Selecting cases for feedback to pre-hospital clinicians - a pilot study

Background. There are currently limited avenues for routine feedback from hospitals to pre-hospital clinicians aimed at improvements in clinical practice. Objective. The aim of this study was to pilot a method for selectively identifying cases where there was a clinically significant difference between the pre-hospital and in-hospital diagnoses that could have led to a difference in pre-hospital patient care. Methods. This was a single-centre retrospective study involving cases randomly selected through informatics extraction of final diagnoses at hospital discharge. Additional data on demographics, triage and diagnoses were extracted by explicit chart review. Blinded groups of pre-hospital and in-hospital clinicians assessed data to detect clinically significant differences between pre-hospital and in-hospital diagnoses. Results. Most (96.9%) patients were of Australasian Triage Scale category 1-3 and in-hospital mortality rate was 32.9%. Of 353 cases, 32 (9.1%; 95% CI: 6.1-12.1) were determined by both groups of clinical assessors to have a clinically significant difference between the pre-hospital and final in-hospital diagnoses, with moderate inter-rater reliability (kappa score 0.6, 95% CI: 0.5-0.7). Conclusion. A modest proportion of cases demonstrated discordance between the pre-hospital and in-hospital diagnoses. Selective case identification and feedback to pre-hospital services using a combination of informatics extraction and clinician consensus approach can be used to promote ongoing improvements to pre-hospital patient care.