Could low-acuity emergency medical services patients be redirected to primary care? Findings from a multi-center survey in Berlin, Germany.

Abstract

Background: Emergency medical services (EMS) are frequently used by low-acuity patients, which contributes to emergency department (ED) crowding. The feasibility of EMS transporting low-acuity patients directly to general practitioner (GP) practices remains a matter of debate. We therefore investigated the circumstances of EMS utilization in patients who subsequently receive ambulatory treatment in the ED. We wanted to find out how often a primary care (PC) consultation could have been a suitable alternative in such cases.

Methods: Low-acuity ED utilizers transported by EMS were surveyed on demographics and medical characteristics and asked about the appropriateness and acceptability of a potential PC redirection, supplemented with case assessments by EMS personnel. Additionally, treatment documentation from both the ED and EMS was analyzed. Descriptive statistics were conducted. Associations between categorical variables were examined by Chi² tests.

Results: A total of n = 358 low-acuity EMS participants were recruited. Participants had a mean age of 47.6 years; gender f/m: 58.1%/41.9%. In the hospital, 71.8% were assigned to the Manchester triage system (MTS) category 3 and 28.0% to category 4. A third of the patients had decided to alert EMS at their discretion, while other people (e.g., relatives, colleagues) had been involved twice as often. Patients most commonly cited severe symptoms and related fears as reasons for engaging EMS services. EMS personnel categorized the complaints as treatable by a GP in 37.0%, while 44.5% of patients would have been open to PC management. However, these assessments exhibited substantial discrepancies, as evidenced by a Cohen's Kappa coefficient of approximately 0.1. From a preclinical perspective, only 24.4% of cases met the criteria for potentially realistic diversion. These encompassed both patient openness to alternative care pathways and EMS discernment of cases as potentially appropriate.

Conclusions: PC diversion is estimated to be feasible for a maximum of a quarter of ED outpatients. Markers for potential management in PC show highly discrepant results, and there is no validated system or score for preclinical identification of patients eligible for safe redirection. As EMS is intended for high-acuity emergencies, such patients could potentially also benefit from options like telemedicine care at home or alternative transportation.

Trial registration: German Clinical Trials Register (DRKS00023480); date: 27/11/2020.