The Ability of Emergency Medical Dispatch Codes of Medical Complaints to Predict ALS Prehospital Interventions

Objective. The Medical Priority Dispatch System (MPDS) is an emergency medical dispatch (EMD) system that is commonly used to triage 9-1-1 calls andoptimize paramedic andEMT dispatch. The objective of this study was to determine the sensitivity, specificity, andpositive andnegative predictive values of selected MPDS dispatch codes to predict the need for ALS medication or procedures. Methods. Patients with selected MPDS codes between November 1, 2003, andOctober 31, 2005, from a suburban California county were matched with their electronic patient care record. The records of all transported patients were queried for prehospital interventions andmatched to their MPDS classification [Basic Life Support (BLS) versus Advanced Life Support (ALS)]. Patients who received prehospital interventions or medications were considered ALS Intervention. With true positive = ALS by MPDS + ALS Intervention, true negative = BLS by MPDS + BLS Interventions, false positive = ALS by MPDS + BLS Interventions, andfalse negative = BLS by MPDS + ALS Interventions, the screening performance of the San Mateo County EMD system was determined for selected complaint categories (abdominal pain, breathing problems chest pain, sick person, seizures, andunconscious/fainting). Results. There were a total of 64,647 medical calls, and42,651 went through the EMD process; 31,187 went through the EMD process andwere transported; 22,243of these were matched to a patient care record. The sensitivity andspecificity with 95% confidence intervals in () were as follows: all EMD calls 84 (83–85), 36 (35–36); abdominal pain, 53 (41–65), 47 (43–51); chest pain 99 (99–100), 2 (1–3); seizure 83 (77–88), 20 (17–23), sick 59 (53–64), 51 (49–54), andunconscious/fainting 99 (98–100), 2 (2–3). Conclusion. In our EMS system, MPDS coding for all medical calls had high sensitivity andlow specificity for the prediction of calls that required ALS intervention. Chest pain andunconscious/fainting calls were screened with very high sensitivity but very low specificity.     

Prehospital Care Research Forum/NAEMSE 2005

Objective. The Medical Priority Dispatch System is an emergency medical dispatch (EMD) system that is widely used to categorize 9-1-1 calls andoptimize resource allocation. This study evaluates the ability of EMD andnon-EMD codes (calls not processed by EMD) to predict prehospital use of medications andprocedures. Methods. All transported prehospital patients placed in an EMD or non-EMD category that exceeded 500 total calls from January 1, 2004, to December 31, 2006, in a suburban California county were matched with their prehospital electronic patient care record. These records (N = 69,541) were queried for the following prehospital interventions: basic life support (BLS) care only, intravenous line placement only, medication given, andprocedures. Advanced life support (ALS) interventions were defined as the administration of a medications or a procedure. The numbers of medications andprocedures that were performed on patients in each EMD code were measured. Results. Thirty-one of 141 EMD andnon-EMD codes met inclusion criteria andcomprised 73% of all calls during the study period. Non-EMD codes accounted for 48% of all calls in this study. Patients with shortness of breath, chest pain, diabetic problems, andaltered mental status received the most medications. High rates of medication administration were also seen in the following codes: 17A (fall, 27%), 17B (fall, 14%), EMDX (unable to complete EMD process, 22%), MED (medical aid requested—details to follow, 26%), andMED3 (medical aid requested by police—code 3, 18%). Procedures were performed on only 0.9% of all calls, of which 75% were related to advanced airways. Higher rates of ALS interventions in higher-acuity categories (Alpha, Bravo, etc.) were seen in a number of EMD categories, including seizure, laceration/hemorrhage, sick, andtraffic accident, but not seen in many categories, including abdominal pain, falls, andchest pain. Conclusions. This study demonstrated only a modest ability of the EMD system to predict which patients would require ALS intervention. There were limited differences noted in the ALS rates between the different codes (Alpha, Bravo, etc.) in the same complaint category, bringing into question the utility of the multiple subgroups. Non-EMD codes made up a large portion of calls (48%) andshould be included in future studies.     

The Effect of Language Barriers on Dispatching EMS Response

Abstract

Objective. The objective of this study was to investigate the effect of language barriers during medical 9-1-1 calls, on the time to dispatch and level of medical aid (Basic or Advanced Life Support). Methods. All 9-1-1 medical calls to two large call centers during one week for each of the months of August, October, December 2010 and February 2011, were reviewed for a notation of language barrier (LB). Non-language barrier calls were identified from the same time period such that there were an equal proportion of LB and non-LB calls by dispatch code and dispatcher. A total of 272 language barrier calls were identified. The computer-assisted dispatch (CAD) reports for the LB and non-LB calls were abstracted by research staff using a standard form, including: Start time of call, time to dispatch of BLS, time to dispatch of ALS, dispatch code, interpretation service use, on-scene upgrade to ALS, and on-scene downgrade to BLS. 9-1-1 recordings were abstracted for LB calls only to obtain information about use of interpreter services. Difference between LB and English speakers in time to assignment of BLS and ALS was examined using linear mixed effects models with log time as the outcome; language barrier, call center and dispatch code as fixed effects and dispatcher as a random effect. Results. The effect of language barrier on time to BLS assignment was, on average, 33% longer (p < 0.001) and time to ALS assignment 43% longer (P = 0.008). A majority of the effect was due to the effect of interpreter use, which increased time to BLS by 82% and 125% for ALS, when compared to non-language barrier calls. Data from the 9-1-1 recordings showed an average of 49 seconds between connecting to the service operator and connecting to the language interpreter. Language barrier calls were more likely to be up- and down-graded, only statistically significantly so for on-scene downgrades. Conclusion. Language barriers increase time to dispatch and the accuracy of the level of aid dispatched during medical emergency calls. Decreasing the time to connecting to an actual interpreter when using an interpretation service could minimize existing delays.     

G UIDELINES FOR A IR M EDICAL D ISPATCH

Abstract

Objective. We investigated 9-1-1 telecommunicators’ perceptions of communication difficulties with callers who have limited English proficiency (LEP) and the frequency and outcomes of specific communication behaviors. Methods. A survey was administered to 150 telecommunicators from four 9-1-1 call centers of a metropolitan area in the Pacific Northwest to assess their experience working with LEP callers. In addition, 172 9-1-1 recordings (86 of which were labeled by telecommunicators as having a “language barrier”) were abstracted for telecommunicators’ communication behaviors and care delivery outcomes. All recordings were for patients who were in presumed cardiac arrest (patient unconscious and not breathing). Additionally, computer-assisted dispatch (CAD) reports were abstracted to assess dispatch practices with regard to timing of basic life support (BLS) and advanced life support (ALS) dispatch. Results. One hundred twenty-three of the telecommunicators (82%%) filled out the survey. The majority (70%%) reported that they encounter LEP callers almost daily and most (78%%) of them reported that communication difficulties affect the medical care these callers receive. Additionally, the telecommunicators reported that calls with LEP callers are often (36%%) stressful. The number one strategy for communication with LEP callers reported by telecommunicators was the use of a telephone interpreter line known as the Language Line. However, the Language Line was utilized in only 13%% of LEP calls abstracted for this study. The analysis of 9-1-1 recordings suggests that the LEP callers received more repetition, rephrasing, and slowing of speech than the non-LEP callers. Although there was no difference in time from onset of call to dispatching BLS, there was a significant difference in simultaneous dispatching of BLS and ALS between the LEP calls (20%%) and non-LEP calls (38%%, p < 0.05). Conclusion. Our study shows that 9-1-1 telecommunicators believe language barriers with LEP callers negatively impact communication and care outcomes. More research needs to be conducted on “best practices” for phone-based emergency communication with LEP callers. Additionally, LEP communities need to better understand the 9-1-1 system and how to effectively communicate during emergencies.     

Cancellation of responding ALS units by BLS providers: A national survey

Objective. In many emergency medical services (EMS) systems, personnel without advanced life support (ALS) training are authorized to cancel responding ALS units before the ALS personnel arrive and examine the patient. This study was conducted to examine these cancellations in major U.S. cities. Methods. A survey was mailed to the physician medical directors of the EMS services of the 125 largest U.S. cities, with telephone follow-up of nonresponders. The survey requested information on system structure, and on policies governing cancellation of responding ALS units by non-ALS personnel. Results. Ninety-four cities responded (75%), from 35 states. Nineteen systems (20%) are all-ALS with no basic life support (BLS) tier, and these were eliminated. Of the remaining 75 systems, eight (11%) use BLS ambulances (BLS-A), 35 (47%) use BLS first responders (BLS-FR), and 32 (43%) use both. Of these 75 systems, 60 (80%) allow cancellation of responding ALS units by BLS personnel. Only 24 of these (40%) have written protocols for such cancellations, and only 12 of those (50%) involve specific medical criteria, with two (8%) relying on the best judgment of the BLS personnel with no medical criteria, and another eight (33%) allowing cancellation only for logistic reasons. Of the 60 systems that permit cancellation, 13 (22%) perform some type of medical oversight review of all such calls, 26 (43%) review some such calls (median 10%, range 2-80% for the 19 systems specifying a percentage), 15 (25%) do not review any, and six did not specify. Conclusions. Fewer than half of the surveyed EMS systems that permit non-ALS personnel to cancel responding ALS units use written protocols to guide these decisions, and only half of those protocols utilize specific medical criteria. Medical oversight review of these calls is highly variable, with many systems reviewing few or none of these cancellations. PREHOSPITAL EMERGENCY CARE 2000;4:227-233     

P REHOSPITAL C ARE R ESEARCH F ORUM /NAEMSE 2002

Objectives. Emergency medical dispatch (EMD) protocols are intended to match response resources with patient needs. In a small city that previously sent a first-responder basic life support (BLS) engine company lights-and-siren response to every emergency medical services (EMS) call, regardless of nature or severity, an EMD system was implemented in order to reduce the number of such responses. The study objectives were to determine the effects of the EMD system on first-responder call volume andto assess the safety of the system. Methods. This was a prospective, before–after trial. Using computer-assisted dispatch (CAD) records, all EMS calls in the 120 days before implementation of the EMD protocol andthe 120 days after implementation were identified (excluding a one-month wash-in period). In the “after” phase, patient care reports of a random sample of cases in which an ambulance was dispatched with no first responders was manually reviewed to assess whether there might have been any benefit to first-responder dispatch. Given the lack of accepted clinical criteria for need for first responders, the investigators' clinical judgment was used. Paired t-tests were used to compare groups. Results. There were 9,820 EMS calls in the “before” phase, with 8,278 first-responder engine runs (84.3%), and9,943 EMS calls in the “after” phase, with 3,804 first-responder engine runs (39.1%). The first-responder companies were dispatched to a median of 5.65 runs/day (range 1.1–12.7) in the “before” phase, and3.17 runs/day (range 0.6–5.0) in the “after” phase (p = 0.0008 by paired t-test). Review of 1,816 “after” phase ambulance-only patient care reports (PCRs) found ten (0.55%) in which first-responder dispatch might have been beneficial, but review of EMS andemergency department (ED) records found no adverse outcomes in these ten patients. Conclusions. This study suggests that a formal EMD system can reduce first-responder call volume by roughly one-half. The system appears to be safe for patients, with an undertriage rate of about one-half of one percent.     

C AN B ASIC L IFE S UPPORT P ERSONNEL S AFELY D ETERMINE THAT A DVANCED L IFE S UPPORT I S N OT N EEDED ?

Objective. To determine whether firefighter/emergency medical technicians-basic (FF/EMT-Bs) staffing basic life support (BLS) ambulances in a two-tiered emergency medical services (EMS) system can safely determine when advanced life support (ALS) is not needed. Methods. This was a prospective, observational study conducted in two academic emergency departments (EDs) receiving patients from a large urban fire-based EMS system. Runs were studied to which ALS and BLS ambulances were simultaneously dispatched, with the patient transported by the BLS unit. Prospectively established criteria for potential need for ALS were used to determine whether the FF/EMT-B's decision to cancel the ALS unit was safe, and simple outcomes (admission rate, length of stay, mortality) were examined. In the system studied, BLS crews may cancel responding ALS units at their discretion; there are no protocols or medical criteria for cancellation. Results. A convenience sample of 69 cases was collected. In 52 cases (75%), the BLS providers indicated that they cancelled the responding ALS unit because they did not feel ALS was needed. Of these, 40 (77%) met study criteria for ALS: 39 had potentially serious chief complaints, nine had abnormal vital signs, and ten had physical exam findings that warranted ALS. Forty-five (87%) received an intervention immediately upon ED arrival that could have been provided in the field by an ALS unit, and 16 (31%) were admitted, with a median length of stay of 3.3 days (range 1.1–73.4 days). One patient died. Conclusion. Firefighter/EMT-Bs, working without protocols or medical criteria, cannot always safely determine which patients may require ALS intervention.     

Prehospital care and outcome of pediatric out-of-hospital cardiac arrest

Cardiac arrest in children outside the hospital is associated with high mortality rates. Recent investigations have suggested that the use of advanced life support (ALS) measures by emergency medical services (EMS) personnel may decrease survival. These studies have used the pediatric Utstein style of defining ALS and basic life support (BLS) measures. The pediatric Utstein style defines BLS as “an attempt to restore effective ventilation and circulation” using noninvasive means to open the airway but specifically excludes the use of bag-valve-mask devices. Advanced life support is defined as the “addition of invasive maneuvers to restore effective ventilation and circulation.” The authors of the study described below believe that using this definition would categorize some patients into an ALS group who would otherwise be categorized as having received BLS (i.E., “bag-valve-mask only”). Objective: To compare survival rates among children receiving BLS or ALS following out-of-hospital cardiac arrest using amended definitions of prehospital life support measures. Specifically, the definition of BLS was expanded to include the use of bag-valve-mask devices only. Methods: This was a retrospective chart review in an urban, pediatric emergency department. Patients included all children presenting to the emergency department between January 1, 1986, and December 31, 1999, following out-of-hospital cardiac arrest. The main outcome measure was survival to hospital discharge. Results: Two hundred ten children were identified. Twenty-one patients were excluded from further analysis because of absent or incomplete medical records. One hundred eighty-nine patients were studied. Five children (2.6%) survived to discharge from the hospital. Of 189 children, 39 (20.6%) were provided BLS measures by prehospital personnel; 150 (79.4%) received ALS. There was no significant difference between groups in survival to hospital discharge. Patients who survived to hospital discharge were more likely to be in sinus rhythm upon arrival in the emergency department (p < 0.001) and to have received fewer doses of standard-dose epinephrine in the emergency department (p < 0.001). Conclusion: The use of ALS by prehospital personnel for children with out-of-hospital cardiac arrest did not improve survival to discharge from the hospital when compared with the use of BLS. PREHOSPITAL EMERGENCY CARE 2002;6:283-290     

Does the level of prehospital care influence the outcome of patients with altered levels of consciousness?

HYPOTHESIS: Significant differences exist in the outcome of patients with altered level of consciousness (ALOC) cared for by advanced life support (ALS) compared with basic life support (BLS) prehospital providers. METHODS: Patients transported by ambulance to a community teaching hospital during an 11-month period were studied retrospectively. Study patients were those considered not alert by prehospital personnel. Exclusion criteria included; trauma, intoxication, drowning, shock, and cardiac arrest. Data were abstracted from the ambulance reports and hospital records. RESULTS: Two hundred three patients with an ALOC were identified; 113 were transported by ALS providers (56%) and 90 (44%) by BLS providers. Prehospital levels of consciousness, according to the "alert, verbal, painful, unresponsive" scale (ALS vs BLS) were: "verbal" (40% vs 51%), "painful" (23% vs 23%), and "unresponsive" (37% vs 25%). The mean value for some time was 15 +/- 6 minutes for ALS versus 10 +/- 4 minutes for BLS (p < 0.001). On arrival in the emergency department, the LOC of 72 (64%) ALS patients and 58 (64%) BLS patients had improved to "alert." The level of consciousness in one ALS patient worsened. Fifty-two ALS (46%) and 38 (42%) BLS patients were admitted. Principal final diagnoses were seizure (27% ALS vs 38% BLS), hypoglycemia (23% ALS vs 23% BLS), and stroke (22% ALS vs 20% BLS). Remaining diagnoses each constituted less than 7% of total discharge diagnoses. No statistically significant differences in measures of outcome were noted between ALS or BLS patients. Diagnoses of seizure, stroke, and hypoglycemia were studied individually. No differences in admission rate, mortality rate, or disposition were identified. Hypoglycemic patients conveyed by ALS providers had significantly shorter emergency department treatment times than did those transported by BLS providers (160 +/- 62 minutes ALS vs 229 +/- 67 minutes BLS [p < 0.005]). CONCLUSION: Advanced life support levels of care of patients with an ALOC does not significantly change outcome compared with those receiving BLS care with the exception of shorter emergency department treatment times for hypoglycemic patients.     

Validation of Low-Acuity Emergency Medical Services Dispatch Codes

Background. Computer-aided dispatch systems are used to assess the severity of a 9-1-1 caller's complaint andthen assign an appropriate level of emergency medical services (EMS) response. Objective. To evaluate a group of low-acuity codes (defined as requiring advanced life support [ALS] intervention in fewer than 10% of cases) that has been derived andvalidated in one community. Methods. All of the 9-1-1 medical calls assigned to these predetermined emergency medical dispatch codes between January 1, 2004, andJuly 1, 2004, were analyzed. ALS care was defined as receiving one or more of the following: pulse oximetry measurement, blood glucose measurement, cardiac defibrillation, administration of any medication, airway maneuvers, or the placement of an intravenous (IV) catheter. A more restrictive definition of ALS care (use of IV fluid bolus, medication administration, intubation, or defibrillation) was also calculated. Results. A total of 1,799 calls were assigned low-acuity dispatch codes, and1,597 met inclusion criteria. None of the 26 dispatch codes were found to be low-acuity by the study definition. Fifty-six percent of these patients received ALS care. Placement of an IV-catheter was the ALS intervention used most frequently (45% of cases), followed by pulse oximetry measurement (32%), glucose measurement (22%), medication administration (11%), intubation (0.13%), anddefibrillation (0%). The medication administered most frequent was morphine. When using the more restrictive definition of acuity, patients in 19 of the 28 categories received ALS intervention less than 10% of the time. Patients in the other seven categories were considered high-acuity 13% to 36% of the time. Conclusion. Dispatch codes that had previously been determined to be low-acuity were found not to be so in this community. The variation in clinical practice is likely explained by a more precautionary approach to care in this EMS system andthe increased use of analgesics. This study demonstrates the need to define the optimal subset of prehospital patients who would benefit from these treatments.     

Can First Responders Be Sent to Selected 9‐1‐1 Emergency Medical Services Calls without an Ambulance?

OBJECTIVES: To evaluate the feasibility and safety of initially dispatching only first responders (FRs) to selected low-risk 9-1-1 requests for emergency medical services. First responders are rapidly-responding fire crews on apparatus without transport capabilities, with firefighters trained to at least a FR level and in most cases to the basic emergency medical technician (EMT) level. Low-risk 9-1-1 requests include automatic medical alerts (ALERTs), motor vehicle incidents (MVIs) for which the caller was unable to answer any medical dispatch questions designed to prioritize the call, and 9-1-1 call disconnects (D/Cs). METHODS: A before-and-after study of patient dispositions was conducted using historical controls for comparison. During the historical control phase of six months, one year prior to the study phase, basic life support ambulances (staffed with two basic EMTs) were dispatched to selected low-risk 9-1-1 incidents. During the six-month study phase, a fire FR crew equipped with automated external defibrillators (AEDs) was sent initially without an ambulance to these incidents. RESULTS: For ALERTs (n = 290 in historical group vs. 330 in study group), there was no statistical difference in the transport rate (7% vs 10%), but there was a statistically significant increase in the follow-up use of advanced life support (ALS) (1% vs 4%, p = 0.009). No patient in the ALERTs historical group required airway management, while one patient in the study group received endotracheal intubation. No patient required defibrillation in either group. Analysis of the MVIs showed a significant decrease (p < 0.0001) in the patient transport rate from 39% of controls to 33% of study patients, but no change in the follow-up use of ALS interventions (2% for each group). For both the ALERTs and MVIs, the FR's mean response time was faster than ambulances (p < 0.0001). Among the 9-1-1 D/Cs with FRs only (n = 1,028), 15% were transported and 43 (4%) received subsequent ALS care. Four of these patients (0.4%) received intubation and two (0.2%) required defibrillation. However, no patient was judged to have had adverse outcomes as a result of the dispatch protocol change. CONCLUSIONS: Fire apparatus crews trained in the use of AEDs can safely be used to initially respond alone (without ambulances) to selected, low-risk 9-1-1 calls. This tactic improves response intervals while reducing ambulance responses to these incidents.     

The demand for prehospital advanced life support and the appropriateness of dispatch in Taipei

INTRODUCTION: Implementing prehospital advanced life support (ALS) services requires more medical and societal resources in training and equipment. The actual demand for ALS services in our communities was not clear. To ensure good use of expensive resources, it is important to evaluate the demand and appropriateness of ALS services before full-scale implementation takes place. OBJECTIVE: To evaluate the rate and characteristics of demand for ALS, and the appropriateness of ALS dispatch of the emergency medical service (EMS) system in metropolitan Taipei City. METHODS: A retrospective, cross-sectional analysis of the EMS records of Taipei City Fire Department from April 1999 to December 2000 was conducted. Stratified random sampling of all EMS records in the second week of January, April, July and October of 2000 were obtained, along with the corresponding ALS dispatch records. Retrospective ALS demand criteria, including the chief complaints, mechanisms of injury/illness, initial vital signs and types of care rendered, were developed to estimate the rate of ALS demand. ALS demand is expressed as the percentage of cases fulfilling ALS criteria over the total number of EMS cases. Appropriate ALS dispatches were those ALS dispatches determined as fulfilling the ALS demand criteria. RESULTS: Among the sampled 5433 EMS cases, 490 (9.02%) were determined as a demand for ALS care. ALS demands varied from region to region, and were higher during winter months and afternoon rush hours. There were 175 actual ALS dispatches, accounting for 3.22% of the sampled EMS services. The triage performance was suboptimal: the appropriateness of ALS dispatch was 37.14%; the overtriage rate was 72.86%. CONCLUSION: Around nine percent of EMS calls demand ALS services. The current triage performance for proper ALS dispatch was suboptimal. A correct ALS dispatch protocol and more dispatcher training programmes should be established in the communities to ensure best use of valuable ALS resources.     

Does advanced life support provide benefits to patients?: A literature review

INTRODUCTION: Emergency medical services have invested substantial resources to establish advanced life support (ALS) programs. However, it is unclear whether ALS care provides better outcomes to patients compared to basic life support (BLS) care. OBJECTIVE: To evaluate the current evidence regarding the benefits of ALS. METHODS: Electronic medical databases were searched to identify articles that directly compared ALS versus BLS care. A total of 455 articles were found. Articles were excluded for the following reasons: (1) the article was not written in English; (2) BLS response was not compared to an ALS response; (3) a physician or nurse was included as part of the ALS response; (4) it was an aeromedical response; or (5) defibrillation was included in the ALS, but not the BLS, scope of care. Twenty-one articles met the inclusion criteria for this literature review. RESULTS: Results were divided into four categories: (1) trauma; (2) cardiac arrest; (3) myocardial infarction; and (4) altered mental status. Trauma: The majority of articles showed that ALS provided no benefits over BLS in urban trauma patients. In fact, most studies showed higher mortality rates for trauma patients receiving ALS care. Further research is needed to evaluate the benefits of ALS for rural trauma patients, and whether ALS care improves outcomes in subgroups of urban trauma patents. Cardiac Arrest: Cardiac arrest studies show that early CPR plus early defibrillation provide the greatest improvement in survival. However, most cardiac arrest research includes defibrillation as an ALS skill which has now moved into the BLS scope of care. The 2004 multi-center OPALS study provided good evidence that ALS does not improve cardiac arrest survival over early defibrillation. Further research is needed to address whether any ALS interventions improve cardiac arrest outcome. Myocardial Infarction: Only one study directly compared the outcome of BLS and ALS care on myocardial infarction. The study found no difference in outcomes between BLS and ALS care in an urban setting. Advanced Life Support: Only one study directly compared the outcome of BLS and ALS care on patients with altered mental status. The study found that the same number of patients had improved to "alert" on arrival at the emergency department, but there was a decreased length of emergency department stay for patients treated by ALS for hypoglycemia. Limitations: This review article does not take into account the benefits of 2005 ALS interventions, such as thrombolytics, dextrose, or nitroglycerin, since no studies directly compared these interventions to BLS care. Furthermore, only one study in this literature review was a large, multi-center trial. CONCLUSIONS: ALS shows little, if any, benefits for urban trauma patients. Cardiac arrest studies show that ALS does not provide additional benefits over BLS-defibrillation care, but more research is needed in this area. In two small studies, ALS care did not provide benefits over BLS care for patients with myocardial infarctions or altered mental status. Larger-scale studies are needed to evaluate which specific ALS interventions improve patient outcomes.     

Data errors in emt licensure evaluator article

Objective. To examine the effects of transferring nonurgent 911 calls to a telephone consulting nurse. It was hypothesized that the telephone referral program would result in fewer basic life support (BLS) responses with no adverse patient outcome or decrease in patient satisfaction. Methods. A two-phased prospective study was conducted in an urban and rural setting with a population of 650,000. During phase I, a BLS unit was dispatched on all calls and a nurse intervention was simulated. During phase II, no BLS unit was dispatched for calls meeting study criteria. Callers were transferred to the nurse, and consulting nurse protocols were used to direct care. Data were collected from dispatch, BLS, nurse, and hospital records and patient self-assessment. Results. During phase I, 38 callers were transferred to the consulting nurse with no nurse intervention. During phase II, 133 cases were transferred to the nurse line. There were no adverse outcomes detected. The nurse recommended home care for 31%, physician referral for 24%, referral back to 911 for 17%, community resource for 11%, and other referral for 17%. Nurses contacted 85 patients for telephone follow-up. Ninety-four percent of the patients reported feeling better, 6% felt the same, and none felt worse. Patients were satisfied with the outcome in 96% of the cases. Conclusion. Transferring 911 calls to a nurse line resulted in fewer BLS responses and no adverse patient outcomes, while maintaining high patient satisfaction. Dispatch criteria correctly identified cases with minimal medical needs. A high percentage of the patients reported feeling better after the intervention. This study has major implications for communities interested in efficient use of emergency medical services resources.     

Emergency medical service systems in Japan: past, present, and future

Emergency medical services are provided by the fire defence headquarters of the local government in Japan. There is a one-tiered EMS system. Ambulances are staffed by three crew members trained in rescue, stabilisation, transport, and advanced care of traumatic and medical emergencies. There are three levels of care provided by ambulance personnel including a basic-level ambulance crew (First Aid Class One, FAC-1), a second level (Standard First Aid Class, SFAC), and the highest level (Emergency Life Saving Technician, ELST). ELSTs are trained in all aspects of BLS and some ALS procedures relevant to pre-hospital emergency care. Further development of an effective medical control system is imperative as the activities of ambulance crews become more sophisticated. A marked recent increase in the volume of emergency calls is another issue of concern. Currently, private services for transportation of non-acute or minor injury/illness have been introduced in some areas, and dispatch protocols to triage 119 calls are being developed.     

Reduction of the call-response interval with ambulance base paging

Objective. To determine whether the call-response interval for an emergency medical services (EMS) system would be decreased through the introduction of ambulance base paging. Methods. The study community included a mixture of urban and rural areas with a total population of approximately 400,000. The EMS system is composed of two ambulance services and one central ambulance communication center with computer-aided dispatching capabilities. Approximately 30,000 calls are responded to yearly by the combined ambulance services. A before-and-after study design was used. In a retrospective review of one ambulance service, there were 224 calls collected in the period before base paging and 200 calls collected in the period after base paging was introduced. In the other ambulance service, there were 571 calls captured in the period before base paging and 515 calls captured in the period after base paging. Results. The call-receipt-to-crew-notified interval was reduced from the before period to the after period in both ambulance services: Cambridge—61.8 to 49.8 seconds (p < 0.0001); Kitchener—66.6 to 46.2 seconds (p < 0.0001). The crew-notified-to-vehicle-mobile interval was reduced from the before period to the after period in both ambulance services: Cambridge—91.8 to 73.2 seconds (p < 0.0001); Kitchener—80.4 to 66.0 seconds (p < 0.0001). Conclusions. The introduction of ambulance base paging reduced components of the call-response interval in this EMS system. Overall, the reduction in time was approximately 30 seconds, which was found to be statistically significant. PREHOSPITAL EMERGENCY CARE 2000;4:318-321     

C ANCELLATION OF R ESPONDING ALS U NITS BY BLS P ROVIDERS : A N ATIONAL S URVEY

Objective. In many emergency medical services (EMS) systems, personnel without advanced life support (ALS) training are authorized to cancel responding ALS units before the ALS personnel arrive and examine the patient. This study was conducted to examine these cancellations in major U.S. cities. Methods. A survey was mailed to the physician medical directors of the EMS services of the 125 largest U.S. cities, with telephone follow-up of nonresponders. The survey requested information on system structure, and on policies governing cancellation of responding ALS units by non-ALS personnel. Results. Ninety-four cities responded (75%), from 35 states. Nineteen systems (20%) are all-ALS with no basic life support (BLS) tier, and these were eliminated. Of the remaining 75 systems, eight (11%) use BLS ambulances (BLS-A), 35 (47%) use BLS first responders (BLS-FR), and 32 (43%) use both. Of these 75 systems, 60 (80%) allow cancellation of responding ALS units by BLS personnel. Only 24 of these (40%) have written protocols for such cancellations, and only 12 of those (50%) involve specific medical criteria, with two (8%) relying on the best judgment of the BLS personnel with no medical criteria, and another eight (33%) allowing cancellation only for logistic reasons. Of the 60 systems that permit cancellation, 13 (22%) perform some type of medical oversight review of all such calls, 26 (43%) review some such calls (median 10%, range 2–80% for the 19 systems specifying a percentage), 15 (25%) do not review any, and six did not specify. Conclusions. Fewer than half of the surveyed EMS systems that permit non-ALS personnel to cancel responding ALS units use written protocols to guide these decisions, and only half of those protocols utilize specific medical criteria. Medical oversight review of these calls is highly variable, with many systems reviewing few or none of these cancellations.     

Few emergency medical services patients with lower-extremity fractures receive prehospital analgesia

Previous literature has identified prehospital pain management as an important emergency medical services (EMS) function, and few patients transported by EMS with musculoskeletal injuries receive prehospital analgesia (PA). Objectives. 1) To describe the frequency with which EMS patients with lower-extremity and hip fracture receive prehospital and emergency department (ED) analgesia; 2) to describe EMS and patient factors that may affect administration of PA to these patients; and 3) to describe the time interval between EMS and ED medication administrations. Methods. This was a four-month (April to July 2000) retrospective study of patients with a final hospital diagnosis of hip or lower-extremity fracture who were transported by EMS to a single suburban community hospital. Data including patient demographics, fracture type, EMS response, and treatment characteristics were abstracted from review of EMS and ED records. Patients who had ankle fractures, had multiple traumatic injuries, were under the age of 18 years, or did not have fractures were excluded. Results. One hundred twenty-four patients met inclusion criteria. A basic life support (BLS)-only response was provided to 20 (16.0%). Another 38 (38.4%) received an advanced life support (ALS) response and were triaged to BLS transport. Of all the patients, 22 (18.3%) received PA. Patients who received PA were younger (64.0 vs. 77.3 years, p < 0.001) and more likely to have a lower-extremity fracture other than a hip fracture (31.8% vs. 10.7%, p < 0.004). Of all patients, 113 (91.1%) received ED analgesia. Patients received analgesia from EMS almost 2.0 hours sooner that in the ED (mean 28.4 ± 36 min vs. 146 ± 74 min after EMS scene arrival, p < 0.001). Conclusion. A minority of the study group received PA. Older patients and patients with hip fracture are less likely to receive PA. It is unclear whether current EMS system design may adversely impact administration of PA. Further work is needed to clarify whether patient need or EMS practice patterns result in low rates of PA. PREHOSPITAL EMERGENCY CARE 2002;6:406-410