Outcomes in children evaluated but not transported by ambulance personnel: retrospective cohort study

Abstract

BackgroundNot all children with an out-of-hospital emergency medical contact are transported by ambulance to the emergency department (ED). Non-transport means that after on-scene evaluation and possible treatment, ambulance personnel may advise the patient to monitor the situation at home or may refer the patient to seek medical attention by other means of transport. As selecting the right patients for ambulance transport is critical for optimising patient safety and resource use, we studied outcomes in non-transported children to identify possible risk groups that could benefit from ambulance transport.MethodsIn a population-based retrospective cohort study of all children aged 0–15 years encountered but not transported by ambulance in Helsinki, Finland, between 1 January 2014 and 31 December 2016, we evaluated (1) 12-month mortality, (2) intensive care admissions, (3) unscheduled ED contacts within the following 96 hours after the non-transport decision and (4) the clinical status of the child on presentation to ED in the case of a secondary ED visit.ResultsOf all children encountered by out-of-hospital emergency medical services, 3579/7765 (46%) were not transported to ED by ambulance. There was no mortality or intensive care admissions related to the non-transport. The risk factors for an unscheduled secondary ED visit after a non-transport decision were young age (p=0.001), non-transport decision during the early morning hours (p<0.001) and certain dispatch codes, including ‘dyspnoea’ (p<0.001), ‘vomiting/diarrhoea’ (p=0.030) and ‘mental illness’ (p=0.019). We did not detect deterioration in patients’ clinical presentation at ED traceable to non-transport decisions.ConclusionsNot transporting all children by ambulance after an out-of-hospital emergency medical contact was not associated with deaths, intensive care admissions or significant deterioration in general condition in our study population and healthcare system. Special attention and a formal non-transport protocol are warranted in certain subgroups, including infants.

Why do infants need out-of-hospital emergency medical services? A retrospective, population-based study

“…Not all pediatric patients in Finland are transported to hospital by ambulance [ 1 , 15 ]. After appropriate examination and possible treatment, the ambulance personnel may decide that the patient does not require ambulance transport.…”

“…To explore the unfavorable patient outcomes, we chose to study 12-month mortality after the EMS contact. Based on our previous studies, mortality in this population was expected to be low [ 1 , 15 ]. Therefore, we also studied the following outcomes reflecting the severity of the condition of the infants transported to the ED: 1) PICU admissions during the same hospital visit; 2) medical state of the infant upon arrival to the ED, which was judged based on the first documented physiologic measurements and the verbal evaluation by the physician; and categorized to “good” (all measurements and the presentation documented as normal) or “other than good” (any abnormal measurement or presentation documented); 3) any medication or respiratory support given at the ED (i.e.…”

“…Children form a minority group of the emergency medical services (EMS) contacts. The reported proportion of EMS contacts in pediatric patients varies between 4% in Finland [ 1 ], 5% in Canada [ 2 ] and 7% in Denmark, Korea and United States [ 3 – 5 ]. However, children have unique needs in a healthcare setting and EMS has to address these needs [ 6 ].…”

“…Discomfort and anxiety seem to translate into true patient safety hazards, as significant medication errors [ 10 , 11 ], non-systematic evaluation [ 12 , 13 ], and other challenges [ 14 , 15 ] in the emergency care of small children have been reported. Education, protocol development, mental aids, and encouragement for systematic evaluation have been proposed to address the challenges in pediatric emergency care [ 1 , 14 – 16 ].…”

“…It has previously been shown that infants are overrepresented in pediatric EMS responses [ 1 , 15 , 17 ]. It has also been reported that the challenges that EMS personnel face when attending to children are most pronounced when attending to very young, nonverbal children [ 11 , 13 ].…”