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Comparing performance and impact of first responders on outcome in prehospital emergency medicine in Switzerland

Urwyler N, Theiler L, Schönhofer J, Kämpfen B, Stave C, Greif R

University Department of Anesthesiology and Pain Therapy, University Hospital of Bern, Bern, Switzerland. Department of Pathology, Stanford University School of Medicine, Stanford, California, USA. Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida, USA. Department of Anesthesiology, Spitalzentrum Oberwallis, Visp, Switzerland. Lane Medical Library & Knowledge Management Center, Stanford University School of Medicine, Stanford, California, USA.

Background: Contradictory results are reported in the medical literature on effectiveness
of first responders in prehospital emergency medicine. In this study we evaluated
responders performance and impact on outcome.
Methods: In a retrospective cohort study we evaluated the accuracy of diagnoses by
emergency physicians, paramedics, and general practitioners. We compared the
diagnosis made in the prehospital emergency situation to the diagnosis at discharge
from the hospital. Primary outcome was the impact of accuracy of diagnosis on
mortality. Secondary outcomes were, 1) time on scene, 2) duration of hospitalization.
The influence of clinical experience and postgraduate training on accuracy of diagnoses
was of particular interest.
Results: We evaluated 1241 diagnoses. Patients admitted with a wrong or missing
diagnosis showed an increased mortality risk (P = 0.04, OR 1.9; CI 1.04-3.34). The time
spent on scene and the duration of his/her hospital stay was shorter if the diagnosis was
correct. Emergency physicians, paramedics and general practitioners made diagnoses
with comparable accuracy (P = 0.139) but emergency physicians showed a significant
increase in accuracy correlated to their years of clinical experience (P < 0.001). After
postgraduate year six they reached a level of diagnostic accuracy > 90%. This effect
could not be shown for paramedics or general practitioners.
Conclusion: A correct diagnosis in prehospital emergency medicine reduces mortality
and length of hospital stay. Trained emergency physicians make diagnoses with a high
degree of accuracy. Therefore, they should be increasingly integrated into prehospital
emergency medicine, particularly for more severe cases.

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