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Paramedic Checklists do not Accurately Identify Post-ictal or Hypoglycaemic Patients Suitable for Discharge at the Scene

Published online by Cambridge University Press:  30 March 2016

Hideo Tohira ,
Daniel Fatovich ,
Teresa A. Williams ,
Alexandra Bremner ,
Glenn Arendts ,
Ian R. Rogers ,
Antonio Celenza ,
David Mountain ,
Peter Cameron  and
Peter Sprivulis
...Show all authors
Hideo Tohira*
Affiliation:
Prehospital, Resuscitation, and Emergency Care Research Unit, School of Nursing, Midwifery, and Paramedicine, Curtin University, Bentley, Western Australia, Australia
Daniel Fatovich
Affiliation:
Emergency Medicine, Royal Perth Hospital, The University of Western Australia, Perth, Western Australia, Australia Harry Perkins Institute of Medical Research, Centre for Clinical Research in Emergency Medicine, Perth, Western Australia, Australia
Teresa A. Williams
Affiliation:
Prehospital, Resuscitation, and Emergency Care Research Unit, School of Nursing, Midwifery, and Paramedicine, Curtin University, Bentley, Western Australia, Australia Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, Western Australia, Australia St John Ambulance Western Australia, Belmont, Western Australia, Australia Royal Perth Hospital, Perth, Western Australia, Australia
Alexandra Bremner
Affiliation:
School of Population Health, The University of Western Australia, Crawley, Western Australia, Australia
Glenn Arendts
Affiliation:
Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, Western Australia, Australia Royal Perth Hospital, Perth, Western Australia, Australia
Ian R. Rogers
Affiliation:
St John of God Murdoch Hospital, Murdoch, Western Australia, Australia University of Notre Dame Australia, Fremantle, Western Australia, Australia
Antonio Celenza
Affiliation:
Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, Western Australia, Australia Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
David Mountain
Affiliation:
Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, Western Australia, Australia Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
Peter Cameron
Affiliation:
School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
Peter Sprivulis
Affiliation:
Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, Western Australia, Australia Fiona Stanley Hospital, Murdoch, Western Australia, Australia
Tony Ahern
Affiliation:
St John Ambulance Western Australia, Belmont, Western Australia, Australia
Judith Finn
Affiliation:
Prehospital, Resuscitation, and Emergency Care Research Unit, School of Nursing, Midwifery, and Paramedicine, Curtin University, Bentley, Western Australia, Australia Discipline of Emergency Medicine, School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, Western Australia, Australia St John Ambulance Western Australia, Belmont, Western Australia, Australia School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
*
Correspondence: Hideo Tohira, MD, MPH, MEng, PhD, FJAAM Prehospital, Resuscitation, and Emergency Care Research Unit School of Nursing, Midwifery, and Paramedicine Curtin University GPO Box U1987 Perth, Western Australia 6845 Australia E-mail: [email protected]
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Abstract

Objectives

The objective of this study was to assess the accuracy and safety of two pre-defined checklists to identify prehospital post-ictal or hypoglycemic patients who could be discharged at the scene.

Methods

A retrospective cohort study of lower acuity, adult patients attended by paramedics in 2013, and who were either post-ictal or hypoglycemic, was conducted. Two self-care pathway assessment checklists (one each for post-ictal and hypoglycemia) designed as clinical decision tools for paramedics to identify patients suitable for discharge at the scene were used. The intention of the checklists was to provide paramedics with justification to not transport a patient if all checklist criteria were met. Actual patient destination (emergency department [ED] or discharge at the scene) and subsequent events (eg, ambulance requests) were compared between patients who did and did not fulfill the checklists. The performance of the checklists against the destination determined by paramedics was also assessed.

Results

Totals of 629 post-ictal and 609 hypoglycemic patients were identified. Of these, 91 (14.5%) and 37 (6.1%) patients fulfilled the respective checklist. Among those who fulfilled the checklist, 25 (27.5%) post-ictal and 18 (48.6%) hypoglycemic patients were discharged at the scene, and 21 (23.1%) and seven (18.9%) were admitted to hospital after ED assessment. Amongst post-ictal patients, those fulfilling the checklist had more subsequent ambulance requests (P=.01) and ED attendances with seizure-related conditions (P=.04) within three days than those who did not. Amongst hypoglycemic patients, there were no significant differences in subsequent events between those who did and did not meet the criteria. Paramedics discharged five times more hypoglycemic patients at the scene than the checklist predicted with no significant differences in the rate of subsequent events. Four deaths (0.66%) occurred within seven days in the hypoglycemic cohort, and none of them were attributed directly to hypoglycemia.

Conclusions

The checklists did not accurately identify patients suitable for discharge at the scene within the Emergency Medical Service. Patients who fulfilled the post-ictal checklist made more subsequent health care service requests within three days than those who did not. Both checklists showed similar occurrence of subsequent events to paramedics’ decision, but the hypoglycemia checklist identified fewer patients who could be discharged at the scene than paramedics actually discharged. Reliance on these checklists may increase transportations to ED and delay initiation of appropriate treatment at a hospital.

TohiraH , FatovichD , WilliamsTA , BremnerA , ArendtsG , RogersIR , CelenzaA , MountainD , CameronP , SprivulisP , AhernT , FinnJ . Paramedic Checklists do not Accurately Identify Post-ictal or Hypoglycaemic Patients Suitable for Discharge at the Scene. Prehosp Disaster Med. 2016;31(3):282–293.

Keywords

clinical practice guidelineEmergency Medical Serviceshypoglycemiaseizures
Type
Original Research
Information
Prehospital and Disaster Medicine , Volume 31 , Issue 3 , June 2016 , pp. 282 - 293
Copyright
© World Association for Disaster and Emergency Medicine 2016 

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