Rural paramedics’ choice of destination hospital for paediatric patients

Paramedics face a variety of decisions with every patient they attend: the nature of the patient’s condition, the course of management, which hospital to transport the patient to.  Not every rural hospital has the same capacity and capabilities for paediatric patients. Although there are numerous guidelines and hospital classifications for adult patients, very little exists for paediatric patients. Hospital choice is of particular importance in rural areas due to transport time and distance; a less than optimal choice of hospital may result in a subsequent transfer that could have been avoided.

There have been various studies examining paramedic decision-making in terms of patient management for adult patients, but little in the area of destination hospital, particularly for paediatric patients.  Centralization of paediatric hospital care has been shown to improve patient outcome in some circumstances and may cause unnecessary stress in others, but how are paramedics in rural Victoria determining which is the most appropriate destination hospital for their paediatric patients?  Determining current decision-making processes will allow for the development of guidelines to assist paramedics in their choice of destination hospital for paediatric patients, and improve patient care.

This project aims to determine the current characteristics of paediatric patients and the destination hospital chosen for these patients transported by emergency ambulance in rural Victoria, and the decision-making processes employed by paramedics when arriving at their choice of hospital.  The questions this project aims to answer are:

  • What factors influence rural paramedics’ choice of destination hospital for paediatric patients:
  • What is the impact of patient presentation,
  • What is the impact of paramedic skill set,
  • What is the impact of the time of day,
  • What is the impact of hospital clinical capabilities and capacity,
  • What is the impact of the availability of other ambulance resources, and
  • What other factors influence the choice of destination hospital,
  • What is the extent and characteristics of current hospital bypass for paediatric patients,
  • What is the extent of paediatric secondary transfer in rural Victoria, and
  • What evidence is there that hospital choice affects paediatric patient outcomes?

In order to answer these questions, the project will involve three phases requiring a mix of both quantitative and qualitative research to be undertaken.

Phase One will determine current paediatric patient characteristics and their destination hospitals, and the extent of paediatric secondary transfer in rural Victoria.  Data will be obtained from Ambulance Victoria from the Victorian Ambulance Clinical Information Service (VACIS) and Computer Aided Dispatch (CAD) databases for paediatric patients transported from the Barwon South West region since April 1, 2008.  Information to be collected from VACIS and CAD will include patient age, destination, case nature, and final assessment.

To examine the factors that influence paramedics’ decision-making for paediatric patients (Phase Two), a focus group will be held in the South Coast, Gippsland region so as not to influence future decision-making in the data collection region.  This region has been chosen as it has similar characteristics (number, size and distribution of hospitals) to the Barwon South West region, and, as the paramedics from both regions have received the same training, decision-making processes would be expected to be similar in both regions.   This group will involve between eight and 12 paramedics, have a series of indicative questions to help initiate discussion, and will be audio-taped for later transcription.

Results from the Phase Two session will be used to formulate a series of interview scenarios that will be utilised in Phase Three.  The aim of this phase is to test the factors that have been identified in the focus group.  These interviews will involve a series of escalating scenarios.  Paramedics will be recruited from the Barwon South West region.  Each paramedic will be given a hypothetical case which will worsen over three stages, using the factors identified in Phase Two.  It is hoped that the results of this research will aid in paramedic guideline development to improve the choice of destination hospital for paediatric patients.