Does the Norwegian emergency medical dispatch classification as non-urgent predict no need for pre-hospital medical treatment? An observational study

Emergency call utilization over a 10-years period: an observational study in Region Zealand, Denmark, 2013-2022

BACKGROUND

Improving prehospital emergency care requires a comprehensive understanding of the efficiency of emergency medical services and demand fluctuations. The medical emergency call is the primary contact between citizens and the emergency medical dispatch center, serving as the gateway to accessing emergency assistance. This study aimed to characterize the emergency call population and analyze the development of emergency call utilization in Region Zealand in Denmark during a 10-years period.

METHODS

This was an observational register-based study of administrative data from the emergency medical dispatch center in Region Zealand. Data was collected from 1 January 2013 to 31 December 2022. All unique emergency calls from residents to the emergency number "1-1-2" were included. Descriptive analyses were used to characterize the study population. Poisson regression models were used to calculate ratio estimates for the association between years and hospital catchment areas, using the incidence rate of emergency calls as outcome measure.

RESULTS

A total of 641,457 emergency calls were included. A significant increase in the total number of emergency calls was found, with an increase from 58,454 annual calls to 80,819 calls over the study period. The incidence rate per 1000 residents per year increased from 71.1 to 95.2, a 35% increase. The southern part of the region had significantly more emergency calls per 1000 residents per year during the study period compared to the eastern part of the region (IRR 1.70). Demographically, males comprised 52.3% of cases, and patients aged 65 and older represented 48.2% of calls. Emergency calls were "Emergency level A" in 45.5% and "Emergency level B" in 39.1%. In 22.3% of cases, the emergency call was categorized as "Unclear problem." The most frequent categories were "chest pain" (12.7%), "impaired consciousness" (9.6%), "breathing difficulties" (8.8%), "accidents" (7.9%), and "minor injuries" (7.6%).

CONCLUSIONS

The study revealed a significant increase in emergency calls, both in absolute numbers and per 1000 residents per year, indicating growing demand for emergency care, along with a surge in activity at the region's dispatch center. Regional disparities underscores the potential necessity for tailored developmental approaches over time.

[Alternative care concepts for low-acuity emergency medical service missions in the German ambulance service: Descriptive results of an online survey]

INTRODUCTION

In Germany, the number of emergency missions has been rising for several years. At the same time, it can be observed that the amount of missions involving emergency physicians is decreasing, while the number of outpatient treatments without transport is increasing. To cope with this situation, different alternative care concepts have been developed as complementary resources throughout Germany. This study comprehensively compares these concepts, and it aims to highlight best-practice examples and stimulate a joint learning process.

METHODS

As part of an online survey project leaders of various concepts were asked to take part in a standardized online survey. The survey comprised a total of 28 questions relating to various areas such as qualifications and training or resource equipment. The information was supplemented by documents, which were additionally submitted by the respondents.

RESULTS

A total of seven concepts were examined. They all have in common that they are alerted by the dispatch centers to care mainly for low-code cases. Furthermore, the resources are staffed by trained paramedics, and patient transport is not possible. All resources are able to contact other medical facilities. Differences can be seen in the areas of funding, training, equipment, availability, and further areas of responsibility.

DISCUSSION

The development of a large number of different care concepts in Germany has taken place in parallel with the development in other European countries, where different approaches have also been established for low-priority requests for assistance. In order to direct low-priority requests for assistance to a needs-based care unit in Germany as well, rescue dispatch centers should have a broader repertoire of care at their disposal. Implications for research arising from this lie in particular in evaluating the various concepts adequately, especially with regard to the quality of care, and thus ensuring needs-based and targeted care.

CONCLUSION

Widespread introduction of alternative care concepts might help relieve the burden on emergency medical care. This requires more research and evaluation as well as optimized data quality and standardization. In addition, it is desirable to enhance cooperation with the medical on-call service.

Evaluating a training intervention for improving alignment between emergency medical telephone operators and callers: a pilot study of communication behaviours

Background

Calls to emergency medical lines are an essential component in the chain of survival. Operators make critical decisions based on information they elicit from callers. Although smooth cooperation is necessary, the field lacks evidence-based guidelines for how to achieve it while adhering to strict parameters of index-driven questioning. We aimed to evaluate the effect of a training intervention for emergency medical operators at a call centre in Tønsberg, Norway. The course was designed to enhance operators’ communication skills for smoothing cooperation with callers.

Methods

Calls were analyzed using inductively developed coding based on the course rationale and content. To evaluate whether the course generated consolidated behavioral change in everyday practice, the independent analyst evaluated 32 calls, selected randomly from eight operators, two calls before and two after course completion. To measure whether skill attainment delayed decision making, we compared the time to the first decision logged by intervention operators to eight control operators. Analysis included 3034 calls: 1375 to intervention operators (T1 = 815; T2 = 560) and 1659 to control operators (T1 = 683; T2 = 976).

Results

Operators demonstrated improved behaviours on how they greeted the caller (p < .001), acknowledged the caller (p < .001), and displayed empathy (p = 0.015). No change was found in the use of open-ended questions and agreeing with the caller. Contrary to expectations, operators who took the course logged first decisions more quickly than the control group (p < .001).

Conclusions

This pilot study demonstrated that the training intervention generated behavioural change in these operators, providing justification for scaling up the intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00917-y.

Validity and risk factor analysis for helicopter emergency medical services in Japan: a pilot study

Background

Some emergency departments use triage scales, such as the Canadian Triage and Acuity Scale and Japan Urgent Stroke Triage Score, to detect life-threatening situations. However, these protocols have not been used for aeromedical services. Therefore, we investigated the factors predicting these life-threatening situations in aeromedical services as a pilot study for establishing the protocol.

Method

We retrospectively evaluated helicopter emergency medical service cases from 1 April 2015 to 31 March 2020 at Gifu University Hospital using the mission records. We only evaluated cases dealing with suggested internal medicine issues. We excluded cases influenced by external factors such as trauma or cases that included hospital-to-hospital transportation, focusing only on prehospital care. We evaluated the validity of the medical emergencies based on the needs for emergency interventions and hospital admission and of the suggested diagnoses and associated risk factors.

Result

A total of 451 cases were suitable for inclusion in the study. In the analysis for all emergency calls, 235 (52.11%) cases needed emergency intervention and 300 (64.4%) required hospital admission. The suggested diagnosis was valid for 261 (57.87%) cases. After the first assessment by emergency medical technicians, 75 cases were removed. Analysis after this first assessment found that 52.31% cases required emergency intervention, 70.26% needed admission, and the suggested diagnosis was valid for 69.41% of cases. In the analysis of emergency calls, the multivariate analysis of some key variables identified age, playing sports, and gasping as risk factors for emergency intervention. Hospital admission risk factors included being age only. The suggested diagnosis was valid only for sports situations. In the analysis after the first assessment by an emergency medical technician, risk factors for emergency intervention included being age being male, playing sports, and gasping, and those for hospital admission was being age, being male, and experiencing stroke symptoms and/or disturbance of consciousness. The suggested diagnosis was valid only for sports situations.

Conclusion

Some ‘second’ keywords/phrases predict medical emergencies. Therefore, the dispatch commander should gather these keyword/phrases to assess.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00471-x.

Trends and Characteristics of Emergency Medical Services in Italy: A 5-Years Population-Based Registry Analysis

Background: Emergency Medical Services (EMS) plays a fundamental role in providing good quality healthcare services to citizens, as they are the first responders in distressing situations. Few studies have used available EMS data to investigate EMS call characteristics and subsequent responses. Methods: Data were extracted from the emergency registry for the period 2013–2017. This included call and rescue vehicle dispatch information. All relationships in analyses and differences in events proportion between 2013 and 2017 were tested against the Pearson’s Chi-Square with a 99% level of confidence. Results: Among the 2,120,838 emergency calls, operators dispatched at least one rescue vehicle for 1,494,855. There was an estimated overall incidence of 96 emergency calls and 75 rescue vehicles dispatched per 1000 inhabitants per year. Most calls were made by private citizens, during the daytime, and were made from home (63.8%); 31% of rescue vehicle dispatches were advanced emergency medical vehicles. The highest number of rescue vehicle dispatches ended at the emergency department (74.7%). Conclusions: Our data showed that, with some exception due to environmental differences, the highest proportion of incoming emergency calls is not acute or urgent and could be more effectively managed in other settings than in an Emergency Departments (ED). Better management of dispatch can reduce crowding and save hospital emergency departments time, personnel, and health system costs.

How medical transport service professionals perceive risk/protective factors with regard to occupational burnout syndrome: Differences and similarities between an Anglo-American and Franco-German model

BACKGROUND

Several studies show that professionals in the two main models of pre-hospital care (Franco-German (FG) and Anglo-American (AA)) are exposed to different psychosocial risk factors, with consequences such as burnout syndrome. Few studies provide information on protective factors, nor are there any results on risk/protective factors from the perspective of professionals and comparing both models (FG and AA).

OBJECTIVE

From the perspective of medical transport (MT) professionals, we aimed to identify the risk/protective factors that may be involved in occupational burnout syndrome (OBS), comparing Franco-German (FG) and Anglo-American (AA) pre-hospital care models, as well as emergency (EMT) and non-emergency (non-EMT) services.

METHOD

This was a qualitative research, through 12 semi-structured, in-depth interviews with participants chosen through intentional and snowball sampling. Content analysis and coding was carried out based on Bronfenbrenner's ecological model and supported by the N-VIVO computer program.

RESULTS

Our results illustrate the multi-causal nature of OBS, with risk/protective factors interacting at different levels of the ecological model. Among the data found at the different levels, some of the risk factors provoking OBS most commonly cited by professionals from both models are: work overload, work schedules, the coordinating centre, relationships with managers, the lack of work-life balance, the institutional model, the privatization of companies and the bureaucratization of management. The most cited factors acting as protectors include the stress involved in the emergency services, relationships with colleagues, relationships with other professionals or users, and social recognition.

DISCUSSION

In general, we conclude that there are more similarities than differences in terms of how the workers in each model perceive the risk/protective factors.

Telephone triage performed by nurses reduces non-urgent ambulance missions: A prospective observational pilot study in Finland

BACKGROUND

The increased workload in emergency medical services (EMS) is a global phenomenon in welfare states. It has been suggested that telephone triage by nurses may reduce the increasing use of EMS services, by directing patient flow to appropriate care. This study aimed to investigate whether, after an emergency medical communication centre (EMCC) provider assessed risk, a telephone nurse could assess the patient's needs and guide patients to social and health care services in non-urgent cases.

METHODS

This prospective observational study was performed in the Kainuu Hospital District in northern Finland from March to April 2018. All EMS requests classified as non-urgent by the EMCC were transferred to a telephone triage nurse. Subsequent patient guidance was recorded. The International Classifications of Primary Care categories were recorded.

RESULTS

We studied phone calls of 700 patients with non-urgent needs. Of these, the nurse transferred 63.7% to EMS and 17.3% were guided to other social and health care services. Nineteen per cent of the calls were handled over the phone by the nurse, who provided health advice and instructions. The most common needs for care were general and unspecified symptoms, musculoskeletal symptoms, mental health problems and substance abuse.

CONCLUSION

By providing telephone counseling, care instructions and patient guidance to other social and health services than EMS, the telephone triage reduced non-urgent EMS missions by one third. The results imply that telephone triage could be a viable model for managing non-urgent missions. Patient safety issues should be monitored when developing new service concepts.

Patient motives for contacting out-of-hours care in Denmark: a cross-sectional study

BACKGROUND

Patients in need of acute health care do not always contact the most suitable health care service provider. Contacting out-of-hours primary care for an urgent problem may delay care, whereas contacting emergency medical services for a non-urgent problem could ultimately affect patient safety. More insight into patient motives for contacting a specific health care provider may help optimise patient flows. This study aims to explore patient motives for contacting out-of-hours primary care and the emergency medical services in Denmark.

METHODS

We conducted a cross-sectional observational study by sending a questionnaire to patients contacting out-of-hours primary care and emergency medical services, both of which can be directly contacted by patients, in two of five Danish regions in 2015. As we aimed to focus on the first access point, the emergency department was not included. The questionnaire included items on patient characteristics, health problem and 26 pre-defined motives. Descriptive analyses of patient characteristics and motives were conducted, stratified by the two health care service providers. Factors associated with contacting each of the two service providers were explored in a modified Poisson regression analysis, and adjusted risk ratios were calculated.

RESULTS

Three key motives for contacting the two service providers were identified: 'unpleasant symptoms', 'perceived need for prompt action' and 'perceived most suitable health care provider'. Other important motives were 'need arose outside office hours' and 'wanted to talk to a physician' (out-of-hours primary care) and 'expected need for ambulance' and 'worried' (emergency medical services). Higher probability of contacting the emergency medical services versus out-of-hours primary care was seen for most motives relating to own assessment and expectations, previous experience and knowledge, and own needs and wishes. Lower probability was seen for most motives relating to perceived barriers and benefits.

CONCLUSIONS

Patient motives for contacting the two health care service providers were partly overlapping. The study contributes with new knowledge on the complex decision-making process of patients in need of acute health care. This knowledge could help optimise existing health care services, such as patient safety and the service level, without increasing health care costs.

Differences between cases admitted to hospital and discharged from the emergency department after emergency medical services transport

OBJECTIVE

Rising emergency medical services (EMS) utilisation increases transport to hospital emergency departments (ED). However, some patients receive outpatient treatment (discharged) while others are hospitalised (admitted). The aims of this analysis were to compare admitted and discharged cases, to assess whether cases that were discharged from the ED could be identified using dispatch data and to compare dispatch keyword categories and hospital diagnoses.

DESIGN

Retrospective observational study using linked secondary data.

SETTING AND PARTICIPANTS

78 303 cases brought to 1 of 14 ED in the city of Munich, Germany, by EMS between 1 July 2013 and 30 June 2014.

MAIN OUTCOME MEASURES

Characteristics of admitted and discharged cases were assessed. Logistic regression was used to estimate the association between discharge and age, sex, time of day, ambulance type and dispatch keyword category. Keyword categories were compared to hospital diagnoses.

RESULTS

39.4% of cases were discharged. They were especially likely to be young (OR 10.53 (CI 9.31 to 11.92), comparing <15-year-olds to >70-year-olds) and to fall under the categories 'accidents/trauma' (OR 2.87 (CI 2.74 to 3.01)) or 'other emergencies (unspecified)' (OR 1.23 (CI 1.12 to 1.34) (compared with 'cardiovascular'). Most frequent diagnoses came from chapter 'injury and poisoning' (30.1%) of the 10th revision of the international statistical classification of disease and related health problems (ICD-10), yet these diagnoses were more frequent at discharge (42.7 vs 22.0%) whereas circulatory system disease was less frequent (2.6 vs 21.8%). Except for accidents/trauma and intoxication/poisoning many underlying diagnoses were observed for the same dispatch keyword.

CONCLUSION

Young age and dispatch for accidents or trauma were the strongest predictors of discharge. Even within the same dispatch keyword category the distribution of diagnoses differed between admitted and discharged cases. Discharge from the ED does not indicate that urgent response was unnecessary. However, these cases could be suitable for allocation to hospitals with low inpatient bed capacities and are of particular interest for future studies regarding the urgency of their condition.

The appropriateness of low-acuity cases referred for emergency ambulance dispatch following ambulance service secondary telephone triage: A retrospective cohort study

Objective

Ambulance-based secondary telephone triage systems have been established in ambulance services to divert low-acuity cases away from emergency ambulance dispatch. However, some low-acuity cases still receive an emergency ambulance dispatch following secondary triage. To date, no evidence exists identifying whether these cases required an emergency ambulance. The aim of this study was to investigate whether cases were appropriately referred for emergency ambulance dispatch following secondary telephone triage.

Methods

A retrospective cohort analysis was conducted of cases referred for emergency ambulance dispatch in Melbourne, Australia following secondary telephone triage between September 2009 and June 2012. Appropriateness was measured by assessing the frequency of advanced life support (ALS) treatment by paramedics, and paramedic transport to hospital.

Results

There were 23,696 cases included in this study. Overall, 54% of cases received paramedic treatment, which was similar to the state-wide rate for emergency ambulance cases (55.5%). All secondary telephone triage cases referred for emergency ambulance dispatch had transportation rates higher than all metropolitan emergency ambulance cases (82.2% versus 71.1%). Two-thirds of the cases that were transported were also treated by paramedics (66.5%), and 17.7% of cases were not transported to hospital by ambulance following paramedic assessment.

Conclusions

Overall, the cases returned for emergency ambulance dispatch following secondary telephone triage were appropriate. Nevertheless, the paramedic treatment rates in particular indicate a considerable rate of overtriage requiring further investigation to optimize the efficacy of secondary telephone triage.

Emergency department crowding and length of stay before and after an increased catchment area

Background

Emergency department (ED) crowding and prolonged length of stay (LOS) are associated with delays in treatment, adverse outcomes and decreased patient satisfaction. Hospital restructuring and mergers are often associated with increased ED crowding. The aim of this study was to explore ED crowding and LOS in Norway’s largest ED before and after an increased catchment area.

Methods

The catchment area of Akershus University Hospital increased by approximately 150,000 inhabitants in 2011, from 340,000 to 490,000. In this retrospective study, admissions to the ED during a six-year period, from Jan 1st 2010 to Dec 31st 2015 were included and analyzed.

Results

A total of 179,989 admissions were included (51.0% men). The highest occupancy rate was in the age group 70–79 years. Following the increase in the catchment area, the annual ED admissions increased by 8343 (40.9%) from 2010 to 2011, and peaked in 2013 (34,002). Mean LOS increased from 3:59 h in 2010 to 4:17 in 2012 (highest), and decreased to 3:45 h in 2015 after staff, capacity and organizational measures. In 2010, 37.9% of the ED patients experienced crowding, and this proportion increased to between 52.9–77.6% in 2011–2015. Crowding peaked between 4 and 5 PM.

Conclusions

LOS increased and crowding was more frequent after a major increase in the hospital’s catchment area in Norway’s largest emergency department. Even after 5 years, the LOS was higher than before the expansion, mainly because of the throughput and output components, which were not properly adapted to the changes in input.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4342-4) contains supplementary material, which is available to authorized users.

Psychometric properties of the Norwegian version of the hospital survey on patient safety culture in a prehospital environment

Background

To develop a culture of patient safety in a regime that strongly focuses on saving patients from emergencies may seem counter-intuitive and challenging. Little research exists on patient safety culture in the context of Emergency Medical Services (EMS), and the use of survey tools represents an appropriate approach to improve patient safety. Research indicates that safety climate studies may predict safety behavior and safety-related outcomes. In this study we apply the Norwegian versions of Hospital Survey on Patient Safety Culture (HSOPSC) and assess the psychometric properties when tested on a national sample from the EMS.

Methods

This study adopted a web based survey design. The Norwegian HSOPSC has 13 dimensions, consisting of 46 items, in addition to two single-item outcome variables. SPSS (version 21) was used for descriptive data analysis, estimating internal consistency, and performing exploratory factor analysis. Confirmatory factor analysis (CFA) was applied to test the dimensional structure of the instruments using Amos (version 21).

Results

N = 1387 (27%) EMS employees participated in the survey. Overall, acceptable psychometric properties were observed, i.e. acceptable internal consistencies and construct validity. The patient safety climate dimensions with highest scores (number of positive answers) were “teamwork within units” and “manager expectations & actions promoting patient safety”. The dimension “hospital management support for patient safety” had the lowest score.

Conclusions

The results provided a validated instrument, the Prehospital Survey on Patient Safety Culture (PreHSOPSC), for measuring patient safety climate in an EMS setting. In addition, the explanatory power was strong for several of the outcome dimensions; i.e., several of the safety climate dimensions have a strong predictive effect on outcome variables related to employees’ perceptions on patient safety and safety-related attitude.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3576-x) contains supplementary material, which is available to authorized users.

A comparative study on the frequency of simulation-based training and assessment of non-technical skills in the Norwegian ground ambulance services and helicopter emergency medical services

BACKGROUND

Inadequate non-technical skills (NTSs) among employees in the Norwegian prehospital emergency medical services (EMSs) are a risk for patient and operational safety. Simulation-based training and assessment is promising with respect to improving NTSs. The frequency of simulation-based training in and assessment of NTSs among crewmembers in the Norwegian helicopter emergency medical service (HEMS) has gained increased attention over recent years, whereas there has been much less focus on the Norwegian ground emergency medical service (GEMS). The aim of the study was to compare and document the frequencies of simulation-based training in and assessment of seven NTSs between the Norwegian HEMS and GEMS, conditional on workplace and occupation.

METHOD

A comparative study of the results from cross-sectional questionnaires responded to by employees in the Norwegian prehospital EMSs in 2016 regarding training in and assessment of NTSs during 2015, with a focus on the Norwegian GEMS and HEMS. Professional groups of interest are: pilots, HEMS crew members (HCMs), physicians, paramedics, emergency medical technicians (EMTs), EMT apprentices, nurses and nurses with an EMT licence.

RESULTS

The frequency of simulation-based training in and assessment of seven generic NTSs was statistically significantly greater for HEMS than for GEMS during 2015. Compared with pilots and HCMs, other health care providers in GEMS and HEMS undergo statistically significantly less frequent simulation-based training in and assessment of NTSs. Physicians working in the HEMS appear to be undergoing training and assessment more frequently than the rest of the health trust employees. The study indicates a tendency for lesser focus on the assessment of NTSs compared to simulation-based training.

CONCLUSION

HEMS has become superior to GEMS, in terms of frequency of training in and assessment of NTSs. The low frequency of training in and assessment of NTSs in GEMS suggests that there is a great potential to learn from HEMS and to strengthen the focus on NTSs. Increased frequency of assessment of NTSs in both HEMS and GEMS is called for.

Patient and case characteristics associated with 'no paramedic treatment' for low-acuity cases referred for emergency ambulance dispatch following a secondary telephone triage: a retrospective cohort study

BACKGROUND

Predicting case types that are unlikely to be treated by paramedics can aid in managing demand for emergency ambulances by identifying cases suitable for alternative management pathways. The aim of this study was to identify the patient characteristics and triage outcomes associated with 'no paramedic treatment' for cases referred for emergency ambulance dispatch following secondary telephone triage.

METHODS

A retrospective cohort analysis was conducted of cases referred for emergency ambulance dispatch following secondary telephone triage between September 2009 and June 2012. Multivariable logistic regression modelling was used to identify explanatory variables associated with 'no paramedic treatment'.

RESULTS

There were 19,041 cases eligible for inclusion in this study over almost three years, of which 8510 (44.7%) were not treated after being sent an emergency ambulance following secondary triage. Age, time of day, pain, triage guideline group, and comorbidities were associated with 'no paramedic treatment'. In particular, cases 0-4 years of age or those with psychiatric conditions were significantly less likely to be treated by paramedics, and increasing pain resulted in higher rates of paramedic treatment.

CONCLUSIONS

This study highlights that case characteristics can be used to identify particular case types that may benefit from care pathways other than emergency ambulance dispatch. This process is also useful to identify gaps in the alternative care pathways currently available. These findings offer the opportunity to optimise secondary telephone triage services to support their strategic purpose of minimising unnecessary emergency ambulance demand and to match the right case with the right care pathway.

Stroke identification by criteria based dispatch - a register based study

BACKGROUND

Rapid and precise dispatch of resources is a key element in pre-hospital emergency medicine. Emergency medical communication centres (EMCCs) dispatch resources based on protocols and guidelines, balancing the acute need of the individual and the resource allocation of the pre-hospital emergency medical system. The aim of this study was to determine the validity of stroke identification by the Norwegian dispatch guidelines.

METHOD AND MATERIAL

This was a register-based study where patients suspected for stroke were compared to those with the final diagnosis of stroke as an indicator group for the guideline validation. One EMCC and its three associated hospitals participated with 13 months of data. Four subcodes of the stroke dispatch code were defined as suspicious of stroke and further analysed. Factors associated with stroke identification were explored.

RESULTS

The sensitivity for identifying a stroke patient at initial EMCC contact was 57.9% (51.5, 64.1), specificity was 99.1% (98.9, 99.2), positive predictive value was 45.7% (40.1, 51.4) and negative predictive value was 99.4% (99.3, 99.5). The emergency medical access telephone (113) was initial EMCC contact line in only 48% of the cases. Paralyses and admittance to a smaller hospital were associated with increased probability for stroke (OR 2.6, P = 0.001 and OR 2.7, P = 0.01), respectively.

CONCLUSION

The sensitivity for identification of stroke patients by the dispatch guidelines is modest, while the specificity is high. The 113 telephone line was initial EMCC access point for less than half of the stroke patients.

A comparison of two emergency medical dispatch protocols with respect to accuracy

Background

Emergency medical dispatching should be as accurate as possible in order to ensure patient safety and optimize the use of ambulance resources. This study aimed to compare the accuracy, measured as priority level, between two Swedish dispatch protocols – the three-graded priority protocol Medical Index and a newly developed prototype, the four-graded priority protocol, RETTS-A.

Methods

A simulation study was carried out at the Emergency Medical Communication Centre (EMCC) in Stockholm, Sweden, between October and March 2016. Fifty-three voluntary telecommunicators working at SOS Alarm were recruited nationally. Each telecommunicator handled 26 emergency medical calls, simulated by experienced standard patients. Manuscripts for the scenarios were based on recorded real-life calls, representing the six most common complaints. A cross-over design with 13 + 13 calls was used. Priority level and medical condition for each scenario was set through expert consensus and used as gold standard in the study.

Results

A total of 1293 calls were included in the analysis. For priority level, n = 349 (54.0%) of the calls were assessed correctly with Medical Index and n = 309 (48.0%) with RETTS-A (p = 0.012). Sensitivity for the highest priority level was 82.6% (95% confidence interval: 76.6–87.3%) in the Medical Index and 54.0% (44.3–63.4%) in RETTS-A. Overtriage was 37.9% (34.2–41.7%) in the Medical Index and 28.6% (25.2–32.2%) in RETTS-A. The corresponding proportion of undertriage was 6.3% (4.7–8.5%) and 23.4% (20.3–26.9%) respectively.

Conclusion

In this simulation study we demonstrate that Medical Index had a higher accuracy for priority level and less undertriage than the new prototype RETTS-A. The overall accuracy of both protocols is to be considered as low. Overtriage challenges resource utilization while undertriage threatens patient safety. The results suggest that in order to improve patient safety both protocols need revisions in order to guarantee safe emergency medical dispatching.

Long-Term Mortality of Emergency Medical Services Patients

STUDY OBJECTIVE

Emergency medical services (EMS) provides out-of-hospital care to patients with life-threatening conditions, but the long-term outcomes of EMS patients are unknown. We seek to determine the long-term mortality of EMS patients in Denmark.

METHODS

We analyzed linked EMS, hospital, and vital status data from 3 of 5 geographic regions in Denmark. We included events from July 1, 2011, to December 31, 2012. We classified EMS events according to primary dispatch category (unconsciousness/cardiac arrest, accidents/trauma, chest pain, dyspnea, neurologic symptoms, and other EMS patients). The primary outcome was 1-year mortality adjusted for age, sex, and Charlson comorbidity index.

RESULTS

Among 142,125 EMS events, primary dispatch categories were unconsciousness or cardiac arrest 5,563 (3.9%), accidents or trauma 40,784 (28.7%), chest pain 20,945 (14.7%), dyspnea 9,607 (6.8%), neurologic symptoms 17,804 (12.5%), and other EMS patients 47,422 (33.4%). One-year mortality rates were unconscious or cardiac arrest 54.7% (95% confidence interval [CI] 53.4% to 56.1%), accidents or trauma 7.8 (95% CI 7.5% to 8.1%), chest pain 8.5% (95% CI 8.1% to 9.0%), dyspnea 27.7% (95% CI 26.7% to 28.7%), neurologic symptoms 14.1% (95% CI 13.6% to 14.7%), and other EMS patients 11.1% (95% CI 10.8% to 11.4%). Compared with other EMS conditions, adjusted 1-year mortality was higher in unconsciousness or cardiac arrest (risk ratio [RR] 2.6; 95% CI 2.5 to 2.7), dyspnea (RR 1.5; 95% CI 1.4 to 1.5), and in neurologic symptoms (RR 1.1; 95% CI 1.0 to 1.1), but lower in chest pain (RR 0.6; 95% CI 0.6 to 0.7) and accidents or trauma (RR 0.8; 95% CI 0.8 to 0.8).

CONCLUSION

EMS patients with unconsciousness or cardiac arrest, dyspnea, and neurologic symptoms are at highest risk of long-term mortality. Our results suggest a potential for outcome improvement in these patients.

The difficult medical emergency call: A register-based study of predictors and outcomes

BACKGROUND

Pre-hospital emergency care requires proper categorization of emergency calls and assessment of emergency priority levels by the medical dispatchers. We investigated predictors for emergency call categorization as "unclear problem" in contrast to "symptom-specific" categories and the effect of categorization on mortality.

METHODS

Register-based study in a 2-year period based on emergency call data from the emergency medical dispatch center in Copenhagen combined with nationwide register data. Logistic regression analysis (N = 78,040 individuals) was used for identification of predictors of emergency call categorization as "unclear problem". Poisson regression analysis (N = 97,293 calls) was used for examining the effect of categorization as "unclear problem" on mortality.

RESULTS

"Unclear problem" was the registered category in 18% of calls. Significant predictors for "unclear problem" categorization were: age (odds ratio (OR) 1.34 for age group 76+ versus 18-30 years), ethnicity (OR 1.27 for non-Danish vs. Danish), day of week (OR 0.92 for weekend vs. weekday), and time of day (OR 0.79 for night vs. day). Emergency call categorization had no effect on mortality for emergency priority level A calls, incidence rate ratio (IRR) 0.99 (95% confidence interval (CI) 0.90-1.09). For emergency priority level B calls, an association was observed, IRR 1.26 (95% CI 1.18-1.36).

DISCUSSIONS

The results shed light on the complexity of emergency call handling, but also implicate a need for further improvement. Educational interventions at the dispatch centers may improve the call handling, but also the underlying supportive tools are modifiable. The higher mortality rate for patients with emergency priority level B calls with "unclear problem categorization" could imply lowering the threshold for dispatching a high level ambulance response when the call is considered unclear. On the other hand a "benefit of the doubt" approach could hinder the adequate response to other patients in need for an ambulance as there is an increasing demand and limited resources for ambulance services.

CONCLUSIONS

Age, ethnicity, day of week and time of day were significant predictors of emergency call categorization as "unclear problem". "Unclear problem" categorization was not associated with mortality for emergency priority level A calls, but a higher mortality was observed for emergency priority level B calls.