The results indicated that neither EMS nor EDs use CPGs that support comprehensive patient assessment. The CPGs generally lacked scientific support and were generally not evidence based. Methods of evidence collection and criteria for CPG development were not consistently documented.
This study indicates that no CPGs for comprehensive patient assessment are available in Swedish emergency care. Instead, most CPGs focus on assessing patients’ medical care needs. These results are in line with previous research showing that medical issues are given priority in emergency care and that caring for other aspects of the patients’ wellbeing is not perceived as equally important (2, 32, 33). The absence of comprehensive patient assessments may indicate that neither EMS nor EDs provide patient-centred care. However, this is not a new phenomenon in ED (32, 34). EMS research indicates that it is difficult to have a caring approach since most CPGs are designed for medical assessment only (35). This tendency is further reinforced by the fact that EMS clinicians do not always accept patients’ life situations as being essential parts of an assessment (10). However, clinicians need to apply a caring attitude in encounters with patients to understand their unique needs (33). To fully grasp a patient’s illness and care needs, it is essential to include the patient’s lifeworld in the assessment (36). This is also necessary to promote the patients’ wellbeing in terms of personal dignity, physical and mental health, and their ability to have control in their daily lives.
Patient assessment in social and cultural contexts is the core of the nursing profession (37). Comprehensive patient assessment increases quality of life (38) and could facilitate benefits, such as reducing the frequency of ED visits among elderly patients with multiple comorbidities (39). Comprehensive patient assessment could also help identify psychological conditions, such as sleep problems, depression, stress, melancholy, or suicide risk (40). Finally, assessing existential care needs is important since illnesses may cause patients to lose hope in life and question their own existence (41). However, comprehensive patient assessment is more complex (39), expensive (38), and time-consuming (39) compared to only assessing patient medical care needs. Nonetheless, comprehensive patient assessment could increase patient safety and reduce possible harm (39, 42).
The results show that a few CPGs address adverse events, such as pressure ulcers, fall injuries, and malnutrition. Such events are preventable, and patients might be unaware of the potential risks. Therefore, the responsibility lies with the clinicians to prevent such risks from arising. However, underlying beliefs, attitudes, and contexts may either support or obstruct patients’ participation (43), thus making it more difficult to prevent adverse events. The absence of CPGs guiding a comprehensive patient assessment may be a sign of system failure in EMS and EDs. To counteract this, increased awareness is needed throughout the organization. Awareness of the most common factors causing adverse events will enable targeted actions, reducing the risk of care and treatment complications and the frequency of readmissions (5).
The results also reveal ambiguity concerning the intended target population of CPGs. One consequence of this is the risk of not using CPGs for the intended patients or of using CPGs for the wrong patient groups. This could harm patients, causing missed treatments or the application of incorrect treatments (44). Patients seeking emergency care must be able to rely on the clinicians’ competence and provision of safe care. However, patient assessments in emergency care combined with decision making in chaotic environments have been found to be challenging from a patient-safety perspective (42), and adverse events related to medical issues are common in emergency care (45). Therefore, constructing systems that prevent adverse events constitutes a crucial component of patient safety.
The current study indicates that only one CPG included patient perspectives. This low number may be due to CPG developers not perceiving patient contributions as relevant to CPG issues or failing to see any value in having representatives from patient associations contribute their experiences (46). However, not including patient perspectives when developing CPGs is counterproductive since patients are the focus and objects of the care proposed.
Additionally, the results show that both EMS and ED are deficient in developing evidence-based CPGs. Other research has highlighted similar deficiencies; for example, the development of CPG content and its connection to scientific literature (24). A possible reason for this deficiency is limited knowledge regarding how to construct evidence-based CPGs. Whatever the reason, the risk remains that patient assessment may be performed without any foundation in evidence (36).
This study also illustrates that CPG development has mainly been executed by senior executives and management physicians. This means that clinicians, who are responsible for the patient assessments in everyday care, are generally not included in CPG development. Thus, it is likely that other aspects of patient care needs are not given the same importance as medical care (2, 32). This highlights the necessity for healthcare clinicians to determine the unique care needs of each patient. Safety in emergency care can only be ensured through responsiveness to each patient’s situation by confirming and understanding the patient (47).
Finally, neither in EMS nor EDs do patient assessments focus on patients’ psychological, social, or existential care needs. Thus, the CPG implementation process in emergency care settings is deficient. This lack may be explained by CPG development and implementation processes being separate activities (48), or it may exist because CPG developers are not involved in everyday emergency clinical work. In summary, our result confirms that existing evidenced-based CPGs are not in use in Swedish emergency care and that the shortage of evidence-based CPGs may result in patients not being provided the best care and treatment.
Limitations and strengths
This study presents certain limitations. For instance, few EMS and EDs participated. This is not optimal since it influences the generalizability of the results and the conclusions that may be drawn. Thus, comprehensive patient assessment and scientific support for CPGs may exist to a greater extent than demonstrated in the current research. Another limitation is the deficiency in the register of existing EMS and EDs, making it difficult to identify the managers. Therefore, some EMS and EDs risked being excluded. However, the strength of this study is that as far as the authors are aware, this is the first national cross-sectional survey on this topic. In fact, all EMS and EDs in Sweden were invited, and the results are likely transferable to other countries and healthcare contexts with similar organizations, education, and staffing.