Safety of telephone consultation for "non-serious" emergency ambulance service patients

Clinical decision support system in emergency telephone triage: A scoping review of technical design, implementation and evaluation

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.

Increasing emergency number utilisation is not driven by low-acuity calls: an observational study of 1.5 million emergency calls (2018-2021) from Berlin

BACKGROUND

The Emergency Medical Service (EMS) in Germany is increasingly challenged by strongly rising demand. Speculations about a greater utilisation for minor cases have led to intensive media coverage, but empirical evidence is lacking. We investigated the development of low-acuity calls from 2018 to 2021 in the federal state of Berlin and its correlations with sociodemographic characteristics.

METHODS

We analysed over 1.5 million call documentations including medical dispatch codes, age, location and time using descriptive and inferential statistics and multivariate binary logistic regression. We defined a code list to classify low-acuity calls and merged the dataset with sociodemographic indicators and data on population density.

RESULTS

The number of emergency calls (phone number 112 in Germany) increased by 9.1% from 2018 to 2021; however, the proportion of low-acuity calls did not increase. The regression model shows higher odds of low-acuity for young to medium age groups (especially for age 0-9, OR 1.50 [95% CI 1.45-1.55]; age 10-19, OR 1.77 [95% CI 1.71-1.83]; age 20-29, OR 1.64 [95% CI 1.59-1.68] and age 30-39, OR 1.40 [95% CI 1.37-1.44]; p < 0.001, reference group 80-89) and for females (OR 1.12 [95% CI 1.1-1.13], p < 0.001). Odds were slightly higher for calls from a neighbourhood with lower social status (OR 1.01 per index unit increase [95% CI 1.0-1.01], p < 0.05) and at the weekend (OR 1.02 [95% CI 1.0-1.04, p < 0.05]). No significant association of the call volume with population density was detected.

CONCLUSIONS

This analysis provides valuable new insights into pre-hospital emergency care. Low-acuity calls were not the primary driver of increased EMS utilisation in Berlin. Younger age is the strongest predictor for low-acuity calls in the model. The association with female gender is significant, while socially deprived neighbourhoods play a minor role. No statistically significant differences in call volume between densely and less densely populated regions were detected. The results can inform the EMS in future resource planning.

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

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

[Pre-emptive emergency service-Preventive missions and promotion of health literacy at the intersections with emergency medical services]

In the Emergency Medical Service Acts of the Federal States, the statements in these Acts have so far essentially been limited to the implementation of measures to maintain the health of emergency patients and to transport them to a suitable hospital. Preventive fire protection, on the other hand, is regulated in the Fire Brigade Acts or by statutory ordinances. Increasing numbers of emergency service missions and a lack of facilities for alternative care justify the need for a preventive emergency service. This includes all measures that take place before an event occurs in order to prevent emergencies from occurring. As a result, the risk of an emergency event leading to the emergency call 112 should be reduced or delayed. The preventive rescue service should also help to improve the outcome of medical care for patients. Furthermore, it should be made possible to provide those seeking help with a suitable form of care at an early stage.

Perception and Attitude toward Teleconsultations among Different Healthcare Professionals in the Era of the COVID-19 Pandemic

Teleconsultation has become one of the most important and sometimes the only possible forms of communication between healthcare professionals (HCPs) and their patients during the COVID-19 pandemic. The perceptions and attitudes of HCPs to teleconsultations may affect the quality of the therapeutic process provided using them. Therefore, this study aimed to understand the attitudes to and perceptions of medical teleconsultation among various HCPs during the COVID-19 pandemic. We analyzed data from a dedicated questionnaire on preferences, attitudes, and opinions about teleconsultation, which was filled by 780 Polish HCPs. Most of the HCPs were doctors and nurses (69% and 19%, respectively); most of the doctors were family physicians (50.1%). During the pandemic, teleconsultation and face-to-face contact were reported as the preferred methods of providing medical services with similar frequency. Doctors and nurses displayed the most positive attitude toward teleconsultation while the paramedics and physiotherapists took the least positive view of it. The most frequently indicated ratio of the optimal number of teleconsultations to in-person visits in primary health facilities care was 20%:80%. Most HCPs appreciate the value of teleconsultation, and more than half of them are willing to continue this form of communication with the patient when necessary or desirable.

Outpatient care in acute and prehospital emergency medicine by emergency medical and patient transport service over a 10-year period: a retrospective study based on dispatch data from a German emergency medical dispatch centre (OFF-RESCUE)

Background

The number of operations by the German emergency medical service almost doubled between 1994 and 2016. The associated expenses increased by 380% in a similar period. Operations with treatment on-site, which retrospectively proved to be misallocated (OFF-Missions), have a substantial proportion of the assignment of the emergency medical service (EMS). Besides OFF-Missions, operations with patient transport play a dominant role (named as ON-Missions). The aim of this study is to work out the medical and economic relevance of both operation types.

Methods

This analysis examined N = 819,780 missions of the EMS and patient transport service (PTS) in the catchment area of the emergency medical dispatch centre (EMDC) Bad Kreuznach over the period from 01/01/2007 to 12/31/2016 in terms of triage and disposition, urban-rural distribution, duration of operations and economic relevance (p < .01).

Results

53.4% of ON-Missions are triaged with the indication non-life-threatening patient transport; however, 63.7% are processed by the devices of the EMS. Within the OFF-Mission cohort, 78.2 and 85.8% are triaged or dispatched for the EMS. 74% of all ON-Missions are located in urban areas, 26% in rural areas; 81.3% of rural operations are performed by the EMS. 66% of OFF-Missions are in cities. 93.2% of the remaining 34% of operations in rural locations are also performed by the EMS. The odds for both ON- and OFF-Missions in rural areas are significantly higher than for PTS (OR_ON 3.6, 95% CI 3.21–3.30; OR_OFF 3.18, 95% CI 3.04–3.32). OFF-Missions last 47.2 min (SD 42.3; CI 46.9–47.4), while ON-Missions are processed after 79.7 min on average (SD 47.6; CI 79.6–79.9). ON-Missions generated a turnover of more than € 114 million, while OFF-Missions made a loss of almost € 13 million.

Conclusions

This study particularly highlights the increasing utilization of emergency devices; especially in OFF-Missions, the resources of the EMS have a higher number of operations than PTS. OFF-Missions cause immensely high costs due to misallocations from an economic point of view. Appropriate patient management appears necessary from both medical and economic perspective, which requires multiple solution approaches.

The Development of Consensus-Based Descriptors for Low-Acuity Emergency Medical Services Cases for the South African Setting

INTRODUCTION

Emergency Medical Services (EMS) are designed to respond to and manage patients experiencing life-threatening emergencies; however, not all emergency calls are necessarily emergent and of high acuity. Emergency responses to low-acuity patients affect not only EMS, but other areas of the health care system. However, definitions of low-acuity calls are vague and subjective; therefore, it was necessary to provide a clear description of the low-acuity patient in EMS.

AIM

The goal of this study was to develop descriptors for "low-acuity EMS patients" through expert consensus within the EMS environment.

METHODS

A Modified Delphi survey was used to develop call-out categories and descriptors of low acuity through expert opinion of practitioners within EMS. Purposive, snowball sampling was used to recruit 60 participants, of which 29 completed all three rounds. An online survey tool was used and offered both binary and free-text options to participants. Consensus of 75% was accepted on the binary options while free text offered further proposals for consideration during the survey.

RESULTS

On completion of round two, consensus was obtained on 45% (70/155) of the descriptors, and a further 30% (46/155) consensus was obtained in round three. Experts felt that respiratory distress, unconsciousness, chest pain, and severe hemorrhage cannot be considered low acuity. For other emergency response categories, specific descriptors were offered to denote a case as low acuity.

CONCLUSION

Descriptors of low acuity in EMS are provided in both medical and trauma cases. These descriptors may not only assist in the reduction of unnecessary response and transport of patients, but also assist in identifying the most appropriate response of EMS resources to call-outs. Further development and validation are required of these descriptors in order to improve accuracy and effectiveness within the EMS dispatch environment.

Effectiveness of hospital emergency department regionalization and categorization policy on appropriate patient emergency care use: a nationwide observational study in Taiwan

BACKGROUND

Emergency department (ED) overcrowding is a health services issue worldwide. Modern health policy emphasizes appropriate health services utilization. However, the relationship between accessibility, capability, and appropriateness of ED use is unknown. Thus, this study aimed to examine the effect of hospital ED regionalization policy and categorization of hospital emergency capability policy (categorization policy) on patient-appropriate ED use.

METHODS

Taiwan implemented a nationwide three-tiered hospital ED regionalization and categorization of hospital emergency capability policies in 2007 and 2009, respectively. We conducted a retrospective observational study on the effect of emergency care policy intervention on patient visit. Between 2005 and 2011, the Taiwan National Health Insurance Research Database recorded 1,835,860 ED visits from 1 million random samples. ED visits were categorized using the Yang-Ming modified New York University-ED algorithm. A time series analysis was performed to examine the change in appropriate ED use rate after policy implementation.

RESULTS

From 2005 to 2011, total ED visits increased by 10.7%. After policy implementation, the average appropriate ED visit rate was 66.9%. The intervention had no significant effect on the trend of appropriate ED visit rate.

CONCLUSIONS

Although regionalization and categorization policies did increase emergency care accessibility, it had no significant effect on patient-appropriate ED use. Further research is required to improve data-driven policymaking.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A validation of machine learning-based risk scores in the prehospital setting

BACKGROUND

The triage of patients in prehospital care is a difficult task, and improved risk assessment tools are needed both at the dispatch center and on the ambulance to differentiate between low- and high-risk patients. This study validates a machine learning-based approach to generating risk scores based on hospital outcomes using routinely collected prehospital data.

METHODS

Dispatch, ambulance, and hospital data were collected in one Swedish region from 2016-2017. Dispatch center and ambulance records were used to develop gradient boosting models predicting hospital admission, critical care (defined as admission to an intensive care unit or in-hospital mortality), and two-day mortality. Composite risk scores were generated based on the models and compared to National Early Warning Scores (NEWS) and actual dispatched priorities in a prospectively gathered dataset from 2018.

RESULTS

A total of 38203 patients were included from 2016-2018. Concordance indexes (or areas under the receiver operating characteristics curve) for dispatched priorities ranged from 0.51-0.66, while those for NEWS ranged from 0.66-0.85. Concordance ranged from 0.70-0.79 for risk scores based only on dispatch data, and 0.79-0.89 for risk scores including ambulance data. Dispatch data-based risk scores consistently outperformed dispatched priorities in predicting hospital outcomes, while models including ambulance data also consistently outperformed NEWS. Model performance in the prospective test dataset was similar to that found using cross-validation, and calibration was comparable to that of NEWS.

CONCLUSIONS

Machine learning-based risk scores outperformed a widely-used rule-based triage algorithm and human prioritization decisions in predicting hospital outcomes. Performance was robust in a prospectively gathered dataset, and scores demonstrated adequate calibration. Future research should explore the robustness of these methods when applied to other settings, establish appropriate outcome measures for use in determining the need for prehospital care, and investigate the clinical impact of interventions based on these methods.

Sachstandsbericht: Strukturierte medizinische Ersteinschätzung in Deutschland (SmED)

Ab 01.01.2020 müssen die Kassenärztlichen Vereinigungen eine telefonische Ersteinschätzung im 24/7-Betrieb anbieten. Ziel ist die Ersteinschätzung der Dringlichkeit akuter Beschwerden und eine Vermittlung an die angemessene Versorgungsstufe. Sehr schwer kranke Patienten müssen unmittelbar der Notfallversorgung, weniger oder nicht dringliche Anliegen alternativen Versorgungsangeboten zugeführt werden. Diese anspruchsvolle Aufgabe werden Fachpersonen übernehmen, die durch geeignete Software unterstützt werden. Im Ausland existieren hierfür Vorbilder. Das Zentralinstitut für die kassenärztliche Versorgung (Zi) überträgt gemeinsam mit der Health Care Quality System GmbH (HCQS) das in Teilen der Schweiz bereits angewendete Swiss Medical Assessment System (SMASS) für eine Anwendung in Deutschland. Das System soll unter dem Namen Strukturierte medizinische Ersteinschätzung in Deutschland (SmED) im Jahr 2019 in den Arztrufzentralen unter der Nummer 116117 eingeführt werden. Auch eine Anwendung für den sogenannten „gemeinsamen Tresen“ von Bereitschaftsdienstpraxen und Krankenhausnotaufnahmen wird entwickelt. Beide Anwendungen werden in dem vom Innovationsfonds geförderten DEMAND-Projekt evaluiert. Die Entwicklung von SmED erfolgt unter Einbeziehung von Vertretern des Marburger Bundes sowie der Deutschen Gesellschaft Interdisziplinäre Notfall- und Akutmedizin (DGINA) und Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI). Eine technische Integration mit der 112 ist in Arbeit.

Outcomes for Patients Who Contact the Emergency Ambulance Service and Are Not Transported to the Emergency Department: A Data Linkage Study

Objectives: Emergency ambulance services do not transport all patients to hospital. International literature reports non-transport rates ranging from 3.7-93.7%. In 2017, 38% of the 11 million calls received by ambulance services in England were attended by ambulance but not transported to an Emergency Department (ED). A further 10% received clinical advice over the telephone. Little is known about what happens to patients following a non-transport decision. We aimed to investigate what happens to patients following an emergency ambulance telephone call that resulted in a non-transport decision, using a linked routine data-set. Methods: Six-months individual patient level data from one ambulance service in England, linked with Hospital Episode Statistics and national mortality data, were used to identify subsequent health events (ambulance re-contact, ED attendance, hospital admission, death) within 3 days (primary analysis) and 7 days (secondary analysis) of an ambulance call ending in non-transport to hospital. Non-clinical staff used a priority dispatch system e.g. Medical Priority Dispatch System to prioritize calls for ambulance dispatch. Non-transport to ED was determined by ambulance crew members at scene or clinicians at the emergency operating center when an ambulance was not dispatched (telephone advice). Results: The data linkage rate was 85% for patients who were discharged at scene (43,108/50,894). After removal of deaths associated with end of life care (N = 312), 9% (3,861/42,796) re-contacted the ambulance service, 12.6% (5,412/42,796) attended ED, 6.3% (2,694/42,796) were admitted to hospital, and 0.3% (129/42,796) died within 3 days of the call. Rates were higher for events occurring within 7 days. For example, 12% re-contacted the ambulance service, 16.1% attended ED, 9.3% were admitted to hospital, and 0.5% died. The linkage rate for telephone advice calls was low because ambulance services record less information about these patients (24% 2,514/10,634). A sensitivity analysis identified a range of subsequent event rates: 2.5-10.5% of patients were admitted to hospital and 0.06-0.24% of patient died within 3 days of the call. Conclusions: Most non-transported patients did not have subsequent health events. Deaths after non-transport are an infrequent event that could be selected for more detailed review of individual cases, to facilitate learning and improvement.

Understanding variation in ambulance service non-conveyance rates: a mixed methods study

Background

In England in 2015/16, ambulance services responded to nearly 11 million calls. Ambulance Quality Indicators show that half of the patients receiving a response by telephone or face to face were not conveyed to an emergency department. A total of 11% of patients received telephone advice only. A total of 38% of patients were sent an ambulance but were not conveyed to an emergency department. For the 10 large ambulance services in England, rates of calls ending in telephone advice varied between 5% and 17%. Rates of patients who were sent an ambulance but not conveyed to an emergency department varied between 23% and 51%. Overall non-conveyance rates varied between 40% and 68%.

Objective

To explain variation in non-conveyance rates between ambulance services.

Design

A sequential mixed methods study with five work packages.

Setting

Ten of the 11 ambulance services serving > 99% of the population of England.

Methods

(1) A qualitative interview study of managers and paramedics from each ambulance service, as well as ambulance commissioners (totalling 49 interviews undertaken in 2015). (2) An analysis of 1 month of routine data from each ambulance service (November 2014). (3) A qualitative study in three ambulance services with different published rates of calls ending in telephone advice (120 hours of observation and 20 interviews undertaken in 2016). (4) An analysis of routine data from one ambulance service linked to emergency department attendance, hospital admission and mortality data (6 months of 2013). (5) A substudy of non-conveyance for people calling 999 with breathing problems.

Results

Interviewees in the qualitative study identified factors that they perceived to affect non-conveyance rates. Where possible, these perceptions were tested using routine data. Some variation in non-conveyance rates between ambulance services was likely to be due to differences in the way rates were calculated by individual services, particularly in relation to telephone advice. Rates for the number of patients sent an ambulance but not conveyed to an emergency department were associated with patient-level factors: age, sex, deprivation, time of call, reason for call, urgency level and skill level of attending crew. However, variation between ambulance services remained after adjustment for patient-level factors. Variation was explained by ambulance service-level factors after adjustment for patient-level factors: the percentage of calls attended by advanced paramedics [odds ratio 1.05, 95% confidence interval (CI) 1.04 to 1.07], the perception of ambulance service staff and commissioners that advanced paramedics were established and valued within the workforce of an ambulance service (odds ratio 1.84, 95% CI 1.45 to 2.33), and the perception of ambulance service staff and commissioners that senior management was risk averse regarding non-conveyance within an ambulance service (odds ratio 0.78, 95% CI 0.63 to 0.98).

Limitations

Routine data from ambulance services are complex and not consistently collected or analysed by ambulance services, thus limiting the utility of comparative analyses.

Conclusions

Variation in non-conveyance rates between ambulance services in England could be reduced by addressing variation in the types of paramedics attending calls, variation in how advanced paramedics are used and variation in perceptions of the risk associated with non-conveyance within ambulance service management. Linking routine ambulance data with emergency department attendance, hospital admission and mortality data for all ambulance services in the UK would allow comparison of the safety and appropriateness of their different non-conveyance rates.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Unplanned reattendances at the paediatric emergency department within 72 hours: a one-year experience in KKH

INTRODUCTION

Unscheduled reattendances at the paediatric emergency department may contribute to overcrowding, which may increase financial burdens. The objectives of this study were to determine the rate of reattendances and characterise factors influencing these reattendances and hospital admission during the return visits.

METHODS

Medical records of all patients who attended the emergency department at KK Women's and Children's Hospital, Singapore, from 1 June 2013 to 31 May 2014 were retrospectively reviewed. We collected data on patient demographics, attendance data and clinical characteristics. Planned reattendances, recalled cases, reattendances for unrelated complaints and patients who left without being seen were excluded. A multivariate analysis was conducted to determine the odds ratio of variables associated with hospital admission for reattendances.

RESULTS

Of 162,566 children, 6,968 (4.3%) returned within 72 hours, and 2,925 (42.0% of reattendance group) were admitted on their return visits. Children more likely to reattend were under three years of age, Chinese, triaged as Priority 2 at the first visit, and were initially diagnosed with respiratory or gastrointestinal conditions. However, children more likely to be admitted on their return visits were over 12 years of age, Malay, had a higher triage acuity or were uptriaged, had the presence of a comorbidity, and were diagnosed with gastrointestinal conditions.

CONCLUSION

We identified certain subgroups in the population who were more likely to be admitted if they reattended. These findings would help in implementing further research and directing strategies to reduce potentially avoidable reattendances and admissions.

Non-urgent Emergency Callers: Characteristics and Prognosis

OBJECTIVE

In Denmark, calls to the Danish emergency number 1-1-2 concerning medical emergencies are received by an emergency medical communication center (EMCC). At the EMCC, health care professionals (nurses, paramedics, and physicians) decide the necessary response, depending on the level of emergency as indicated by the Danish Index for Emergency Care. The index states 37 main criteria (symptoms) and five levels of emergency, descending from A (life threatening) to E (not serious). An ambulance is not sent to emergency level-E patients (level-E patients), but they are given other kinds of help/advice. No prior studies focusing on Danish level-E patients exist, hence the sparse knowledge about them. This study aimed to characterize level-E patients in the Central Denmark Region and to investigate their progress in the health care system after the 1-1-2 call, regarding contacting 1-1-2 again, general practitioner and Emergency Department (ED) visits, hospital admission, and death.

METHODS

This is a retrospective follow-up study of callers who contacted the EMCC of the Central Denmark Region and were assessed as level-E patients from August 2013 to July 2014. The study population was identified in the EMCC dispatch software, whose data were supplemented with health care data from three national registries.

RESULTS

Of the 53,414 patients who called 1-1-2 over the study period, 4,962 level-E patients were included in the study. The median age was 47 years (IQR: 24.3-67.7), and 53.4% were men. The most common main criteria were extremity pain - minor wounds. Within 1 day after their 1-1-2 call, 42.1% had a subsequent contact with the health care system. Of those, 5.9% called 1-1-2 again, 24.3% contacted an ED, and 8.6% were admitted. The fatality rate was 0.1%.

CONCLUSIONS

Level-E patients who contacted the EMCC of the Central Denmark Region were most frequently young adults. Almost 60% of level E-patients, who could be tracked, had no further contact with the health care system within a day after their 1-1-2 call. Of those who did, a quarter contacted an ED, indicating that level-E patients needed medical attention. The low fatality rates suggest limited undertriage, that is, level-E patients do not seem to need emergency medical service transportation. Further studies on undertriage among other things are needed.

Emergency medical triage decisions are swayed by computer-manipulated cues of physical dominance in caller's voice

In humans as well as other animals, displays of body strength such as power postures or deep masculine voices are associated with prevalence in conflicts of interest and facilitated access to resources. We conduct here an ecological and highly critical test of this hypothesis in a domain that, on first thought, would appear to be shielded from such influences: access to emergency medical care. Using acoustic manipulations of vocal masculinity, we systematically varied the perceived level of physical dominance of mock patients calling a medical call center simulator. Callers whose voice were perceived as indicative of physical dominance (i.e. those with low fundamental and formant frequency voices) obtained a higher grade of response, a higher evaluation of medical emergency and longer attention from physicians than callers with strictly identical medical needs whose voice signaled lower physical dominance. Strikingly, while the effect was important for physician participants, it was virtually non-existent when calls were processed by non-medically-trained phone operators. This finding demonstrates an unprecedented degree of vulnerability of telephone-based medical decisions to extra-medical factors carried by vocal cues, and shows that it may not simply be assumed that more medical training will shield decisions from such influences.

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

Background

In 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.

Objective

The purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.

Data sources

MEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.

Methods

We have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.

Results

The review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.

Limitations

Although there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.

Conclusions

The evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.

Funding

The National Institute for Health Research Health Services and Delivery Research Programme.

Patient safety in ambulance services: a scoping review

Background

The role of ambulance services has changed dramatically over the last few decades with the introduction of paramedics able to provide life-saving interventions, thanks to sophisticated equipment and treatments available. The number of 999 calls continues to increase, with adverse events theoretically possible with each one. Most patient safety research is based on hospital data, but little is known concerning patient safety when using ambulance services, when things can be very different. There is an urgent need to characterise the evidence base for patient safety in NHS ambulance services.

Objective

To identify and map available evidence relating to patient safety when using ambulance services.

Design

Mixed-methods design including systematic review and review of ambulance service documentation, with areas for future research prioritised using a Delphi process.

Setting and participants

Ambulance services, their staff and service users in UK.

Data sources

A wide range of data sources were explored. Multiple databases, reference lists from key papers and citations, Google and the NHS Confederation website were searched, and experts contacted to ensure that new data were included in the review. The databases MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Science Direct, Emerald, Education Resources Information Center (ERIC), Applied Social Sciences Index and Abstracts, Social Services Abstracts, Sociological Abstracts, International Bibliography of the Social Sciences (IBSS), PsycINFO, PsycARTICLES, Health Management Information Consortium (HMIC), NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED),Health Technology Assessment, the FADE library, Current Awareness Service for Health (CASH), OpenDOAR (Directory of Open Access Repositories) and Open System for Information on Grey Literature in Europe (OpenSIGLE) and Zetoc (The British Library's Electronic Table of Contents) were searched from 1 January 1980 to 12 October 2011. Publicly available documents and issues identified by National Patient Safety Agency (NPSA), NHS Litigation Authority (NHSLA) and coroners’ reports were considered. Opinions and perceptions of senior managers, ambulance staff and service users were solicited.

Review methods

Data were extracted from annual reports using two-stage thematic analysis, data from quality accounts were collated with safety priorities tabulated and considered using thematic analysis, NPSA incident report data were collated and displayed comparatively using descriptive statistics, claims reported to NHSLA were analysed to identify number and cost of claims from mistakes and/or poor service, and summaries of coroners’ reports were assessed using thematic analysis to identify underlying safety issues. The depth of analysis is limited by the remit of a scoping exercise and availability of data.

Results

We identified studies exploring different aspects of safety, which were of variable quality and with little evidence to support activities currently undertaken by ambulance services. Adequately powered studies are required to address issues of patient safety in this service, and it appeared that national priorities were what determined safety activities, rather than patient need. There was inconsistency of information on attitudes and approaches to patient safety, exacerbated by a lack of common terminology.

Conclusion

Patient safety needs to become a more prominent consideration for ambulance services, rather than operational pressures, including targets and driving the service. Development of new models of working must include adequate training and monitoring of clinical risks. Providers and commissioners need a full understanding of the safety implications of introducing new models of care, particularly to a mobile workforce often isolated from colleagues, which requires a body of supportive evidence and an inherent critical evaluation culture. It is difficult to extrapolate findings of clinical studies undertaken in secondary care to ambulance service practice and current national guidelines often rely on consensus opinion regarding applicability to the pre-hospital environment. Areas requiring further work include the safety surrounding discharging patients, patient accidents, equipment and treatment, delays in transfer/admission to hospital, and treatment and diagnosis, with a clear need for increased reliability and training for improving handover to hospital.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Alternatives to Traditional EMS Dispatch and Transport: A Scoping Review of Reported Outcomes

Objectives

Emergency medical services (EMS) programs, which provide an alternative to traditional EMS dispatch or transport to the emergency department (ED), are becoming widely implemented. This scoping review identified and catalogued all outcomes used to measure such alternative EMS programs.

Data Source

Broad systematized bibliographic and grey literature searches were conducted.

Study Selection

Inclusion criteria were 911 callers/EMS patients, reported on alternatives to traditional EMS dispatch OR traditional EMS transport to the ED, and reported an outcome measure.

Data Extraction

The reports were categorized as either alternative to dispatch or to EMS transport, and outcome measures were categorized and described.

Data Synthesis

The bibliographic search retrieved 13,215 records, of which 34 articles met the inclusion criteria, with an additional 10 added from reference list hand-searching (n=44 included). In the grey literature search, 31 websites were identified, from which four met criteria and were retrieved (n=4 included). Fifteen reports (16 studies) described alternatives to EMS dispatch, and 33 reports described alternatives to EMS transport. The most common outcomes reported in the alternatives to EMS dispatch reports were service utilization and decision accuracy. Twenty-four different specific outcomes were reported. The most common outcomes reported in the alternatives to EMS transport reports were service utilization and safety, and 50 different specific outcomes were reported.

Conclusions

Numerous outcome measures were identified in reports of alternative EMS programs, which were catalogued and described. Researchers and program leaders should achieve consensus on uniform outcome measures, to allow benchmarking and improve comparison across programs.

Secondary triage in prehospital emergency ambulance services: a systematic review

OBJECTIVE

Secondary telephone triage to divert low-acuity patients to alternative non-ambulance services before ambulance arrival has been trialled in the UK and USA as a management strategy to cope with the increase in ambulance demand. The objective of this systematic review was to examine the literature on the structure, safety and success of secondary triage systems.

METHODS

For inclusion in the study, the telephone triage system had to be a secondary process, receiving referred patients who had already been categorised as low priority by a primary triage process. Two independent reviewers conducted the search to identify relevant studies. Six articles and one report were identified.

RESULTS

The major theme of the papers was the safety and accuracy of secondary telephone triage in identifying low-acuity patients. Two studies also discussed patient satisfaction. There was a low incidence of adverse events, as expected as these patients had already been subjected to primary telephone triage. In the studies identifying ambulance dispatch as a potential final disposition, at least half of the patients were diverted away from ambulance dispatch. In the studies that identified self/home care as a final disposition, a maximum of 31% of patients were categorised to this outcome. Otherwise all patients were recommended for assessment by a healthcare professional other than ambulance clinicians. Patients appeared to be satisfied with secondary telephone triage on follow-up.

CONCLUSIONS

These results suggest that, while secondary triage of these patients is safe, further research is required to determine its most appropriate structure and its effect on ambulance demand.

A study of automated self-assessment in a primary care student health centre setting

We evaluated the advice given by a prototype self-assessment triage system in a university student health centre. Students attending the health centre with a new problem used the automated self-assessment system prior to a face-to-face consultation with the general practitioner (GP). The system's rating of urgency was available to the GP, and following the consultation, the GP recorded their own rating of the urgency of the patient's presentation. Full data were available for 154 of the 207 consultations. Perfect agreement, where both the GP and the self-assessment system selected the same category of advice, occurred in 39% of consultations. The association between the GP assessment and the self-assessment rankings of urgency was low but significant (rho = 0.19, P = 0.016). The self-assessment system tended to be risk averse compared to the GP assessments, with advice for more urgent level of care seeking being recommended in 86 consultations (56%) and less urgent advice in only 8 (5%). This difference in assessment of urgency was significant (P < 0.001). The agreement between self-assessed and GP-assessed urgency was not associated with symptom site or socio-demographic characteristics of the user. Although the self-assessment system was more risk averse than the GPs, which resulted in a high proportion of patients being triaged as needing emergency or immediate care, the self-assessment system successfully identified a proportion of patients who were felt by the GP to have a self-limiting condition that did not need a consultation. In its prototype form, the self-assessment system was not a replacement for clinician assessment and further refinement is necessary.

Ethical Challenges in Emergency Medical Services: Controversies and Recommendations

Emergency Medical Services (EMS) providers face many ethical issues while providing prehospital care to children and adults. Although provider judgment plays a large role in the resolution of conflicts at the scene, it is important to establish protocols and policies, when possible, to address these high-risk and complex situations. This article describes some of the common situations with ethical underpinnings encountered by EMS personnel and managers including denying or delaying transport of patients with non-emergency conditions, use of lights and sirens for patient transport, determination of medical futility in the field, termination of resuscitation, restriction of EMS provider duty hours to prevent fatigue, substance abuse by EMS providers, disaster triage and difficulty in switching from individual care to mass-casualty care, and the challenges of child maltreatment recognition and reporting. A series of ethical questions are proposed, followed by a review of the literature and, when possible, recommendations for management.

BeckerTK, Gausche-HillM, AsweganAL, BakerEF, BookmanKJ, BradleyRN, De LorenzoRA, SchoenwetterDJ for the American College of Emergency Physicians’ EMS Committee. Ethical challenges in Emergency Medical Services: controversies and recommendations. Prehosp Disaster Med. 2013;28(5):1-10.

New models of emergency prehospital care that avoid unnecessary conveyance to emergency department: translation of research evidence into practice?

Background. Achieving knowledge translation in healthcare is growing in importance but methods to capture impact of research are not well developed. We present an attempt to capture impact of a programme of research in prehospital emergency care, aiming to inform the development of EMS models of care that avoid, when appropriate, conveyance of patients to hospital for immediate care. Methods. We describe the programme and its dissemination, present examples of its influence on policy and practice, internationally, and analyse routine UK statistics to determine whether conveyance practice has changed. Results. The programme comprises eight research studies, to a value of >£4 m. Findings have been disseminated through 18 published papers, cited 274 times in academic journals. We describe examples of how evidence has been put into practice, including new models of care in Canada and Australia. Routine statistics in England show that, alongside rising demand, conveyance rates have fallen from 90% to 58% over a 12-year period, 2,721 million fewer journeys, with publication of key studies 2003–2008. Comment. We have set out the rationale, key features, and impact on practice of a programme of publicly funded research. We describe evidence of knowledge translation, whilst recognising limitations in methods for capturing impact.

Telephone triage assessment for musculoskeletal disorders: part 1

Changes in the delivery of occupational health and wellbeing services can affect the employer, employees and service users. Despite the impact of such changes, many organisations implement them without understanding their true effects. Support of staff and service users is needed if change is to be implemented and services reconfigured to improve overall efficiency. A diagnostic analysis has been recommended as a precursor to assess what impact a change would have. This paper explores the process of a diagnostic analysis before nursing telephone triage assessment for musculoskeletal disorders was implemented in an occupational health and wellbeing service. Mixed methods were used to gather the relevant information.

Reconfiguring the emergency and urgent care workforce: mixed methods study of skills and the everyday work of non-clinical call-handlers in the NHS

OBJECTIVES

To examine the skills and expertise required and used by non-clinical call-handlers doing telephone triage and assessment, supported by a computer decision support system (CDSS) in urgent and emergency care services.

METHODS

Comparative case study of three different English emergency and urgent care services. Data consisted of nearly 500 hours of non-participant observation, 61 semi-structured interviews with health service staff, documentary analysis, and a survey of 106 call-handlers.

RESULTS

Communication skills and 'allowing the CDSS to drive the assessment' are viewed by the CDSS developers and staff as key competencies for call-handling. Call-handlers demonstrated high levels of experience, skills and expertise in using the CDSS. These workers are often portrayed simply as 'trained users' of technology, but they used a broader set of skills including team work, flexibility and 'translation'. Call-handlers develop a 'pseudo-clinical' expertise and draw upon their experiential knowledge to bring the CDSS into everyday use.

CONCLUSIONS

Clinical assessment and triage by non-clinical staff supported by a CDSS represents a major change in urgent and emergency care delivery, warranting a detailed examination of call-handlers' skills and expertise. We found that this work appears to have more in common with clinical work and expertise than with other call-centre work that it superficially resembles. Recognizing the range of skills call-handlers demonstrate and developing a better understanding of this should be incorporated into the training for, and management of, emergency and urgent care call-handling.

Physiological Scoring: An Aid to Emergency Medical Services Transport Decisions?

Introduction:

Attendance at UK emergency departments is rising steadily despite the proliferation of alternative unscheduled care providers. Evidence is mixed on the willingness of emergency medical services (EMS) providers to decline to transport patients and the safety of incorporating such an option into EMS provision. Physiologically based Early Warning Scores are in use in many hospitals and emergency departments, but not yet have been proven to be of benefit in the prehospital arena.

Hypothesis:

The use of a physiological-social scoring system could safely identify patients calling EMS who might be diverted from the emergency department to an alternative, unscheduled, care provider.

Methods:

This was a retrospective, cohort study of patients with a presenting complaint of “shortness of breath” or “difficulty breathing” transported to the emergency department by EMS. Retrospective calculation of a physiologicalsocial score (PMEWS) based on first recorded data from EMS records was performed. Outcome measures of hospital admission and need for physiologically stabilizing treatment in the emergency department also were performed.

Results:

A total of 215 records were analyzed. One hundred thirty-nine (65%) patients were admitted from the emergency department or received physiologically stabilizing treatment in the emergency department. Area Under the Receiver Operating Characteristic Curve (AUROC) for hospital admission was 0.697 and for admission or physiologically stabilizing treatment was 0.710. No patient scoring <2 was admitted or received stabilizing treatment.

Conclusions:

Despite significant over-triage, this system could have diverted 79 patients safely from the emergency department to alternative, unscheduled, care providers.

The appropriateness of, and compliance with, telephone triage decisions: a systematic review and narrative synthesis

AIM

This paper is a report of the synthesis of evidence on the appropriateness of, and compliance with, telephone triage decisions.

BACKGROUND

Telephone triage plays an important role in managing demand for health care. Important questions are whether triage decisions are appropriate and patients comply with them.

DATA SOURCES

CINAHL, Cochrane Clinical Trials Database, Medline, Embase, Web of Science, and Psyc Info were searched between 1980-June 2010.

DESIGN

LITERATURE REVIEW

Rapid Evidence Synthesis.

REVIEW METHODS

The principles of rapid evidence assessment were followed.

RESULTS

We identified 54 relevant papers: 26 papers reported appropriateness of triage decision, 26 papers reported compliance with triage decision, and 2 papers reported both. Nurses triaged calls in most of the studies (n=49). Triage decisions rated as appropriate varied between 44-98% and compliance ranged from 56-98%. Variation could not be explained by type of service or method of assessing appropriateness. However, inconsistent definitions of appropriateness may explain some variation. Triage decisions to contact primary care may have lower compliance than decisions to contact emergency services or self care.

CONCLUSION

Telephone triage services can offer appropriate decisions and decisions that callers comply with. However, the association between the appropriateness of a decision and subsequent compliance requires further investigation and further consideration needs to be given to the minority of calls which are inappropriately managed. We suggest that a definition of appropriateness incorporating both accuracy and adequacy of triage decision should be encouraged.

Patient safety in emergency medical services: a systematic review of the literature

BACKGROUND

Preventable harm from medical care has been extensively documented in the inpatient setting. Emergency medical services (EMS) providers care for patients in dynamic and challenging environments; prehospital emergency care is a field that represents an area of high risk for errors and harm, but has received relatively little attention in the patient safety literature.

OBJECTIVE

To identify the threats to patient safety unique to the EMS environment and interventions that mitigate those threats, we completed a systematic review of the literature.

METHODS

We searched MEDLINE, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) for combinations of key EMS and patient safety terms composed by a pan-canadian expert panel using a year limit of 1999 to 2011. We excluded commentaries, opinions, letters, abstracts, and non-english publications. Two investigators performed an independent hierarchical screening of titles, abstracts, and full-text articles blinded to source. We used the kappa statistic to examine interrater agreement. Any differences were resolved by consensus.

RESULTS

We retrieved 5,959 titles, and 88 publications met the inclusion criteria and were categorized into seven themes: adverse events and medication errors (22 articles), clinical judgment (13), communication (6), ground vehicle safety (9), aircraft safety (6), interfacility transport (16), and intubation (16). Two articles were randomized controlled trials; the remainder were systematic reviews, prospective observational studies, retrospective database/chart reviews, qualitative interviews, or surveys. The kappa statistics for titles, abstracts, and full-text articles were 0.65, 0.79, and 0.87, respectively, for the first search and 0.60, 0.74, and 0.85 for the second.

CONCLUSIONS

We found a paucity of scientific literature exploring patient safety in EMS. Research is needed to improve our understanding of problem magnitude and threats to patient safety and to guide interventions.

Safety of telephone triage in out-of-hours care: a systematic review

OBJECTIVE

Telephone triage in patients requesting help may compromise patient safety, particularly if urgency is underestimated and the patient is not seen by a physician. The aim was to assess the research evidence on safety of telephone triage in out-of-hours primary care.

METHODS

A systematic review was performed of published research on telephone triage in out-of-hours care, searching in PubMed and EMBASE up to March 2010. Studies were included if they concerned out-of-hours medical care and focused on telephone triage in patients with a first request for help. Study inclusion and data extraction were performed by two researchers independently. Post-hoc two types of studies were distinguished: observational studies in contacts with real patients (unselected and highly urgent contacts), and prospective observational studies using high-risk simulated patients (with a highly urgent health problem).

RESULTS

Thirteen observational studies showed that on average triage was safe in 97% (95% CI 96.5-97.4%) of all patients contacting out-of-hours care and in 89% (95% CI 86.7-90.2%) of patients with high urgency. Ten studies that used high-risk simulated patients showed that on average 46% (95% CI 42.7-49.8%) were safe. Adverse events described in the studies included mortality (n = 6 studies), hospitalisations (n = 5), attendance at emergency department (n=1), and medical errors (n = 6).

CONCLUSIONS

There is room for improvement in safety of telephone triage in patients who present symptoms that are high risk. As these have a low incidence, recognition of these calls poses a challenge to health care providers in daily practice.

Validity of telephone and physical triage in emergency care: the Netherlands Triage System

BACKGROUND

Due to emergency care overcrowding, right care at the right place and time is necessary. Uniform triage of patients contacting different emergency care settings will improve quality of care and communication between health care providers.

OBJECTIVE

Validation of the computer-based Netherlands Triage System (NTS) developed for physical triage at emergency departments (EDs) and telephone triage at general practitioner cooperatives (GPCs).

METHODS

Prospective observational study with patients attending the ED of a university-affiliated hospital (September 2008 to November 2008) or contacting an urban GPC (December 2008 to February 2009). For validation of the NTS, we defined surrogate urgency markers as best proxies for true urgency. For physical triage (ED): resource use, hospitalization and follow-up. For telephone triage (GPC): referral to ED, self-care advice after telephone consultation or GP advice after physical consultation. Associations between NTS urgency levels and surrogate urgency markers were evaluated using chi-square tests for trend.

RESULTS

We included nearly 10 000 patients. For physical triage at ED, NTS urgency levels were associated with resource use, hospitalization and follow-up. For telephone triage at GPC, trends towards more ED referrals in high NTS urgency levels and more self-care advices after telephone consultation in lower NTS urgency levels were found. The association between NTS urgency classification and GP advice was less explicit. Similar results were found for children; however, we found no association between NTS urgency level and GP advice.

CONCLUSIONS

Physically and telephone-assigned NTS urgency levels were associated with majority of surrogate urgency markers. The NTS as single triage system for physical and telephone triage seems feasible.

Economic impact of prescreening on gastroenterology outpatient clinic practice

BACKGROUND

Outpatient clinic activity represents a major workload for clinicians. Unnecessary outpatient visits place a strain on service provision, resulting in unnecessary delays for more urgent cases.

GOALS

We sought to determine both the impact and economic benefit of employing phone follow-up and physician assistant (PA) triage systems on attendances at a gastroenterology outpatient department.

STUDY

We performed a retrospective chart review of all patients attending a gastroenterology outpatient clinic over a 2-week period. Patients were categorized into new or follow-up attendees and the follow-up patients were further subcategorized into 1 of 4 groups: (1) those attending to receive results of investigations requiring no further treatment (group A); (2) those attending to receive results of investigations requiring further treatment (group B); (3) those attending with a chronic gastrointestinal disease requiring no active change in management (group C); (4) those attending with a chronic gastrointestinal disease requiring active change in management (group D). It was assumed that patients in group A could be managed by phone follow-up in place of clinic attendance and patients in group C could be triaged to see a PA.

RESULTS

Out of a total of 329 outpatient attendees, 40 (12%) required no active intervention (group A) and would have been suitable for phone follow-up. A further 58 (18%) had stable disease, requiring no change in management and hence, could have been triaged to see a PA. Implementation of phone follow-up and patient review by PA could reduce salary expenses of outpatient practice by 17%.

CONCLUSIONS

Our findings support routine prescreening of outpatient attendees to enhance the efficiency of gastroenterology outpatient practice.

Support and Assessment for Fall Emergency Referrals (SAFER 1) trial protocol. Computerised on-scene decision support for emergency ambulance staff to assess and plan care for older people who have fallen: evaluation of costs and benefits using a pragmatic cluster randomised trial

Background

Many emergency ambulance calls are for older people who have fallen. As half of them are left at home, a community-based response may often be more appropriate than hospital attendance. The SAFER 1 trial will assess the costs and benefits of a new healthcare technology - hand-held computers with computerised clinical decision support (CCDS) software - to help paramedics decide who needs hospital attendance, and who can be safely left at home with referral to community falls services.

Methods/Design

Pragmatic cluster randomised trial with a qualitative component. We shall allocate 72 paramedics ('clusters') at random between receiving the intervention and a control group delivering care as usual, of whom we expect 60 to complete the trial.

Patients are eligible if they are aged 65 or older, live in the study area but not in residential care, and are attended by a study paramedic following an emergency call for a fall. Seven to 10 days after the index fall we shall offer patients the opportunity to opt out of further follow up. Continuing participants will receive questionnaires after one and 6 months, and we shall monitor their routine clinical data for 6 months. We shall interview 20 of these patients in depth. We shall conduct focus groups or semi-structured interviews with paramedics and other stakeholders.

The primary outcome is the interval to the first subsequent reported fall (or death). We shall analyse this and other measures of outcome, process and cost by 'intention to treat'. We shall analyse qualitative data thematically.

Discussion

Since the SAFER 1 trial received funding in August 2006, implementation has come to terms with ambulance service reorganisation and a new national electronic patient record in England. In response to these hurdles the research team has adapted the research design, including aspects of the intervention, to meet the needs of the ambulance services.

In conclusion this complex emergency care trial will provide rigorous evidence on the clinical and cost effectiveness of CCDS for paramedics in the care of older people who have fallen.

Trial Registration

ISRCTN10538608

Medical emergency motorcycles: are they safe?

OBJECTIVE

Ambulances in emergency medical services (EMS) might be supplemented or supported by vehicles that lack the capacity to transport a patient, especially in crowded urban areas. This paper addresses the safety of a first-response vehicle, the medical emergency motorcycle (MEM), which is driven by an emergency medical technician provider. We analysed the number of crashes, as well as the incidence and nature of injuries sustained.

MATERIAL AND METHODS

A prospective study was conducted from July 2004 to January 2007. Administrative data were collected over this period regarding MEMs operating in a metropolitan EMS group who had responded to 3626 calls. The MEM responders use limited equipment to perform initial assessments and interventions (basic life support and defibrillation). Undergoing an emergency driving course and wearing protective equipment are mandatory. We analysed the number of crashes, the proper use of the protective equipment, and the type and severity of the injuries sustained.

RESULTS

Accidents included 12 (n=12) motorcycle falls, resulting in three injured MEM drivers. No fatality was registered. One serious injury and two slight accidents occurred. One victim presented a dental trauma and another presented minor abrasion skin lesions. The third sustained a femur fracture. The first and second victims had not been using the protective equipment properly.

CONCLUSION

MEMs can impart a quick and efficient response to EMS services in urban areas, if managed with acceptable levels of safety. Defensive driving courses as well as correct use of personal protective equipment can improve security.

Out-of-hours demand for GP care and emergency services: patients' choices and referrals by general practitioners and ambulance services

Background

Over the last five years, Dutch provision of out-of-hours primary health care has shifted from practice-based services towards large-scale general practitioner (GP) cooperatives. Only few population-based studies have been performed to assess the out-of-hours demand for GP and emergency care, including the referral patterns to the Accident and Emergency Department (AED) by GPs and ambulance services.

Method

During two four-month periods (five-year interval), a prospective cross-sectional study was performed for a Dutch population of 62,000 people. Data were collected on all patient contacts with one GP cooperative and three AEDs bordering the region.

Results

Overall, GPs handled 88% of all out-of-hours contacts (275/1000 inhabitants/year), while the AED dealt with the remaining 12% of contacts (38/1000 inhabitants/year). Within the AED, the self-referrals represented a substantial number of contacts (43%), although within the total out-of-hours demand they only represented 5% of all contacts. Self-referrals were predominantly young adult males presenting with an injury, nineteen percent of whom had a fracture. Compared to self-referrals, patients who were referred by the GP or brought in by the ambulance services were generally older and were more frequently admitted for both injury and non-injury (p < 0.01 for all differences).

Conclusion

The GP cooperative deals with the large majority of out-of-hours problems presented. Within the total demand, self-referrals constitute a stable, yet small group of patients, many of whom seem to have made a reasonable choice to attend the AED. The GPs and the ambulance services appear to be effectively selecting the problems that are presented to the AED.

Emergency motorcycle: has it a place in a medical emergency system?

INTRODUCTION/AIM

In an emergency medical service system, response time is an important factor in determining the prognosis of a victim. There are well-documented increases in response time in urban areas, mainly during rush hour. Because prehospital emergency care is required to be efficient and swift, alternative measures to achieve this goal should be addressed. We report our experience with a medical emergency motorcycle (MEM) and propose major criteria for dispatching it.

MATERIAL AND METHODS

This work presents a prospective analysis of the data relating to MEM calls from July 2004 to December 2005. The analyzed parameters were age, sex, reason for call, action, and need for subsequent transport. A comparison was made of the need to activate more means and, if so, whether the MEM was the first to arrive.

RESULTS

There were 1972 calls. The average time of arrival at destination was 4.4 +/- 2.5 minutes. The main action consisted of administration of oxygen (n = 626), immobilization (n = 118), and control of hemorrhage (n = 101). In 63% of cases, MEM arrived before other emergency vehicles. In 355 cases (18%), there was no need for transport.

CONCLUSION

The MEM can intervene in a wide variety of clinical situations and a quick response is guaranteed. Moreover, in specific situations, MEM safely and efficiently permits better management of emergency vehicles. We propose that it should be dispatched mainly in the following situations: true life-threatening cases and uncertain need for an ambulance.

Computer-supported telephone nurse triage: an evaluation of medical quality and costs

AIM

To evaluate a telephone nurse triage model in terms of appropriateness of referrals to the appropriate level of care, patient's compliance with given advice and costs.

BACKGROUND

A key concern in each telephonic consultation is to evaluate if appropriate.

METHOD

An evaluative design in primary health care with consecutive patients (N = 362) calling telephone nurse triage between November 2002 and February 2003.

RESULTS

The advice was considered adequate in 325 (97.6%) cases. The patients' compliance with self-care was 81.3%, to primary health care 91.1% and to Accident and Emergency department 100%. The nurses referred self-care cases (64.7%) and Accident and Emergency cases (29.6%) from a less adequate to an appropriate level of care. The cost saving per call leading to a recommendation of self-care was euro 70.3, to primary health care euro 24.3 and to Accident and Emergency department euro 22.2.

CONCLUSIONS

The telephone nurse triage model showed adequate guidance for the patients concerning level of care and released resources for the benefit of both patients and the health care system.

Teleconsultation for cardiac patients: a comparison between nurses and physicians: the SHL experience in Israel

The absence of randomized studies on sufficiently large patient cohorts precludes the drawing of any firm conclusions on the comparative performance between nurses and physicians in transtelephonic triage and consultations and in diagnostic and management decision-making. We conducted such a comparative study at the SHL telemedicine facility. This facility also provides face-to-face medical management for its subscribers by means of mobile intensive care units (MICUs) staffed by physicians. The outcome of calls that came between 7:00 AM and 11:00 PM throughout the study year and that were handled at random by specially trained physicians (n = 15) or nurses (n = 35) were analyzed. Of 48,707 subscribers who fulfilled the study entry criteria 25,106 used the service at least once, producing 88,103 calls (81,817 handled by nurses and 6,286 by physicians). Teleconsultations were sufficient for most of the cases (80.13%). There were no significant differences between the performance of nurses and physicians regarding demographics (age, gender) and medical diagnoses of the applicants. The nurses' performance and decisions were comparable to those of physicians with respect to teleconsultations, medically justified dispatches of an MICU, repeated calls to the center and mortality during the week after the index call, although the duration of the physicians' telephone consultations was longer. Delegation of equal authority to nurses and physicians in triage and consultation in telecardiology results in equivalent and highly satisfactory medical care in a system in which subscribers receive service orchestrated from a single center of telecommunications.

Are they really refusing to travel? A qualitative study of prehospital records

Background

Refusal by the patient to travel after calling an emergency ambulance may lead to a preventable waste of scarce resources if it can be shown that an alternative more appropriate response could be employed. A greater understanding is required of the reasons behind 'refusal to travel' (RTT) in order to find appropriate solutions to address this issue. We sought to investigate the reasons why patients refuse to travel following emergency call-out in a rural county.

Methods

Written records made by ambulance crews for patients (n = 397) who were not transported to hospital following an emergency call-out during October 2004 were retrospectively analysed.

Results

Twelve main themes emerged for RTT which included non injury or minor injury, falls and recovery after treatment on scene; other themes included alternative supervision, follow-up and treatment arrangements or patients arranging their own transport. Importantly, only 8% of the sample was recorded by ambulance crews as truly refusing to travel against advice.

Conclusion

A system that facilitates standardised recording of RTT information including social reasons for non-transportation needs to be designed. 'Refused to travel' disclaimers need to reflect instances when crew and patient are satisfied that not going to hospital is the right outcome. These recommendations should be considered within the context of the plans for widening the role of ambulance services.

Medically unnecessary emergency medical services (EMS) transports among children ages 0 to 17 years

OBJECTIVES

Estimate the prevalence of medically unnecessary Emergency Medical Services (EMS) transports among children.

METHODS

We linked EMS and emergency department (ED) billing records for all EMS-to-hospital transports of children originating in three counties in South Carolina between January 1, 2001 and March 31, 2003. EMS responses resulting in no transport, transports to destinations other than the ED, or multiple trips for the same child in a single day could not be linked to ED data and were excluded. Medically unnecessary transports were identified with an algorithm using pre-hospital impressions, ED diagnoses and ED procedures. After exclusions, 5,693 transports of children between 0 and 17 years were available for study.

RESULTS

Sixteen percent (16.4%) of all transports were medically unnecessary. Among children through age 12, upper respiratory and viral problems were the most common diagnoses associated with medically unnecessary transports; among older children, behavioral problems such as conduct disturbance or drug abuse were common. In multivariable analysis, the odds of an unnecessary transport were higher among younger children, non-white children, rural children, and children insured by Medicaid.

CONCLUSIONS

The proportion of EMS transports which may be medically unnecessary is relatively modest compared to previous studies. However, many questions remain for future research. Further investigation should include examination of primary care availability and occurrence of unnecessary EMS use, existence of race-based disparities, and transports involving conduct disturbance and other behavioral conditions among children.

Help on the line: telephone-triage use, outcomes, and satisfaction within an uninsured population

Telephone triage programs have been shown to be cost-effective and favorably utilized by insured populations. However, there are 45 million Americans who are uninsured and who do not have access to telephone nursing. A telephone triage service was piloted for local uninsured residents. Within the 17-month trial period, 320 calls were received, representing 207 clients. This study reports on the results of the telephone survey with a cross-sectional sample of uninsured triage patrons (N = 80). One half reported they would have sought other medical care if the telephone triage service had not been available. Most callers (98%) believed that their health care concern was understood. Moreover, 98% agreed with the advice given, and 90% reported following up on the advice given. Overall satisfaction by the uninsured population with the telephone-based nurse triage service was positive and appears to be an effective and acceptable tool by those uninsured individuals who utilized its services.