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.

Key findings

 

  • Prediction of disposition from ED by PHPs had pooled sensitivity of 0.73 (95% CI 0.67–0.79) and specificity of 0.78 (95% CI 0.69–0.85).
  • Concordance of PHPs with triage categories, clinical course and patient outcomes was moderate.
  • Further training and familiarity is indicated to incorporate opinions of PHPs into in‐hospital clinical practice.

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