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Research paper|Articles in Press

Association between initial presenting level of consciousness and patient acuity – A potential application for secondary triage in emergency ambulance calls

  • Jason Belcher
    Correspondence
    Correspondence to: Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Curtin University, GPO Box U1987, Perth 6845, Western Australia, Australia.
    Affiliations
    Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Curtin University, Perth, Western Australia, Australia

    St John Western Australia, Australia
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  • Judith Finn
    Affiliations
    Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Curtin University, Perth, Western Australia, Australia

    St John Western Australia, Australia
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  • Austin Whiteside
    Affiliations
    Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Curtin University, Perth, Western Australia, Australia

    St John Western Australia, Australia
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  • Stephen Ball
    Affiliations
    Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Curtin University, Perth, Western Australia, Australia

    St John Western Australia, Australia
    Search for articles by this author
Published:December 07, 2022DOI:https://doi.org/10.1016/j.auec.2022.11.002

      Abstract

      Introduction

      Conscious state assessment is important for the triage of emergency patients. In this study, we measured the association between ambulance patients’ conscious state and high versus lower acuity, with a view to informing telephone triage assessment of conscious state.

      Methods

      Data were analysed from one year of emergency ambulance incidents in Perth, Western Australia. Patient conscious state at the time of paramedic arrival was compared to acuity (based on paramedic assessment and management). We determined the proportion of high-acuity patients across six levels of consciousness (Alert, Confused, Drowsy, Voice Response, Pain Response, Unresponsive) overall, and within individual protocols of the Medical Priority Dispatch System (MPDS).

      Results

      The proportion of high acuity patients increased with each step across the consciousness scale. Applying conscious state as a binary predictor of acuity, the largest increases occurred moving the threshold from Alert to Confused (22.0–48.6% high acuity) and Drowsy to Voice Response (61.9–89.5% high acuity). The Area Under the Curve (AUC) of the Receiver Operating Characteristic was 0.65. Within individual protocols, the highest AUC was in Cardiac Arrest (0.89), Overdose/Poisoning (0.81), Unknown Problem (0.76), Diabetic Problem, (0.74) and Convulsions/Fitting (0.73); and lowest in Heart problems (0.55), Abdominal Pain (0.55), Breathing Problems (0.55), Back Pain (0.53), and Chest Pain (0.52).

      Conclusion

      Based on these proportions of high acuity patients, it is reasonable to consider patients with any altered conscious state a high priority. The value of conscious state assessment for predicting acuity varies markedly between MPDS protocols. These findings could help inform secondary triage of ambulance patients during the emergency call.

      Keywords

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      References

        • Andrew E.
        • Jones C.
        • Stephenson M.
        • Walker T.
        • Bernard S.
        • Cameron P.
        • et al.
        Aligning ambulance dispatch priority to patient acuity: a methodology.
        Emerg Med Austral. 2019; 31: 405-410https://doi.org/10.1111/1742-6723.13181
        • Bohm K.
        • Kurland L.
        The accuracy of medical dispatch - a systematic review.
        Scand J Trauma Resusc Emerg Med. 2018; 26: 94-94https://doi.org/10.1186/s13049-018-0528-8
        • Eastwood K.
        • Morgans A.
        • Smith K.
        • Hodgkinson A.
        • Becker G.
        • Stoelwinder J.
        A novel approach for managing the growing demand for ambulance services by low-acuity patients.
        Aust Health Rev. 2016; 40: 378-384https://doi.org/10.1071/ah15134
        • Yancey A.
        • Clawson J.
        EMD position paper resource document.
        Ann Emerg Dispatch Response. 2014; 2
        • Ball S.J.
        • Williams T.A.
        • Smith K.
        • Cameron P.
        • Fatovich D.
        • O'Halloran K.L.
        • et al.
        Association between ambulance dispatch priority and patient condition.
        Emerg Med Austral. 2016; 28: 716-724
        • Belcher J.
        • Finn J.
        • Whiteside A.
        • Ball S.
        ‘Is the patient completely alert?’ – accuracy of emergency medical dispatcher determination of patient conscious state.
        Australas J Paramed. 2021; : 18https://doi.org/10.33151/ajp.18.858
        • Feldman M.J.
        • Verbeek P.R.
        • Lyons D.G.
        • Chad S.J.
        • Craig A.M.
        • Schwartz B.
        Comparison of the medical priority dispatch system to an out-of-hospital patient acuity score.
        Acad Emerg Med. 2006; 13: 954-960https://doi.org/10.1197/j.aem.2006.04.018
        • Hodell E.M.
        • Sporer K.A.
        • Brown J.F.
        Which emergency medical dispatch codes predict high prehospital nontransport rates in an urban community.
        Prehosp Emerg Care. 2014; 18: 28-34https://doi.org/10.3109/10903127.2013.825349
        • Hoikka M.
        • Länkimäki S.
        • Silfvast T.
        • Ala-Kokko T.I.
        Medical priority dispatch codes—comparison with National Early Warning Score.
        Scand J Trauma Resusc Emerg Med. 2016; 24: 142https://doi.org/10.1186/s13049-016-0336-y
        • Neely K.W.
        • Eldurkar J.A.
        • Drake M.E.R.
        Do emergency medical services dispatch nature and severity codes agree with paramedic field findings?.
        Acad Emerg Med. 2000; 7: 174-180
        • Sporer K.A.
        • Craig A.M.
        • Johnson N.J.
        • Yeh C.C.
        Does emergency medical dispatch priority predict delphi process-derived levels of prehospital intervention?.
        Prehosp Disaster Med. 2010; 25: 309-317
        • Sporer K.A.
        • Youngblood G.M.
        • Rodriguez R.M.
        The ability of emergency medical dispatch codes of medical complaints to predict ALS prehospital interventions.
        Prehosp Emerg Care. 2007; 11: 192-198https://doi.org/10.1080/10903120701205984
        • Mosley I.
        • Morphet J.
        • Innes K.
        • Braitberg G.
        Triage assessments and the activation of rapid care protocols for acute stroke patients.
        Australas Emerg Nurs J. 2013; 16: 4-9https://doi.org/10.1016/j.aenj.2012.12.002
      1. American College of Surgeons, Committee on Trauma. Advanced Trauma Life Support: Student Course Manual. Chicago, IL; 2018.

        • Umpierrez G.
        • Korytkowski M.
        Diabetic emergencies - ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia.
        Nat Rev Endocrinol. 2016; 12: 222-232https://doi.org/10.1038/nrendo.2016.15
        • Kelly C.
        • Upex A.
        • Bateman D.
        Comparison of consciousness level assessment in the poisoned patient using the alert/verbal/painful/unresponsive scale and the Glasgow Coma Scale.
        Ann Emerg Med. 2004; 44: 108-113
      2. Australian Government Department of Health and Ageing. Emergency Triage Education Kit. Canberra, Australia: Australian Government Department of Health and Ageing; 2009 [cited 7 May 2022]. Available from: 〈https://acem.org.au/getmedia/c9ba86b7-c2ba-4701–9b4f-86a12ab91152/Triage-Education-Kit.aspx〉.

      3. Advanced Life Support Group. Manchester Triage [Internet]. 2017 [cited 7 May 2022]. Available from: 〈https://www.triagenet.net/〉.

      4. International Academy of Emergency Medical Dispatch. Medical Priority Dispatch System QA Guide v13. Salt Lake City: Priority Dispatch Corporation; 2016.

      5. Australian Bureau of Statistics. Regional Population Growth, Australia, 2017–18 Canberra:2019.

        • McNarry A.F.
        • Goldhill D.R.
        Simple bedside assessment of level of consciousness: comparison of two simple assessment scales with the Glasgow Coma scale.
        Anaesthesia. 2004; 59: 34-37https://doi.org/10.1111/j.1365-2044.2004.03526.x
        • Teasdale G.
        • Jennett B.
        Assessment of coma and impaired consciousness. A practical scale.
        Lancet. 1974; 2: 81-84
        • Muschelli J.
        ROC and AUC with a binary predictor: a potentially misleading metric.
        J Classif. 2020; 37: 696-708https://doi.org/10.1007/s00357-019-09345-1
      6. Royal College of Physicians. National Early Warning Score (NEWS) 2; 2017. Available from: 〈https://www.rcplondon.ac.uk/file/8636/download〉.

        • Martín-Rodríguez F.
        • Sanz-García A.
        • Ortega G.J.
        • Delgado Benito J.F.
        • Aparicio Obregon S.
        • Martínez Fernández F.T.
        • et al.
        Tracking the national early warning score 2 from prehospital care to the emergency department: a prospective, ambulance-based, observational study.
        Prehosp Emerg Care. 2021; : 1-9https://doi.org/10.1080/10903127.2021.2011995
        • Andrew E.
        • Nehme Z.
        • Cameron P.
        • Smith K.
        Drivers of increasing emergency ambulance demand.
        Prehosp Emerg Care. 2020; 24: 385https://doi.org/10.1080/10903127.2019.1635670
      7. Tasmanian Government Department of Health. Secondary Triage [Internet]. 2021 [cited 20 Feb 2022]. Available from: 〈https://www.health.tas.gov.au/hospitals/ambulance/ambulance-services-tasmanians/secondary-triage〉.

      8. SA Ambulance Service. Clinical Telephone Assessment [Internet]. 2021 [cited 20 Feb 2022]. Available from: 〈https://saambulance.sa.gov.au/what-we-do/clinical-telephone-assessment/〉.

      9. St John New Zealand. How we deal with non-urgent 111 calls [Internet]. 2021 [cited 20 Feb 2022]. Available from: 〈https://stjohn.org.nz/what-we-do/st-john-ambulance-services/clinical-hub-auckland/〉.

      10. Global Resuscitation Alliance. Telephone CPR (T-CPR) Program Recommendations and Performance Measures [Internet]. 2019. Available from: 〈https://www.globalresuscitationalliance.org/wp-content/uploads/2019/12/AHA_TCPR.pdf〉.