Consensus on paramedic clinical decisions during high-acuity emergency calls: results of a Canadian Delphi study.

OBJECTIVES: To establish consensus on the most important clinical decisions paramedics make during high-acuity emergency calls and to visualize these decisions on a process map of an emergency call. A secondary objective was to measure agreement among paramedics and medical director panel members.
METHODS: A multiround online survey of Canadian paramedics and medical directors. In round 1, participants listed important clinical decisions. In round 2, participants scored each decision in terms of its importance for patient outcome and safety. In rounds 3 and 4, participants could revise their scores. Consensus was defined a priori: 80% or more agreement that a decision was important or extremely important. The included decisions were plotted on a process map of a typical emergency call.
RESULTS: The panel response rates were as follows: round 1, 96%; round 2, 92%; round 3, 83%; and round 4, 96%. Consensus was reached on 42 decisions, grouped into six categories: airway management (n  =  13); assessment (n  =  3); cardiac management (n  =  7); drug administration (n  =  9); scene management (n  =  4); and general treatment (n  =  6). The on-scene treatment phase of the process map was found to have the highest decision density. Paramedics and medical directors differed in their scoring in 5 of 42 decisions (p < 0.05 or less).
CONCLUSION: Consensus was reached among paramedics and medical directors on 42 decisions important for clinical outcome and patient safety. These decisions were visualized on a process map of an emergency call to learn more about where decision density exists during a typical call.