Exploring paramedic patient assessment
Abstract
Objective:
This study explored the topic of paramedic patient assessment, investigating how they informed clinical decisions, the challenges associated with performing assessments and the perceived effectiveness of current approaches.
Methods:
Using a Delphi research method, expert participants were independently interviewed which encouraged them to share experiences and views. A thematic analysis approach was then used and the data coded and organised into a series of statements to represent the collective expert views. Statements were then returned to the expert participants for validation and comment.
Results:
A process of paramedic care delivery was defined, whose activities were largely identified as representing areas of assessment. Protocols and guidelines which are designed to inform paramedic interventions influenced every stage of care delivery. The depth and breadth of a paramedic's patient assessment were found to be limited once indications for a treatment guideline have been satisfied and the main contraindications are excluded. Current formal assessment tools skills being utilised by paramedic staff (including protocols and practice guidelines) were considered only effective for encounters with critically ill patients, and were of limited benefit to the assessment of patients of a lower clinical acuity. There was a direct correlation between the increased paramedic confidence in their patient assessment skills and the more critical the patient's condition. Paramedics were the least familiar or confident with the assessment principles and skills linked with the lower acuity of patient illness.
Conclusion:
When compared to both national and international ambulance case loads, it is significant that those groups of patient complaints representing the vast majority of ambulance work are the same patient cohorts for whom the paramedic has the least knowledge, preparation and confidence in relation to assessment. Findings relating to the defining of a paramedic's role and process of care distinctly features assessment skills to be both a major component of all pre-hospital activities and integral to the effectiveness of all interventions to follow. This should firmly place
Patient assessment informs clinicians of the essential data required to produce effective clinical decisions. Failure to identify or understand clinical signs, which should be recognised through accurate history taking, inevitably leads to issues such as: misdiagnosis, the incorrect treatment pathways being followed, and detrimental patient outcomes. Traditional models of ambulance practice predominantly focused on the resuscitation and rapid transport of critical patients, with assessment tools such as primary and secondary survey serving the industry well. Today the expectations on pre-hospital care provision are far greater. A more diverse and complex range of patient complaints are now common occurrence to the paramedic, yet the existing assessment tools and guidelines for practice continue to exclusively address the needs of the ‘traditional ambulance patient’.
Records of battlefield first aid can be evidenced on Grecian pottery from as early as 500 BC, demonstrating early records of ambulances in alignment with military activities (Pearn, 1994). With global industrial advancements, in particular the introduction of mechanised transport, it was not long before the merits of a service designed for the hostility of war was found to have civilian applications (Haller, 1990). Since this time, great advances have been made in pre-hospital care, with the advancement curve scaling significantly in the last 20 years (Ball, 2005). The modern ambulance serves as a concise mobile resuscitation room or intensive care bay, with a paramedic trained to deliver a rapidly increasing range of interventions for patients. Although the benefits to patients experiencing major trauma or life-threatened injury or illness is unquestionable, industry statistics fail to represent these ‘traditional ambulance patients’ as major stakeholders for ambulance service provisions (Callaham, 1997; Squires and Mason 2004; Lowthian et al, 2011). Meanwhile, everything from vehicle and equipment design, pharmaceuticals, protocols for practice, and even training continue to maintain a focus upon the critically ill or imminently life-threatened patient. This focus is not reflective of the changing face of the modern ambulance patient and the diverse demographic of modern ambulance work (Richards and Farrall, 1999; Silvestri et al, 2002). Locally, ambulance statistics report that 53% of all ambulance calls are considered non-urgent from outset and that another 10% of these patients remain at home (SA Ambulance Annual Report 2009–2010). Of the remaining 37% receiving an emergency dispatch, a reduced fraction of these remain prioritised as a life-threatening emergency once assessed by paramedic crews. Those interviewed in this study estimated the figure of critically ill patient encounters at approximately 5–7% of ambulance work (SA Ambulance Annual Report 2009–2010).
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