Effects of on-line medical control in the prehospital treatment of atraumatic illness

Objective. On-line medical control (OLMC) is costly and time-consuming, yet little is known about the direct effect of OLMC on the quality of care provided. The objective of this study was to analyze the effect of OLMC on adherence to protocol and quality of care provided. Methods. Retrospective review of trip sheets completed by out-of-hospital personnel in an urban/suburban/rural emergency medical services system with a volume of 144,000 calls/year; approximately 15,000/year are ALS calls. Two levels of provider - paramedics and critical care technicians (CCTs) - work under single standard protocols and a single medical director. Prehospital trip sheets of 774 sequential patients with atraumatic illnesses for whom an ALS crew was dispatched were re-viewed for adherence to standard protocol and for appropriateness of deviations from protocol, with and without the use of OLMC. Results. Adherence to protocols occurred in 78.3% of all patient encounters. OLMC was utilized in 61.5% of patient encounters. The CCTs were more likely to utilize OLMC than were the paramedics, 72% vs 56% (p < 0.001). There was a trend towards paramedics' adhering to protocol more frequently than did the CCTs, 80% vs 74%, which did not reach statistical significance (p = 0.057). Adherence to protocol was significantly less likely to occur with OLMC than without OLMC, regardless of the training of the provider, 72.8% vs 86.5% (95% CI 8.1-19.3%, p < 0.001). Adherence to protocol was significantly less likely to occur as the acuity of the patient's condition increased (p < 0.001). Nonadherence was more likely to be judged appropriate rather than inappropriate (p < 0.05) as the acuity level increased. When there was nonadherence to protocol, the use of OLMC did not improve the care provided. Conclusions. OLMC does not improve adherence to protocol or the quality of care provided in the treatment of atraumatic illness.