• C J Holliman, R C Wuerz, G Vazquez-de Miguel, and S A Meador.
• Center for Emergency Medicine, Milton S. Hershey Medical Center, Pennsylvania State University, Hershey 17033, USA.
• Prehosp Disaster Med. 1994 Oct 1; 9 (4): 202-9.

ObjectiveThe aim of this study was to compare the patient care measures provided by paramedics according to standing orders versus measures ordered by direct [on-line] medical command in order to determine the types and frequency of medical command orders.DesignProspective identification of patient care measures done as part of a prehospital quality assurance program.SettingAn urban paramedic service in the northeast United States with direct medical command from three local hospitals.ParticipantsOne thousand eight paramedic reports from October 1992 through March 1993.InterventionsAll patient care interventions recorded as done by standing orders or by direct medical command orders. Errors in patient care were determined by the same criteria as in the prior two studies of the same system.ResultsDirect medical command gave orders in 143/1,008 (14.2%) cases. Paramedics performed 2,453/2,624 (93.5%) of the total patient care interventions using standing orders. In 61 cases (6.1%), medical command ordered a potentially beneficial intervention not specified by standing orders or not done by the paramedic. 21/171 (12.3%) command orders were for additional doses of epinephrine or atropine in cardiac arrest cases (where the initial doses had been given under standing orders), and 59/171 (34.5%) were for interventions already mandated or permitted by standing orders. The paramedic error rate was 0.6%, and the medical command error rate was 1.8% (unchanged form the prior study of the same standing-orders system).ConclusionDirect medical command gave orders in 14% of cases in this standing-orders system, but 35% of command orders only reiterated the standing orders. More selective and reduced uses of on-line command could be done in this system with no change in the types or numbers of patient care interventions performed.

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