Background

The emergency medical service (EMS) addresses all chief complaints across all ages in various contexts. Children in EMS present a particular challenge due to their unique anatomical and physical properties, which require specific training that EMS clinicians often report lacking. This combination exposes children to incidents threatening patient safety. The most common method to highlight incidents is the incident reporting system. Studies have shown underreporting of such incidents, highlighting the need for multiple methods to measure and enhance patient safety in EMS for children. Thus, the aim of this study was to modify and adapt the current Ambulance TT for road-based EMS (ATT) to a pediatric version (pATT) with a guide containing definitions of triggers.

Methods

The adaption of the ambulance trigger tool to a version suitable for children followed a stepwise manner, including (1) a review of previous literature to pinpoint areas of risk regarding patient safety among children in EMS. (2) Three sessions of expert panel discussions via video meetings were held to evaluate each trigger of the ATT in terms of clinical relevance, comprehensibility, language and areas of risk regarding patient safety among children in EMS. (3) Clinical use of the pATT along with Retrospective Record Review (RRR). (4) Calculation of Item-level validity index and positive predictive value (PPV) for each trigger. (5) calculate inter-rater reliability between two independent record reviewers.

Results

MethodsThe adaption of the ambulance trigger tool to a version suitable for children followed a stepwise manner, including (1) a review of previous literature to pinpoint areas of risk regarding patient safety among children in EMS. (2) Three sessions of expert panel discussions via video meetings were held to evaluate each trigger of the ATT in terms of clinical relevance, comprehensibility, language and areas of risk regarding patient safety among children in EMS. (3) Clinical use of the pATT along with Retrospective Record Review (RRR). (4) Calculation of Item-level validity index and positive predictive value (PPV) for each trigger. (5) calculate inter-rater reliability between two independent record reviewers.

Conclusion

This study demonstrates the adaptation of an existing trigger tool (ATT) to one suitable for children. It also shows that the trigger tool, along with retrospective record review, is a feasible method to evaluate patient safety in EMS, thus complementing existing methods. 

Background

Emergency Medical Services (EMS) are a unique setting because care for the chief complaint is given across all ages in a complex and high-risk environment that may pose a threat to patient safety. Traditionally, a reporting system is commonly used to raise awareness of adverse events (AEs); however, it could fail to detect an AE. Several methods are needed to evaluate patient safety in EMS. In this light, this study was conducted to (1) develop a national ambulance trigger tool (ATT) with a guide containing descriptions of triggers, examples of use, and categorization of near misses (NMs), no harm incidents (NHIs), and harmful incidents (HIs) and (2) use the ATT on randomly selected ambulance records.

Methods

The ambulance trigger tool was developed in a stepwise manner through (1) a literature review; (2) three sessions of structured group discussions with an expert panel having knowledge of emergency medical service, patient safety, and development of trigger tools; (3) a retrospective record review of 900 randomly selected journals with three review teams from different geographical locations; and (4) inter-rater reliability testing between reviewers.

Results

From the literature review, 34 triggers were derived. After removing clinically irrelevant ones and combining others through three sessions of structured discussions, 19 remained. The most common triggers identified in the 900 randomly selected records were deviation from treatment guidelines (30.4%), the patient is non conveyed after EMS assessment (20.8%), and incomplete documentation (14.4%). The positive triggers were categorized as a near miss (40.9%), no harm (3.7%), and harmful incident (0.2%). Inter-rater reliability testing showed good agreement in both sessions.

Conclusion

This study shows that a trigger tool together with a retrospective record review can be used as a method to measure the frequency of harmful incidents, no harm incidents, and near misses in the EMS, thus complementing the traditional reporting system to realize increased patient safety.

Background

The emergency medical services (EMS) have undergone dramatic changes during the past few decades. Increased utilisation, changes in care-seeking behaviour and competence among EMS clinicians have given rise to a shift in EMS strategies in many countries. From transport to the emergency department to at the scene deciding on the most appropriate level of care and mode of transport. Among the non-conveyed patients some may suffer from “time-sensitive conditions” delaying diagnosis and treatment. Thus, four questions arise:

1) How often are time-sensitive cases referred to primary care or self-care advice?

2) How can we measure and define the level of inappropriate clinical decision-making?

3) What is acceptable?

4) How to increase patient safety?

Main text

To what extent time-sensitive cases are non-conveyed varies. About 5–25% of referred patients visit the emergency department within 72 hours, 5% are hospitalised, 1–3% are reported to have a time-sensitive condition and seven-day mortality rates range from 0.3 to 6%.

The level of inappropriate clinical decision-making can be measured using surrogate measures such as emergency department attendances, hospitalisation and short-term mortality. These measures do not reveal time-sensitive conditions. Defining a scoring system may be one alternative, where misclassifications of time-sensitive cases are rated based on how severely they affected patient outcome.

In terms of what is acceptable there is no general agreement. Although a zero-vision approach does not seem to be realistic unless under-triage is split into different levels of severity with zero-vision in the most severe categories.

There are several ways to reduce the risk of misclassifications. Implementation of support systems for decision-making using machine learning to improve the initial assessment is one approach. Using a trigger tool to identify adverse events is another.

Conclusion

A substantial number of patients are non-conveyed, including a small portion with time-sensitive conditions. This poses a threat to patient safety. No general agreement on how to define and measure the extent of such EMS referrals and no agreement of what is acceptable exists, but we conclude an overall zero-vision is not realistic. Developing specific tools supporting decision making regarding EMS referral may be one way to reduce misclassification rates.