Review article: Pre‐hospital provider clinical judgement upon arrival to the emergency department: A systematic review and meta‐analysis

Abstract

Pre-hospital providers (PHPs) undertake initial patient assessment, often spending considerable time with patients prior to arrival at ED. However, continuity of this assessment with ongoing care of patients in the ED is limited, with repeated assessment in the ED, starting with the process of triage in hospital. A systematic review of the literature was conducted to assess the ability of PHPs to predict patient outcomes in the ED. Manuscripts were screened and were eligible for inclusion if they included patients transported by non-physician PHPs to the ED and assessed ability of PHPs to predict triage scores, clinical course, treatment requirements or disposition from ED. The initial search returned 10 753 unique articles. After screening and full text review, 10 studies were included in data analysis. Of these, six assessed prediction of disposition (admission versus discharge) from ED, two compared triage score application, one assessed prediction of clinical requirements and one assessed prediction of mortality prior to discharge. Prediction of admission across five studies had a pooled sensitivity of 0.73 (95% confidence interval 0.67-0.79) and specificity of 0.78 (95% confidence interval 0.69-0.85). Triage score application had weighted kappa variables of 0.409 and 0.452 indicating moderate agreement on assessment priority between PHPs and triage nurses. The ability of PHPs to assign triage scores, predict clinical course and predict disposition from the ED have mild concordance with clinical assessment by ED staff. This is an area of potential expansion in PHPs' role; however, training would be required prior to implementation.

Paramedic streaming upon arrival in emergency department: A prospective study

“…It is expected that further training and familiarisation of paramedics with patient flow through EDs may improve concordance levels. Concordance with streaming decision in this study was higher than that reported by a recent systematic review which looked at pre‐hospital providers' ability to predict disposition (admission vs discharge), triage score category, clinical requirements, or mortality prior to discharge 9 . These results raise the prospect that paramedic‐guided streaming may improve overall patient flow in the ED.…”

“…Paramedics can stream patients with high accuracy when compared to the current model of using streaming nurses. This was despite paramedics having limited knowledge of patient load within the ED and therefore inherently biasing the results towards 9 These results raise the prospect that paramedic-guided streaming may improve overall patient flow in the ED. There is scope for paramedics' clinical acumen and knowledge of the patient to be utilised to expedite the triage process.…”

Performance of early warning and risk stratification scores versus clinical judgement in the acute setting: a systematic review

“…Strict adherence to National Early Warning Score (NEWS) by general practitioners was shown to have the potential to increase (unneeded) hospital admissions 15. Classification of disease severity based on developed decision rules is inferior compared with clinical performance 16–20…”

Prediction models in prehospital and emergency medicine research: How to derive and internally validate a clinical prediction model

“…Many prediction models suffer from methodological limitations, such as low sample sizes and poor internal and/or external validation. [6][7][8][9] Despite published guidelines and published reporting standards, 10,11 the majority of prediction model studies do not follow methodological recommendations and therefore have a high risk of bias. This bias limits their validity, which in turn could jeopardize patient care and also results in research waste.…”