The Doctor Is In? Patient Acuity and Its Influence on Paramedic Utilization in the Emergency Department

Introduction: In recent decades hospital emergency departments have increasingly diverged from the traditional medical provider model. Once the sole province of physicians, patients are now attended to by physician assistants, nurse practitioners, and even EMT/paramedics. Given their unique skill set, EMT/paramedics have the capacity to make significant contributions to patient care in the emergency department setting. However, the question remains: Which patients are these providers treating? 

Objective: To explore provider assignments in the emergency department given differing patient acuities. 

Methods: The analysis examined a nationally representative sample of deidentified emergency department patient encounters from 2011 through 2016, gathered from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Triage (acuity) levels followed the standard five-point Emergency Severity Index scale. Multivariate logistic regression analyses were adjusted for the weighted data set and controlled for potential confounders. Likelihoods of medical practitioner consultation were analyzed by presenting acuity level. 

Results: Drawing from the NHAMCS data set, 69,820 emergency department records were analyzed, weighted to represent 350.7 million estimated patient encounters. Patients triaged as “immediate” were 14 times more likely to be cared for by an EMT/paramedic (OR 14.63, p<0.000). Patients triaged as “emergent” were nearly five times more likely to be cared for by an EMT/paramedic (OR 4.80, p<0.000). Patients triaged as “urgent” were also more likely to be cared for by an EMT/paramedic (OR 2.59, p<0.000). Patients attended to by an EMT/paramedic spent more time in the emergency department (B=24.28, p<0.000) and received more total diagnostic services (B=1.55, p<0.000). Findings show that higher-acuity patients were increasingly more likely to see a physician (attending, consultant, or resident) and less likely to see a nurse practitioner or physician assistant. 

Conclusion: In the emergency department, hospitals appear to be utilizing EMT/paramedics for higher-acuity patients. This application of provider expertise profits from the EMT/paramedic’s training and general comfort in a fast-paced emergent setting. With the relatively recent addition of EMT/paramedics into emergency departments, there has been a broad fear of relegation to “minor care” or “fast-track” areas (i.e., low-acuity patient populations). This study, however, suggests the opposite: EMT/paramedics are being reserved for the sickest of patients.