Experiences of adding nurses to increase medical competence at an emergency medical dispatch centre

Clinical Roles in the Medical Communications Centre: A Rapid Scoping Review

In recent years, 911 call volumes have increased, and emergency medical services (EMS) are routinely stretched beyond capacity. To better match resources with patient needs, some EMS systems have integrated clinician roles into the emergency medical communications centre (MCC). Our objective was to explore the nature and scope of clinical roles in emergency MCCs. Using a rapid scoping review methodology, we searched PubMed for studies related to any clinical role employed within an emergency MCC. We accepted reviews, experimental and observational designs, as well as expert opinions. Studies reporting on dispatcher recognition and pre-arrival instructions were excluded. Title and abstract screening were conducted by a single reviewer, included studies were verified by two reviewers, and data extraction was completed in duplicate, all using Covidence review software. The level of evidence was assessed using the prehospital evidence-based practice (PEP) scale. The protocol was registered in Open Science Framework (10.17605/OSF.IO/NX4T8).  Our search yielded 1071 titles, and four were added from other sources; 44 studies were reviewed at the full-text stage and 31 were included. The included studies were published from 2002 to 2022 and represent 17 countries. Studies meeting inclusion criteria consisted of level I (n=4, 11%), II (n=13, 37%), and III (N=6, 17%) methodologies, as well as 12 other studies (34%) with qualitative or other designs. Most of the included studies reported systems that employ nurses in the MCC (n=29, 83%). Twelve (34%) studies reported on the inclusion of paramedics in the MCC, and five (14%) reported physician involvement. The roles of these clinicians chiefly consisted of triage (n=25, 71%), advice (n=20, 57%), referral to non-emergency care (n=14, 40%), and peer-to-peer consulting (n=2, 4%). Alternative dispositions (as opposed to emergency ambulance transport) for low acuity callers included self-care, as well as referral to a general practitioner, pharmacist, or other outreach programs. There is a wide range of literature reporting on clinical roles integrated within MCCs. Our findings revealed that MCC nurses, physicians, and paramedics assist substantively with triage, advice, and referrals to better match resources to patient needs, with or without the requirement for ambulance dispatch.

Patient, family member, and ambulance staff experiences of prehospital acute pain management in adults: A systematic review and meta-synthesis

Background

We aimed to synthesize the qualitative experiences of patients, their family members, and ambulance staff involved in the prehospital management of acute pain in adults and generate recommendations to improve the quality of care.

Methods

A systematic review was conducted following the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines. We searched from inception to June 2021: MEDLINE, CINAHL Complete, PsycINFO and Web of Science (search alerts were screened up to December 2021). Articles were eligible for inclusion if they reported qualitative data and were published in the English language. The Critical Appraisal Skills Program for qualitative studies checklist was used to assess risk of bias, thematic synthesis was performed on included studies and recommendations for clinical practice improvement were generated.

Results

Twenty-five articles were included in the review, representing over 464 patients, family members, and ambulance staff from 8 countries. Six analytical themes and several recommendations to improve clinical practice were generated. Strengthening the patient-clinician relationship by building trust, promoting patient empowerment, addressing patient needs and expectations, and providing a holistic approach to pain treatment is key to improving prehospital pain management in adults. Shared pain management guidelines and training across the prehospital and emergency department intersection should improve the patient journey.

Conclusion

Interventions and guidelines that strengthen the patient-clinician relationship and span the prehospital and emergency department phase of care are likely to improve the quality of care for adults suffering acute pain in the prehospital setting.

A registry-based observational study comparing emergency calls assessed by emergency medical dispatchers with and without support by registered nurses

Background

The requirement concerning formal education for emergency medical dispatcher (EMD) is debated and varies, both nationally and internationally. There are few studies on the outcomes of emergency medical dispatching in relation to professional background. This study aimed to compare calls handled by an EMD with and without support by a registered nurse (RN), with respect to priority level, accuracy, and medical condition.

Methods

A retrospective observational study, performed on registry data from specific regions during 2015. The ambulance personnel’s first assessment of the priority level and medical condition was used as the reference standard. Outcomes were: the proportion of calls dispatched with a priority in concordance with the ambulance personnel’s assessment; over- and undertriage; the proportion of most adverse over- and undertriage; sensitivity, specificity and predictive values for each of the ambulance priorities; proportion of calls dispatched with a medical condition in concordance with the ambulance personnel’s assessment. Proportions were reported with 95% confidence intervals. χ²-test was used for comparisons. P-levels < 0.05 were regarded as significant.

Results

A total of 25,025 calls were included (EMD n = 23,723, EMD + RN n = 1302). Analyses relating to priority and medical condition were performed on 23,503 and 21,881 calls, respectively. A dispatched priority in concordance with the ambulance personnel’s assessment were: EMD n = 11,319 (50.7%) and EMD + RN n = 481 (41.5%) (p < 0.01). The proportion of overtriage was equal for both groups: EMD n = 5904, EMD + RN n = 306, (26.4%) p = 0.25). The proportion of undertriage for each group was: EMD n = 5122 (22.9%) and EMD + RN n = 371 (32.0%) (p < 0.01). Sensitivity for the most urgent priority was 54.6% for EMD, compared to 29.6% for EMD + RN (p < 0.01), and specificity was 67.3% and 84.8% (p < 0.01) respectively. A dispatched medical condition in concordance with the ambulance personnel’s assessment were: EMD n = 13,785 (66.4%) and EMD + RN n = 697 (62.2%) (p = 0.01).

Conclusions

A higher precision of emergency medical dispatching was not observed when the EMD was supported by an RN. How patient safety is affected by the observed divergence in dispatched priorities is an area for future research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00987-y.

A high proportion of prehospital emergency patients are not transported by ambulance: a retrospective cohort study in Northern Finland

BACKGROUND

The number of missions in the emergency medical services (EMS) has increased considerably in recent years. People are requesting ambulance for even minor illnesses and non-medical problems, which is placing financial and resource burdens on the EMS. The aim of this study was to determine the rate of non-transportation missions in Northern Finland and the reasons for these missions.

METHODS

All ambulance missions in two hospital districts in Northern Finland during the 6-month period of January 1 through June 30, 2014, were retrospectively evaluated from the EMS charts to identify missions in which the patients were not transported by the EMS. The non-transportation rates and reasons were calculated and expressed as percentages.

RESULTS

In 41.7% of the 13,354 missions, the patient was not transported from the scene by an ambulance. After a medical assessment and care was provided by the EMS, 48.2% of these non-transport patients were evaluated as not needing further treatment in the emergency department and were directed to contact the municipal health care center during office hours. There was no need for any medical care in 39.9% of non-transportation missions.

CONCLUSION

This study showed a high rate of EMS missions resulting in non-transportation in two hospital districts in Northern Finland. In the majority of these missions there was no need for emergency admission to an emergency department or for any medical care at all. These findings indicate that an improvement in the dispatch process and primary care resources might be of benefit.

Recognition of out-of-hospital cardiac arrest by medical dispatchers in emergency medical dispatch centres in two countries

INTRODUCTION

Survival after out-of-hospital cardiac arrest (OHCA) remains low. Early recognition by emergency medical dispatchers is essential for an effective chain of actions, leading to early cardiopulmonary resuscitation, use of an automated external defibrillator and rapid dispatching of the emergency medical services.

AIM

To analyse and compare the accuracy of OHCA recognition by medical dispatchers in two countries.

METHOD

An observational register-based study collecting data from national cardiac arrest registers in Denmark and Sweden during a six-month period in 2013. Data were analysed in two steps; registry data were merged with electronically registered emergency call data from the emergency medical dispatch centres in the two regions. Cases with missing or non-OHCA dispatch codes were analysed further by auditing emergency call recordings using a uniform data collection template.

RESULTS

The sensitivity for recognition of OHCA was 40.9% (95% CI: 37.1-44.7%) in the Capital Region of Denmark and 78.4% (95% CI: 73.2-83.0%) in the Skåne Region in Sweden (p<0.001). With additional data from the emergency call recordings, the sensitivity was 80.7% (95% CI: 77.7-84.3%) and 86.0% (95% CI: 81.3-89.8%) for the two regions (p=0.06). The majority of the non-recognised OHCA were dispatched with the highest priority.

CONCLUSION

The accuracy of OHCA recognition was high and comparable. We identified large differences in data registration practices despite the use of similar dispatch tools. This raises a discussion of definitions and transparency in general in scientific reporting of OHCA recognition, which is essential if used as quality indicator in emergency medical services.

'You're never making just one decision': exploring the lived experiences of ambulance Emergency Operations Centre personnel

BACKGROUND

The aim of this study was to explore the experiences of ambulance dispatch personnel, identifying key stressors and their impact on staff well-being.

METHODS

Qualitative methodology was used. Nine semistructured interviews were conducted with National Health Service (NHS) ambulance Emergency Operations Centre (EOC) dispatch personnel in the UK between July and August 2014. Participants were asked about their experiences of the role, stress experienced and current strategies they use to deal with stress. Transcripts were analysed using an inductive, bottom-up thematic analysis.

RESULTS

Three key themes were identified: (1) 'How dispatch is perceived by others', (2) 'What dispatch really involves' and (3) 'Dealing with the stresses of dispatch'. All participants expressed pride in their work, but felt overloaded by the workload and undervalued by others. Several sources of additional stress, not directly related to the execution of their work, were identified, including the need to mentally unwind from work at the end of a shift. Participants were able to identify a number of ways in which they currently manage work-related stress, but they also suggested changes the organisation could put in place in order to reduce stress in the working environment.

CONCLUSIONS

Building on existing theory on work stress and postwork recovery, it was concluded that EOC dispatch staff require greater support at work, including skills training to promote postshift recovery, in order to reduce the likelihood of sickness absence, and prevent work-related fatigue.

Registered nurses' experiences of their decision-making at an Emergency Medical Dispatch Centre

AIMS AND OBJECTIVES

To describe registered nurses' experiences at an Emergency Medical Dispatch Centre.

BACKGROUND

It is important that ambulances are urgently directed to patients who are in need of immediate help and of quick transportation to a hospital. Because resources are limited, Emergency Medical Dispatch centres cannot send ambulances with high priority to all callers. The efficiency of the system is therefore dependent on triage. Nurses worldwide are involved in patient triage, both before the patient's arrival to the hospital and in the subsequent emergency care. Ambulance dispatching is traditionally a duty for operators at Emergency Medical Dispatch centres, and in Sweden this duty has become increasingly performed by registered nurses.

DESIGN

A qualitative design was used for this study.

METHODS

Fifteen registered nurses with experience at Emergency Medical Dispatch centres were interviewed. The participants were asked to describe the content of their work and their experiences. They also described the most challenging and difficult situations according to the critical incidence technique. Content analysis was used.

RESULTS

Two themes emerged during the analysis: 'Having a profession with opportunities and obstacles' and 'Meeting serious and difficult situations', with eight sub-themes. The results showed that the decisions to dispatch ambulances were both challenging and difficult. Difficulties included conveying medical advice without seeing the patient, teaching cardio-pulmonary resuscitation via telephone and dealing with intoxicated and aggressive callers. Conflicts with colleagues and ambulance crews as well as fear of making wrong decisions were also mentioned.

CONCLUSIONS

Work at Emergency Medical Dispatch centres is a demanding but stimulating duty for registered nurses.

RELEVANCE TO CLINICAL PRACTICE

Great benefits can be achieved using experienced triage nurses, including increased patient safety and better use of medical resources. Improved internal support systems at Emergency Medical Dispatch centres and striving for a blame-free culture are important factors to attract and retain employees.