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Why are people without medical needs transported by ambulance? A study of indications for pre-hospital care.
Nordic Council of Ministers, Nordic School of Public Health NHV.
Nordic Council of Ministers, Nordic School of Public Health NHV.
2007 (English)In: European journal of emergency medicine, ISSN 0969-9546, E-ISSN 1473-5695, Vol. 14, no 3, 151-6 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: The purpose of this report was to describe the characteristics of patients transported by ambulance, in spite of being evaluated by the ambulance staff at the scene as not requiring prehospital care. A second aim was to compare these patients with those judged as being in need of this care.

METHODS: Three ambulance service districts located in different rural and metropolitan geographical areas were included in the study and all three were covered by a single emergency dispatch centre. Following the dispatch of ambulances, the staff assessed and recorded the medical needs of the patients at the scene, according to a questionnaire developed for the study. In addition to the questionnaire, data were extracted from the ambulance medical records database for each patient. If the patients were just transported by ambulance without receiving any other prehospital intervention, they were assessed as not being in need of the emergency service. The evaluation included events at the scene and during transportation. The ambulance staff making the needs assessments were emergency medical technicians and registered nurses. In this report, 604 patients who did not require prehospital care are described and compared with the remaining group of patients who required this care (1373). For analysis, descriptive statistics were used to analyse the data.

RESULTS: The ambulance staff assessed that, among patients reported by the emergency medical dispatch centre as having abdominal or urinary problems, 42% did not need the ambulance service. Even among intrahospital transports (patients for whom medical personnel made the request for an ambulance), 45% did not require ambulance transport, as judged by the ambulance staff. Among patients reported by the emergency medical dispatch centre as having chest pain or other heart symptoms or trauma/accidents, respectively, only small percentages (18%) and (17%) did not require the ambulance service, as assessed by the ambulance staff. Most of the patients without obvious medical needs had been allocated an ambulance response for nonurgent conditions, that is priority level 2 or 3, but patients without medical needs were even found at the highest priority level 1. Of the patients who did not require an ambulance, more than half (55%) would have been able to get to a hospital in their own car or by taxi, whereas the remainder of the patients needed a transport vehicle in which they could lie down, but which was not equipped and staffed like an ambulance.

CONCLUSION: Among the patients transported by the emergency medical service system in the study areas, a significant percentage were judged by the ambulance staff as not being in need of prehospital interventions. The majority were transported by a fully equipped emergency medical ambulance to an emergency medical department at a hospital, without requiring any prehospital interventions either at the scene or during transportation. The emergency medical service organization has to develop clear criteria for the utilization of ambulance services that can be accepted and implemented by the dispatch centres and by healthcare personnel. These criteria need to include safety margins and at the same time enable the appropriate use of resources.

Place, publisher, year, edition, pages
2007. Vol. 14, no 3, 151-6 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:norden:org:diva-3752DOI: 10.1097/MEJ.0b013e3280146508PubMedID: 17473609OAI: oai:DiVA.org:norden-3752DiVA: diva2:787094
Available from: 2015-02-09 Created: 2015-02-09 Last updated: 2015-02-09Bibliographically approved
In thesis
1. Att värdera vårdbehov- ett kliniskt dilemma: En studie av nyttjandet av ambulanssjukvård i olika geografiska områden
Open this publication in new window or tab >>Att värdera vårdbehov- ett kliniskt dilemma: En studie av nyttjandet av ambulanssjukvård i olika geografiska områden
2010 (Swedish)Doctoral thesis, comprehensive summary (Other academic)
Abstract [sv]

De nordiska ländernas hälso- och sjukvård bygger på att sjukvården finns till hands när den behövs. För att ge företräde för de individer som har störst vårdbehov genomförs inom olika verksamheter vårdbehovsprioriteringar. Behovet av prioriteringar tilltar i takt med att efterfrågan på hälso- och sjukvårdens insatser ökar. Skälet till att göra prioriteringar inom hälso- och sjukvården är att upprätthålla en god vård med god effekt till dem som bäst behöver den. Även om hälso- och sjukvården kvantitativt spelar en begränsad roll för folkhälsan, utgör den en viktig del i samhället genom att skapa trygghet. Särskilt betydelsefullt i detta avseende är akutsjukvård varav ambulanssjukvård är en viktig del. Vid akut uppkommen sjukdom eller skada, förväntar sig befolkningen att snabbt få den hjälp och de sjukvårdsinsatser som de behöver. Prioritering av ambulansbehov och allokering av ambulans sker via en prioriterings och dirigeringscentral som nås av allmänheten via samhällets nödnummer. Avhandlingens övergripande syfte är att undersöka om de medicinska prioriteringar som görs vid ambulansallokering leder till ändamålsenligt vårdutnyttjande. Avhandlingen bygger på fem delstudier (1-5) som genererat sex delarbeten (I-VI) och är genomförda med en kvantitativ forskningsansats. I delstudie 1 (delarbete I-II) beskrivs ambulansallokering i relation till ambulanspersonalens bedömning av ambulansbehov. Delstudie 2 (delarbete III), beskriver hur patienter med akut bröstsmärta nyttjar ambulanssjukvård i olika geografiska områden. I delstudie 3 (delarbete IV) undersöks om nyttjandet av ambulans skiljer sig åt mellan tätort och glesbygd. I delstudie 4 (delarbete IV) beskrivs ambulansutnyttjande i Finland i relation till ambulanspersonalens bedömning av patienternas vårdbehov. Delstudie 5 (delarbeteVI), beskriver i vilken omfattning ambulanstransporterade patienter har behov av ambulanssjukvård och vård på akutmottagning. Resultatet visar att initial prioritering av ambulansrespons överensstämde med patienternas aktuella status såsom bedömt av ambulanspersonalen i hälften av uppdragen, och såsom bedömt retrospektivt av en expertpanel i en tredjedel av fallen. Enligt såväl ambulanspersonalens som expertpanelens bedömningar förelåg omfattande både underprioriteringar och överprioriteringar vid ambulansallokering. Resultatet visar därmed att de medicinska prioriteringar som görs vid ambulansallokering leder till både underutnyttjande och överutnyttjande av ambulanssjukvårdens resurser. Studien indikerar att medicinska prioriteringar leder till suboptimalt resursutnyttjande av hälso- och sjukvårds resurser. Graden av underutnyttjande dvs. patienter som underprioriterats måste betraktas som ett av studiens huvudfynd. Ett prioriteringssystem skall kunna identifiera de patienter som har störst vårdbehov, och ge dessa patienter tillträde till vården för att undvika onödig försämring av hälsotillståndet. Ett prioriteringssystem bör också, med bibehållande av säkerhetsmarginaler, minimera överutnyttjande av hälso- och sjukvårdsresurser. Ett annat huvudfynd i studien är att en hög säkerhetsmarginal med hög andel överprioriteringar inom ambulanssjukvården, tycks leda till att en stor andel av ambulansuppdragen består av transporter i en fullt utrustad ambulans, för patienter utan behov av varken den utrustning eller den kompetens som idag finns inom ambulanssjukvården.

Abstract [en]

The health care system in the Nordic countries’ are based on that those individuals who have urgent need of health care should have access to it without unnecessary delay. But regarded to limited resources prioritisation has to be made. The reason for prioritising is to deliver an appropriate and rapid response to those with the most urgent needs and to guarantee the public a qualitative good and effective health care. The health care system has an important role for creating safety, especially the emergency medical service. When someone become acute ill or injured, there are expectations for immediately rapid response from the health care system. The prioritisation and allocation of the ambulance service is performed from an emergency medical centre by the emergency number 112. Several Emergency Medical Systems use a criteria based prioritizing system for ambulance response. In such a system the operators at the medical emergency dispatch centres have to assess patients’ symptoms and needs for ambulance response. The prioritizing of the ambulance response is based on the seriousness of the patient’s symptoms, on the patient’s current condition and in the case of trauma, on the trauma mechanism. The priority system is supposed to optimize the use of the ambulance service and to match up and meet the patients’ needs with adequate responses of the ambulances. The aim of this thesis is to evaluate if the prioritising of patients medical status leads to appropriate use of the health care service and the emergency medical service. The thesis is based on five parts, including six studies (I-VI) and the methods used have a quantitative approach. Part 1 (study I-II), evaluates the settings of priorities and patients need for prehospital care. Part 2 (study III), describes how patients with chest pain in different geographical areas uses the ambulance service. Part 3 (study IV), analyses the differences in use of the ambulance service between densely and sparsely populated areas. Part 4 (study IV), describes the use of the ambulance service in Finland. Part 5 (study IV), reviews the ambulance patients and the need of care at emergency department or similar level of care. The results show that the initial priority of ambulance response from the dispatch centre was consistent with patients' current status as assessed by ambulance staff in half of the missions, and as assessed retrospectively by an expert panel at one third of cases. According to the assessment of the ambulance personnel and the review from an expert panel there was extensive use of both ”overtriage” and ”undertriage” in the emergency medical dispatching of ambulance missions. The result also shows that decisions lead to sub optimal use of the ambulance service and other health care resources. One of the major findings is the occurrence of undertriage. A triage system has to identify those patients with the most urgent health needs, and give these patients access to care in order to avoid unnecessary deterioration in health status. At the same time must safety margins be maintained and overuse of resources minimised. Another major finding is that a high safety margins and high amount of overtriage leads to that a big part of the ambulance missions are transportation of patients with no need of today’s high tech ambulances or the professional competence of ambulance nurses

Place, publisher, year, edition, pages
Nordic School of Public Health NHV Göteborg, Sweden, 2010. 113 p.
Series
NHV Reports and Doctor of Public Health-Theses, ISSN 0283-1961 ; NHV Report 2010:1
Keyword
prioritizing, dispatching, ambulance use, triag, vårdbehov, ambulansprioritering, nyttjande ambulanssjukvård.
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3754 (URN)978-91-85721-78-8 (ISBN)
Public defence
2010-03-19, Nordic School of Public Health NHV, Göteborg, Sweden, 13:00 (Swedish)
Supervisors
Available from: 2015-02-09 Created: 2015-02-09 Last updated: 2015-02-09Bibliographically approved

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