Spotlight on Research

To ED or not to ED—that is the question

Internationally, demand for emergency medical services (EMS) has changed, with increased activity often driven by patients with non-urgent medical conditions and those not requiring medical intervention from paramedics. These changing demands have led to increased referral pathways and higher numbers of patients being managed without transportation to hospital following EMS attendance. EMS exposure to younger patients is infrequent so the decision to not convey provides specific challenges in relation to assessment and safety. Non-transport rates range from 13–46% in the child population, but the safety of non-transport decisions has not been well explored.

In this retrospective data linkage study, the authors describe the characteristics and outcomes of non-transported children (aged <18 years) in Victoria, Australia between January 2015 and June 2019. Patients were linked to emergency departent (ED), hospital admission and death records. Multivariable logistic regression analyses were used to determine factors associated with EMS recontact, ED presentation, hospital admission and an adverse event within 48 hours of the initial emergency call.

A total of 62 975 non-transported patients were included in the study. Nearly half (48.9%) were male with a mean age of 7.1 (SD 6.0) years. Overall, 2.2% recontacted the EMS within 48 hours, 13.7% self-presented to a public ED, 2.4% were admitted to hospital and 0.1% had an adverse event, including two deaths. Among patients with paramedic-initiated non-transport (excluding transport refusals and transport via other means), 5.6% presented to a public ED, 1.1% were admitted to hospital and 0.05% had an adverse event. Among these, cases occurring in the early hours of the morning (4–8 am) were associated with increased odds of subsequent hospital admission. Interestingly, the odds of ED presentation and hospital admission also increased with increasing prior exposure by crews to non-transported cases.

In this study, adverse events were rare among paramedic-initiated non-transport cases. However, there were limitations relating to data linkage of child patients and the retrospective nature of the project.

12-lead ECG in stroke: does it really contribute to worse outcomes?

The value of the prehospital 12-lead electrocardiogram (PHECG) in acute ischaemic stroke versus the time taken to undertake them is unknown. No prior studies have investigated patient outcomes relating to PHECG, so this study offers new insight.

The study team performed a multi-centre, linked cohort study, based on routinely collected data from participating hospitals. PHECG was defined as any 12-lead electrocardiogram (ECG) recorded prior to arrival at hospital, while in the care of EMS. Data were collected at a time when national clinical guidelines for ambulance services in the UK recommended undertaking PHECG in acute stroke patients, providing this did not result in prolonged prehospital times. The primary outcome for this study was modified Rankin Score (mRS) at discharge from hospital. Secondary outcomes included hospital mortality, EMS interval times, door-to-needle time and rates of thrombolysis received.

There were 2795 patients admitted with confirmed ischaemic stroke during the study period. Of these, 1161 (42%) were eligible and available for analysis. PHECG was performed in 558 (48%) patients. These patients were more frequently male (52% vs 46%, p=0.05), and older (78±13 vs 76±14 years, p=0.01) than those who did not receive PHECG. Hypertension was more common in patients who had no PHECG (52% vs 45%, p=0.03). Those with symptoms of more severe stroke were more likely to have a PHECG than those with no stroke symptoms on arrival at hospital.

PHECG was associated with an increase in mRS (adjusted odds ratio [aOR] 1.30, 95% CI 1.01–1.66, p=0.04) and hospital mortality (aOR 1.83, 95% CI 1.26–2.67, p=0.002). Time on scene increased by a median of 7 minutes for those who had a PHECG and there was no association between PHECG and administration of thrombolytic treatment. The PHECG was associated with worse outcomes and longer delays in patients with acute ischaemic stroke. This may however be accounted for by the increased severity of stroke symptoms in the PHECG group. Therefore, further work is required.

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