The increasing number of emergency calls and especially non-urgent calls [
3,
5] have made it challenging yet crucial for paramedics to assess the care needs of patient and make the proper choices according to the patient’s condition. If the pathophysiology of the disease remains unclear or the emergency situation demands a fast evacuation and transportation, the patient must be treated based on their symptoms and relieving them [
6‐
8]. However, the significance of an accurate preliminary diagnosis is emphasized when long distances are involved and in areas of dispersed settlement when it becomes essential for ensuring effective treatment and definitive care.
The accuracy of preliminary diagnoses
The aim of this study was to evaluate the accuracy of the preliminary diagnoses made by paramedics and the variables related to the diagnosis. The overall accuracy of the preliminary diagnoses made by the paramedics was 70%, which has also been reported in previous studies [
12]. This can be considered satisfactory allowing for the limited information, lack of diagnostics in the field and the challenging environment, even though the majority of the cases in our study were non urgent. Despite the lack of the time pressure, the paramedics are challenged by a large variety of complex cases including aged patients with multiple comorbidities and general weakness.
The highest level of accuracy, that of mental health and drug related emergencies and soft-tissue injuries, seems obvious due to the nature of these situations. Nevertheless, in one other study [
12] the levels of accuracy (58, 75% respectively) in these categories were remarkably different. The high level of recognizing cerebral strokes (81%) is extremely important because of the survival and recovery of the brain and functioning of the patient [
19] and the result is in agreement with other studies [
12], although, in this present study, the categories were more specific including only ischemic and hemorrhagic strokes and transient ischemic attacks. The overall accuracy of the preliminary diagnoses in cardiovascular diseases was satisfactory, however it must be emphasized that the recognition of cardiac arrhythmias was on a very high level, suggesting that the paramedics can consistently interpret electrocardiogram in this area. The effect of prehospital delays in survival in acute illnesses e.g. ST-segment elevation myocardial infarction [
14,
20] patients is unquestionable, which makes it crucial for paramedics to interpret electrocardiograms.
The level of accuracy was lowest in respiratory emergencies (57%) and infectious diseases (31%). The result in respiratory emergencies is even lower than reported in other studies in which the level was 65% [
10,
12]. The unsatisfactory level of accuracy in preliminary diagnoses may be a consequence of the complicated pathophysiology of respiratory diseases [
10‐
12] or suggest an inadequate examining of the patient. Identifying respiratory diseases and understanding the anatomy and pathophysiology of respiratory system is an essential part of paramedic competencies due to the fact that emergencies related to respiratory diseases or shortness of breath are one of the most common emergency calls [
10,
11].
The recognition of infectious diseases seemed lower compared to other preliminary diagnosis areas according to our results. The preliminary diagnosis of influenza proved to be especially difficult but that could partly be explained by the fact that there was no code for influenza in the ICPC-2 classification list, although the participants were instructed to state the preliminary diagnosis with their own words if not found in ICPC-2 classifications. Moreover, urinary infections were not recognized either on a satisfactory level. Although common in the geriatric population, the symptoms of urinary infections may remain very unclear, and it can even be argued, that not all diagnoses of urinary infection made in the ED are necessarily accurate.
The most commonly used preliminary diagnoses that were used instead of a specific infection code were fever and general weakness, which could be considered reasonable options in this context. Ultimately, the most important aspect concerning infections is undoubtedly the early recognition of severe infections, especially sepsis, because early recognition improves the patient’s outcome [
13,
21]. In these situations an accurate preliminary diagnosis must be determined. However, in our study, there were only a few cases of severe infections and no conclusions can be made concerning them. In addition, a more precise preliminary diagnosis might be needed, for example, when considering transportation decisions or the patients need to be isolated. For more accurate diagnostics, adding the possibility of point of care testing for paramedics [
4] might be one solution.
Education matters
The relationship between the bachelor degree in pre-hospital emergency nursing and the accuracy of the preliminary diagnosis was clear. The relationship between specific emergency nursing education and paramedic competencies in general has been reported in previous studies [
6,
10,
15,
22]. In Finland, the bachelor degree in pre-hospital emergency nursing takes 4 years and concentrates on pre-hospital emergencies, however, the students are also registered as nurses. A bachelor’s degree in nursing does not give readiness for working in a pre-hospital setting but, as reported in the study results, the specialization courses in pre-hospital nursing increases the capability of a paramedic’s clinical decision making and the accuracy of their preliminary diagnoses.
The paramedics were asked to provide a self-assessment value to the preliminary diagnosis they determined. Overall, the paramedics were confident with the preliminary diagnoses they made. The results suggest that in cases of a low self-assessment value the actual physician’s diagnosis was also likely to be undefined or related to a general weakening without a specific diagnosis. Furthermore, the paramedics with a work experience of less than 5 years were less confident about their preliminary diagnoses than their more experienced colleagues, nevertheless, the amount of work experience was not statistically significant as regards the accuracy of preliminary diagnoses. The higher self-assessment values may be explained by professional growth and increased self-confidence and it is important to give enough support to novice paramedics in order to reinforce their clinical decision-making.
Limitations
The main limitation of this study and generalization of the results is the sample size and the possibility of bias. The number of patient cases included in this study was 378 and all the cases that meet the inclusion criteria were recruited. The size of the sample was sufficient for the patient cases to be divided in statistically representative categories by the type of the emergency or illness and the cases also represent the national distribution of EMS’s transportation codes. We were not, however, able to make prior power calculations since there were only estimations available for the numbers of patients transported by ambulances to the emergency department. However, based on the estimations we achieved a response rate of approximately 40%.
The data was collected in the area of one hospital district during 1 month in the spring, and this also reduces the generalization of the results as more of a certain type of illnesses e.g. influenzas may occur at this time of year. Furthermore, the sample covers well the variety of different cases, except pediatrics or incidents of labor which were not included in this study due to the fact that they are not treated in the emergency department.
Second, the questionnaire used in this study was self-developed since there was no suitable questionnaires available. The questionnaire was not pilot-tested but there was an expert panel and two rounds of assessment to ensure the validity and clarity of the instrument. The questionnaire was designed to be semi-structured to maintain the homogeneity of the answers.
The third limitation of this study is the use of the diagnosis made by physician’s as a reference standard to determine the accuracy of the paramedic’s preliminary diagnosis. A physician’s diagnosis may not always be completely accurate and there is a possibility that the time between the preliminary and actual diagnosis and treatment given in the prehospital care may affect the patient’s condition and symptoms, thus resulting in a different diagnosis. We wanted to use the diagnosis at the patient’s discharge from ED and not the admission diagnosis due to the fact that the discharge diagnosis differs from the admittance diagnosis in every ninth patient [
23]. Furthermore, the preliminary diagnoses were made by using the ICPC-2 classification, whereas the ED discharge diagnoses were made by using the ICD-10 classification. This may have affected the agreement analysis of the preliminary diagnosis and physician’s diagnosis since the ICPC-2 classification codes included more general descriptions of symptoms.