School of Health Studies, Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands.
Emergency Medical Service, RAV Utrecht, Utrecht, The Netherlands.
BMC Emerg Med. 2023 Oct 5;23(1):118. doi: 10.1186/s12873-023-00890-y.
The clinical decision-making of non-conveyance is perceived as complex and difficult by emergency medical services (EMS) professionals. Patients with a transient loss of consciousness (TLOC) based on syncope constitute a significant part of the non-conveyance population. Risk stratification is the basis of the clinical decision-making process by EMS professionals. This risk stratification is based on various patient factors. This study aimed to explore patient factors significantly associated with conveyance decision-making by EMS professionals in patients with a TLOC based on syncope.
A cross-sectional vignette study with a factorial survey design was conducted. Patient factors were derived from the "National Protocol Ambulance Care", and all possible combinations of these factors and underlying categories were combined, resulting in 256 unique vignettes (24442 = 256). Patient factors presented either low-risk or high-risk factors for adverse events. Data were collected through an online questionnaire, in which participants received a random sample of 15 vignettes. For each vignette, the respondent indicated whether the patient would need to be conveyed to the emergency department or not. A multilevel logistic regression analysis with stepwise backward elimination was performed to analyse factors significantly associated with conveyance decision-making. In the logistic model, we modelled the probability of non-conveyance.
110 respondents were included, with 1646 vignettes being assessed. Mean age 45.5 (SD 9.3), male gender 63.6%, and years of experience 13.2 (SD 8.9). Multilevel analysis showed two patient factors contributing significantly to conveyance decision-making: 'red flags' and 'prehospital electrocardiogram (ECG)'. Of these patient factors, three underlying categories were significantly associated with non-conveyance: 'sudden cardiac death < 40 years of age in family history' (OR 0.33, 95% CI 0.22-0.50; p < 0.001), 'cardiovascular abnormalities, pulmonary embolism or pulmonary hypertension in the medical history' (OR 0.62, 95% CI 0.43-0.91; p = 0.01), and 'abnormal prehospital ECG' (OR 0.54, 95% CI 0.41-0.72; p < 0.001).
Sudden cardiac death < 40 years of age in family history, medical history, and abnormal ECG are significantly negatively associated with non-conveyance decision-making by EMS professionals in patients with a TLOC based on syncope. Low-risk factors do not play a significant role in conveyance decision-making.
非转运的临床决策被认为是复杂和困难的紧急医疗服务（EMS）专业人员。以晕厥为基础的短暂性意识丧失（TLOC）患者构成了非转运人群的重要组成部分。风险分层是 EMS 专业人员临床决策过程的基础。这种风险分层基于各种患者因素。本研究旨在探讨 TLOC 基于晕厥的患者中与 EMS 专业人员转运决策显著相关的患者因素。
采用交叉案例研究和析因调查设计进行横断面研究。患者因素源自《国家协议救护车护理》，并将这些因素的所有可能组合和潜在类别结合起来，得出 256 个独特的案例（24442=256）。患者因素呈现出不良事件的低风险或高风险因素。数据通过在线问卷收集，参与者收到了 15 个随机样本的案例。对于每个案例，回答者都要指示患者是否需要被转送到急诊室。采用逐步向后消除的多水平逻辑回归分析来分析与转运决策显著相关的因素。在逻辑模型中，我们对非转运的概率进行建模。
共纳入 110 名受访者，评估了 1646 个案例。平均年龄 45.5（SD 9.3），男性 63.6%，经验年限 13.2（SD 8.9）。多水平分析显示两个患者因素对转运决策有显著影响：“红色标记”和“院前心电图（ECG）”。在这些患者因素中，有三个潜在类别与非转运显著相关：“家族史中<40 岁的突发性心脏死亡”（OR 0.33，95%CI 0.22-0.50；p<0.001），“病史中有心血管异常、肺栓塞或肺动脉高压”（OR 0.62，95%CI 0.43-0.91；p=0.01）和“院前心电图异常”（OR 0.54，95%CI 0.41-0.72；p<0.001）。
家族史中<40 岁的突发性心脏死亡、病史和异常心电图与 EMS 专业人员在 TLOC 基于晕厥的患者中非转运决策显著负相关。低风险因素在转运决策中不起重要作用。
