Thinking on scene: using vignettes to assess the accuracy and rationale of paramedic decision making

Abstract

Aim Paramedics make important decisions on-scene as to whether a patient requires transport to hospital, referred, or discharged on scene. Research shows that nearly 20% of patients brought to ED by ambulance, could be treated elsewhere. This study aims to investigate the accuracy of conveyance decisions made by on-scene paramedics. Method Individual real-patient vignettes were created using linked ambulance, ED and GP data and used in an online survey to paramedics in Yorkshire. Half the vignettes were categorised as clinically necessary attendances at the ED and the other half were categorised as clinically unnecessary. Vignettes were validated by a small expert panel. Participants were asked to determine the appropriate conveyance decision and to explain the rationale behind their decisions using a free text box. Abstracts BMJ Open 2018;8(Suppl 1):A1–A34 A23 Trust (NHS). Protected by copyright. on 13 August 2019 at Manchester University NHS Foundation http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2018-EMS.62 on 16 April 2018. Downloaded from Results 143 paramedics undertook the survey and 858 vignettes were completed. There was clear agreement between paramedics for transport decisions (k=0.63) and for admission prediction (k=0.86). Overall accuracy was 0.69 (95% CI: 0.66 to 0.73). Paramedics were better at ‘ruling in’ the ED with sensitivity of 0.89 (95% CI: 0.86 to 0.92). The specificity of ‘ruling out’ the ED was 0.51 (95% CI: 0.46 to 0.56). Text comments were focused on patient safety and risk aversion. Conclusion Paramedics make accurate conveyance decisions but are more likely to over-convey than under-convey, meaning that whilst decisions are safe they are not always appropriate. Some risk-averse decisions were made due to patient and professional safety reasons. It is important that paramedics feel supported by the service to make non-conveyance decisions. Reducing over-conveyance is a potential method of reducing ED demand. https://bmjopen.bmj.com/content/8/Suppl_1/A23.3 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/bmjopen-2018-EMS.62