Using vignettes to assess the accuracy and rationale of paramedic decisions on conveyance to the emergency department

Introduction: Paramedics make important decisions about whether a patient needs transport to hospital, or can be discharged on scene. These decisions require a degree of accuracy, as taking low acuity patients to the emergency department (ED) can support ambulance ramping. In contrast, leaving mid‐high acuity patients on scene can lead to incidents and recontact. This study aims to investigate the accuracy of conveyance decisions made by paramedics when looking at real life patient scenarios with known outcomes. It also aims to explore how the paramedic made the decision.

Methods: We undertook a prospective mixed method triangulation design. Six individual patient vignettes were created using linked ambulance and ED data. These were then presented in an online survey to paramedics in Yorkshire. Half the vignettes related to mid‐high acuity attendances at the ED and the other half were low acuity. 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.

Results: A total of 143 paramedics undertook the survey and 858 vignettes were completed. There was clear agreement between paramedics for transport decisions ( = 0.63). Overall accuracy was 0.69 (95% CI 0.66‐0.73). Paramedics were better at ‘ruling in’ the ED, with sensitivity of 0.89 (95% CI 0.86‐0.92). The specificity of ‘ruling out’ the ED was 0.51 (95% CI 0.46‐0.56). Text comments were focused on patient safety and risk aversion.

Discussion: Paramedics make accurate conveyance decisions but are more likely to over-convey than under-convey, meaning that while decisions are safe they are not always appropriate. It is important that paramedics feel supported by the service to make safe and confident non-conveyance decisions. Reducing over-conveyance is a potential method of reducing demand in the urgent and emergency care system.