A national census of ambulance response times to emergency calls in Ireland

Background—Equity of access to appropriate pre-hospital emergency care is a core principle underlying an effective ambulance service. Care must be provided within a timeframe in which it is likely to be effective. A national census of response times to emergency and urgent calls in statutory ambulance services in Ireland was undertaken to assess current service provision.

Methods—A prospective census of response times to all emergency and urgent calls was carried out in the nine ambulance services in the country over a period of one week. The times for call receipt, activation, arrival at and departure from scene and arrival at hospital were analysed. Crew type, location of call and distance from ambulance base were detailed. The type of incident leading to the call was recorded but no further clinical information was gathered.

Results—2426 emergency calls were received by the services during the week. Fourteen per cent took five minutes or longer to activate (range 5–33%). Thirty eight per cent of emergencies received a response within nine minutes (range 10–47%). Only 4.5% of emergency calls originating greater than five miles from an ambulance station were responded to within nine minutes (range 0–10%). Median patient care times for "on call" crews were three times longer than "on duty" crews.

Conclusion—Without prioritised use of available resources, inappropriately delayed responses to critical incidents will continue. Recommendations are made to improve the effectiveness of emergency medical service utilisation.

     

Ambulance alerting of paediatric emergencies to a general hospital

BACKGROUND: There are at present only a small number of dedicated paediatric emergency departments in the UK. Severely ill and injured children are often taken by ambulance to the nearest general hospital. Efforts have been made to provide better care for these sickest children pending the establishment of dedicated paediatric emergency services within general emergency departments by 2004 [Royal College of Paediatrics and Child Health; Accident and Emergency Services for Children-Report of a Multidisciplinary Working Party, June 1999]. To learn more of the staffing implications for the establishment of dedicated paediatric emergency units within the general hospital, 30 months of paediatric alert call data are presented. METHODS: A prospective review of paediatric alert calls over 30 months, (from January 1999 until June 2001). All alert calls from the ambulance service to a large urban emergency department were recorded on a specific form. Data from these forms is presented. RESULTS: There were 1754 alert calls of all types during this 30-month period, of which 153 (9%) were for patients under the age of 16 (mean 1.2 each week). Of these, 102 (66%) were for medical conditions and 51 (34%) were for trauma. The mean estimated time of arrival from the time of the alert call was 6 min. The majority of both medical and trauma paediatric alert calls occur in the afternoon and progress well into the night. The 51.6% of paediatric medical alert calls and 64.4% of paediatric trauma alert calls occur 'out of normal hours'. There was little reduction in the frequency of alert calls at the weekend. There were no paediatric trauma alert calls between 2 a.m. and 10 a.m., although medical paediatric alert calls continued throughout the night. CONCLUSIONS: Resident senior trauma personnel to manage injured children should be provided until at least midnight. Hospitals that maintain a facility for the reception of sick children must be able to provide a rapid response to paediatric medical emergencies on a 24 h basis. Guidelines for alert calls for ambulance crews are required.     

Emergency (999) calls to the ambulance service that do not result in the patient being transported to hospital: an epidemiological study

Methods: The first 500 consecutive non-transported patients from 1 March 2000 were identified from the ambulance service command and control data. Epidemiological and clinical data were then obtained from the patient report form completed by the attending ambulance crew and compared with the initial priority dispatch (AMPDS) code that determined the urgency of the ambulance response.

Results: Data were obtained for 498 patients. Twenty six per cent of these calls were assigned an AMPDS delta code (the most urgent category) at the time the call was received. Falls accounted for 34% of all non-transported calls. This group of patients were predominantly elderly people (over 70 years old) and the majority (89%) were identified as less urgent (coded AMPDS alpha or bravo) at telephone triage. The mean time that an ambulance was committed to each non-transported call was 34 minutes.

Conclusions: This study shows that falls in elderly people account for a significant proportion of non-transported 999 calls and are often assigned a low priority when the call is first received. There could be major gains if some of these patients could be triaged to an alternative response, both in terms of increasing the ability of the ambulance service to respond faster to clinically more urgent calls and improving the cost effectiveness of the health service. The AMPDS priority dispatch system has been shown to be sensitive but this study suggests that its specificity may be poor, resulting in rapid responses to relatively minor problems. More research is required to determine whether AMPDS prioritisation can reliably and safely identify 999 calls where an alternative to an emergency ambulance would be a more appropriate response.

     

The "Vertical Response Time": Barriers to Ambulance Response in an Urban Area

Background: Ambulance response time is typically reported as the time interval from call dispatch to arrival on-scene. However, the often unmeasured "vertical response time" from arrival on-scene to arrival at the patient's side may be substantial, particularly in urban areas with high-rise buildings or other barriers to access.
Objectives: To measure the time interval from arrival on-scene to the patient in a large metropolitan area and to identify barriers to emergency medical services arrival.
Methods: This was a prospective observational study of response times for high-priority call types in the New York City 9-1-1 emergency medical services system. Research assistants riding with paramedics enrolled a convenience sample of calls between 2001 and 2003.
Results: A total of 449 paramedic calls were included, with a median time from call dispatch to arrival on-scene of 5.2 minutes. The median on-scene to patient arrival interval was 2.1 minutes, leading to an actual response interval (dispatch to patient) of 7.6 minutes. The median on-scene to patient interval was 2.8 minutes for residential buildings, 2.7 minutes for office complexes, 1.3 minutes for private homes (less than four stories), and 0.5 minutes for outdoor calls. Overall, for all calls, the on-scene to patient interval accounted for 28% of the actual response interval. When an on-scene escort provided assistance in locating and reaching the patient, the on-scene to patient interval decreased from 2.3 to 1.9 minutes. The total dispatch to patient arrival interval was less than 4 minutes in 8.7%, less than 6 minutes in 28.5%, and less than 8 minutes in 55.7% of calls.
Conclusions: The time from arrival on-scene to the patient's side is an important component of overall response time in large urban areas, particularly in multistory buildings.     

Study of early warning of accident and emergency departments by ambulance services.

OBJECTIVE: To determine the warning time given to accident and emergency (A&E) departments by the ambulance service before arrival of a critically ill or injured patient. To determine if this could be increased by ambulance personnel alerting within five minutes of arrival at scene. METHODS: Use of computerised ambulance control room data to find key times in process of attending a critically ill or injured patient. Modelling was undertaken with a scenario of the first responder alerting the A&E department five minutes after arrival on scene. RESULTS: The average alert warning time was 7 min (range 1-15 min). Mean time on scene was 22 min (range 4-59 min). In trauma patients alone, the average alert time was 7 min, range 2-15 min, with an average on scene time of 23 min, range 4-53 min. There was a potential earlier alert time averaging 25 min (SD 18.6, range 2-59 min) if the alert call was made five minutes after arrival on scene. CONCLUSIONS: A&E departments could be alerted much earlier by the ambulance service. This would allow staff to be assembled and preparations to be made. Disadvantages may be an increased "alert rate" and wastage of staff time while waiting the ambulance arrival.     

Study of early warning of accident and emergency departments by ambulance services.

OBJECTIVE: To determine the warning time given to accident and emergency (A&E) departments by the ambulance service before arrival of a critically ill or injured patient. To determine if this could be increased by ambulance personnel alerting within five minutes of arrival at scene. METHODS: Use of computerised ambulance control room data to find key times in process of attending a critically ill or injured patient. Modelling was undertaken with a scenario of the first responder alerting the A&E department five minutes after arrival on scene. RESULTS: The average alert warning time was 7 min (range 1-15 min). Mean time on scene was 22 min (range 4-59 min). In trauma patients alone, the average alert time was 7 min, range 2-15 min, with an average on scene time of 23 min, range 4-53 min. There was a potential earlier alert time averaging 25 min (SD 18.6, range 2-59 min) if the alert call was made five minutes after arrival on scene. CONCLUSIONS: A&E departments could be alerted much earlier by the ambulance service. This would allow staff to be assembled and preparations to be made. Disadvantages may be an increased "alert rate" and wastage of staff time while waiting the ambulance arrival.     

Physicians at the roadside: Pre-hospital emergency care in the United Kingdom

In some parts of the United Kingdom (UK), family doctors (or "general practitioners" as they are called in the UK) are routinely called upon by the emergency medical services (EMS) system to attend road accidents. The doctors are volunteers and travel to the scene of the accident in their own cars. Members of one such general practitioner accident service operating in Mid-Anglia complete an accident report form after attending each incident. In 1983, the Mid-Anglia General Practitioner Accident Service (MAGPAS) received 1,715 calls for medical assistance, and in 95% of these a doctor was sent immediately. Of these calls, 57% were passed to the doctor within one minute of the receipt of the call in the MAGPAS control room, and 78% were relayed within two minutes. This rapid call-out, combined with the close proximity of the local doctor to the accident site, resulted in the doctors arriving ahead of the ambulance in 42% of the calls. A total of 54 patients with airway obstruction were treated by the doctors prior to the arrival of the ambulance. Ninety-nine patients required immediate intravenous fluid replacement in the pre-hospital phase of their medical care. This report suggests that general practitioners in rural areas can play a vital role in the early management of trauma patients, especially in the absence of ambulance personnel trained in advanced life support skills.     

Early stroke care in Italy--a steep way ahead: an observational study

Objectives

To measure the performance of selected Italian emergency medical system (EMS) dispatch centres managing calls for patients suffering from stroke. Data on outcome and on early treatment in the ED were collected.

Methods

Prospective data collection for a trimester from interventions for a suspected stroke in 13 EMS dispatch centres over five Italian regions.

Results

Altogether, 1041 calls for a suspected stroke were analysed. Mean intervals of the sequential phases were 2.3±2 minutes between call and ambulance dispatch, 8.4±5.5 minutes to reach the patient, 14.5±8.5 minutes on the scene, and 40.2±16.2 minutes between call and arrival at the ED. Interventions were performed in 56% of cases by a basic life support (BLS) crew, advanced life support (ALS) crews intervened in 28% of cases, and a combination of ALS and BLS in the remaining 16%. Mean diagnostic interval was 99±85 minutes between emergency system call and the first CT scan. This was performed 71±27 minutes after ED admission. Only 1.6% were admitted to a stroke unit. One month outcome according to GCS was good recovery in 32%, moderate disability in 28%, severe disability in 14%, and death in 25% of the patients.

Conclusions

Mean times show a rapid response of the selected EMS dispatch centres to calls for a suspected stroke. Nevertheless, mean times of the ED phase are still unacceptable according to international guidelines such as Brain Attack Coalition and American Stroke Association guidelines. Efforts should be spent to reduce the time between the arrival and the CT scan and more patients should be admitted to a stroke unit.     

Computer assisted assessment and advice for "non-serious" 999 ambulance service callers: the potential impact on ambulance despatch

Design: Pragmatic controlled trial. Calls identified using priority dispatch protocols as non-serious were allocated to intervention and control groups according to time of call. Ambulance dispatch occurred according to existing procedures. During intervention sessions, nurses or paramedics within the control room used a computerised decision support system to provide telephone assessment, triage and, if appropriate, offer advice to permit estimation of the potential impact on ambulance dispatch. Setting: Ambulance services in London and the West Midlands. Subjects: Patients for whom emergency calls were made to the ambulance services between April 1998 and May 1999 during four hour sessions sampled across all days of the week between 0700 and 2300. Main outcome measures: Triage decision, ambulance cancellation, attendance at an emergency department. Results: In total, there were 635 intervention calls and 611 controls. Of those in the intervention group, 330 (52.0%) were triaged as not requiring an emergency ambulance, and 119 (36.6%) of these did not attend an emergency department. This compares with 55 (18.1%) of those triaged by a nurse or paramedic as requiring an ambulance (odds ratio 2.62; 95% CI 1.78 to 3.85). Patients triaged as not requiring an emergency ambulance were less likely to be admitted to an inpatient bed (odds ratio 0.55; 95% CI 0.33 to 0.93), but even so 30 (9.2%) were admitted. Nurses were more likely than paramedics to triage calls into the groups classified as not requiring an ambulance. After controlling for age, case mix, time of day, day of week, season, and ambulance service, the results of a logistic regression analysis revealed that this difference was significant with an odds ratio for nurses:paramedics of 1.28 (95% CI 1.12 to 1.47). Conclusions: The findings indicate that telephone assessment of Category C calls identifies patients who are less likely to require emergency department care and that this could have a significant impact on emergency ambulance dispatch rates. Nurses were more likely than paramedics to assess calls as requiring an alternative response to emergency ambulance despatch, but the extent to which this relates to aspects of training and professional perspective is unclear. However, consideration should be given to the acceptability, reliability, and cost consequences of this intervention before it can be recommended for full evaluation.     

Prehospital response to respiratory distress by the public ambulance system in a Ukrainian city

BACKGROUND: The capability of the public ambulance system in Ukraine to address urgent medical complaints in a prehospital environment is unknown. Evaluation using reliable sources of patient data is needed to provide insight into current treatments and outcomes. METHODS: We obtained access to de-identified computer records from the emergency medical services (EMS) dispatch center in Poltava, a medium-sized city in central Ukraine. Covering a five-month period, we retrieved data for urgent calls with a patient complaint of respiratory distress. We evaluated ambulance response and treatment times, field diagnoses, and patient disposition, and analyzed factors related to fatal outcomes. RESULTS: Over the five-month period of the study, 2,029 urgent calls for respiratory distress were made to the Poltava EMS dispatch center. A physician-led ambulance typically responded within 10 minutes. Seventy-seven percent of patients were treated and released, twenty percent were taken to hospital, and three percent died in the prehospital phase. On univariate analysis, age over 60 and altered mental status at the time of the call were strongly associated with a fatal outcome. CONCLUSION: The EMS dispatch center in a medium-sized city in Ukraine has adequate organizational infrastructure to ensure that a physician-led public ambulance responds rapidly to complaints of respiratory distress. That EMS system was able to manage most patients without requiring hospital admission. However, a prehospital fatality rate of three percent suggests that further research is warranted to determine training, equipment, or procedural needs of the public ambulance system to manage urgent medical conditions.     

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.     

NHS Direct: consistency of triage outcomes

Methods: 119 scenarios were constructed based on calls to ambulance services that had been assigned the lowest priority category by the emergency medical dispatch systems in use. These scenarios were presented to nurses working in four NHS Direct call centres using different computerised decision support software, including the NHS Clinical Assessment System.

Results: The overall level of agreement between the nurses using the four systems was "fair" rather than "moderate" or "good" (κ=0.375, 95% CI: 0.34 to 0.41). For example, the proportion of calls triaged to accident and emergency departments varied from 22% (26 of 119) to 44% (53 of 119). Between 21% (25 of 119) and 31% (37 of 119) of these low priority ambulance calls were triaged back to the 999 ambulance service. No system had both high sensitivity and specificity for referral to accident and emergency services.

Conclusions: There were large differences in outcome between nurses using different software systems to triage the same calls. If the variation is primarily attributable to the software then standardising on a single system will obviously eliminate this. As the calls were originally made to ambulance services and given the lowest priority, this study also suggests that if, in the future, ambulance services pass such calls to NHS Direct then at least a fifth of these may be passed back unless greater sensitivity in the selection of calls can be achieved.

     

Ambulance emergency services for patients with coronary heart disease in Lancashire: achieving standards and improving performance

Methods: Audit datasets on two cohorts of patients with chest pain and suspected AMI were assembled by the Lancashire Ambulance Service NHS Trust in north west England: 3706 patients during 1996/97 and 3423 in 2001. They were transported to four hospitals. The analyses covered journey timings, role of rapid response vehicles (RRV), and clinical procedures and the results were compared with prevailing national standards.

Results: Hourly and daily usage patterns were similar in the two periods. During 1996/97 the national rural target of 95% of response times being within 19 minutes was achieved (96% of calls), unlike the target of 50% within eight minutes (45.3% of calls). During 2001, 2684 (78.4%) calls had response times within eight minutes thus exceeding the revised national target of 75%. RRVs were despatched for 1214 (35.5%) of calls in 2001, and the mean response time (SD) for these vehicles was significantly shorter than for front line ambulances (0:05:53 (0:02:49) versus 0:07:04 (0:04:19), p<0.001), likewise the mean call to hospital time (0:32:38 (0:09:28) v 0:35:01 (0:12:09), p<0.001). Patients in 2001 were more likely to be given aspirin by the ambulance crews (74% of cases), while the rate of cannulation was lower.

Conclusion: A significant improvement has been achieved in the performance of ambulance services in Lancashire since 1996, because of recently introduced strategies, notably RRVs, and in the presence of more demanding national standards and targets.

     

Misuse of the London ambulance service: How much and why?

OBJECTIVES: To assess the degree of inappropriate use of the London Ambulance Service and analyse the reasons for misuse. DESIGN: An immediate assessment of the appropriateness of the "999" call by the ambulanceperson and casualty senior house officer followed by a retrospective review of each case by the accident and emergency (A&E) consultant. SETTING: A busy inner London A&E department. METHODS: Three hundred consecutive emergency ambulance arrivals to the A&E department underwent assessment as to the appropriateness of the call. RESULTS: Overall 53.7% of patients were considered justified in their call, 15.7% of calls were inappropriate, and in 19.0% of cases a unanimous decision was not reached. Eleven per cent of all forms were incompletely filled. CONCLUSIONS: Almost 16% of emergency ambulance calls were considered unanimously to be inappropriate. This suggests that 75,000 emergency calls per year to the London Ambulance Service are not necessary. The commonest reason for inappropriately calling an ambulance was that the caller felt that they had a serious or life threatening condition. The need for public education and deterrents of ambulance abuse are discussed. The further introduction of a nursing led triage "hot line" to appropriately dispatch ambulances according to clinical needs of the patient, and other alternatives to this are discussed.     

患者与院前急救服务伦理冲突的调查分析

目的 了解院前患者与救护人员判断及急救网络管理制度的冲突情况.方法 采用〈院前急救中遇到伦理学问题调查表〉,对全市80家急救网络医院从事院前急救工作的80名医生和248名护士进行问卷调查,调查患者与院前急救服务伦理冲突的情况.结果 328份问卷中,认为需要救护的患者中完全拒绝的患者占（8.046±6.990）%,部分拒绝的占（14.544±10.558）%;需要救护车转运的患者中拒绝的占（14.451±14.747）%;拒绝救护和转运的原因中付费问题占（23.52±19.79）%.认为自己不需要占（22.22±20.84）%,自己想死占（5.77±4.47）%,难以判断占（19.44±18.65）%,其他原因占（30.08±25.78）%;（20.31±16.66）%的患者拒绝救护人员判断其处于某种状态;得到救护车服务的患者中（29.66±24.02）%的患者认为无出车必要;（22.11＋19.52）%患者的要求与院前急救服务管理的规定有冲突.结论 院前患者与院前急救服务伦理存在一定程度上的冲突.     

Response Time Effectiveness:Comparison of Response Time and Survival in an Urban Emergency Medical Services System

Emergency medical services (EMS) administrators seek methods to enhance system performance. One component scrutinized is the response time (RT) interval between call receipt and arrival on scene. While reducing RTs may improve survival, this remains speculative and unreported. OBJECTIVE: To determine the effect of current RTs on survival in an urban EMS system. METHODS: The study was conducted in a metropolitan county (population 620,000). The EMS system is a single-tier, paramedic service and provides all service requests. The 90% fractile RT specifications required for county compliance include 10:59 minutes for emergency life-threatening calls (priority I) and 12:59 minutes for emergency non-life-threatening calls (priority II). All emergency responses resulting in a priority I or priority II transport to a Level 1 trauma center emergency department over a six-month period were evaluated to determine the relation between specified and arbitrarily assigned RTs and survival. RESULTS: Five thousand, four hundred twenty-four transports were reviewed. Of these, 71 patients did not survive (1.31%; 95% CI = 1.04% to 1.67%). No significant difference in median RTs between survivors (6.4 min) and nonsurvivors (6.8 min) was noted (p = 0.10). Further, there was no significant difference between observed and expected deaths (p = 0.14). However, mortality risk was 1.58% for patients whose RT exceeded 5 minutes, and 0.51% for those whose RT was under 5 minutes (p = 0.002). The mortality risk curve was generally flat over RT intervals exceeding 5 minutes. CONCLUSIONS: In this observational study, emergency calls where RTs were less than 5 minutes were associated with improved survival when compared with calls where RTs exceeded 5 minutes. While variables other than time may be associated with this improved survival, there is little evidence in these data to suggest that changing this system's response time specifications to times less than current, but greater than 5 minutes, would have any beneficial effect on survival.