Re: Paramedics Cannot Determine Which Patients Require Transport

September 6, 2009

I truly see both sides of this argument, I am a proponent of Paramedic Initiated

Refusals, always have been and always will be, with the proper training.

Most of the arguments are the extremes.

For arguments sake, I do not advocate no riding chest pain, or abdominal pain

etc., neither can you convince me that every cut fingers and stubbed toes need

an ambulance. They need a chit to call a cab and get a ride to where they choose

to go and get their finger or toe cared for.

The argument that if the patient thinks it is an emergency, then it is......not

true. I can't remember all the times that the family member came screaming out

of the house about " all teh blood " , to find a small laceration with minor

bleeding controlled with a large band aid.

I have heard the argument that it takes as long to write a refusal as it does to

write a report, and thats true, but at the same time, with a refusal you are

back in service immediately, rather than after a trip to the hospital (trip time

dtermined by your own city/county).

Is there a place for them? Absolutely, is it in the near future? No. Do I see it

happening? Yes.

But I promise not to tell you 'I told you so'.....assuming I am still alive...

Hatfield

" The main part of intellectual education is not the acquisition of facts but

learning how to make facts live. " - Oliver Wendell Holmes

www.michaelwhatfield.net

Subject: Re: Paramedics Cannot Determine Which Patients Require

Transport

To: texasems-l

Date: Sunday, September 6, 2009, 8:41 PM

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]

> > >

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

> > >

September 6, 2009