Skip to main content Accessibility help

Paramedic Checklists do not Accurately Identify Post-ictal or Hypoglycaemic Patients Suitable for Discharge at the Scene

  • Hideo Tohira (a1), Daniel Fatovich (a2) (a3), Teresa A. Williams (a1) (a4) (a5) (a6), Alexandra Bremner (a7), Glenn Arendts (a4) (a6), Ian R. Rogers (a8) (a9), Antonio Celenza (a4) (a10), David Mountain (a4) (a10), Peter Cameron (a11), Peter Sprivulis (a4) (a12), Tony Ahern (a5) and Judith Finn (a1) (a4) (a5) (a11)...



The objective of this study was to assess the accuracy and safety of two pre-defined checklists to identify prehospital post-ictal or hypoglycemic patients who could be discharged at the scene.


A retrospective cohort study of lower acuity, adult patients attended by paramedics in 2013, and who were either post-ictal or hypoglycemic, was conducted. Two self-care pathway assessment checklists (one each for post-ictal and hypoglycemia) designed as clinical decision tools for paramedics to identify patients suitable for discharge at the scene were used. The intention of the checklists was to provide paramedics with justification to not transport a patient if all checklist criteria were met. Actual patient destination (emergency department [ED] or discharge at the scene) and subsequent events (eg, ambulance requests) were compared between patients who did and did not fulfill the checklists. The performance of the checklists against the destination determined by paramedics was also assessed.


Totals of 629 post-ictal and 609 hypoglycemic patients were identified. Of these, 91 (14.5%) and 37 (6.1%) patients fulfilled the respective checklist. Among those who fulfilled the checklist, 25 (27.5%) post-ictal and 18 (48.6%) hypoglycemic patients were discharged at the scene, and 21 (23.1%) and seven (18.9%) were admitted to hospital after ED assessment. Amongst post-ictal patients, those fulfilling the checklist had more subsequent ambulance requests (P=.01) and ED attendances with seizure-related conditions (P=.04) within three days than those who did not. Amongst hypoglycemic patients, there were no significant differences in subsequent events between those who did and did not meet the criteria. Paramedics discharged five times more hypoglycemic patients at the scene than the checklist predicted with no significant differences in the rate of subsequent events. Four deaths (0.66%) occurred within seven days in the hypoglycemic cohort, and none of them were attributed directly to hypoglycemia.


The checklists did not accurately identify patients suitable for discharge at the scene within the Emergency Medical Service. Patients who fulfilled the post-ictal checklist made more subsequent health care service requests within three days than those who did not. Both checklists showed similar occurrence of subsequent events to paramedics’ decision, but the hypoglycemia checklist identified fewer patients who could be discharged at the scene than paramedics actually discharged. Reliance on these checklists may increase transportations to ED and delay initiation of appropriate treatment at a hospital.

Tohira H , Fatovich D , Williams TA , Bremner A , Arendts G , Rogers IR , Celenza A , Mountain D , Cameron P , Sprivulis P , Ahern T , Finn J . Paramedic Checklists do not Accurately Identify Post-ictal or Hypoglycaemic Patients Suitable for Discharge at the Scene. Prehosp Disaster Med. 2016;31(3):282293.


Corresponding author

Correspondence: Hideo Tohira, MD, MPH, MEng, PhD, FJAAM Prehospital, Resuscitation, and Emergency Care Research Unit School of Nursing, Midwifery, and Paramedicine Curtin University GPO Box U1987 Perth, Western Australia 6845 Australia E-mail:


Hide All
1. Lowthian, JA, Cameron, PA, Stoelwinder, JU, et al. Increasing utilisation of emergency ambulances. Aust Health Rev. 2011;35(1):63-69.
2. Australian Institute of Health and Welfare (AIHW). “Australian hospital statistics 2012-2013: emergency department care and elective surgery waiting times.” In: Health Services Series No 52 Cat No HSE 142. Canberra, Australia; 2013.
3. St John Ambulance Western Australia. 2012-13 Annunal Report. Accessed July 16, 2014.
4. Australian Bureau of Statistics. Regional Population Growth, Australia, 2012-13. Accessed April 3, 2014.
5. Malone, G. Extended Care Paramedic: Extended Care Paramedic: referring low acuity patients to alternative care. extended%20care%20paramedic.pdf. Accessed May 22, 2014.
7. Modernisation Agency, Department of Health. The Emergency Care Practitioner Report, 2004. London, UK; 2004.
8. Tohira, H, Williams, TA, Jacobs, I, Bremner, A, Finn, J. The impact of new prehospital practitioners on ambulance transportation to the emergency department: a systematic review and meta-analysis. Emerg Med J. 2013;31(e1):e88-e94.
9. Newton, M, Tunn, E, Moses, I, Ratcliffe, D, Mackway-Jones, K. Clinical navigation for beginners: the clinical utility and safety of the Paramedic Pathfinder. Emergency Medicine Journal. 2014;31(e1):e29-e34.
10. Newton, M. Personal communication. February 17, 2014.
11. Western Australian Department of Health. National Emergency Access Target Quaterly Reports. Accessed July 8, 2104.
12. Jurczyk, P, Lu, JJ, Xiong, L, Cragan, JD, Correa, A. Fine-grained record integration and linkage tool. Birth Defects Res A Clin Mol Teratol. 2008;82(11):822-829.
13. St John Ambulance Western Australia. 7.1A Hypoglycaemia, Clinical Practice Guidelines Paramedics, 2012. Western Australia; 2012.
14. Sprivulis, P, Grainger, S, Nagree, Y. Ambulance diversion is not associated with low acuity patients attending Perth metropolitan emergency departments. Emergency Medicine Australasia. 2005;17(1):11-15.
15. Spaite, DW, Valenzuela, TD, Meislin, HW, Criss, EA, Ross, J. A prospective evaluation of the impact of initial Glasgow Coma Score on prehospital treatment and transport of seizure patients. Prehosp Disaster Med. 1992;7(2):127-132.
16. Australian Consortium for Classification Development. ICD-10-AM/ACHI/ACS EIGHTH EDITION. Accessed August 20, 2014.
17. Finn, JC, Fatovich, DM, Arendts, G, et al. Evidence-based paramedic models of care to reduce unnecessary emergency department attendance -- feasibility and safety. BMC Emerg Med. 2013;13(1):13.
18. Fitzpatrick, D, Duncan, EAS. Improving post-hypoglycaemic patient safety in the prehospital environment: a systematic review. Emergency Medicine Journal. 2009;26(7):472-478.
19. Roberts, K, Smith, A. Outcome of diabetic patients treated in the prehospital arena after a hypoglycaemic episode, and an exploration of treat and release protocols: a review of the literature. Emergency Medicine Journal. 2003;20(3):274-276.
20. Joint Royal Colleges Ambulance Liaison Committee. “Convulsions in Adults.” In: Fisher JD, Brown SN, Cooke MW, (eds). UK Ambulance Service Clinical Practice Guidelines 2006. London, UK; 2006.
21. Epilepsy Foundation. Seizure recognition and first aid. docs/Seizure-Recognition-and-First-Aid.pdf. Accessed July 16, 2014.
22. Joint Royal Colleges Ambulance Liaison Committee. “Glycaemic Emergencies in Adults.” In: Fisher JD, Brown SN, Cooke MW, (eds). UK Ambulance Service Clinical Practice Guidelines 2006. London, UK; 2006.
23. Cain, E, Ackroyd-Stolarz, S, Alexiadis, P, Murray, D. Prehospital hypoglycemia: the safety of not transporting treated patients. Prehosp Emerg Care. 2003;7(4):458-465.
24. Carter, AJE, Keane, PS, Dreyer, JF. Transport refusal by hypoglycemic patients after on-scene intravenous dextrose. Academic Emergency Medicine. 2002;9(8):855-857.
25. Lerner, EB, Billittier, Iv AJ, Lance, DR, Janicke, DM, Teuscher, JA. Can paramedics safely treat and discharge hypoglycemic patients in the field? American Journal of Emergency Medicine. 2003;21(2):115-120.
26. Mechem, CC, Kreshak, AA, Barger, J, Shofer, FS. The short-term outcome of hypoglycemic diabetic patients who refuse ambulance transport after out-of-hospital therapy. Academic Emergency Medicine. 1998;5(8):768-772.
27. Socransky, SJ, Pirrallo, RG, Rubin, JM. Out-of-hospital treatment of hypoglycemia: refusal of transport and patient outcome. Academic Emergency Medicine. 1998;5(11):1080-1085.
28. Anderson, S, Høgskilde, PD, Wetterslev, J, et al. Appropriateness of leaving Emergency Medical Service treated hypoglycemic patients at home: a retrospective study. Acta Anaesthesiologica Scandinavica. 2002;46(4):464-468.



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed