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.

Considerations on out-of-hospital pain assessment of a diverse population

Nearly all medical emergency calls are related to someone experiencing some form of discomfort—either due to trauma or pain. Initial pain assessment may be undertaken over the telephone by an emergency medical dispatcher, without seeing the patient; however, the next key moment in pain assessment is completed patient-side by the paramedic. This inquiry is detailed and guides the paramedic in the formation of a differential diagnosis and provision of appropriate pain management. The research team recently conducted and published a study on pain assessment which raised concerns on the subjectivity of pain scoring. The work presented was in the context of a very multicultural environment. The aim of this commentary article is to further explore this topic and encourage health professionals to reflect on this aspect of patient assessment.

PP27 Features of emergency medical system calls that facilitate or inhibit call-taker recognition that a patient is in, or at risk of, cardiac arrest: a systematic mixed studies review

AimTo identify and appraise evidence relating to the features of an Emergency Medicine System call interaction that enable, or inhibit, an Emergency Medical Dispatcher’s recognition that a patient is in out-of-hospital cardiac arrest, or at imminent risk of out-of-hospital cardiac arrest.MethodsAll study designs were eligible for inclusion. Data sources included Medline, BNI, CINAHL, EMBASE, PubMed, Cochrane Database of Systematic Reviews, AMED and OpenGrey. Stakeholder resources were screened and experts in resuscitation were asked to review the studies identified. Studies were appraised using the Mixed Methods Appraisal Tool. Synthesis was completed using a segregated mixed research synthesis approach.ResultsTwenty-five studies were included in the review. ‘Recognition studies’ involving patients already in out-of-hospital cardiac arrest dominated this SMSR and challenges associated with recognition of out-of-hospital cardiac arrest were apparent. Four main themes were identified: Recognising abnormal/agonal breathing during the emergency call, Managing the emergency call, Emotional distress, Patient’s colour.ConclusionA dominant finding is the difficulty in recognising abnormal/agonal breathing during the Emergency Medical Service call. The interaction between the caller and the Emergency Medical Dispatcher is critical in the recognition of patients who suffer an out-of-hospital cardiac arrest. Emergency Medical Dispatchers adapt their approach to the Emergency Medical Service call, and regular training for Emergency Medical Dispatchers is recommended to optimise out-of-hospital cardiac arrest recognition. Further research is required with a focus on the Emergency Medical Service call interaction of patients who are alive at the time of the Emergency Medical Service call and who later deteriorate into OHCA.

‘Is the patient completely alert?’ – accuracy of emergency medical dispatcher determination of patient conscious state

Introduction During emergency ambulance calls, one of the key issues assessed is the patient’s level of consciousness. An altered conscious state can be indicative of a need for a high priority response; however, the reliability of the resulting triage depends on how accurately alertness can be ascertained over the phone. This study investigated the accuracy of emergency medical dispatcher (EMD) determination of conscious state in emergency ambulance calls in Perth, Western Australia. Methods The study compared EMD determination of patient alertness based on the Medical Priority Dispatch System (MPDS), with conscious state as recorded by paramedics on arrival, for all emergency ambulance calls in a 1-year period in metropolitan Perth. Diagnostic accuracy was reported across the whole system and stratified by MPDS chief complaint. Results There were 109,678 calls included for analysis. In terms of identifying patients as not alert, the overall positive predictive value was 6.62% and negative predictive value was 99.93%, with 10 times as many patients dispatched as not alert than found to be not alert at scene. Sensitivity was only 69.94%. There was significant variation in accuracy between chief complaints. Conclusion The study found high levels of inaccuracy between dispatch identification of not-alert patients, and what paramedics found on scene. While not-alert dispatch was 10 times more common than patients being determined not-alert on scene, only 70% of not-alert patients on scene were classified as such during dispatch. Further research is suggested into the factors that affect the accuracy of EMD determination of patient conscious state.

Out-of-hospital cardiac arrest protocol comparison

BackgroundEarly identification of out-of-hospital cardiac arrest (OHCA) has been proven to increase survival rates. Toward this goal, emergency medical dispatchers commonly use one of two types of emergency medical dispatcher systems, each with a unique OHCA protocol. The criteria-based dispatch (CBD) protocol is a set of guidelines and prompts intended for dispatchers with clinical background and experience, while the medical priority dispatch (MPD) is a scripted caller interrogation protocol intended for non-healthcare dispatchers. The objective of this study was to compare CBD and MPD protocols in terms of accuracy and duration of the identification process.MethodsTo compare the two protocols we conducted an OHCA simulation of an emergency phone call by a bystander. Two groups participated in the simulation: 1) emergency medical technicians during paramedic vocational training, in the role of CBD dispatchers, and 2) non-healthcare personnel in the role of MPD dispatchers. Dispatchers were asked to identify whether a patient was having a cardiac arrest based on the information they received from the bystander.ResultsDuration of the OHCA identification process was significantly shorter for participants using MPD (CBD 50 seconds vs. MPD 33 seconds, p=0.003). The OHCA accuracy was 86.49% for the CBD and 82.86% for MPD, but this difference was not statistically significant (p=0.60).ConclusionThe advantages of each protocol suggest that some combination of the two protocols may optimise the OHCA identification process, leading to increased accuracy and shorter duration of the identification process.