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Patient Care

The Top 5 Papers of 2016: #5

Every year, three EMS experts take to the stage at the National Association of EMS Physicians annual conference to sum up the top five research articles of the previous year. Their goal? Identify research that is relevant, counter-intuitive and practice changing—research that is important to the patients who call 9-1-1 with the expectation that they will be served with the best available care possible. This year, paramedic and emergency room resident Blair Bigham describes the articles he and co-experts Drs. Jon Rittenberger and Michael Millin selected.

The Case of the Non-Transport

The Case: A 26-year-old woman is assessed by paramedics for influenza-like symptoms in her home. After a discussion, the paramedics leave the woman in the care of her roommate. The next morning, they receive a 9-1-1 call to the residence and find the woman without vital signs. She is pronounced dead on scene.

The Evidence: Tohira H, et al. Is it appropriate for patients to be discharged at the scene by paramedics? Prehosp Emerg Care, 2016 Jul–Aug;20(4):539–49.

In a retrospective cohort study, 47,000 consecutive patients were seen by Perth-area EMS crews in 2013. Nearly 40% were left at scene, while 60% were transported by paramedics. EMS, hospital and death records were linked. The investigators compared the 9-1-1 call-back rate, admission rate and death rate of those left at scene with the rates of those transported to hospital. (Results shown are % non-transport vs % transport.) The OR (odds ratio) show the odds of the event occurring with non-transported patients compared to those transported (an odds ratio of 2 means patients not transported were twice as likely as those transported to experience the event).

Within 24 hours:

  • Request ambulance: 6.1 vs 1.8 (OR 3.4)
  • Get admitted: 3.3 vs 0.8 (OR 4.2)
  • Die: 0.2 vs 0.1 (OR 1.8, CI 0.99-3.2)

Within 7 days:

  • Request ambulance: 11.8 vs 6.7 (OR 1.7)
  • Get admitted: 5.7 vs 3.0 (OR 1.8)
  • Die: 0.5 vs 0.3 (OR 1.8)

The Bottom Line: Sign-off rates are variable by EMS service, but account for 20%–40% of all patient contacts. Patients who are not transported by ambulance have significantly higher rates of calling back an ambulance, being admitted to hospital and dying. Paramedics should self reflect on their abilities to recognize who does not require transport to hospital. EMS services, medical directors and regulators should consider strategies to make non-transport situations less risky, including better training and education, policies, medical directives, alternate disposition pathways to ensure follow-up, and EMS-led community follow-up programs.

After a decade working as a helicopter paramedic, Blair Bigham, MD, MSC, ACPF, completed medical school in Ontario, Canada, where he is now a resident physician in the emergency department. He has authored over 30 scientific articles, led major national projects to advance prehospital research and participated in multiple collaboratives, including the Resuscitation Outcomes Consortium. He has taught and mentored clinical and academic paramedics and loves his new role teaching medical students. He serves as a volunteer on the board of directors for the MedicAlert Foundation of Canada and is a task force member for the International Liaison Committee on Resuscitation. 

Michael Millin is a board certified EM and EMS physician from Baltimore, MD. He is a member of the faculty of the Johns Hopkins University School of Medicine and medical director of the Johns Hopkins Lifeline critical care transport program. He is also medical director for the BWI Airport Fire and Rescue Department, Maryland Search and Rescue, and associate medical dDirector for the Prince George’s County Fire/EMS Department.

Jon Rittenberger, MD, is an associate professor of emergency medicine and medical command physician for UPMC Prehospital Care. In addition to his emergency medicine practice, he is a founding member of the Post Cardiac Arrest Service at UPMC Presbyterian hospital. His research interest is in brain resuscitation during critical illness states. He brings over 20 years of EMS experience as a provider and researcher. 

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