some medical conditions we

could probably deal with, but at present we lack the depth of education and

training to do that reliably, as shown by the studies.

All medics are not equal in their assessment abilities; neither are all

physicians. The difference is that a physician has a license saying that s/he

has the legal power to make independent medical judgments and

determinations. We do not.

I do not believe that a 500 hour course in paramedicine is adequate to

prepare anyone to do field triage of medical problems. Even if we were given

field laboratories and x-ray machines in the truck, with our present level of

training we're not prepared to do that.

Many paramedics do not have basic college science courses under their belts

or equivalent knowledge. We allow people to become paramedics without

having the basic underlying knowledge necessary to understand pharmacology and

disease processes. We resist adding more education for many reasons, most

of which have been debated here ad infinitum.

The case of a patient with abdominal pain was used as an example. I

responded to that example. Perhaps the writer could have chosen another case

as

a better example. Abdominal pain is one of the most difficult conditions

to diagnose; the number of differential diagnoses is huge, and many of them

carry extremely serious consequences if missed.

All I am saying is that at present we are not prepared to make what amounts

to field diagnoses and no-ride patients based on our assessments. We lack

the education and tools to do that. I'm not talking about isolated minor

trauma. I'm talking about medical cases.

I have worked hard for years along with many others to improve education

requirements and standards, only to see our efforts stymied by those who have

a financial interest in keeping medics poorly educated and underpaid.

Until our system changes radically, we'll have to transport most

patients.

GG

>  

>

> If the medical field didn't make some advancements of the hundreds of

> years we would not be where we are today. By no means am I compairing myself

to

> a doctor or level of doctors knowledge, but you think doctors are 100%

> perfect? No, not by a long shot, but they still have to do a proper

> assessment, run labs, etc. to make a proper diagnoses. I'm not saying it would

be

> perfect by any means, but you take a chance every day you get on the truck.

> Non-STEMI M.I.'s, A.A.A.'s, etc... It's going to happen, but if you have been

> trained, and yes even more training would be needed, this would be a mute

> point. Like I said we can all come up with the disease that very few have

> heard of, or the what if's that we have all run into, but where do you draw

> the line and say let's move forward? We can all draw out the worse case

> scenero and make it sound sooooo bad, but what about the good cases that would

> exist too? I honestly believe the good would out weight the bad by a long

> shot. Earlier was not a personal attack on the individuals just a comment

> to open eyes and make you think about what we do on a daily basis...

>

>

> > > >

> > > > Abstract

> > > > Introduction. Reducing unnecessary ambulance transports may have

> > > operational

> > > > and economic benefits for emergency medical services (EMS) agencies

> and

> > > > receiving emergency departments. However, no consensus exists on the

> > > ability

> > > > of paramedics to accurately and safely identify patients who do not

> > > require

> > > > ambulance transport. Objective. This systematic review and

> meta-analysis

> > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > medical

> > > > necessity of ambulance transport. Methods. PubMed, Cumulative Index

> to

> > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > databases were searched using Cochrane Prehospital and Emergency

> Care

> > > Field

> > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > D*$¢®triageD*$¢® D*$¢®triageD*$¢® ; D*$¢®utilization

> reviewD*$¢®; D*$¢®health servi

> > > severity of

> > > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two

> reviewers

> > > independently

> > > > evaluated each title to identify relevant studies; each abstract

> then

> > > > underwent independent review to identify studies requiring full

> > > appraisal.

> > > > Inclusion criteria were original research; emergency responses;

> > > > determinations of medical=2

> > > 0necessity by U.S. paramedics; and a reference

> > > > standard comparison. The primary outcome measure of interest was the

> > > > negative predictive value (NPV) of paramedic determinations. For

> studies

> > > > 20reporting sufficient data, agreement between paramedic and

> reference

> > > > standard determinations was measured using kappa; sensitivity,

> > > specificity,

> > > > and positive predictive value (PPV) were also calculated. Results.

> From

> > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> studies

> > > > selected for full review. Five studies met the inclusion criteria

> > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > physician opinion (n = 3), hospital admission (n = 1), and a

> composite

> > > of

> > > > physician opinion and patient clinical circumstances (n = 1). The

> NPV

> > > ranged

> > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > meta-analysis using a random-effects model produced an aggregate NPV

> of

> > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence

> inte

> > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992

> and

> > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > determinations of medical necessity for ambulance transport vary

> > > > considerably, and only two studies report complete data. The

> aggregate

> > > NPV

> > > > of the paramedic determinations is 0.91, with a lower confidence

> limit

> > > of

> > > > 0.71. These data do not support the practice of paramedics'

> determining

> > > > whether patients require ambulance transport. These

> > > findings have

> > > > implications for EMS systems, emergency departments, and third-party

> > > payers.

> > > >

> > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > >

> > > >

> > > > [Non-text portions of this mess

> > > > age have been removed]

> > > >

> > > >

> > > >

> > > > ------------ -------- -------- ----

> > > >

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Posted
Posted

I am not at all against moving forward. I'm commenting on the status quo.

As it is, paramedics do not have the education necessary to make some

determinations in the field. I wish they did. In fact, I just wrote my

Congresswoman about how EMS could improve basic medical care if we were allowed

to

transport to alternative locations other than hospitals and get paid for

it. I also would love to see all paramedics with a four year degree and

training comparable to a PA. There are lots of things we could do in the field

that we're not doing now. But I believe that most existing paramedic

education programs do not prepare paramedics to make many field determinations

about transport correctly.

Obviously the isolated cut finger or stubbed toe does not need ambulance

transport. We could, with the right training, even fix the cut finger right

there and release the patient. There are even some medical conditions we

could probably deal with, but at present we lack the depth of education and

training to do that reliably, as shown by the studies.

All medics are not equal in their assessment abilities; neither are all

physicians. The difference is that a physician has a license saying that s/he

has the legal power to make independent medical judgments and

determinations. We do not.

I do not believe that a 500 hour course in paramedicine is adequate to

prepare anyone to do field triage of medical problems. Even if we were given

field laboratories and x-ray machines in the truck, with our present level of

training we're not prepared to do that.

Many paramedics do not have basic college science courses under their belts

or equivalent knowledge. We allow people to become paramedics without

having the basic underlying knowledge necessary to understand pharmacology and

disease processes. We resist adding more education for many reasons, most

of which have been debated here ad infinitum.

The case of a patient with abdominal pain was used as an example. I

responded to that example. Perhaps the writer could have chosen another case

as

a better example. Abdominal pain is one of the most difficult conditions

to diagnose; the number of differential diagnoses is huge, and many of them

carry extremely serious consequences if missed.

All I am saying is that at present we are not prepared to make what amounts

to field diagnoses and no-ride patients based on our assessments. We lack

the education and tools to do that. I'm not talking about isolated minor

trauma. I'm talking about medical cases.

I have worked hard for years along with many others to improve education

requirements and standards, only to see our efforts stymied by those who have

a financial interest in keeping medics poorly educated and underpaid.

Until our system changes radically, we'll have to transport most

patients.

GG

>  

>

> If the medical field didn't make some advancements of the hundreds of

> years we would not be where we are today. By no means am I compairing myself

to

> a doctor or level of doctors knowledge, but you think doctors are 100%

> perfect? No, not by a long shot, but they still have to do a proper

> assessment, run labs, etc. to make a proper diagnoses. I'm not saying it would

be

> perfect by any means, but you take a chance every day you get on the truck.

> Non-STEMI M.I.'s, A.A.A.'s, etc... It's going to happen, but if you have been

> trained, and yes even more training would be needed, this would be a mute

> point. Like I said we can all come up with the disease that very few have

> heard of, or the what if's that we have all run into, but where do you draw

> the line and say let's move forward? We can all draw out the worse case

> scenero and make it sound sooooo bad, but what about the good cases that would

> exist too? I honestly believe the good would out weight the bad by a long

> shot. Earlier was not a personal attack on the individuals just a comment

> to open eyes and make you think about what we do on a daily basis...

>

>

> > > >

> > > > Abstract

> > > > Introduction. Reducing unnecessary ambulance transports may have

> > > operational

> > > > and economic benefits for emergency medical services (EMS) agencies

> and

> > > > receiving emergency departments. However, no consensus exists on the

> > > ability

> > > > of paramedics to accurately and safely identify patients who do not

> > > require

> > > > ambulance transport. Objective. This systematic review and

> meta-analysis

> > > > evaluated studies reporting U.S. paramedics' ability to determine

> > > medical

> > > > necessity of ambulance transport. Methods. PubMed, Cumulative Index

> to

> > > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > > databases were searched using Cochrane Prehospital and Emergency

> Care

> > > Field

> > > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > > D*$¢®triageD*$¢® D*$¢®triageD*$¢® ; D*$¢®utilization

> reviewD*$¢®; D*$¢®health servi

> > > severity of

> > > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two

> reviewers

> > > independently

> > > > evaluated each title to identify relevant studies; each abstract

> then

> > > > underwent independent review to identify studies requiring full

> > > appraisal.

> > > > Inclusion criteria were original research; emergency responses;

> > > > determinations of medical=2

> > > 0necessity by U.S. paramedics; and a reference

> > > > standard comparison. The primary outcome measure of interest was the

> > > > negative predictive value (NPV) of paramedic determinations. For

> studies

> > > > 20reporting sufficient data, agreement between paramedic and

> reference

> > > > standard determinations was measured using kappa; sensitivity,

> > > specificity,

> > > > and positive predictive value (PPV) were also calculated. Results.

> From

> > > > 9,752 identified titles, 214 abstracts were evaluated, with 61

> studies

> > > > selected for full review. Five studies met the inclusion criteria

> > > > (interrater reliability, kappa = 0.75). Reference standards included

> > > > physician opinion (n = 3), hospital admission (n = 1), and a

> composite

> > > of

> > > > physician opinion and patient clinical circumstances (n = 1). The

> NPV

> > > ranged

> > > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > > meta-analysis using a random-effects model produced an aggregate NPV

> of

> > > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence

> inte

> > > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992

> and

> > > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > > determinations of medical necessity for ambulance transport vary

> > > > considerably, and only two studies report complete data. The

> aggregate

> > > NPV

> > > > of the paramedic determinations is 0.91, with a lower confidence

> limit

> > > of

> > > > 0.71. These data do not support the practice of paramedics'

> determining

> > > > whether patients require ambulance transport. These

> > > findings have

> > > > implications for EMS systems, emergency departments, and third-party

> > > payers.

> > > >

> > > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > > >

> > > >

> > > > [Non-text portions of this mess

> > > > age have been removed]

> > > >

> > > >

> > > >

> > > > ------------ -------- -------- ----

> > > >

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Posted
Posted

Mike's right. Put ETOH into the scenario and all bets are off. One of

the best docs I ever knew told me early in my career that one of the most

dangerous things one can do is to ascribe a patient's condition to " just

drunk. " That's tunnel vision and it will lead you underneath the wheels of the

train every time.

Now, back to the scenario. Just because one knows the patient and his

history, that he is noncompliant (an assumption) , and is drunk (another

assumption) , does not warrant the conclusion that his condition is " just wants

a

ride to the ER. " You're making a dangerous assumption that will not hold

up under scrutiny. If it turns out that this time he's really having a

heart attack, your assumption will be shredded quickly. And what if he does

just want a ride? Since he has an identifiable medical problem, he is

entitled to a ride, whether we like it or not. He may not be our favorite

customer, but he's a customer, and to deny service to him based upon a

conclusion

not supported by anything other than empirical observation is dangerous

indeed.

I don't like it that my tax dollars go for a lot of things that they're

spent on, but my feelings are irrelevant when it comes to patient care. We

have a legal duty to our patients, and we must have good reason if we deny

transport to a patient who has a complaint. The legal duty to a patient at

any one time transcends our duty to all citizens as a whole. We may hate the

way the system works, but we work with one patient at a time. Yes, we may

be tied up with a patient we don't like when another serious call comes in,

but the system says that we owe a legal and ethical duty to our present

patient.

I don't like misuse of the system. I wish there were better ways to

prevent it, but refusal of transport is not the right way to do it, either

legally or ethically.

GG

In a message dated 9/6/09 8:54:34 PM, michaelwhatfield@...

writes:

>  

> I have to disagree on a couple of points....

>  

> 1) pt has a Hx of gallbladder issues

>  

> That certainly doesn't mean that's what his current diagnosis is....

>  

> 2) vomited bile earlier(cause he's drunk too)

>  

> If he's drunk, then your ability to do a thorough assessment is already

> out the window.

>  

> I realize your patient is just an example, but one that even as a

> proponent of PIR's, I wouldn't 'no-ride' myself.

>

> Hatfield

> " The main part of intellectual education is not the acquisition of facts

> but learning how to make facts live. " - Oliver Wendell Holmes

> www.michaelwhatfiel www.

>

>

>

>

> Subject: Re: Paramedics Cannot Determine Which Patients

> Require Transport

> To: texasems-l@yahoogrotexasem

> Date: Sunday, September 6, 2009, 10:37 PM

>

>  

>

> Okay, I know I'm sure I'm going to piss off a lot of people, but get over

> it... This is what discussion is for! Now back to my scenero from

> earlier... Under a proper assessment you find the pt has a Hx of gallbladder

issues,

> vomited bile earlier(cause he's drunk too), refuses all ALS interventions(

> I.V.,Phenergan, etc.), just wants a ride to the ER and that's it... Okay!

> Now were back to the " Taxi Ride " again. I have been dealing with such a pt

> for at least a year now. Yes, I know things can memic other stuff, but do

> you think am I truly going to " No Ride " an undiagnosed abd. pain? Uhhhh, No!

> Key word here is UNDIAGNOSED. ..and since we know his history and is

> non-compliant and wants just a " Ride " to the ER... No, he can find another

way!

> I'm tired of my tax dollars being waisted on crap like this.

>

> Heck, for that matter the cut finger brought up earlier... well if they're

> on blood thinners and dont tell you and you " No Ride " them and they die,

> then back in the same boat! Proper assessment would find that they were on

> blood thinners and this would be avoided!?!?

>

> It's not going to happen tomorrow or next week, but it will happen and

> sooner then you think. If the current administration gets their way and the

> reembursments to doctors, hospitals and ambulances services are cut...

> Something is going to have to give or a lot services will be shutting their

> doors...

>

>

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Guest guest

Guest guest

Posted
Posted

Mike's right. Put ETOH into the scenario and all bets are off. One of

the best docs I ever knew told me early in my career that one of the most

dangerous things one can do is to ascribe a patient's condition to " just

drunk. " That's tunnel vision and it will lead you underneath the wheels of the

train every time.

Now, back to the scenario. Just because one knows the patient and his

history, that he is noncompliant (an assumption) , and is drunk (another

assumption) , does not warrant the conclusion that his condition is " just wants

a

ride to the ER. " You're making a dangerous assumption that will not hold

up under scrutiny. If it turns out that this time he's really having a

heart attack, your assumption will be shredded quickly. And what if he does

just want a ride? Since he has an identifiable medical problem, he is

entitled to a ride, whether we like it or not. He may not be our favorite

customer, but he's a customer, and to deny service to him based upon a

conclusion

not supported by anything other than empirical observation is dangerous

indeed.

I don't like it that my tax dollars go for a lot of things that they're

spent on, but my feelings are irrelevant when it comes to patient care. We

have a legal duty to our patients, and we must have good reason if we deny

transport to a patient who has a complaint. The legal duty to a patient at

any one time transcends our duty to all citizens as a whole. We may hate the

way the system works, but we work with one patient at a time. Yes, we may

be tied up with a patient we don't like when another serious call comes in,

but the system says that we owe a legal and ethical duty to our present

patient.

I don't like misuse of the system. I wish there were better ways to

prevent it, but refusal of transport is not the right way to do it, either

legally or ethically.

GG

In a message dated 9/6/09 8:54:34 PM, michaelwhatfield@...

writes:

>  

> I have to disagree on a couple of points....

>  

> 1) pt has a Hx of gallbladder issues

>  

> That certainly doesn't mean that's what his current diagnosis is....

>  

> 2) vomited bile earlier(cause he's drunk too)

>  

> If he's drunk, then your ability to do a thorough assessment is already

> out the window.

>  

> I realize your patient is just an example, but one that even as a

> proponent of PIR's, I wouldn't 'no-ride' myself.

>

> Hatfield

> " The main part of intellectual education is not the acquisition of facts

> but learning how to make facts live. " - Oliver Wendell Holmes

> www.michaelwhatfiel www.

>

>

>

>

> Subject: Re: Paramedics Cannot Determine Which Patients

> Require Transport

> To: texasems-l@yahoogrotexasem

> Date: Sunday, September 6, 2009, 10:37 PM

>

>  

>

> Okay, I know I'm sure I'm going to piss off a lot of people, but get over

> it... This is what discussion is for! Now back to my scenero from

> earlier... Under a proper assessment you find the pt has a Hx of gallbladder

issues,

> vomited bile earlier(cause he's drunk too), refuses all ALS interventions(

> I.V.,Phenergan, etc.), just wants a ride to the ER and that's it... Okay!

> Now were back to the " Taxi Ride " again. I have been dealing with such a pt

> for at least a year now. Yes, I know things can memic other stuff, but do

> you think am I truly going to " No Ride " an undiagnosed abd. pain? Uhhhh, No!

> Key word here is UNDIAGNOSED. ..and since we know his history and is

> non-compliant and wants just a " Ride " to the ER... No, he can find another

way!

> I'm tired of my tax dollars being waisted on crap like this.

>

> Heck, for that matter the cut finger brought up earlier... well if they're

> on blood thinners and dont tell you and you " No Ride " them and they die,

> then back in the same boat! Proper assessment would find that they were on

> blood thinners and this would be avoided!?!?

>

> It's not going to happen tomorrow or next week, but it will happen and

> sooner then you think. If the current administration gets their way and the

> reembursments to doctors, hospitals and ambulances services are cut...

> Something is going to have to give or a lot services will be shutting their

> doors...

>

>

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Share on other sites
Guest guest

Guest guest

Posted
Posted

Mike's right. Put ETOH into the scenario and all bets are off. One of

the best docs I ever knew told me early in my career that one of the most

dangerous things one can do is to ascribe a patient's condition to " just

drunk. " That's tunnel vision and it will lead you underneath the wheels of the

train every time.

Now, back to the scenario. Just because one knows the patient and his

history, that he is noncompliant (an assumption) , and is drunk (another

assumption) , does not warrant the conclusion that his condition is " just wants

a

ride to the ER. " You're making a dangerous assumption that will not hold

up under scrutiny. If it turns out that this time he's really having a

heart attack, your assumption will be shredded quickly. And what if he does

just want a ride? Since he has an identifiable medical problem, he is

entitled to a ride, whether we like it or not. He may not be our favorite

customer, but he's a customer, and to deny service to him based upon a

conclusion

not supported by anything other than empirical observation is dangerous

indeed.

I don't like it that my tax dollars go for a lot of things that they're

spent on, but my feelings are irrelevant when it comes to patient care. We

have a legal duty to our patients, and we must have good reason if we deny

transport to a patient who has a complaint. The legal duty to a patient at

any one time transcends our duty to all citizens as a whole. We may hate the

way the system works, but we work with one patient at a time. Yes, we may

be tied up with a patient we don't like when another serious call comes in,

but the system says that we owe a legal and ethical duty to our present

patient.

I don't like misuse of the system. I wish there were better ways to

prevent it, but refusal of transport is not the right way to do it, either

legally or ethically.

GG

In a message dated 9/6/09 8:54:34 PM, michaelwhatfield@...

writes:

>  

> I have to disagree on a couple of points....

>  

> 1) pt has a Hx of gallbladder issues

>  

> That certainly doesn't mean that's what his current diagnosis is....

>  

> 2) vomited bile earlier(cause he's drunk too)

>  

> If he's drunk, then your ability to do a thorough assessment is already

> out the window.

>  

> I realize your patient is just an example, but one that even as a

> proponent of PIR's, I wouldn't 'no-ride' myself.

>

> Hatfield

> " The main part of intellectual education is not the acquisition of facts

> but learning how to make facts live. " - Oliver Wendell Holmes

> www.michaelwhatfiel www.

>

>

>

>

> Subject: Re: Paramedics Cannot Determine Which Patients

> Require Transport

> To: texasems-l@yahoogrotexasem

> Date: Sunday, September 6, 2009, 10:37 PM

>

>  

>

> Okay, I know I'm sure I'm going to piss off a lot of people, but get over

> it... This is what discussion is for! Now back to my scenero from

> earlier... Under a proper assessment you find the pt has a Hx of gallbladder

issues,

> vomited bile earlier(cause he's drunk too), refuses all ALS interventions(

> I.V.,Phenergan, etc.), just wants a ride to the ER and that's it... Okay!

> Now were back to the " Taxi Ride " again. I have been dealing with such a pt

> for at least a year now. Yes, I know things can memic other stuff, but do

> you think am I truly going to " No Ride " an undiagnosed abd. pain? Uhhhh, No!

> Key word here is UNDIAGNOSED. ..and since we know his history and is

> non-compliant and wants just a " Ride " to the ER... No, he can find another

way!

> I'm tired of my tax dollars being waisted on crap like this.

>

> Heck, for that matter the cut finger brought up earlier... well if they're

> on blood thinners and dont tell you and you " No Ride " them and they die,

> then back in the same boat! Proper assessment would find that they were on

> blood thinners and this would be avoided!?!?

>

> It's not going to happen tomorrow or next week, but it will happen and

> sooner then you think. If the current administration gets their way and the

> reembursments to doctors, hospitals and ambulances services are cut...

> Something is going to have to give or a lot services will be shutting their

> doors...

>

>

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Guest guest

Guest guest

Posted
Posted

Wow, really... Were none of you taught how to do a proper assessment? I knew

this was just how it would go... If you don't have confidence in your assessment

then maybe you should go back to school and learn what a proper assessment is

and how it's done. STEMI...that would show up under a proper assessment?!?!

That's one thing I have noticed here on the Group... There are a lot of people

scared to move the field of EMS forward and make it what it really needs to be,

not just a taxi service. It's going to move forward with you or without you... I

suggest you get on board and learn the up and coming technology, ideas, etc. or

get left behind. I-stat machines are capable of doing certain level of lab work

with results that are just as accurate as a lab at a hospital, or the military

wouldn't be using them, they will eventually become a standard of care in the

field. Pull your heads out of the sand and look at the big picture. Change is

coming, either embrace it or run from it... It's your choice.

> > >

> > > Abstract

> > > Introduction. Reducing unnecessary ambulance transports may have

> > operational

> > > and economic benefits for emergency medical services (EMS) agencies and

> > > receiving emergency departments. However, no consensus exists on the

> > ability

> > > of paramedics to accurately and safely identify patients who do not

> > require

> > > ambulance transport. Objective. This systematic review and meta-analysis

> > > evaluated studies reporting U.S. paramedics' ability to determine

> > medical

> > > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > databases were searched using Cochrane Prehospital and Emergency Care

> > Field

> > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > D*$¢®triageD*$¢®; D*$¢®utilization reviewD*$¢®; D*$¢®health services

misuseD*$¢®; D*$¢®

> > severity of

> > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two reviewers

> > independently

> > > evaluated each title to identify relevant studies; each abstract then

> > > underwent independent review to identify studies requiring full

> > appraisal.

> > > Inclusion criteria were original research; emergency responses;

> > > determinations of medical=2

> > 0necessity by U.S. paramedics; and a reference

> > > standard comparison. The primary outcome measure of interest was the

> > > negative predictive value (NPV) of paramedic determinations. For studies

> > > 20reporting sufficient data, agreement between paramedic and reference

> > > standard determinations was measured using kappa; sensitivity,

> > specificity,

> > > and positive predictive value (PPV) were also calculated. Results. From

> > > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> > > selected for full review. Five studies met the inclusion criteria

> > > (interrater reliability, kappa = 0.75). Reference standards included

> > > physician opinion (n = 3), hospital admission (n = 1), and a composite

> > of

> > > physician opinion and patient clinical circumstances (n = 1). The NPV

> > ranged

> > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > meta-analysis using a random-effects model produced an aggregate NPV of

> > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence inte

> > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > determinations of medical necessity for ambulance transport vary

> > > considerably, and only two studies report complete data. The aggregate

> > NPV

> > > of the paramedic determinations is 0.91, with a lower confidence limit

> > of

> > > 0.71. These data do not support the practice of paramedics' determining

> > > whether patients require ambulance transport. These

> > findings have

> > > implications for EMS systems, emergency departments, and third-party

> > payers.

> > >

> > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > >

> > >

> > > [Non-text portions of this mess

> > > age have been removed]

> > >

> > >

> > >

> > > ------------ -------- -------- ----

> > >

Link to comment
Share on other sites
Guest guest

Guest guest

Posted
Posted

Wow, really... Were none of you taught how to do a proper assessment? I knew

this was just how it would go... If you don't have confidence in your assessment

then maybe you should go back to school and learn what a proper assessment is

and how it's done. STEMI...that would show up under a proper assessment?!?!

That's one thing I have noticed here on the Group... There are a lot of people

scared to move the field of EMS forward and make it what it really needs to be,

not just a taxi service. It's going to move forward with you or without you... I

suggest you get on board and learn the up and coming technology, ideas, etc. or

get left behind. I-stat machines are capable of doing certain level of lab work

with results that are just as accurate as a lab at a hospital, or the military

wouldn't be using them, they will eventually become a standard of care in the

field. Pull your heads out of the sand and look at the big picture. Change is

coming, either embrace it or run from it... It's your choice.

> > >

> > > Abstract

> > > Introduction. Reducing unnecessary ambulance transports may have

> > operational

> > > and economic benefits for emergency medical services (EMS) agencies and

> > > receiving emergency departments. However, no consensus exists on the

> > ability

> > > of paramedics to accurately and safely identify patients who do not

> > require

> > > ambulance transport. Objective. This systematic review and meta-analysis

> > > evaluated studies reporting U.S. paramedics' ability to determine

> > medical

> > > necessity of ambulance transport. Methods. PubMed, Cumulative Index to

> > > Nursing and Allied Health Literature (CINAHL), and Cochrane Library

> > > databases were searched using Cochrane Prehospital and Emergency Care

> > Field

> > > search terms combined with the Medical Subject Headings (MeSH) terms

> > > D*$¢®triageD*$¢®; D*$¢®utilization reviewD*$¢®; D*$¢®health services

misuseD*$¢®; D*$¢®

> > severity of

> > > illness index,D*$¢® and D*$¢®trauma severity indices.D*$¢® Two reviewers

> > independently

> > > evaluated each title to identify relevant studies; each abstract then

> > > underwent independent review to identify studies requiring full

> > appraisal.

> > > Inclusion criteria were original research; emergency responses;

> > > determinations of medical=2

> > 0necessity by U.S. paramedics; and a reference

> > > standard comparison. The primary outcome measure of interest was the

> > > negative predictive value (NPV) of paramedic determinations. For studies

> > > 20reporting sufficient data, agreement between paramedic and reference

> > > standard determinations was measured using kappa; sensitivity,

> > specificity,

> > > and positive predictive value (PPV) were also calculated. Results. From

> > > 9,752 identified titles, 214 abstracts were evaluated, with 61 studies

> > > selected for full review. Five studies met the inclusion criteria

> > > (interrater reliability, kappa = 0.75). Reference standards included

> > > physician opinion (n = 3), hospital admission (n = 1), and a composite

> > of

> > > physician opinion and patient clinical circumstances (n = 1). The NPV

> > ranged

> > > from 0.610 to 0.997. Results lacked homogeneity across studies;

> > > meta-analysis using a random-effects model produced an aggregate NPV of

> > > 0.912 (95% confidence interval: 0.707-0.978) 0.912 (95% confidence inte

> > > complete 2 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and

> > > 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

> > > Conclusion. The results of the few studies evaluating U.S. paramedic

> > > determinations of medical necessity for ambulance transport vary

> > > considerably, and only two studies report complete data. The aggregate

> > NPV

> > > of the paramedic determinations is 0.91, with a lower confidence limit

> > of

> > > 0.71. These data do not support the practice of paramedics' determining

> > > whether patients require ambulance transport. These

> > findings have

> > > implications for EMS systems, emergency departments, and third-party

> > payers.

> > >

> > > Prehospital Emergency Care 2009, Volume 13, Issue 4 pages 516 - 527

> > >

> > >

> > > [Non-text portions of this mess

> > > age have been removed]

> > >

> > >

> > >

> > > ------------ -------- -------- ----

> > >

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