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Levy MJ, Crowe RP, Abraham H, Bailey A, Blue M, Ekl R, Garfinkel E, Holloman JB, Hutchens J, Jacobsen R, Johnson C, Margolis A, Troncoso R, Williams JG, Myers JB. Dispatch Categories as Indicators of Out-of-Hospital Time Critical Interventions and Associated Emergency Department Outcomes. PREHOSP EMERG CARE 2024:1-6. [PMID: 38626286 DOI: 10.1080/10903127.2024.2342015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/04/2024] [Indexed: 04/18/2024]
Abstract
OBJECTIVES Emergency medical services (EMS) systems increasingly grapple with rising call volumes and workforce shortages, forcing systems to decide which responses may be delayed. Limited research has linked dispatch codes, on-scene findings, and emergency department (ED) outcomes. This study evaluated the association between dispatch categorizations and time-critical EMS responses defined by prehospital interventions and ED outcomes. Secondarily, we proposed a framework for identifying dispatch categorizations that are safe or unsafe to hold in queue. METHODS This retrospective, multi-center analysis encompassed all 9-1-1 responses from 8 accredited EMS systems between 1/1/2021 and 06/30/2023, utilizing the Medical Priority Dispatch System (MPDS). Independent variables included MPDS Protocol numbers and Determinant levels. EMS treatments and ED diagnoses/dispositions were categorized as time-critical using a multi-round consensus survey. The primary outcome was the proportion of EMS responses categorized as time-critical. A non-parametric test for trend was used to assess the proportion of time-critical responses Determinant levels. Based on group consensus, Protocol/Determinant level combinations with at least 120 responses (∼1 per week) were further categorized as safe to hold in queue (<1% time-critical intervention by EMS and <5% time-critical ED outcome) or unsafe to hold in queue (>10% time-critical intervention by EMS or >10% time-critical ED outcome). RESULTS Of 1,715,612 EMS incidents, 6% (109,250) involved a time-critical EMS intervention. Among EMS transports with linked outcome data (543,883), 12% had time-critical ED outcomes. The proportion of time-critical EMS interventions increased with Determinant level (OMEGA: 1%, ECHO: 38%, p-trend < 0.01) as did time-critical ED outcomes (OMEGA: 3%, ECHO: 31%, p-trend < 0.01). Of 162 unique Protocols/Determinants with at least 120 uses, 30 met criteria for safe to hold in queue, accounting for 8% (142,067) of incidents. Meanwhile, 72 Protocols/Determinants met criteria for unsafe to hold, accounting for 52% (883,683) of incidents. Seven of 32 ALPHA level Protocols and 3/17 OMEGA level Protocols met the proposed criteria for unsafe to hold in queue. CONCLUSIONS In general, Determinant levels aligned with time-critical responses; however, a notable minority of lower acuity Determinant level Protocols met criteria for unsafe to hold. This suggests a more nuanced approach to dispatch prioritization, considering both Protocol and Determinant level factors.
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Affiliation(s)
| | | | | | - Anna Bailey
- Office of the Medical Director, Metropolitan Oklahoma City and Tulsa, Oklahoma
| | - Matt Blue
- Charleston County EMS, Charleston, South Carolina
| | | | | | | | | | - Ryan Jacobsen
- Office of the Medical Director, Johnson County EMS System, Olathe, Kansas
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Michel J, Manns A, Boudersa S, Jaubert C, Dupic L, Vivien B, Burgun A, Campeotto F, Tsopra R. Clinical decision support system in emergency telephone triage: A scoping review of technical design, implementation and evaluation. Int J Med Inform 2024; 184:105347. [PMID: 38290244 DOI: 10.1016/j.ijmedinf.2024.105347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/09/2024] [Accepted: 01/21/2024] [Indexed: 02/01/2024]
Abstract
OBJECTIVES Emergency department overcrowding could be improved by upstream telephone triage. Emergency telephone triage aims at managing and orientating adequately patients as early as possible and distributing limited supply of staff and materials. This complex task could be improved with the use of Clinical decision support systems (CDSS). The aim of this scoping review was to identify literature gaps for the future development and evaluation of CDSS for Emergency telephone triage. MATERIALS AND METHODS We present here a scoping review of CDSS designed for emergency telephone triage, and compared them in terms of functional characteristics, technical design, health care implementation and methodologies used for evaluation, following the PRISMA-ScR guidelines. RESULTS Regarding design, 19 CDSS were retrieved: 12 were knowledge based CDSS (decisional algorithms built according to guidelines or clinical expertise) and 7 were data driven (statistical, machine learning, or deep learning models). Most of them aimed at assisting nurses or non-medical staff by providing patient orientation and/or severity/priority assessment. Eleven were implemented in real life, and only three were connected to the Electronic Health Record. Regarding evaluation, CDSS were assessed through various aspects: intrinsic characteristics, impact on clinical practice or user apprehension. Only one pragmatic trial and one randomized controlled trial were conducted. CONCLUSION This review highlights the potential of a hybrid system, user tailored, flexible, connected to the electronic health record, which could work with oral, video and digital data; and the need to evaluate CDSS on intrinsic characteristics and impact on clinical practice, iteratively at each distinct stage of the IT lifecycle.
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Affiliation(s)
- Julie Michel
- SAMU 93-UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, 125, rue de Stalingrad, 93009 Bobigny, France
| | - Aurélia Manns
- Université Paris Cité, Sorbonne Université, Inserm, Centre de Recherche des Cordeliers, F-75006 Paris, France; Department of Medical Informatics, AP-HP, Hôpital Européen Georges-Pompidou et Hôpital Necker-Enfants Malades, F-75015 Paris, France.
| | - Sofia Boudersa
- Department of Medical Informatics, AP-HP, Hôpital Européen Georges-Pompidou et Hôpital Necker-Enfants Malades, F-75015 Paris, France
| | - Côme Jaubert
- Université Paris Cité, Sorbonne Université, Inserm, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Laurent Dupic
- Régulation Régionale Pédiatrique, SAMU de Paris, Hôpital Necker - Enfants Malades, AP-HP, Paris, France
| | - Benoit Vivien
- Digital Health Program of Université de Paris Cité, Paris, France; Régulation Régionale Pédiatrique, SAMU de Paris, Hôpital Necker - Enfants Malades, AP-HP, Paris, France
| | - Anita Burgun
- Université Paris Cité, Sorbonne Université, Inserm, Centre de Recherche des Cordeliers, F-75006 Paris, France; Department of Medical Informatics, AP-HP, Hôpital Européen Georges-Pompidou et Hôpital Necker-Enfants Malades, F-75015 Paris, France
| | - Florence Campeotto
- Digital Health Program of Université de Paris Cité, Paris, France; Régulation Régionale Pédiatrique, SAMU de Paris, Hôpital Necker - Enfants Malades, AP-HP, Paris, France; Faculté de Pharmacie, Université de Paris Cité, Inserm UMR S1139, Paris, France
| | - Rosy Tsopra
- Université Paris Cité, Sorbonne Université, Inserm, Centre de Recherche des Cordeliers, F-75006 Paris, France; Department of Medical Informatics, AP-HP, Hôpital Européen Georges-Pompidou et Hôpital Necker-Enfants Malades, F-75015 Paris, France
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Belcher J, Finn J, Whiteside A, Ball S. Association between initial presenting level of consciousness and patient acuity - A potential application for secondary triage in emergency ambulance calls. Australas Emerg Care 2023; 26:199-204. [PMID: 36496330 DOI: 10.1016/j.auec.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 11/17/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Conscious state assessment is important for the triage of emergency patients. In this study, we measured the association between ambulance patients' conscious state and high versus lower acuity, with a view to informing telephone triage assessment of conscious state. METHODS Data were analysed from one year of emergency ambulance incidents in Perth, Western Australia. Patient conscious state at the time of paramedic arrival was compared to acuity (based on paramedic assessment and management). We determined the proportion of high-acuity patients across six levels of consciousness (Alert, Confused, Drowsy, Voice Response, Pain Response, Unresponsive) overall, and within individual protocols of the Medical Priority Dispatch System (MPDS). RESULTS The proportion of high acuity patients increased with each step across the consciousness scale. Applying conscious state as a binary predictor of acuity, the largest increases occurred moving the threshold from Alert to Confused (22.0-48.6% high acuity) and Drowsy to Voice Response (61.9-89.5% high acuity). The Area Under the Curve (AUC) of the Receiver Operating Characteristic was 0.65. Within individual protocols, the highest AUC was in Cardiac Arrest (0.89), Overdose/Poisoning (0.81), Unknown Problem (0.76), Diabetic Problem, (0.74) and Convulsions/Fitting (0.73); and lowest in Heart problems (0.55), Abdominal Pain (0.55), Breathing Problems (0.55), Back Pain (0.53), and Chest Pain (0.52). CONCLUSION Based on these proportions of high acuity patients, it is reasonable to consider patients with any altered conscious state a high priority. The value of conscious state assessment for predicting acuity varies markedly between MPDS protocols. These findings could help inform secondary triage of ambulance patients during the emergency call.
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Affiliation(s)
- Jason Belcher
- Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Curtin University, Perth, Western Australia, Australia; St John Western Australia, Australia.
| | - Judith Finn
- Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Curtin University, Perth, Western Australia, Australia; St John Western Australia, Australia
| | - Austin Whiteside
- Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Curtin University, Perth, Western Australia, Australia; St John Western Australia, Australia
| | - Stephen Ball
- Prehospital, Resuscitation and Emergency Care Research Unit, School of Nursing, Curtin University, Perth, Western Australia, Australia; St John Western Australia, Australia
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Drabecki M, Toczyłowski E, Pieńkosz K, Honisz G, Kułak K. Multi-criteria assignment problems for optimising the emergency medical services (EMS), considering non-homogeneous speciality of the emergency departments and EMS crews. Sci Rep 2023; 13:7496. [PMID: 37161017 PMCID: PMC10170167 DOI: 10.1038/s41598-023-33831-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 04/19/2023] [Indexed: 05/11/2023] Open
Abstract
Dispatching of the EMS crews (ambulances) to awaiting patients and then directing the patients, that are already onboard, to appropriate Emergency Departments (ED), is a nontrivial decision problem. In many emergency medical systems it is handled by the Medical Dispatcher using various strategies-sometimes preferring the closest unit. However, applying a wrong strategy may result in transferring acute-state patients, who require very specialised medical aid, to low-speciality EDs with insufficient treatment capabilities. Then, they would need to be re-transferred to referential units, prolonging substantially the time to receive treatment. In some cases such a delay might make the treatment less effective or even impossible. In this work we propose two multi-criteria mathematical optimisation problems-the first one allows us to calculate the ambulance-to-patient assignment, the second one-to establish the patient-to-hospital assignment. These problems not only take the time-to-support criterion into consideration but also optimise for the speciality of care received by each patient. The ED dispatching problem proposed allows both for direct transfers of patients to referential units and for re-transferring them from non-referential EDs. The performance of the proposed approach is tested in simulations with real-life emergency cases from the NEMSIS data set and compared with classic assignment strategies. The tests showed the proposed approach is able to produce better and more fit-for-purpose dispatching results than other strategies tested. Additionally, we propose a framework for embedding the proposed optimisation problems in the current EMS/ED dispatching process.
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Affiliation(s)
- Mariusz Drabecki
- Institute of Control and Computation Engineering, Warsaw University of Technology, Warsaw, Poland.
- Order of Malta Poland, Maltese Medical Service, Katowice, Poland.
| | - Eugeniusz Toczyłowski
- Institute of Control and Computation Engineering, Warsaw University of Technology, Warsaw, Poland
| | - Krzysztof Pieńkosz
- Institute of Control and Computation Engineering, Warsaw University of Technology, Warsaw, Poland
| | - Grzegorz Honisz
- Silesian Centre for Heart Deseases in Zabrze, Zabrze, Poland
- Order of Malta Poland, Maltese Medical Service, Katowice, Poland
| | - Klaudia Kułak
- Faculty of Medicine, Lazarski University Warsaw, Warsaw, Poland
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5
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Leggio WJ, Grawey T, Stilley J, Dorsett M. EMS Curriculum Should Educate Beyond a Technical Scope of Practice: Position Statement and Resource Document. PREHOSP EMERG CARE 2021; 25:724-729. [PMID: 33945384 DOI: 10.1080/10903127.2021.1925793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Position Statement and Resource document approved by the NAEMSP Board of Directors on April 27, 2021.
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Improving the Appropriateness of Advanced Life Support Teams' Dispatch: A Before-After Study. Prehosp Disaster Med 2021; 36:195-201. [PMID: 33517934 DOI: 10.1017/s1049023x21000030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND IMPORTANCE The dispatch of Advanced Life Support (ALS) teams in Emergency Medical Services (EMS) is still a hardly studied aspect of prehospital emergency logistics. In 2015, the dispatch algorithm of Emilia Est Emergency Operation Centre (EE-EOC) was implemented and the dispatch of ALS teams was changed from primary to secondary based on triage of dispatched vehicles for high-priority interventions when teams with Immediate Life Support (ILS) skills were dispatched. OBJECTIVES This study aimed to evaluate the effects on the appropriateness of ALS teams' intervention and their employment time, and to compare sensitivity and specificity of the algorithm implementation. DESIGN This was a retrospective before-after observational study. SETTINGS AND PARTICIPANTS Primary dispatches managed by EE-EOC involving ambulances and/or ALS teams were included. Two groups were created on the basis of the years of intervention (2013-2014 versus 2017-2018). INTERVENTION A switch from primary to secondary dispatch of ALS teams in case of high-priority dispatches managed by ILS teams was implemented. OUTCOMES Appropriateness of ALS team intervention, total task time of ALS vehicles, and sensitivity and specificity of the algorithm were reviewed. RESULTS The study included 242,501 emergency calls that generated 56,567 red code dispatches. The new algorithm significantly increased global sensitivity and specificity of the system in terms of recognition of potential need of ALS intervention and the specificity of primary ALS dispatch. The appropriateness of ALS intervention was significantly increased; total tasking time per day for ALS and the number of critical dispatches without ALS available were reduced. CONCLUSION The revision of the dispatch criteria and the extension of the two-tiered dispatch for ALS teams significantly increased the appropriateness of ALS intervention and reduced both the global tasking time and the number of high-priority dispatches without ALS teams available.
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Tollinton L, Metcalf AM, Velupillai S. Enhancing predictions of patient conveyance using emergency call handler free text notes for unconscious and fainting incidents reported to the London Ambulance Service. Int J Med Inform 2020; 141:104179. [PMID: 32663739 DOI: 10.1016/j.ijmedinf.2020.104179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/28/2020] [Accepted: 05/13/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Pre-hospital emergency medical services use clinical decision support systems (CDSS) to triage calls. Call handlers often supplement this by making free text notes covering key incident information. We investigate whether machine learning approaches using features from such free text notes can improve prediction of unconscious patients who require conveyance. MATERIALS AND METHODS We analysed a subset of all London Ambulance Service calls that were triaged through the Medical Priority Dispatch System (MPDS) as involving an unconscious or fainting patient in 2018. We use and compare two machine learning algorithms: random forest (RF) and gradient boosting machine (GBM). For each incident, we predict whether the patient will be conveyed to a hospital emergency department or equivalent using as features 1) the MPDS code, 2) the free text notes and 3) the two together. We evaluate model performance using the area under the curve (AUC) metric. Given the imbalance of outcomes (patient conveyed 71 %, not conveyed 29 %), we also consider sensitivity and specificity. RESULTS Using only the MPDS code resulted in an AUC of 0.57. Using the text notes gave an improved AUC score of 0.63 and combining the two gave an AUC score of 0.64 (scores were similar for RF and GBM). GBM models scored better on sensitivity (0.93 vs 0.62 for RF in the combined model), but specificity was lower (0.17 vs. 0.56 for RF in the combined model). CONCLUSIONS Using information contained in the free text notes made by call handlers in combination with MPDS improves prediction of unconscious and fainting patients requiring conveyance to a hospital emergency department (or equivalent) when compared with machine learning models using MPDS codes only. This suggests there is some useful information in unstructured data captured by emergency call handlers that complements MPDS codes. Quantifying this gain can help inform emergency medical service policy when evaluating the decision to expand or augment existing CDSS.
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Affiliation(s)
- Liam Tollinton
- Centre for Urban Science and Progress Studies, King's College London, UK
| | | | - Sumithra Velupillai
- Centre for Urban Science and Progress Studies, King's College London, UK; Institute for Psychiatry, Psychology & Neuroscience, King's College London, UK.
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Blodgett JM, Robertson DJ, Ratcliffe D, Rockwood K. Piloting data linkage in a prospective cohort study of a GP referral scheme to avoid unnecessary emergency department conveyance. BMC Emerg Med 2020; 20:48. [PMID: 32532217 PMCID: PMC7291513 DOI: 10.1186/s12873-020-00343-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/03/2020] [Indexed: 11/29/2022] Open
Abstract
Background UK Ambulance services are under pressure to safely stream appropriate patients away from the Emergency Department (ED). Even so, there has been little evaluation of patient outcomes. We investigated differences between patients who are conveyed directly to ED after calling 999 and those referred by an ambulance crew to a novel GP referral scheme. Methods This was a prospective study comparing patients from two cohorts, one conveyed directly to the ED (n = 4219) and the other referred to a GP by the on-scene paramedic (n = 321). To compare differences in patient outcomes, we include follow-up data of a smaller subset of each cohort (up to n = 150 in each) including hospital admission, history of long-term illness, previous ED attendance, length of stay, hospital investigations, internal transfers, 30-day re-admission and 10-month mortality. Results Older individuals, females, and those with minor incidents were more likely to be referred to a GP than conveyed directly to ED. Of those patients referred to the GP, only 22.4% presented at ED within 30 days. These patients were more likely to be admitted then than were those initially conveyed directly to ED (59% vs 31%). Those conveyed to ED had a higher risk of death compared to those who were referred to the GP (HR: 2.59; 95% CI 1.14–5.89), however when analyses were restricted to those who presented at ED within 30 days, there was no difference in mortality risk (HR: 1.45; 95% CI 0.58–3.65). Conclusions Despite limited data and a small sample size, there were differences between patients conveyed directly to ED and those who were referred into GP care. Initial evidence suggests that referring individuals to a GP may provide an appropriate and safe alternative path of care. This pilot study demonstrated a need for larger scale, methodologically rigorous study to demonstrate the benefits of alternative conveyance schemes and recommend changes to the current system of urgent and emergency care.
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Affiliation(s)
- Joanna M Blodgett
- MRC Unit for Lifelong Health and Ageing at UCL, 1-19 Torrington Place, London, WC1E 7HB, UK. .,North West Ambulance Service, NHS Trust, Bolton, Greater Manchester, UK.
| | - Duncan J Robertson
- North West Ambulance Service, NHS Trust, Bolton, Greater Manchester, UK.,Welsh Ambulance Services Trust, Saint Asaph, Denbighshire, UK
| | - David Ratcliffe
- North West Ambulance Service, NHS Trust, Bolton, Greater Manchester, UK.,Greater Manchester Health and Social Care Partnership, Greater Manchester, UK.,Salford Royal NHS Foundation Trust, Greater Manchester, UK
| | - Kenneth Rockwood
- Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, N.S, Canada
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Population-based analysis of the effect of a comprehensive, systematic change in an emergency medical services resource allocation plan on 24-hour mortality. CAN J EMERG MED 2020; 22:86-94. [PMID: 31659952 DOI: 10.1017/cem.2019.429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Resource allocation planning for emergency medical services (EMS) systems determines appropriate resources including what paramedic qualification and how rapidly to respond to patients for optimal outcomes. The British Columbia Emergency Health Services implemented a revised response plan in 2013. METHODS A pre- and post-methodology was used to evaluate the effect of the resource allocation plan revision on 24-hour mortality. All adult cases with evaluable outcome data (obtained through linked provincial health administrative data) were analyzed. Multivariable logistic regression was used to adjust for variations in other significant associated factors. Interrupted time series analysis was used to estimate immediate changes in level or trend of outcome after the start of the revised resource allocation plan implementation, while simultaneously controlling for pre-existing trends. RESULTS The derived cohort comprised 562,546 cases (April 2012-March 2015). When adjusted for age, sex, urban/metro region, season, day, hour, and dispatch determinant, the probability of dying within 24 hours of an EMS call was 7% lower in the post-resource allocation plan-revision cohort (OR = 0.936; 95% CI: 0.886-0.989; p = 0.018). A subgroup analysis of immediately life-threatening cases demonstrated similar effect (OR = 0.890; 95% CI: 0.808-0.981; p = 0.019). Using time series analysis, the descending changes in overall 24-hour mortality trend and the 24-hour mortality trend in immediately life-threatening cases, were both statistically significant (p < 0.001). CONCLUSION Comprehensive, evidence-informed reconstruction of a provincial EMS resource allocation plan is feasible. Despite change in crew level response and resource allocation, there was significant decrease in 24-hour mortality in this pan-provincial population-based cohort.
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10
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Abramson TM, Sanko S, Kashani S, Eckstein M. Safety of Tiered-Dispatch for 911 Calls for Abdominal Pain. West J Emerg Med 2019; 20:957-961. [PMID: 31738724 PMCID: PMC6860400 DOI: 10.5811/westjem.2019.9.44100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 09/07/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Many dispatch systems send Advanced Life Support (ALS) resources to patients complaining of abdominal pain even though the majority of these incidents require only Basic Life Support (BLS). With increasing 911-call volume, resource utilization has become more important to ensure that ALS resources are available for time-critical emergencies. In 2015, a large, urban fire department implemented an internally developed, tiered-dispatch system. Under this system, patients reporting a chief complaint of abdominal pain received the closest BLS ambulance dispatched alone emergency if located within three miles of the incident. The objective of this study was to determine the safety of BLS-only dispatch to abdominal pain by determining the frequency of time-sensitive events. Methods This was a retrospective review of electronic health records of one emergency medical service provider agency from May 2015–2018. Inclusion criteria were a chief complaint of abdominal pain from a first- or second-party caller, age over 15, and the patient was reported to be alert and breathing normally. The primary outcome was the prevalence of time-sensitive events, including cardiopulmonary resuscitation (CPR), defibrillation, or airway management. Secondary outcomes were hypotension (systolic blood pressure < 90 mmHg); or a prehospital 12 lead-electrocardiogram (ECG) demonstrating ST-elevation myocardial infarction (STEMI) criteria or a wide complex arrhythmia. Descriptive statistics were used. Results During the study period, there were 1,220,820 EMS incidents, of which 33,267 (2.72%) met inclusion criteria. The mean age was 49.9 years (range 16–111, standard deviation [SD] 19.6); 14,556 patients (56.2%) were female. Time-sensitive events occurred in seven cases (0.021%), mean age was 75.3 years (range 30–86, SD18.7); 85.7% were female. Airway management was required in seven cases (0.021%), CPR in six cases (0.018%), and defibrillation in one case (0.003%). Two of the seven (28.6%) cases involved dispatch protocol deviations. Hypotension was present in 240 (0.72%) cases; six (0.018%) cases had 12-lead ECGs meeting STEMI criteria; and no cases demonstrated wide complex arrhythmia. Conclusion Among adult 911 patients with a dispatch chief complaint of abdominal pain, time-sensitive events were exceedingly rare. Dispatching a BLS ambulance alone appears to be safe.
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Affiliation(s)
- Tiffany M Abramson
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Division of Emergency Medical Services, Los Angeles, California
| | - Stephen Sanko
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Division of Emergency Medical Services, Los Angeles, California.,Los Angeles Fire Department, Emergency Medical Services Bureau, Los Angeles, California
| | - Saman Kashani
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Division of Emergency Medical Services, Los Angeles, California.,Los Angeles Fire Department, Emergency Medical Services Bureau, Los Angeles, California
| | - Marc Eckstein
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Division of Emergency Medical Services, Los Angeles, California.,Los Angeles Fire Department, Emergency Medical Services Bureau, Los Angeles, California
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11
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Eastwood K, Morgans A, Stoelwinder J, Smith K. The appropriateness of low-acuity cases referred for emergency ambulance dispatch following ambulance service secondary telephone triage: A retrospective cohort study. PLoS One 2019; 14:e0221158. [PMID: 31408496 PMCID: PMC6691999 DOI: 10.1371/journal.pone.0221158] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/31/2019] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Kathryn Eastwood
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
- * E-mail:
| | - Amee Morgans
- Emergency Services Telecommunications Authority, Burwood, Victoria, Australia
| | - Johannes Stoelwinder
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
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12
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Andrew E, Jones C, Stephenson M, Walker T, Bernard S, Cameron P, Smith K. Aligning ambulance dispatch priority to patient acuity: A methodology. Emerg Med Australas 2018; 31:405-410. [DOI: 10.1111/1742-6723.13181] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 06/27/2018] [Accepted: 08/20/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Emily Andrew
- Ambulance Victoria Melbourne Victoria Australia
- Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
| | - Colin Jones
- Ambulance Victoria Melbourne Victoria Australia
| | - Michael Stephenson
- Ambulance Victoria Melbourne Victoria Australia
- Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
- Department of Community Emergency Health and Paramedic PracticeMonash University Melbourne Victoria Australia
| | - Tony Walker
- Ambulance Victoria Melbourne Victoria Australia
| | - Stephen Bernard
- Ambulance Victoria Melbourne Victoria Australia
- Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
- The Alfred Hospital Melbourne Victoria Australia
| | - Peter Cameron
- Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
- The Alfred Hospital Melbourne Victoria Australia
| | - Karen Smith
- Ambulance Victoria Melbourne Victoria Australia
- Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
- Department of Community Emergency Health and Paramedic PracticeMonash University Melbourne Victoria Australia
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Kill C, Betz S, Bösl E. [Syncope in prehospital emergency medicine]. Med Klin Intensivmed Notfmed 2018; 115:88-93. [PMID: 30014263 DOI: 10.1007/s00063-018-0458-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/07/2018] [Accepted: 02/07/2018] [Indexed: 11/28/2022]
Abstract
Loss of consciousness is a frequent cause for an emergency call to the emergency medical services (EMS). It can be associated with life-threatening conditions. A distinction must be made between transient loss of consciousness (TLOC) and syncope, which is of cardiovascular origin by definition. Initial assessment in prehospital emergency care should follow the ABCDE algorithm including a 12-lead ECG. The presence of important risk factors such as occurrence in supine position, physical stress, palpitations, history of heart diseases, and any abnormalities in the ECG warrants hospital admission. Initial treatment without admission to an emergency department may only be acceptable for healthy patients without any risk factors and injuries, when vital signs are normal and an orthostatic etiology seems most likely.
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Affiliation(s)
- C Kill
- Zentrum für Notfallmedizin, Universitätsmedizin Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - S Betz
- Zentrum für Notfallmedizin, Universitätsklinikum Marburg, 35033, Marburg, Deutschland
| | - E Bösl
- Zentrum für Notfallmedizin, Universitätsklinikum Marburg, 35033, Marburg, Deutschland
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Eastwood K, Morgans A, Stoelwinder J, Smith K. 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. Scand J Trauma Resusc Emerg Med 2018; 26:8. [PMID: 29321074 PMCID: PMC5763642 DOI: 10.1186/s13049-018-0475-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 01/03/2018] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Kathryn Eastwood
- Department of Epidemiology and Preventive Medicine, The Alfred Centre, Monash University, 99 Commercial Road, Melbourne, VIC, 3004, Australia. .,Ambulance Victoria, Victoria, Australia.
| | - Amee Morgans
- Emergency Services Telecommunications Authority, Victoria, Australia
| | - Johannes Stoelwinder
- Department of Epidemiology and Preventive Medicine, The Alfred Centre, Monash University, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Karen Smith
- Department of Epidemiology and Preventive Medicine, The Alfred Centre, Monash University, 99 Commercial Road, Melbourne, VIC, 3004, Australia.,Ambulance Victoria, Victoria, Australia.,Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, VIC, Australia
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Ebrahimian A, Masoumi G, Jamshidi-Orak R, Seyedin H. Development and Psychometric Evaluation of the Pre-hospital Medical Emergencies Early Warning Scale. Indian J Crit Care Med 2017; 21:205-212. [PMID: 28515604 PMCID: PMC5416787 DOI: 10.4103/ijccm.ijccm_49_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction: The number of requests for emergency medical services (EMSs) has increased during the past decade. However, most of the transports are not essential. Therefore, it seems crucial to develop an instrument to help EMS staff accurately identify patients who need pre-hospital care and transportation. The aim of this study was to develop and evaluate the psychometric properties of the Pre-hospital Medical Emergencies Early Warning Scale (Pre-MEWS). Materials and Methods: This mixed-method study was conducted in two phases. In the first phase, a qualitative content analysis study was conducted to identify the predictors of medical patients' need for pre-hospital EMS and transportation. In the second phase, the face and the content validity as well as the internal consistency of the scale were evaluated. Finally, the items of the scale were scored and scoring system was presented. Results: The final version of the scale contained 22 items and its total score ranged from 0 to 54. Conclusions: Pre-MEWS helps EMS staffs properly understand medical patients' conditions in pre-hospital environments and accurately identify their need for EMS and transportation.
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Affiliation(s)
- Abbasali Ebrahimian
- Nursing Care Research Center, Semnan University of Medical Sciences, Semnan, Iran
| | - Gholamreza Masoumi
- Emergency Management Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | | | - Hesam Seyedin
- Department of School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
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Grusd E, Kramer-Johansen J. Does the Norwegian emergency medical dispatch classification as non-urgent predict no need for pre-hospital medical treatment? An observational study. Scand J Trauma Resusc Emerg Med 2016; 24:65. [PMID: 27154472 PMCID: PMC4859986 DOI: 10.1186/s13049-016-0258-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 05/03/2016] [Indexed: 11/10/2022] Open
Abstract
Background The number of ambulance call-outs in Norway is increasing owing to societal changes and increased demand from the public. Together with improved but more expensive education of ambulance staff, this leads to increased costs and staffing shortages. We wanted to study whether the current dispatch triage tools could reliably identify patients who only required transport, and not pre-hospital medical care. This could allow selection of such patients for designated transport units, freeing up highly trained ambulance staff to attend patients in greater need. Methods A cross-sectional observational study was used, drawing on all electronic and paper records in our ambulance service from four random days in 2012. The patients were classified into acuity groups, based on Emergency Medical Dispatch codes, and pre-hospital interventions were extracted from the Patient Report Forms. Results Of the 1489 ambulance call-outs included in this study, 82 PRFs (5 %) were missing. A highly significant association was found between acuity group and recorded pre-hospital intervention (p ≤ 0.001). We found no correlation between gender, distance to hospital, age and pre-hospital interventions. Ambulances staffed by paramedics performed more interventions (234/917, 26 %) than those with emergency medical technicians (42/282, 15 %). The strongest predictor for needing pre-hospital interventions was found to be the emergency medical dispatch acuity descriptor. Discussion This study has demonstrated that the Norwegian dispatch system is able to correctly identify patients who do not need pre-hospital interventions. Patients with a low acuity code had a very low level of pre-hospital interventions. Evaluation of adherence to protocol in the Emergency Medical Dispatch is not possible due to the inherent need for medical experience in the triage process. Conclusions This study validates the Norwegian dispatch tool (Norwegian index) as a predictor of patients who do not need pre-hospital interventions.
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Affiliation(s)
- Eystein Grusd
- Institute of Health and Society, Faculty of Medicine, University of Oslo, PO Box 1130, Blindern, 0318, Oslo, Norway. .,Division of Prehospital Services, Ambulance Department, Oslo University Hospital HF, PO Box 4950, Nydalen, 0424, Oslo, Norway.
| | - Jo Kramer-Johansen
- Division of Prehospital Services, Ambulance Department, Oslo University Hospital HF, PO Box 4950, Nydalen, 0424, Oslo, Norway.,Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS), Oslo University Hospital and University of Oslo, Ullevål, PO Box 4950, Nydalen, 0424, Oslo, Norway
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The found down patient: A Western Trauma Association multicenter study. J Trauma Acute Care Surg 2016; 79:976-82; discussion 982. [PMID: 26488323 DOI: 10.1097/ta.0000000000000862] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Unconscious patients who present after being "found down" represent a unique triage challenge. These patients are selected for either trauma or medical evaluation based on limited information and have been shown in a single-center study to have significant occult injuries and/or missed medical diagnoses. We sought to further characterize this population in a multicenter study and to identify predictors of mistriage. METHODS The Western Trauma Association Multicenter Trials Committee conducted a retrospective study of patients categorized as found down by emergency department triage diagnosis at seven major trauma centers. Demographic, clinical, and outcome data were collected. Mistriage was defined as patients being admitted to a non-triage-activated service. Logistic regression was used to assess predictors of specified outcomes. RESULTS Of 661 patients, 33% were triaged to trauma evaluations, and 67% were triaged to medical evaluations; 56% of all patients had traumatic injuries. Trauma-triaged patients had significantly higher rates of combined injury and a medical diagnosis and underwent more computed tomographic imaging; they had lower rates of intoxication and homelessness. Among the 432 admitted patients, 17% of them were initially mistriaged. Even among properly triaged patients, 23% required cross-consultation from the non-triage-activated service after admission. Age was an independent predictor of mistriage, with a doubling of the rate for groups older than 70 years. Combined medical diagnosis and injury was also predictive of mistriage. Mistriaged patients had a trend toward increased late-identified injuries, but mistriage was not associated with increased length of stay or mortality. CONCLUSION Patients who are found down experience significant rates of mistriage and triage discordance requiring cross-consultation. Although the majority of found down patients are triaged to nontrauma evaluation, more than half have traumatic injuries. Characteristics associated with increased rates of mistriage, including advanced age, may be used to improve resource use and minimize missed injury in this vulnerable patient population. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Dami F, Golay C, Pasquier M, Fuchs V, Carron PN, Hugli O. Prehospital triage accuracy in a criteria based dispatch centre. BMC Emerg Med 2015; 15:32. [PMID: 26507648 PMCID: PMC4624668 DOI: 10.1186/s12873-015-0058-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 10/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Priority dispatch accuracy is a key issue in optimizing the match between patients' medical needs and pre-hospital resources. This study measures the accuracy of a Criteria Based Dispatch (CBD) system, by evaluating discrepancies between dispatch priorities and ambulance crews' severity evaluations. METHODS This is a retrospective study conducted from January 2011 to December 2011. We ruled that a National Advisory Committee for Aeronautics (NACA) score > 3 (injuries/diseases which can possibly lead to deterioration of vital signs) to 7 (lethal injuries/ diseases) should require a priority dispatch with lights and siren (L&S), while NACA scores < 4 should require a priority dispatch without L&S. Over triage was defined as the proportion of L&S dispatches with a NACA score < 4, and under triage as the proportion of dispatches without L&S with a NACA score > 3. RESULTS There were 29,008 primary missions in 2011, 1122 were excluded. Of the 15,749 L&S missions, 12,333 patients had a NACA score < 4, leading to an over triage rate of 78 %; 561 missions out of 12,137 missions without L&S had a NACA score > 3, leading to an under triage rate of 4.6 %. Sensitivity was 86 % (95 % confidence interval: 85.6-86.4 %), specificity 48 % (47.4-48.6 %), positive predictive value 21.7 % (21.2-22.2 %), and negative predictive value 95.4 % (95.2-95.6 %). CONCLUSION The rates of over triage and under triage in our CBD are 78 and 4.6 % respectively. The lack of consistent or universal metrics is perhaps the most important limitation in dispatch accuracy research. This is mainly due to the large heterogeneity of dispatch systems and prehospital emergency system.
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Affiliation(s)
- Fabrice Dami
- Dispatch centre, State of Vaud (Fondation Urgences-Santé), César-Roux 31, 1005, Lausanne, Switzerland.
- Department of Emergency Medicine, University Hospital Center (CHUV), Bugnon 46, 1011, Lausanne, Switzerland.
| | - Christel Golay
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
| | - Mathieu Pasquier
- Department of Emergency Medicine, University Hospital Center (CHUV), Bugnon 46, 1011, Lausanne, Switzerland.
| | - Vincent Fuchs
- Dispatch centre, State of Vaud (Fondation Urgences-Santé), César-Roux 31, 1005, Lausanne, Switzerland.
| | - Pierre-Nicolas Carron
- Department of Emergency Medicine, University Hospital Center (CHUV), Bugnon 46, 1011, Lausanne, Switzerland.
| | - Olivier Hugli
- Department of Emergency Medicine, University Hospital Center (CHUV), Bugnon 46, 1011, Lausanne, Switzerland.
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Ek B, Svedlund M. Registered nurses' experiences of their decision-making at an Emergency Medical Dispatch Centre. J Clin Nurs 2014; 24:1122-31. [PMID: 25273221 DOI: 10.1111/jocn.12701] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2014] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Bosse Ek
- Department of Nursing Sciences, Mid Sweden University, Östersund, Sweden
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Tobias AZ, Guyette FX, Seymour CW, Suffoletto BP, Martin-Gill C, Quintero J, Kristan J, Callaway CW, Yealy DM. Pre-resuscitation lactate and hospital mortality in prehospital patients. PREHOSP EMERG CARE 2014; 18:321-7. [PMID: 24548128 DOI: 10.3109/10903127.2013.869645] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Serum lactate elevations are associated with morbidity and mortality in trauma patients, but their value in prehospital medical patients prior to resuscitation is unknown. We sought to assess the distribution of blood lactate concentrations prior to intravenous (i.v.) resuscitation and examine the association of elevation on in-hospital death. METHODS A convenience sample of adult patients over 14 months who received an i.v. line by eight EMS agencies in Western Pennsylvania had lactate measurement prior to any i.v. treatment. We assessed the lactate values and any relationship between these and hospital mortality (our primary outcome) and admission to the intensive care unit (ICU). We also compared the ability of lactate to discriminate outcomes with a prehospital critical illness score using age, Glasgow Coma Score, and initial vital signs. RESULTS We included 673 patients, among whom 71 (11%) were admitted to the ICU and 21 (3.1%) died in-hospital. Elevated lactate (≥2 mmol/L) occurred in 307 (46%) patients and was strongly associated with hospital death after adjustment for known covariates (odds ratio = 3.57, 95% confidence interval [CI]: 1.10, 11.6). Lactate ≥2 mmol/L had a modest sensitivity (76%) and specificity (55%), and discrimination for hospital death (area under the curve [AUC] = 0.66, 95%CI: 0.56, 0.75). Compared to the prehospital critical illness score alone (AUC = 0.69, 95% CI: 0.59, 0.80), adding lactate to the score offered modest improvement (net reclassification improvement = 0.63, 95%CI: 0.23, 1.01, p < 0.05). CONCLUSIONS Initial lactate concentration in our prehospital medical patient population was associated with hospital mortality. However, it is a modest predictor of outcome, offering similar discrimination to a prehospital critical illness score.
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Hodell EM, Sporer KA, Brown JF. Which emergency medical dispatch codes predict high prehospital nontransport rates in an urban community? PREHOSP EMERG CARE 2013; 18:28-34. [PMID: 24028558 DOI: 10.3109/10903127.2013.825349] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The Medical Priority Dispatch System (MPDS) is a commonly used computer-based emergency medical dispatch (EMD) system that is widely used to prioritize 9-1-1 calls and optimize resource allocation. There are five major priority classes used to dispatch 9-1-1 calls in the San Francisco System; Alpha codes are the lowest priority (lowest expected acuity) and Echo are the highest priority. OBJECTIVE We sought to determine which MPDS dispatch codes are associated with high prehospital nontransport rates (NTRs). METHODS All unique MPDS call categories from 2009 in a highly urbanized, two-tier advanced life support (ALS) system were sorted according to highest NTRs. There are many reasons for nontransport, such as "gone on arrival," and "patient denied transport." Those categories with greater than 100 annual calls were further evaluated. MPDS groups that included multiple categories with NTRs exceeding 25% were then identified and each category was analyzed. Results. EMS responded to a total of 81,437 calls in 2009, of which 18,851 were not transported by EMS. The majority of the NTRs were found among "cardiac/ respiratory arrest/death," "assault/sexual assaults," "unknown problem/man down," "traffic/transportation accidents," and "unconscious/fainting." "Cardiac or respiratory arrest/death -obvious death" (9B1) had the highest overall nontransport rate, 99.25% (1/134), most likely due to declaration of death. "Unknown problem -man down -medical alert notification" had the second highest NTR, 67.22% (138/421). However, Echo priority codes had the highest overall nontransport rates (45.45%) and Charlie had the lowest (13.84%). CONCLUSIONS The nontransport rates of individual MPDS categories vary considerably and should be considered in any system design. We identified 52 unique call categories to have a 25% or greater NTR, 18 of which exceeded 40%. The majority of NTRs occurred among the "cardiac/respiratory arrest/death," "assault/sexual assaults," "unknown problem/man down," "traffic/transportation accidents," and "unconscious/fainting" categories. The higher the priority code within each subset (AB vs. CDE), the less likely the patient was to be transported. Charlie priority codes had a lower NTR than Delta, and Delta was lower than Echo. Charlie codes were therefore the strongest predictors of hospital transport, while Echo codes (highest priority) were those with the highest nontransport rates and were the worst predictors of hospital transport in the emergent subset.
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Affiliation(s)
- Evan M Hodell
- From the University of California, San Francisco, School of Medicine (EMH), San Francisco , California , USA ; the Department of Emergency Medicine (JFB), University of California , San Francisco, California , USA ; and Alameda County EMS Agency (KAS) , Oakland, California , USA
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How Well Do Emergency Medical Dispatch Codes Predict Prehospital Medication Administration in a Diverse Urban Community? J Emerg Med 2013; 44:413-422.e3. [DOI: 10.1016/j.jemermed.2012.02.086] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 08/09/2011] [Accepted: 02/26/2012] [Indexed: 11/22/2022]
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Hettinger AZ, Cushman JT, Shah MN, Noyes K. Emergency medical dispatch codes association with emergency department outcomes. PREHOSP EMERG CARE 2012; 17:29-37. [PMID: 23140195 DOI: 10.3109/10903127.2012.710716] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Emergency medical dispatch systems are used to help categorize and prioritize emergency medical services (EMS) resources for requests for assistance. OBJECTIVE We examined whether a subset of Medical Priority Dispatch System (MPDS) codes could predict patient outcomes (emergency department [ED] discharge versus hospital admission/ED death). METHODS This retrospective observational cohort study analyzed requests for EMS through a single public safety answering point (PSAP) serving a mixed urban, suburban, and rural community over one year. Probabilistic matching was used to link subjects. Descriptive statistics, 95% confidence intervals (CIs), and logistic regression were calculated for the 107 codes and code groupings (9E vs. 9E1, 9E2, etc.) that were used 50 or more times during the study period. RESULTS Ninety percent of PSAP records were matched to EMS records and 84% of EMS records were matched to ED data, resulting in 26,846 subjects with complete records. The average age of the cohort was 46.2 years (standard deviation [SD] 24.8); 54% were female. Of the transported patients, 70% were discharged from the ED, with nine dispatch codes demonstrating a 90% or greater predictive power. Three code groupings had more than 60% predictive power for admission/death. Subjects aged 65 years and older were found to be at increased risk for admission/death in 33 dispatch codes (odds ratio [OR] 2.0 [95% confidence interval 1.3-3.0] to 19.6 [5.3-72.6]). CONCLUSIONS A small subset (8% of codes; 7% by call volume) of MPDS codes were associated with greater than 90% predictive ability for ED discharge. Older adults are at increased risk for admission/death in a separate subset of MPDS codes, suggesting that age criteria may be useful to identify higher-acuity patients within the MPDS code. These findings could assist in prehospital/hospital resource management; however, future studies are needed to validate these findings for other EMS systems and to investigate possible strategies for improvements of emergency response systems.
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Affiliation(s)
- A Zachary Hettinger
- Department of Emergency Medicine, MedStar Washington Hospital Center/MedStar, Washington, DC 20010, USA.
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Association between Patient Unconscious or Not Alert Conditions and Cardiac Arrest or High-Acuity Outcomes within the Medical Priority Dispatch System “Falls” Protocol. Prehosp Disaster Med 2012; 25:302-8. [DOI: 10.1017/s1049023x00008232] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractIntroduction:Falls are one of the most common types of complaints received by 9-1-1 emergency medical dispatch centers. They can be accidental or may be caused by underlying medical problems. Though not alert” falls patients with severe outcomes mostly are “hot” transported to the hospital, some of these cases may be due to other acute medical events (cardiac, respiratory, circulatory, or neurological), which may not always be apparent to the emergency medical dispatcher (EMD) during call processing.Objectives:The objective of this study was to characterize the risk of cardiac arrest and “hot-transport” outcomes in patients with “not alert” condition, within the Medical Priority Dispatch System (MPDS®) Falls protocol descriptors.Methods:This retrospective study used 129 months of de-identified, aggregate, dispatch datasets from three US emergency communication centers. The communication centers used the Medical Priority Dispatch System version 11.3–OMEGA type (released in 2006) to interrogate Emergency Medical System callers, select dispatch codes assigned to various response configurations, and provide pre-arrival instructions. The distribution of cases and percentages of cardiac arrest and hot-transport outcomes, categorized by MPDS® code, was profiled. Assessment of the association between MPDS® Delta-level 3 (D-3) “not alert” condition and cardiac arrest and hot-transport outcomes then followed.Results:Overall, patients within the D-3 and D-2 “long fall” conditions had the highest proportions (compared to the other determinants in the “falls” protocol) of cardiac arrest and hot-transport outcomes, respectively. “Not alert” condition was associated significantly with cardiac arrest and hot-transport outcomes (p < 0.001).Conclusions:The “not alert” determinant within the MPDS® “fall” protocol was associated significantly with severe outcomes for short falls (<6 feet; 2 meters) and ground-level falls. As reported to 9-1-1, the complaint of a “fall” may include the presence of underlying conditions that go beyond the obvious traumatic injuries caused by the fall itself.
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Does Emergency Medical Dispatch Priority Predict Delphi Process-Derived Levels of Prehospital Intervention? Prehosp Disaster Med 2012; 25:309-17. [DOI: 10.1017/s1049023x00008244] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:The Medical Priority Dispatch System (MPDS) is an emergency medical dispatch system widely used to prioritize 9-1-1 calls and optimize resource allocation. This study evaluates whether the assigned priority predicts a Delphi process-derived level of prehospital intervention in each emergency medical dispatch category.Methods:All patients given a MPDS priority in a suburban California county from 2004–2006 were included. A Delphi process of emergency medical services (EMS) professionals in another system developed the following categories of prehospital treatment representing increasing acuity, which were adapted for this study: advanced life support (ALS) intervention, ALS–Stat, and ALS–Critical. The sensitivities and specificities of MPDS priority for level of prehospital intervention were determined for each MPDS category.Results:A total of 65,268 patients met inclusion criteria, representing 61% of EMS calls during the study period. The overall sensitivities of high-priority dispatch codes for ALS, ALS-Stat, and ALS-Critical interventions were 83% (95% confidence interval 83–84%), 83% (82–84%), and 94% (92–96%). Overall specificities were: ALS, 32% (31–32%); ALS-Stat, 31% (30–31%); and ALS-Critical 28% (28–29%). Compared to calls assigned to a low priority, calls with high-priority dispatch codes were more likely to receive ALS interventions by 22%, ALS-Stat by 20%, and ALS-Critical by 32%. A low priority dispatch code decreased the likelihood of ALS interventions by 48%, ALS-Stat by 45%, and ALS-Critical by 80%. Among high-priority dispatch codes, the rates of interventions were: ALS 26%, ALS-Stat 22%, and ALS-Critical 1.5%, all of which were significantly greater than low-priority calls (p <0.05) [ALS 13%, ALS-Stat 11%, and ALS-Critical 0.2%]. Major MPDS were categories with high sensitivities (>95%) for ALS interventions included breathing problems, cardiac or respiratory arrest/death, chest pain, stroke, and unconscious/fainting; these categories had an average specificity of 3%. Medical Priority Dispatch System categories such as back pain, unknown problem, and traumatic injury had sensitivities for ALS interventions <15%.Conclusions:The MPDS is moderately sensitive for the Delphi process derived ALS, ALS-Stat, and ALS-Critical intervention levels, but non-specific. A low MPDS priority is predictive of no prehospital intervention. A high priority, however, is of little predictive value for ALS, ALS-Stat, or ALSCritical interventions.
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Studnek JR, Thestrup L, Blackwell T, Bagwell B. Utilization of Prehospital Dispatch Protocols to Identify Low-Acuity Patients. PREHOSP EMERG CARE 2012; 16:204-9. [DOI: 10.3109/10903127.2011.640415] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ek B, Edström P, Toutin A, Svedlund M. Reliability of a Swedish pre-hospital dispatch system in prioritizing patients. Int Emerg Nurs 2011; 21:143-9. [PMID: 23615523 DOI: 10.1016/j.ienj.2011.11.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 11/29/2011] [Accepted: 11/30/2011] [Indexed: 11/15/2022]
Abstract
The need of emergency help often begins with a call to a dispatch center. The operator uses a medical index to prioritize dispatches. Since the resources of ambulances are limited, it is important that the priority grading decided by the operator at the dispatch center is as adequate as possible. In the county of Jamtland in Sweden, a system for triage named METTS-A (Medical Emergency Triage and Treatment System-A) has been in use since 2009, when the patient is coded according to priority level. The aim of this study was to analyse the sensitivity and specificity of the priority grading made by the dispatch center in comparison with the METTS-A priority assessed by the ambulance nurse. Statistics from a data-base in northern Sweden were analyzed. The material covered every ambulance that was dispatched, 6986 times during the period of data collecting. The results show a high sensitivity but low specificity in the dispatch system. The results also indicate that over prioritization exists since most of the patients with a high acute need of an ambulance are correctly identified, while many patients without that need are also given a high priority ambulance service. Therefore the conclusions were that both over- and under prioritizations were made.
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Affiliation(s)
- Bosse Ek
- Department of Health Sciences, Mid Sweden University, Östersund, Sweden
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Millin MG, Brown LH, Schwartz B. EMS provider determinations of necessity for transport and reimbursement for EMS response, medical care, and transport: combined resource document for the National Association of EMS Physicians position statements. PREHOSP EMERG CARE 2011; 15:562-9. [PMID: 21797787 DOI: 10.3109/10903127.2011.598625] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
With increasing demands for emergency medical services (EMS), many EMS jurisdictions are utilizing EMS provider-initiated nontransport policies as a method to offload potentially nonemergent patients from the EMS system. EMS provider determination of medical necessity, resulting in nontransport of patients, has the potential to avert unnecessary emergency department visits. However, EMS systems that utilize these policies must have additional education for the providers, a quality improvement process, and active physician oversight. In addition, EMS provider determination of nontransport for a specific situation should be supported by evidence in the peer-reviewed literature that the practice is safe. Further, EMS systems that do not utilize these programs should not be financially penalized. Payment for EMS services should be based on the prudent layperson standard. EMS systems that do utilize nontransport policies should be appropriately reimbursed, as this represents potential cost savings to the health care system.
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Affiliation(s)
- Michael G Millin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21209, USA.
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Acute chest pain - a prospective population based study of contacts to Norwegian emergency medical communication centres. BMC Emerg Med 2011; 11:9. [PMID: 21777448 PMCID: PMC3155474 DOI: 10.1186/1471-227x-11-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Accepted: 07/21/2011] [Indexed: 11/21/2022] Open
Abstract
Background Acute chest pain is a frequently occurring symptom in patients with medical emergencies and imposes potentially life threatening situations outside hospitals. Little is known about the epidemiology of patients with acute chest pain in a primary care setting in Norway, and we aimed to obtain more representative data on such patients using data from emergency medical communication centres (EMCCs). Methods Data were collected prospectively during three months in 2007 from three EMCCs, covering 816 000 inhabitants. The EMCCs gathered information on every situation that was triaged as a red response (defined as an "acute" response, with the highest priority), according to the Norwegian Index of Medical Emergencies. Records from ambulances and primary care doctors were subsequently collected. International Classification of Primary Care - 2 symptom codes and The National Committee on Aeronautics (NACA) System scores were assigned retrospectively. Only chest pain patients were included in the study. Results 5 180 patients were involved in red response situations, of which 21% had chest pain. Estimated rate was 5.4 chest pain cases per 1000 inhabitants per year. NACA-scores indicated that 26% of the patients were in a life-threatening medical situation. Median prehospital response time was 13 minutes; an ambulance reached the patient in less than 10 minutes in 30% of the cases. Seventy-six per cent of the patients with chest pain were admitted to a hospital for further investigation, 14% received final treatment at a casualty clinic, while 10% had no further investigation by a doctor ("left at the scene"). Conclusions The majority of patients with acute chest pain were admitted to a hospital for further investigation, but only a quarter of the patients were assessed prehospitally to have a severe illness. This sheds light on the challenges for the EMCCs in deciding the appropriate level of response in patients with acute chest pain. Overtriage is to some extent both expected and desirable to intercept all patients in need of immediate help, but it is also well known that overtriage is resource demanding. Further research is needed to elucidate the challenges in the diagnosis and management of chest pain outside hospitals.
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Michael GE, O'Connor RE. The diagnosis and management of seizures and status epilepticus in the prehospital setting. Emerg Med Clin North Am 2010; 29:29-39. [PMID: 21109100 DOI: 10.1016/j.emc.2010.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Seizure is one of the most common complaints encountered in the prehospital setting. In this review the authors discuss the prehospital management of seizures and review the evidence for specific treatment approaches. Specific attention is devoted to prehospital care of the pediatric seizure patient. Topics of interest to Emergency Medical Services directors such as patient refusal, resource allocation, and dispatch priority are also addressed.
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Affiliation(s)
- Glen E Michael
- Department of Emergency Medicine, University of Virginia School of Medicine, PO Box 800699, Charlottesville, VA 22908, USA
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Martin-Gill C, Hostler D, Callaway CW, Prunty H, Roth RN. Management of prehospital seizure patients by paramedics. PREHOSP EMERG CARE 2010; 13:179-84. [PMID: 19291554 DOI: 10.1080/10903120802706229] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Seizure patients are frequently encountered in the prehospital environment and have the potential to need advanced interventions, though the utility of advanced life support (ALS) interventions in many of these patients has not been proven. OBJECTIVE Our goals were to assess the management of prehospital seizure patients by paramedics in an urban EMS system with an existing ALS-based prehospital seizure protocol and to assess characteristics and short-term outcomes that may aid in addressing the utility of specific ALS interventions. METHODS This was a retrospective study of 97 EMS cases with the chief complaint of seizure. Prehospital records were reviewed for patient and event characteristics, including past seizure history, seizure timing, level of consciousness, on-scene and transport times, and EMS interventions. Emergency department (ED) records were reviewed for recurrence of seizure activity, ED evaluation, and disposition. Data were analyzed using descriptive statistics and Student t-test. RESULTS Of 87 patients meeting the protocol inclusion criteria for all ALS interventions, 11 (12.6%) received cardiac monitoring, 55 (63.2%) had intravenous (IV) access attempted, and 56 (64.4%) had blood glucose determination. Average on-scene time was 5.9 minutes longer if IV access was attempted (p = 0.001), though transport times were not significantly different (11.6 versus 11.3 minutes, respectively; p = 0.851). Additional seizure activity occurred in the prehospital and/or ED settings in 28 patients (28.9% of all cases), including 17 in the prehospital setting and 15 in the ED. Diazepam was administered by EMS for half of the eight (8.2%) patients who had seizures lasting more than 1 minute, while the remainder had seizures that were focal or spontaneously resolved. CONCLUSION This study showed a lower-than-anticipated level of compliance with an ALS-based prehospital seizure protocol, though patient-specific care appeared appropriate. Prehospital seizure patients have the potential for seizure recurrence and may benefit from focused ALS interventions, but their heterogeneity makes uniform protocols difficult to develop and follow.
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Affiliation(s)
- Christian Martin-Gill
- University of Pittsburgh Affiliated Residency in Emergency Medicine, Pittsburgh, Pennsylvania, USA
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Johnson NJ, Sporer KA. How many emergency dispatches occurred per cardiac arrest? Resuscitation 2010; 81:1499-504. [PMID: 20638764 DOI: 10.1016/j.resuscitation.2010.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Revised: 06/12/2010] [Accepted: 06/17/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND The Medical Priority Dispatch System (MPDS) is an emergency medical dispatch (EMD) system that is widely used to prioritize 9-1-1 calls and optimize resource allocation. Calls are assigned an MPDS determinant, which includes a number (1-32) representing chief complaint and priority (Alpha through Echo) representing acuity. OBJECTIVE This study evaluates the number of emergency dispatches per cardiac arrest (NOD-CA) in cardiac arrest and non-cardiac arrest MPDS determinants. METHODS All patients assigned a determinant by MPDS from January 1, 2008 to June 30, 2009 in a large metropolitan area were included. Prehospital electronic patient care records were linked with dispatch data. For each MPDS determinant, the number of calls for which the paramedic impression was listed as "Cardiac Arrest - Non-Traumatic" was tabulated. The NOD-CA was calculated for each cardiac arrest and non-cardiac arrest MPDS determinant. Non-MPDS calls with cardiac arrests were analyzed separately. RESULTS A total of 101,642 patients were included. Among them, 555 had "Cardiac Arrest - Non-Traumatic" listed as the paramedic impression. The Cardiac/Respiratory Arrest/Death protocol had the highest number of cardiac arrests (285), followed by Breathing Problems (99) and Unconscious/Fainting (76). Overall, 183 dispatched occurred for each cardiac arrest, 131 of which resulted in a lights and sirens response. The NOD-CA was 7 in the Cardiac Arrest/Death protocol, 122 in Breathing Problems, and 104 in Unconscious/Fainting. 31 Cardiac arrests occurred in non-MPDS dispatch categories (N=62,989), most of which were calls for medical assistance from police or fire units. CONCLUSIONS MPDS was designed to detect cardiac arrest with high sensitivity, leading to a significant degree of mistriage. The number of dispatches for each cardiac arrest may be a useful way to quantify the degree of mistriage and optimize EMS dispatch. This large descriptive study revealed a low NOD-CA in most cardiac arrest MPDS determinants. We demonstrated significant variability in the NOD-CA among non-cardiac arrest MPDS determinants, and few cardiac arrests in non-MPDS dispatch categories.
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Craig AM, Verbeek PR, Schwartz B. Evidence-based optimization of urban firefighter first response to emergency medical services 9-1-1 incidents. PREHOSP EMERG CARE 2010; 14:109-17. [PMID: 19947875 DOI: 10.3109/10903120903349754] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Many emergency medical services (EMS) systems dispatch nonparamedic firefighter first responders (FFRs) to selected EMS 9-1-1 calls, intending to deliver time-sensitive interventions such as defibrillation, cardiopulmonary resuscitation (CPR), and bag-mask ventilation prior to arrival of paramedics. Deciding when to send FFRs is complicated because critical cases are rare, paramedics often arrive before FFRs, and lights-and-siren responses by emergency vehicles are associated with the risk of en-route traffic collisions. OBJECTIVE To describe a methodology allowing EMS systems to optimize their own FFR programs using local data, and reflecting local medical oversight policy and local risk-benefit opinion. METHODS We constructed a generalized input-output model that retrospectively reviews EMS dispatch and electronic prehospital clinical records to identify a subset of Medical Priority Dispatch System (MPDS) call categories ("determinants") that maximize the opportunities for FFR interventions while minimizing unwarranted responses. Input parameters include local FFR interventions, the local FFR "first-on-scene" rate, and the locally acceptable ratio of risk to benefit. The model uses a receiver-operating characteristic (ROC) curve to identify the optimal mix of response specificity and sensitivity achieved by sending FFRs to progressively more categories of EMS calls while remaining within a defined risk-benefit ratio. The model was applied to a 16-month retrospective sample of 220,358 incidents from a large urban EMS system to compare the model's recommendations with the system's current practices. RESULTS The model predicts that FFR lights-and-siren responses in the sample could be reduced by 83%, from 93,058 to 16,091 incidents, by confining FFR responses to 27 of 509 MPDS dispatch determinants, representing 7.3% of incidents but 58.9% of all predicted FFR interventions. Of the 93,058 incidents, another 58,275 incidents could be downgraded to safer nonemergency FFR responses and 18,692 responses could be eliminated entirely, improving the specificity of FFR response from 57.8% to 93.0%. CONCLUSIONS This model provides a robust generalized methodology allowing EMS systems to optimize FFR lights-and-siren responses to emergency medical calls. Further validation is warranted to assess the model's generality.
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Affiliation(s)
- Alan M Craig
- Toronto Emergency Medical Services, Ontario, Canada.
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Zakariassen E, Hunskaar S. Involvement in emergency situations by primary care doctors on-call in Norway--a prospective population-based observational study. BMC Emerg Med 2010; 10:5. [PMID: 20205933 PMCID: PMC2848227 DOI: 10.1186/1471-227x-10-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Accepted: 03/06/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Primary care doctors on-call in the emergency primary health care services in Norway are, together with the ambulances, the primary resources for handling emergencies outside hospitals. There is a lack of reliable data for Norway on how often the primary care doctors are alerted and on their responses in the most urgent emergency cases. The aim of this study was to investigate how doctors on-call are involved in red responses (highest priority), using three different emergency medical communication centres (EMCC) as catchment area for a prospective population-based study. METHODS In the period from October to December 2007 three dispatch centres covering approximately 816,000 inhabitants prospectively recorded all acute emergency cases. Ambulance records, air ambulance records and records from the doctors on-call were collected. NACA score was used to define the severity of the emergencies. RESULTS 5,105 cases were classified as red responses during the period. We have complete basic recordings (AMIS forms) from all and resaved ambulance records, air ambulance records and records from doctors on-call in 89% of the cases. Ambulances were alerted in 96% and doctors on-call in 47% of the cases, but there were large differences between the three EMCCs. Doctors on-call responded with call-out in 42% of the alerted cases. 28% of all patients were taken to a casualty clinic, 46% were admitted to hospital by a doctor and 24% were taken directly to hospital by ambulances. In total, primary care doctors on-call took active part in 42% of all red response cases, and together with GPs' daytime activity the primary health care services were involved in 50% of the cases. 29% of the cases were classified as life-threatening. Call-out by doctors on-call were found to be more frequent in life-threatening situations compared with not life-threatening situations. CONCLUSION Doctors on-call and GPs on daytime were involved in half of all red responses. There were large differences between the EMCCs in the frequency of doctors alerted. The inhabitants in the three EMMCs were thus offered different levels of professional competency in emergency situations outside hospitals.
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Affiliation(s)
- Erik Zakariassen
- Department of Research, Norwegian Air Ambulance Foundation, Box 94, Drøbak, Norway.
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Zakariassen E, Burman RA, Hunskaar S. The epidemiology of medical emergency contacts outside hospitals in Norway--a prospective population based study. Scand J Trauma Resusc Emerg Med 2010; 18:9. [PMID: 20167060 PMCID: PMC2836273 DOI: 10.1186/1757-7241-18-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 02/18/2010] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION There is a lack of epidemiological knowledge on medical emergencies outside hospitals in Norway. The aim of the present study was to obtain representative data on the epidemiology of medical emergencies classified as "red responses" in Norway. METHOD Three emergency medical dispatch centres (EMCCs) were chosen as catchment areas, covering 816 000 inhabitants. During a three month period in 2007 the EMCCs gathered information on every situation that was triaged as a red response, according to The Norwegian Index of Medical Emergencies (Index). Records from ground ambulances, air ambulances, and the primary care doctors were subsequently collected. International Classification of Primary Care-2 symptom codes (ICPC-2) and The National Committee on Aeronautics (NACA) Score System were given retrospectively. RESULTS Total incidence of red response situations was 5 105 during the three month period. 394 patients were involved in 138 accidents, and 181 situations were without patients, resulting in a total of 5 180 patients. The patients' age ranged from 0 to 107 years, with a median age of 57, and 55% were male. 90% of the red responses were medical problems with a large variation of symptoms, the remainder being accidents. 70% of the patients were in a non-life-threatening situation. Within the accident group, males accounted for 61%, and 35% were aged between 10 and 29 years, with a median age of 37 years. Few of the 39 chapters in the Index were used, A10 "Chest pain" was the most common one (22% of all situations). ICPC-2 symptom codes showed that cardiovascular, syncope/coma, respiratory and neurological problems were most common. 50% of all patients in a sever situation (NACA score 4-7) were > 70 years of age. CONCLUSIONS The results show that emergency medicine based on 816 000 Norwegians mainly consists of medical problems, where the majority of the patients have a non-life-threatening situation. More focus on the emergency system outside hospitals, including triage and dispatch, and how to best deal with "everyday" emergency problems is needed to secure knowledge based decisions for the future organization of the emergency system.
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Affiliation(s)
- Erik Zakariassen
- National Centre for Emergency Primary Health Care, Uni Health, Bergen, Norway, Kalfarveien 31, 5018 Bergen, Norway.
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Brown LH, Hubble MW, Cone DC, Millin MG, Schwartz B, Patterson PD, Greenberg B, Richards ME. Paramedic determinations of medical necessity: a meta-analysis. PREHOSP EMERG CARE 2010; 13:516-27. [PMID: 19731166 DOI: 10.1080/10903120903144809] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Reducing unnecessary ambulance transports may have operational and economic benefits for emergency medical services (EMS) agencies and receiving emergency departments. However, no consensus exists on the ability of paramedics to accurately and safely identify patients who do not require ambulance transport. Objective. This systematic review and meta-analysis evaluated studies reporting U.S. paramedics' ability to determine medical necessity of ambulance transport. METHODS PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library databases were searched using Cochrane Prehospital and Emergency Care Field search terms combined with the Medical Subject Headings (MeSH) terms "triage"; "utilization review"; "health services misuse"; "severity of illness index," and "trauma severity indices." Two reviewers independently evaluated each title to identify relevant studies; each abstract then underwent independent review to identify studies requiring full appraisal. Inclusion criteria were original research; emergency responses; determinations of medical necessity by U.S. paramedics; and a reference standard comparison. The primary outcome measure of interest was the negative predictive value (NPV) of paramedic determinations. For studies reporting sufficient data, agreement between paramedic and reference standard determinations was measured using kappa; sensitivity, specificity, and positive predictive value (PPV) were also calculated. RESULTS From 9,752 identified titles, 214 abstracts were evaluated, with 61 studies selected for full review. Five studies met the inclusion criteria (interrater reliability, kappa = 0.75). Reference standards included physician opinion (n = 3), hospital admission (n = 1), and a composite of physician opinion and patient clinical circumstances (n = 1). The NPV ranged from 0.610 to 0.997. Results lacked homogeneity across studies; meta-analysis using a random-effects model produced an aggregate NPV of 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported complete 2 x 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823. CONCLUSION The results of the few studies evaluating U.S. paramedic determinations of medical necessity for ambulance transport vary considerably, and only two studies report complete data. The aggregate NPV of the paramedic determinations is 0.91, with a lower confidence limit of 0.71. These data do not support the practice of paramedics' determining whether patients require ambulance transport. These findings have implications for EMS systems, emergency departments, and third-party payers.
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Affiliation(s)
- Lawrence H Brown
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA.
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Cone DC, Galante N, MacMillan DS. Can Emergency Medical Dispatch Systems Safely Reduce First-Responder Call Volume? PREHOSP EMERG CARE 2009; 12:479-85. [DOI: 10.1080/10903120802290844] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sporer KA, Johnson NJ, Yeh CC, Youngblood GM. Can emergency medical dispatch codes predict prehospital interventions for common 9-1-1 call types? PREHOSP EMERG CARE 2009; 12:470-8. [PMID: 18924011 DOI: 10.1080/10903120802290877] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The Medical Priority Dispatch System is an emergency medical dispatch (EMD) system that is widely used to categorize 9-1-1 calls and optimize resource allocation. This study evaluates the ability of EMD and non-EMD codes (calls not processed by EMD) to predict prehospital use of medications and procedures. METHODS All transported prehospital patients placed in an EMD or non-EMD category that exceeded 500 total calls from January 1, 2004, to December 31, 2006, in a suburban California county were matched with their prehospital electronic patient care record. These records (N = 69,541) were queried for the following prehospital interventions: basic life support (BLS) care only, intravenous line placement only, medication given, and procedures. Advanced life support (ALS) interventions were defined as the administration of a medications or a procedure. The numbers of medications and procedures that were performed on patients in each EMD code were measured. RESULTS Thirty-one of 141 EMD and non-EMD codes met inclusion criteria and comprised 73% of all calls during the study period. Non-EMD codes accounted for 48% of all calls in this study. Patients with shortness of breath, chest pain, diabetic problems, and altered mental status received the most medications. High rates of medication administration were also seen in the following codes: 17A (fall, 27%), 17B (fall, 14%), EMDX (unable to complete EMD process, 22%), MED (medical aid requested--details to follow, 26%), and MED3 (medical aid requested by police--code 3, 18%). Procedures were performed on only 0.9% of all calls, of which 75% were related to advanced airways. Higher rates of ALS interventions in higher-acuity categories (Alpha, Bravo, etc.) were seen in a number of EMD categories, including seizure, laceration/hemorrhage, sick, and traffic accident, but not seen in many categories, including abdominal pain, falls, and chest pain. CONCLUSIONS This study demonstrated only a modest ability of the EMD system to predict which patients would require ALS intervention. There were limited differences noted in the ALS rates between the different codes (Alpha, Bravo, etc.) in the same complaint category, bringing into question the utility of the multiple subgroups. Non-EMD codes made up a large portion of calls (48%) and should be included in future studies.
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Affiliation(s)
- Karl A Sporer
- Department of Emergency Medicine, University of California, San Francisco, California, USA.
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Clawson J, Olola C, Heward A, Patterson B, Scott G. The Medical Priority Dispatch System's ability to predict cardiac arrest outcomes and high acuity pre-hospital alerts in chest pain patients presenting to 9-9-9. Resuscitation 2008; 78:298-306. [DOI: 10.1016/j.resuscitation.2008.03.229] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 03/13/2008] [Accepted: 03/24/2008] [Indexed: 10/21/2022]
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Intestinal Evisceration From Transanal Suction. Prehosp Disaster Med 2005. [DOI: 10.1017/s1049023x00013789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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The Role of Media in Disaster Management: A Case Study With Nigerian Television Authority (NTA). Prehosp Disaster Med 2005. [DOI: 10.1017/s1049023x00013777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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