ONLINE MEDICAL CONTROL VERSUS PROTOCOL-BASED PREHOSPITAL CARE

Study objective: To compare on-scene time, appropriateness of therapy, and accuracy of paramedic clinical assessments when prehospital care was provided with the use of on-line medical control (OLMC) by EMS-cer tified nurses from a single base station or by paramedics using chief complaint-based protocols. Methods: We assembled a prospective before- and-after series to compare OLMC (phase 1) and protocol (phase 2) care rendered by all paramedics in a single urban municipality using a sin gle base station. The subjects were consecutively enrolled patients wh o met protocol inclusion criteria and presented with altered level of consciousness, nontraumatic chest pain, or shortness of breath. For bo th phases, EMS and corresponding ED records were compiled, ail referen ces identifying phase were removed. After establishing interrater reli ability, we randomly assigned charts to one of two reviewers for scori ng. Complaint-specific scoring elements included on-scene time, assess ments performed, presence or absence of indications for common treatme nts, treatments given, paramedic diagnosis, and emergency physician di agnosis. The percentages of inappropriate treatment decisions and para medic diagnostic accuracy (versus that of the receiving emergency phys ician) were calculated. Results: Phase 1 comprised 287 patients, phase 2 294. Interrater reliability between the two scorers was high. Of 2, 190 elements scored jointly, the raters agreed in 97%, with kappa-valu es ranging from .6 to 1.0. On-scene time was 1 minute shorter during p hase 2 (95% confidence interval [CI] for difference in median time, 0 to 2 minutes, P<.03). From phase 1 to phase 2 (relative risk [RR], 1.5 ; 95% CI, 1.0 to 2.1), inappropriate treatment decisions decreased fro m 7.4% to 5.1%. The percentage of cases in which paramedics and physic ians were in complete diagnostic agreement was high (77% to 78%) and d id not change across phases. Conclusion: The use of protocols resulted in smalt improvements in both on-scene time and the appropriateness o f therapeutic decisions, without a change in agreement between paramed ic and physician. Protocol care for these three chief complaints is cl inically safe and, by reducing training and staffing considerations, m ay offer a cost-effective alternative to OLMC.