Do emergency medical dispatchers choose the same response to serious injury in men and women - a qualitative study

BACKGROUND

Recent research has indicated that sex is an important determinant of emergency medical response in patients with possible serious injuries. Men were found to receive more advanced prehospital treatment and more helicopter transportation and trauma centre destinations and were more often received by an activated trauma team, even when adjusted for injury mechanism. Emergency medical dispatchers choose initial resources when serious injury is suspected after a call to the emergency medical communication centre. This study aimed to assess how dispatchers evaluate primary responses in trauma victims, with a special focus on the sex of the victim.

METHODS

Emergency medical dispatchers were interviewed using focus groups and a semistructured interview guide developed specifically for this study. Two vignettes describing typical and realistic injury scenarios were discussed. Verbatim transcripts of the conversations were analysed via systematic text condensation. The findings were reported in accordance with the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist.

RESULTS

The analysis resulted in the main category "Tailoring the right response to the patient", supported by three categories "Get an overview of location and scene safety", "Patient condition" and "Injury mechanism and special concerns". The informants consistently maintained that sex was not a relevant variable when deciding emergency medical response during dispatch and claimed that they rarely knew the sex of the patient before a response was implemented. Some of the participants also raised the question of whether the Norwegian trauma criteria reliably detect serious injury in women.

CONCLUSIONS

The results indicate that the emergency medical response is largely based on the national trauma criteria and that sex is of little or no importance during dispatch. The observed sex differences in the emergency medical response seems to be caused by other factors during the emergency medical response phase.

Outcomes of audio-instructed and video-instructed dispatcher-assisted cardiopulmonary resuscitation: a systematic review and meta-analysis

BACKGROUND

The present meta-analysis of clinical and simulation trials aimed to compare video-instructed dispatcher-assisted bystander cardiopulmonary resuscitation (V-DACPR) with conventional audio-instructed dispatcher-assisted bystander cardiopulmonary resuscitation (C-DACPR).

METHODS

We searched PubMed, Embase, Web of Science, Cochrane Collaboration databases and Scopus from inception until June 10, 2021. The primary outcomes were the prehospital return of spontaneous circulation (ROSC), survival to hospital discharge, and survival to hospital discharge with a good neurological outcome for clinical trials, and chest compression quality for simulation trials. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) indicated the pooled effect. The analyses were performed with the RevMan 5.4 and STATA 14 software.

RESULTS

Overall, 2 clinical and 8 simulation trials were included in this meta-analysis. In clinical trials, C-DACPR and V-DACPR were characterised by, respectively, 11.8% vs. 24.3% of prehospital ROSC (OR = 0.46; 95% CI: 0.30, 0.69; I² = 66%; p < .001), 10.7% vs. 22.3% of survival to hospital discharge (OR = 0.46; 95% CI: 0.30, 0.70; I² = 69%; p < .001), and 6.3% vs. 16.0% of survival to hospital discharge with a good neurological outcome (OR = 0.39; 95% CI: 0.23, 0.67; I² = 73%; p < .001). In simulation trials, chest compression rate per minute equalled 91.3 ± 22.6 for C-DACPR and 107.8 ± 12.6 for V-DACPR (MD = -13.40; 95% CI: -21.86, -4.95; I² = 97%; p = .002). The respective values for chest compression depth were 38.7 ± 14.3 and 41.8 ± 12.5 mm (MD = -2.67; 95% CI: -8.35, 3.01; I² = 98%; p = .36).

CONCLUSIONS

As compared with C-DACPR, V-DACPR significantly increased prehospital ROSC and survival to hospital discharge. Under simulated resuscitation conditions, V-DACPR exhibited a higher rate of adequate chest compressions than C-DACPR.Key messagesBystander cardiopulmonary resuscitation parameters significantly depend on the dispatcher's support and the manner of the support provided.Video-instructed dispatcher-assisted bystander cardiopulmonary resuscitation can increase the rate of prehospital return of spontaneous circulation and survival to hospital discharge.Video-instructed dispatcher-assisted bystander cardiopulmonary resuscitation improves the quality of chest compressions compared with dispatcher-assisted resuscitation without video instruction.

Firefighters as first-responders in out-of-hospital cardiac arrest- a retrospective study of a time-gain selective dispatch system in the Skåne Region, Sweden

AIM

To analyze the impact of a time-gain selective, first-responder dispatch system on the presence of a shockable initial rhythm (SIR), return of spontaneous circulation (ROSC) and 30-day survival after out-of-hospital cardiac arrest (OHCA).

METHOD

A retrospective observational study comprising OHCA registry data and dispatch data in the Skåne Region, Sweden (2010-2018). Data were categorized according to dispatch procedures, two ambulances (AMB-only) versus two ambulances and firefighter first-responders (DUAL-dispatch), based on the dispatcher's estimation of a time-gain. Dual dispatch was sub-categorized by arrival of first vehicle (first-responder or ambulance). Logistic regressions were used, additionally with groups matched (1:1) for age, witnessed event, bystander cardiopulmonary resuscitation and ambulance response time. Adjusted and conditional odds-ratios (aOR, cOR) with 95% confidence intervals (CI) are presented.

RESULTS

Of 3,245 eligible cases, 43% were DUAL-dispatches with first-responders first on scene (FR-first) in 72%. Despite a five-minute median reduction in response time in the FR-first group, no association with SIR was found (aOR 0.83, 95%CI 0.64-1.07) nor improved 30-day survival (aOR 1.03, 95%CI 0.72-1.47). A positive association between ROSC and the FR-first group (aOR 1.25, 95%CI 1.02-1.54) disappeared in the matched analysis (cOR 1.12, 95%CI 0.87-1.43). Time to first monitored rhythm was 7:06 minutes in the FR-first group versus 3:01 in the combined AMB-only/AMB-first groups.

CONCLUSION

In this time-gain selective first-responder dispatch system, a shorter response time was not associated with increased SIR, improved ROSC rate or survival. Process measures differed between the study groups which could account for the observed findings and requires further investigation.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Factors associated with Emergency Medical Dispatcher request and residents' inappropriate transfers from Nursing Homes to Emergency Department

PURPOSE

In the last decades, the amount of emergency department (ED) transfers of nursing home (NH) residents has disproportionally increased in western countries. The main role of emergency medical dispatcher (EMD) among this population is to refer residents to EDs in the most appropriate way. The aim of this study was to assess risk factors of inappropriate transfers from NH to ED after EMD request.

METHODS

This research was a secondary analysis of a prospective observational multicenter study carried out in 17 EDs entitled FINE aimed to assess potentially inappropriate transfer prevalence among this population. Inappropriate transfers were determined in the FINE study threw a standardized approach by a unique expert team.

RESULTS

Overall, 572/1037 (55.2%) of residents were transferred to the ED after an EMD's decision. Among them, 92/572 (16.1%) transfers was defined as inappropriate. The average age was 87.3 years old (SD = 0.3). The main reason for ED transfer were falls (217/572, 37.9%). In multivariate analysis, the presence of a Special Care Unit in NH was significantly associated with a high rate of inappropriate transfer (OR 1.78; 95 CI [1.07-2.93]; p = 0.02) whereas a medical examination by a general practitioner before the transfer (OR 0.55; 95 CI [0.33-0.83]; p = 0.02) and a prompt access to psychiatric advice (OR 0.54; 95 CI [0.33-0.84]; p = 0.007) were associated with a low rate of potentially inappropriate transfer.

CONCLUSION

Promoting onsite medical assessment and partnership thanks to available geriatrician's advice may help the emergency medical dispatcher to improve the appropriateness of residents' transfer from Nursing Home to the emergency department.

Live video from bystanders' smartphones to medical dispatchers in real emergencies

Background

Medical dispatchers have limited information to assess the appropriate emergency response when citizens call the emergency number. We explored whether live video from bystanders’ smartphones changed emergency response and was beneficial for the dispatcher and caller.

Methods

From June 2019 to February 2020, all medical dispatchers could add live video to the emergency calls at Copenhagen Emergency Medical Services, Denmark. Live video was established with a text message link sent to the caller’s smartphone using GoodSAM®. To avoid delayed emergency response if the video transmission failed, the medical dispatcher had to determine the emergency response before adding live video to the call. We conducted a cohort study with a historical reference group. Emergency response and cause of the call were registered within the dispatch system. After each video, the dispatcher and caller were given a questionnaire about their experience.

Results

Adding live video succeeded in 838 emergencies (82.2% of attempted video transmissions) and follow-up was possible in 700 emergency calls. The dispatchers’ assessment of the patients’ condition changed in 51.1% of the calls (condition more critical in 12.9% and less critical in 38.2%), resulting in changed emergency response in 27.5% of the cases after receiving the video (OR 1.58, 95% CI: 1.30–1.91) compared to calls without video. Video was added more frequently in cases with sick children or unconscious patients compared with normal emergency calls. The dispatcher recognized other or different disease/trauma in 9.9% and found that patient care, such as the quality of cardiopulmonary resuscitation, obstructed airway or position of the patient, improved in 28.4% of the emergencies. Only 111 callers returned the questionnaire, 97.3% of whom felt that live video should be implemented.

Conclusions

It is technically feasible to add live video to emergency calls. The medical dispatcher’s perception of the patient changed in about half of cases. The odds for changing emergency response were 58% higher when video was added to the call. However, use of live video is challenging with the existing dispatch protocols, and further implementation science is necessary.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00493-5.

Diagnostic ability of a newly developed system for recognition of cardiac arrests

BACKGROUND

Early recognition of cardiac arrest is essential for increasing the likelihood of successful resuscitation. However, many factors could obstruct the recognition of cardiac arrest and delay the delivery of cardiopulmonary resuscitation and automated external defibrillator use. We have developed a new system using infrared light to recognize cardiac arrests during emergency. The aim of this study was to evaluate whether cardiac arrests could be appropriately diagnosed by this system in clinical practice.

METHODS

During the initial treatment patients 18 years old and older with unconscious level of 300 on Japan Coma Scale were prospectively registered from May 1st 2016 through May 31st 2017 (University Hospital Medical Information Network-Clinical Trials Registry 000022137). The settings for this study were two critical care medical centers in Osaka Prefecture and two suburban emergency medical services in Chiba Prefecture and Osaka Prefecture in Japan. We evaluated each patient, using the diagnosis of cardiac arrest by relevant physicians or emergency medical services personnel as the "gold standard". Finally, the sensitivity and specificity of the system in understanding whether the patient has cardiac arrest were assessed.

RESULTS

Out of 207 unconscious patients, 163 patients were diagnosed as suffering from cardiac arrest and 44 patients were identified as experiencing pulsating cardiac rhythm. The developed system for diagnosing cardiac arrest when used within 10 s from the activation of the system had a sensitivity of 100% and a specificity of 55.2%. Additionally, the system had a sensitivity of 100% and a specificity of 63.6% for diagnosing cardiac arrest when used within 20 s from activation.

CONCLUSIONS

The newly developed system has 100% sensitivity in detecting cardiac arrests within 10 s from activation of the system in emergency settings. This developed system could help bystanders to promptly initiate resuscitation.

Delays in recognition of the need for telephone-assisted CPR due to caller descriptions of chief complaint

BACKGROUND

The objective of this study was to test if caller descriptions of chief complaint delays emergency medical dispatchers' (EMDs) recognition of the need for telephone-assisted CPR (T-CPR).

METHODS

We conducted an analysis of N = 433 cardiac arrest calls from six large call centers in the United States. Calls were abstracted for initial chief complaint description: caller reports (1) correct medical condition (CMC); (2) incorrect medical condition (IMC), or (3) signs/symptoms only (SS), as well the time interval between call pickup and recognition of the need for T-CPR. In addition, we abstracted if EMDs asked questions related to the caller's chief complaint (rather than, or before), asking about patients' consciousness and breathing status.

RESULTS

The majority of cardiac arrest calls (60%) were reported as SS. Median time to recognition of the need for T-CPR was 64 s for SS chief complaints, 47 s for CMC chief complaints, and 100 s for IMC chief complaints. EMDs pursued chief complaint descriptions for 9% of the calls with SS chief complaints, 41% of the calls with IMC chief complaints, and 19% of the calls with CMC chief complaints. Median time to recognition of the need for CPR for calls in which the chief complaint description was pursued was 166 s compared to 62 s for calls in which the chief complaint description was not pursued.

CONCLUSION

Caller chief complaint description affects the time to recognition of the need for T-CPR.

CLINICAL TRIAL REGISTRATION

http://www.clinicaltrials.gov Trial # NCT01972087.

Using a filming protocol to improve video-instructed cardiopulmonary resuscitation

BACKGROUND:

Video communications during cardiopulmonary resuscitation (CPR) can improve the quality of information exchange between a bystander performing CPR and an emergency medical dispatcher (EMD).

OBJECTIVE:

To improve chest compression effectiveness, a filming protocol instructing video camera placements around a patient was developed. This study measured whether the filming protocol increased chest compressions’ effectiveness.

METHODS:

A simulation study was conducted comparing CPR effectiveness under three conditions: telephone-instructed, video-instructed, and video-instructed with the filming protocol. Twenty-five emergency medical technicians acted as EMDsin the three conditions. A mannequin measured five factors that determined the effectiveness of the chest compressions.

RESULTS:

Compared with telephone-instructed CPR, the filming protocol improved the proportion of time in which the bystander’s hands were in the correct position during chest compressions. Compared with video-instructed CPR, the filming protocol improved both the proportion of time in which the chest was fully released after each compression and the proportion of time in which the compressions were conducted with an appropriate rhythm. The depth and rate of compressions did not improve in the filming protocol condition.

CONCLUSIONS:

Video-instructed CPR with the filming protocol improves CPR effectiveness compared to telephone- and video-instructed CPR. Detailed implementation can improve new technology introduction.

Comparison of the effects of audio-instructed and video-instructed dispatcher-assisted cardiopulmonary resuscitation on resuscitation outcomes after out-of-hospital cardiac arrest

BACKGROUND

This study compared the real-world effects of audio-instructed dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) and video-instructed DA-CPR on resuscitation outcomes after out-of-hospital cardiac arrest (OHCA).

METHODS

A retrospective cohort study was conducted among adult OHCA patients in whom resuscitation was attempted in 2017 in Seoul, Korea. The dispatch center of Seoul introduced video-instructed DA-CPR in 2017, whereas audio-instructed DA-CPR was first implemented in 2010. When more than two bystanders were at the scene and could handle a video-call, the dispatcher call back a video-call and provided CPR instructions. In other situations, standard audio-instructed DA-CPR was provided. The primary outcome was survival to discharge. The secondary outcome was good neurological outcome at hospital discharge. The tertiary outcome was early instruction time interval (ITI, time from call to the initiation of CPR instruction ≤90 s). The study outcomes of audio-instructed DA-CPR (audio group) and video-instructed DA-CPR (video group) were compared. The propensity score matching (PSM) method was used to increase the comparability of the two groups and the logistic regression was performed for the PSM cohort.

RESULTS

A total of 1720 eligible OHCA patients (1489 and 231 in the audio and video groups, respectively) were evaluated. The median ITI was 136 s in the audio group and 122 s in the video group (p = 0.12). The survival to discharge rates were 8.9% in the audio group and 14.3% in the video groups (p < 0.01). Good neurological outcome occurred in 5.8% and 10.4% in the audio and video groups, respectively (p < 0.01). Compared to the audio group, the AORs (95% CIs) for survival to discharge, good neurological outcome and early ITI of the video group were 1.20 (0.74-1.94), 1.28 (0.73-2.26) and 1.00 (0.70-1.43), respectively. The PSM population showed similar results as those of the original cohort.

CONCLUSION

Compared to audio-instructed DA-CPR, video-instructed DA-CPR was not associated with survival improvement in this observational study conducted in one metropolitan city. Randomized controlled trials are needed to compare the effects of video- and audio-instructed DA-CPR.

Effectiveness of dispatcher instructions-dependent or independent bystander cardiopulmonary resuscitation on neurological survival among patients with out-of-hospital cardiac arrest

BACKGROUND

We evaluated the association between survival and bystandercardiopulmonary resuscitation (CPR) with or without dispatcher instructions (DI) considering the time from emergency call receipt by the dispatch center to emergency medical services (EMS) personnel's contact with the patient (i.e. time to EMS arrival).

METHODS

This prospective study conducted in Osaka City, Japan, from 2009 to 2015 included patients with medical cause-related out-of-hospital cardiac arrest who were ≥18 years old. The primary outcome was one-month favorable neurological survival. Using multiple logistic regression models, the adjusted odds ratios (AOR) of independent and DI-dependent CPR for the primary outcome were compared with no CPR. Adjustments were made for patients' age, sex, activities of daily living before the cardiac arrest, year of cardiac arrest, location, presence or absence of witnesses, etiology of cardiac arrest, and the time from EMS contact with the patient to patient's arrival at the hospital. The effective estimated "time to EMS arrival" was also calculated.

RESULTS

For analyses 10,925 individuals were eligible. Independent CPR had a significantly higher one-month favorable neurological survival than no CPR whereas there was no significant difference between DI-dependent CPR and no CPR (AOR, 1.90 [1.47-2.46] and 1.16 [0.91-1.47], respectively). The estimated "time to EMS arrival" for a one-month favorable neurological survival after independent CPR was ≤13min.

CONCLUSIONS

Bystander CPR that did not need DI was associated with significantly higher one-month favorable neurological survival than no CPR, with an effective estimated "time to EMS arrival" of ≤13min.

Exploring individual and work organizational peculiarities of working in emergency medical communication centers in Norway- a qualitative study

Background

Emergency Medical call-takers working in Emergency Medical Communication Centers (EMCCs) are addressing complex and potentially life threatening problems. The call-takers have to make fast decisions, responding to problems described in phone calls. Recent studies focus mainly on individual aspects of call-takers’ work. The objectives of this study were to explore 1) What characterizes individual work performance of call takers in EMCCs? and 2) What characterizes work organizational factors call takers see as most relevant to the performance of their work?

Methods

The research is based upon in-depth interviews with call takers at three EMCCs in Norway (n = 19). Interviews were performed during the period May 2013 to September 2014. Data was analyzed using thematic analysis.

Results

Two main themes that related to individual work performance and to work organizational factors in EMCCs were identified, namely: 1) “Core technologies” and 2) “Environmental issues” . The theme “Core technologies” included the subthemes a) multiple tasks, b) critical incidents, and c) unpredictability. The theme “Environmental issues” included the subthemes a) lack of support, b) lack of resources, c) exposure to complaints, and d) an invisible service.

Conclusion

At the individual level, multiple tasks, how to cope with critical incidents, and the unpredictability of daily work when calls are received, make the work of call takers both stressful and challenging. The individual call taker’s ability to interprete the situation by intuition and experience when calls are received, is the main factor behind the peculiarities working in the centers at the individual level. At the organizational level, the lack of resources and managerial support seems to provoke concerns about the quality of services rendered by the centers. These aspects should be taken into account in the managing of these services, making them a more integrated part of the health service system.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4370-0) contains supplementary material, which is available to authorized users.

Real-time feedback, debriefing, and retraining system of cardiopulmonary resuscitation for out-of-hospital cardiac arrests: a study protocol for a cluster parallel-group randomized controlled trial

Background

The quality of cardiopulmonary resuscitation (CPR) performed by emergency medical services (EMS) personnel affects patient outcomes after cardiac arrest. A CPR feedback device with an accelerometer mounted on a defibrillator can monitor the motion of the patient’s sternum to display and record CPR quality in real time. To evaluate the utility of real-time feedback, debriefing, and retraining using a CPR feedback device outside of the hospital, an open-label, cluster randomized controlled trial will be conducted in five municipalities of Osaka Prefecture, Japan.

Methods

Each EMS station within a fire department will be randomly assigned to: 1) the treatment group with real-time feedback, debriefing, and retraining using the CPR feedback device (intervention group); or 2) the conventional treatment group without real-time feedback, debriefing, and retraining (control group). This trial will include 2850 to 3020 patients over about 4 years. The primary outcome of the trial is 1-month favorable neurological survival, defined as cerebral performance category scale score 1 or 2. Secondary outcomes are 1-month survival, survival to hospital discharge, return of spontaneous circulation, and quality of CPR including fraction, depth, tempo, and ventilation rate.

Discussion

The trial will assess whether treatment monitored by the CPR feedback device, which allows for real-time feedback, debriefing, and retraining using CPR quality data, outperforms conventional treatment without real-time feedback, debriefing, and retraining in terms of 1-month favorable neurological survival in cardiac arrest patients receiving CPR outside the hospital.

Trial registration

University Hospital Medical Information Network (UMIN) Clinical Trials Registry, UMIN000021431. Registered on 11 March 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2852-8) contains supplementary material, which is available to authorized users.

Simulation training to improve 9-1-1 dispatcher identification of cardiac arrest: A randomized controlled trial

BACKGROUND

The objective of this study was to test the effectiveness of simulation training, using actors to make mock calls, on improving Emergency Medical Dispatchers' (EMDs) ability to recognize the need for, and reduce the time to, telephone-assisted CPR (T-CPR) in simulated and real cardiac arrest 9-1-1 calls.

METHODS

We conducted a parallel prospective randomized controlled trial with n=157 EMDs from thirteen 9-1-1 call centers. Study participants were randomized within each center to intervention (i.e., completing 4 simulation training sessions over 12-months) or control (status quo). After the intervention period, performance on 9 call processing skills and 2 time-intervals were measured in 2 simulation assessment calls for both arms. Six of the 13 call centers provided recordings of real cardiac arrest calls taken by study participants during the study period.

RESULTS

Of the N=128 EMDs who completed the simulation assessment, intervention participants (n=66) performed significantly better on 6 of 9 call processing skills and started T-CPR 23s faster (73 vs 91s respectively, p<0.001) compared to participants in the control arm (n=62). In real cardiac arrest calls, EMDs who completed 3 or 4 training sessions were more likely to recognize the need for T-CPR for more challenging cardiac arrest calls than EMDs who completed fewer than 3, including controls who completed no training (68% vs 53%, p=0.018).

CONCLUSIONS

Simulation training improves call processing skills and reduces time to T-CPR in simulated call scenarios, and may improve the recognition of the need for T-CPR in more challenging real-life cardiac arrest calls.

CLINICAL TRIAL REGISTRATION

http://www.clinicaltrials.gov Trial # NCT01972087.