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.

[Degree of implementation of structured answering of emergency calls in German emergency dispatch centers and effects of the introduction in daily practice]. / Implementierungsgrad der strukturierten Notrufabfrage in deutschen Leitstellen und Auswirkungen ihrer Einführung.

BACKGROUND: The emergency call-taking process is crucial for the adequate disposition of emergency vehicles and the provision of first aid instructions. Moreover, it has a direct impact on the quality of out-of-hospital emergency care. Organizations such as the European Resuscitation Council, the German Federal Association of Emergency Medical Directors and the German Association of Emergency Dispatch Centers call for the nationwide implementation of a formal call-taking process in emergency dispatching. This is required for the provision of telephone-assisted cardiopulmonary resuscitation (T-CPR). METHODS: This article presents the results of an online survey among members of the German Association of Emergency Dispatch Centers on the implementation of structured call-taking programs. The survey comprised data on the implementation of a structured call-taking process, its effects on important quality indicators such as the frequency of T­CPR and employee satisfaction. RESULTS: Of the 100 participants who completed the survey, 49 already used formal call-taking systems and 24 (47%) of the remaining 51 emergency dispatch centers intended to implement such a system. Formal call-taking systems were mainly used in the dispatch of emergency medical services (98% of emergency dispatch centers using a formal call-taking system) and fire brigades (83.7% of emergency dispatch centers using a formal call-taking system). In 42 (85.7%) of the 49 emergency dispatch centers using a formal call-taking process, this process is mandatory; however, only 27 (64.3%) reported compliance rates of more than 95% in medical emergencies. Comparing the pre-post results after the introduction of a structured approach, the quality of the inquiries improved for almost all emergency dispatch centers. On the other hand, important quality indicators, e.g. mean dispatch initiation time or the necessity of subsequently alerting an advanced life support unit to the scene, were not recorded in 42.9% and 49.0% of the dispatch centers, respectively. Of the emergency dispatch centers that analyzed the frequency of T­CPR, 94.3% could show an increase in T­CPR. Moreover, 79.5% of the respondents reported improved employee satisfaction. Whereas the demand for dispatchers remained nearly static, 24 out of the 49 dispatch centers that used a formal call-taking system set up new posts for quality management (maximum: 3 posts in dispatch centers handling more than 250,000 missions annually). CONCLUSION: Structured emergency call-taking has not yet been comprehensively implemented in German emergency dispatch centers. Wherever it is used consistently, important quality parameters are improved. Further investigations should aim to identify crucial factors for its implementation and to analyze additional quality parameters.

An expected coverage model with a cutoff priority queue.

Emergency medical services provide immediate care to patients with various types of needs. When the system is congested, the response to urgent emergency calls can be delayed. To address this issue, we propose a spatial Hypercube approximation model with a cutoff priority queue that estimates performance measures for a system where some servers are reserved exclusively for high priority calls when the system is congested. In the cutoff priority queue, low priority calls are not immediately served-they are either lost or entered into a queue-whenever the number of busy ambulances is equal to or greater than the cutoff. The spatial Hypercube approximation model can be used to evaluate the design of public safety systems that employ a cutoff priority queue. A mixed integer linear programming model uses the Hypercube model to identify deployment and dispatch decisions in a cutoff priority queue paradigm. Our computational study suggests that the improvement in the expected coverage is significant when the cutoff is imposed, and it elucidates the tradeoff between the coverage improvement and the cost to low-priority calls that are "lost" when using a cutoff. Finally, we present a method for selecting the cutoff value for a system based on the relative importance of low-priority calls to high-priority calls.

Sizing capacity levels in emergency medical services dispatch centers: Using the newsvendor approach.

BACKGROUND: The increased volume in demand worldwide in the present day has led to the need for the establishment of effective ambulance services. As call centers have become the primary contact point between patients and emergency service providers, the planning of the call center has become a key task for administrators. OBJECTIVES: The aim of this study is to apply a widely used operations management method, the newsvendor model, for optimizing the capacity level in EMS call centers with a minimum cost in order to efficiently meet the calls arriving. METHODS: Real-life data from a call center for ambulance services in a major city in Turkey was used. We propose using the newsvendor model for optimizing this call center's capacity level based on the forecasts of periodic call volumes via basic methods. RESULTS: Ambulance service call volumes vary during the day and weekday call profiles are different from weekends. By separating the analysis into weekdays and weekends and illustrating shorter time intervals within the days, call volume can be forecast. Taking not only the point forecast but also the variation of the forecast into account, the capacity level of each period can be planned in a cost-effective way. CONCLUSIONS: This paper provides a basis for operation planning strategies of ambulance services by reconsidering the uncertainties of demand. The newsvendor model, which works well under parameter uncertainty, can be used in planning the capacities of health care services, especially when high service levels are required.

Dynamic ambulance dispatching: is the closest-idle policy always optimal?

We address the problem of ambulance dispatching, in which we must decide which ambulance to send to an incident in real time. In practice, it is commonly believed that the 'closest idle ambulance' rule is near-optimal and it is used throughout most literature. In this paper, we present alternatives to the classical closest idle ambulance rule. Most ambulance providers as well as researchers focus on minimizing the fraction of arrivals later than a certain threshold time, and we show that significant improvements can be obtained by our alternative policies. The first alternative is based on a Markov decision problem (MDP), that models more than just the number of idle vehicles, while remaining computationally tractable for reasonably-sized ambulance fleets. Second, we propose a heuristic for ambulance dispatching that can handle regions with large numbers of ambulances. Our main focus is on minimizing the fraction of arrivals later than a certain threshold time, but we show that with a small adaptation our MDP can also be used to minimize the average response time. We evaluate our policies by simulating a large emergency medical services region in the Netherlands. For this region, we show that our heuristic reduces the fraction of late arrivals by 18 % compared to the 'closest idle' benchmark policy. A drawback is that this heuristic increases the average response time (for this problem instance with 37 %). Therefore, we do not claim that our heuristic is practically preferable over the closest-idle method. However, our result sheds new light on the popular belief that the closest idle dispatch policy is near-optimal when minimizing the fraction of late arrivals.

The impact of a freestanding ED on a regional emergency medical services system.

OBJECTIVE: The objective of the study is to examine the effect of the opening of a freestanding emergency department (FED) on the surrounding emergency medical services (EMS) system through an examination of EMS system metrics such as ambulance call volume, ambulance response times, and turnaround times. METHODS: This study is based on data from the county's computer-aided dispatch center, the FED, and the Maryland Health Services Cost Review Commission. The analysis involved a pre/post design, with a 6-month washout period. The preintervention period was April to October 2010, and the postintervention period was April to October 2011. Data were analyzed using standard t tests. RESULTS: The average daily number of EMS-related calls received in the computer-aided dispatch center was lower after the FED opened (16.3 [95% confidence interval {CI}, 15.7-16.9] vs 15.8 [95% CI, 14.9-16.9]). One-fourth of all patients were transported by ambulance to the FED after it opened. Use of the FED and adjacent hospitals increased by 8647 visits (15.8%) during the study period. Turnaround time for the county's ALS units decreased from 26.8 (95% CI, 26.2-27.5) to 25.1 (95% CI, 24.3-25.8) minutes. The ambulance out-of-service interval decreased from 87.3 (95% CI, 86.0-88.5) to 81.1 (95% CI, 79.7-82.4) minutes. Based on change in out-of-service this study had a small effect size (Cohen's d = 0.33). CONCLUSIONS: The opening of an FED was associated with a modest improvement in time-specific EMS system metrics: a decrease in ambulance turnaround time and shorter out-of-service intervals.

[Urgency and acuity judgment systems before medical care (emergency telephone consultation center #7119, JTAS etc.)].

Currently growing the demand of the emergency medical care in Japan, sharing the concept about medical urgency is needed in the whole society in order to maintain the emergency medical systems as social resources. The present conditions and challenges are outlined: Emergency Telephone Consultation Center in Tokyo Fire Department (established in June 2007) and on-site triage as representatives of "pre-hospital urgency determination systems", and JTAS (Japan Triage and Acuity System, introduced in April 2012) as a representative of "in-hospital, pre-examination urgency determination systems".

Effectiveness of single medical advice on emergency phone number knowledge in urban adult population--"Health, Alcohol and Psychosocial Factors in Eastern Europe" substudy.

INTRODUCTION: Early access to Emergency Medical Services determines survival in out-of-hospital cardiac arrest. However, a significant proportion of adults do not know the emergency phone number (EN) and no intervention has been proposed to improve it. Therefore, we aimed to assess prospectively the effectiveness of single advice from a physician on knowledge of the EN in adult population. MATERIALS AND METHODS: The study was conducted among participants of "Health, Alcohol and Psychosocial Factors in Eastern Europe" study. A total of 942 persons (aged 48-82 years) randomly selected from an urban population registry were interviewed and then instructed about the correct EN (the intervention group). After 12 months knowledge of the EN was assessed in the intervention group (n=716) and in matched control group (n=435). RESULTS: The correct EN was given by 498 (69.6%) participants at baseline and in 550 (76.8%) participants 12 months afterwards (p<0.001). At follow-up the knowledge of EN was higher by in intervention group than in controls (76.8% vs 70.6%, p=0.02). Factors associated with better educational effect were male sex (OR 1.49; 95% CI 1.04-2.1) and secondary or higher level of education (OR 1.44; 95% CI 1.08-1.91). CONCLUSIONS: We concluded that a single instruction about the EN from a physician increases its long-term knowledge and should be offered during medical visits.

Lessons learned in testing the feasibility of evaluating transfer of training to an operations setting.

INTRODUCTION: The purpose of the study was to explore the feasibility, identify challenges, and offer solutions to evaluating transfer of training to the operations setting. BACKGROUND: The assumption underlying public health emergency preparedness training is competencies and capabilities will transfer to the operations setting. However, there are no studies describing methods for evaluating the transfer of training. METHODS: An online training course that mimicked field decision making was selected. A functional exercise was developed and aligned with the goals and objectives of the online course. Transfer of training was assessed at the individual capability level and at the agency level by examining changes in emergency operating plans. CONCLUSIONS: It was concluded the ability to evaluate transfer of training to an operations setting is feasible. However, it requires more deliberate and coordinated planning between the exercise and the training than the current status quo. LESSONS LEARNED: Eight lessons learned are shared including the need to design training courses to align to an operation-based exercise, and not vice versa, the need to rely on qualitative approaches, and the need for an a priori evaluation rubric.

Effects of improved access to transportation on emergency obstetric care outcomes in Uganda.

Reduction in maternal mortality has not been appreciable in most low-income countries. Improved access to transport for mothers is one way to improve maternal health. This study evaluated a free-of-charge 24-hour ambulance and communication services intervention in Oyam district using 'Caesarean section rate' (CSR) and compared with the neighbouring non-intervention district. Ecological data were collected retrospectively from maternity/theatre registers in October 2010 for 3 years pre and 3 years intervention period. The average CSR in the intervention district increased from 0.57% before the intervention to 1.21% (p = 0.022) during the intervention, while there was no change in the neighbouring district (0.51% to 0.58%, p = 0.512). Hospital deliveries increased by over 50% per year with a slight reduction in the average hospital stillbirths per 1000 hospital births in the intervention district (46.6 to 37.5, p = 0.253). Reliable communication and transport services increased access to and utilization of maternal health services, particularly caesarean delivery services.

Medical relief for the 2011 Japan earthquake: a nursing account.

In 2011 the east coast of Japan experienced a massive earthquake which triggered a devastating tsunami destroying many towns and killing over 15 000 people. The work presented in this paper is a personal account that outlines the relief efforts of the Humanitarian Medical Assistance team and describes the efforts to provide medical assistance to evacuees. The towns most affected had a large proportion of older people who were more likely to have chronic conditions and required medication to sustain their health. Since personal property was destroyed in the tsunami many older people were left without medication and also did not remember which type of medication they were taking. Some evacuees had brought a list of their medication with them, this assisted relief teams in obtaining the required medication for these people. The more successful evacuation centers had small numbers of evacuees who were given tasks to administer the center that kept them occupied and active.

Emergency medical dispatch technologies: Addressing communication challenges and coordinating emergency response in low and middle-income countries.

A majority of emergency response in low and middle-income countries (LMICs) without formal emergency medical services (EMS) rely on uncoordinated layperson first responders (LFRs) to respond to emergencies using readily available mobile phones and private transport. Although formally trained LFRs are an important foundation for nascent emergency medical services (EMS) development, without coordination by standardized emergency medical dispatch (EMD) systems, LFR response is limited to witnessed emergencies, which provides significant but incomplete coverage. After training and equipping LFRs, EMD implementation using telecommunications technologies is the next step in formal EMS development and is essential to coordinate response, given the impact of timely prehospital response, intervention, and transportation on reducing morbidity/mortality. In this paper, we describe the current state of dispatch technologies used for emergency response in LMICs, focusing on the role of communication technologies, current approaches, and challenges in communication, and offer potential strategies for future development.

Emergency medical dispatch codes association with emergency department outcomes.

BACKGROUND: Emergency medical dispatch systems are used to help categorize and prioritize emergency medical services (EMS) resources for requests for assistance. OBJECTIVE: We examined whether a subset of Medical Priority Dispatch System (MPDS) codes could predict patient outcomes (emergency department [ED] discharge versus hospital admission/ED death). METHODS: This retrospective observational cohort study analyzed requests for EMS through a single public safety answering point (PSAP) serving a mixed urban, suburban, and rural community over one year. Probabilistic matching was used to link subjects. Descriptive statistics, 95% confidence intervals (CIs), and logistic regression were calculated for the 107 codes and code groupings (9E vs. 9E1, 9E2, etc.) that were used 50 or more times during the study period. RESULTS: Ninety percent of PSAP records were matched to EMS records and 84% of EMS records were matched to ED data, resulting in 26,846 subjects with complete records. The average age of the cohort was 46.2 years (standard deviation [SD] 24.8); 54% were female. Of the transported patients, 70% were discharged from the ED, with nine dispatch codes demonstrating a 90% or greater predictive power. Three code groupings had more than 60% predictive power for admission/death. Subjects aged 65 years and older were found to be at increased risk for admission/death in 33 dispatch codes (odds ratio [OR] 2.0 [95% confidence interval 1.3-3.0] to 19.6 [5.3-72.6]). CONCLUSIONS: A small subset (8% of codes; 7% by call volume) of MPDS codes were associated with greater than 90% predictive ability for ED discharge. Older adults are at increased risk for admission/death in a separate subset of MPDS codes, suggesting that age criteria may be useful to identify higher-acuity patients within the MPDS code. These findings could assist in prehospital/hospital resource management; however, future studies are needed to validate these findings for other EMS systems and to investigate possible strategies for improvements of emergency response systems.

Dispatch-assisted cardiopulmonary resuscitation: the anchor link in the chain of survival.

PURPOSE OF REVIEW: Early bystander cardiopulmonary resuscitation (CPR) provides a vital bridge after collapse from cardiac arrest until defibrillation can be performed. However, due to multiple barriers and despite large-scale public CPR training, this life-saving therapy is still not rendered in a majority of cardiac arrest events. As a result, cardiac arrest survival remains very low in most communities. RECENT FINDINGS: Several large-scale studies have shown the benefits of dispatch-assisted CPR. These studies have confirmed that on-going dispatch-assisted CPR programs that use a simplified and abbreviated set of standardized questions can hasten the recognition of cardiac arrest. Dispatchers can also utilize strategies to help bystanders overcome the obstacles to beginning CPR. In some communities, dispatch-assisted CPR accounts for up to half of all bystander CPR. Dispatch-assisted CPR programs combined with large-scale public CPR training may be what is needed to elevate CPR rates and survival from out-of-hospital cardiac arrest nationally. SUMMARY: This review focuses on the rationale and evolving science behind dispatch CPR instructions, as well as some best practices for implementing and measuring dispatch-assisted CPR with the goal of maximizing its potential to save lives from sudden cardiac arrest.

The clinical application of mobile technology to disaster medicine.

Mobile health care technology (mHealth) has the potential to improve communication and clinical information management in disasters. This study reviews the literature on health care and computing published in the past five years to determine the types and efficacy of mobile applications available to disaster medicine, along with lessons learned. Five types of applications are identified: (1) disaster scene management; (2) remote monitoring of casualties; (3) medical image transmission (teleradiology); (4) decision support applications; and (5) field hospital information technology (IT) systems. Most projects have not yet reached the deployment stage, but evaluation exercises show that mHealth should allow faster processing and transport of patients, improved accuracy of triage and better monitoring of unattended patients at a disaster scene. Deployments of teleradiology and field hospital IT systems to disaster zones suggest that mHealth can improve resource allocation and patient care. The key problems include suitability of equipment for use in disaster zones and providing sufficient training to ensure staff familiarity with complex equipment. Future research should focus on providing unbiased observations of the use of mHealth in disaster medicine.

Being prepared for the unprepared: a phenomenology field study of Swedish prehospital care.

INTRODUCTION: This paper presents a study of prehospital care with particular focus on how ambulance personnel prepare themselves for their everyday assignments. METHODS: The caring science field study took a phenomenological approach, where data were analyzed for meaning. Two specialist ambulance nurses, three registered nurses, and six paramedics participated. RESULTS: The previously known discrepancy between in-hospital care and prehospital care was further interpreted in this study. The pre-information from an emergency medical dispatch (EMD) center provides ambulance personnel with basic expectations as to what they will have to take care of. At the same time that they maintain their certainty and control, our major findings indicate that prehospital care in emergency medical service requires the personnel to be prepared for an open and flexible encounter with the patient; to be prepared for the unprepared, i.e., to be open and to avoid being governed by predetermined statements. DISCUSSION: Our findings suggest that the outcomes of good prehospital care affect patient security. The seemingly time-consuming dialogue with the patient facilitates understanding and decision-making regarding the patient's medical needs, and it is comforting to the patient. The ambulance personnel need to be well prepared for this task and fully understand that the situation might differ considerably from the information provided by the EMD centers. All objective information is of great value in this care context, but ultimately it is the patient who provides reliable information about her/his own situation.

Smartphone application alerts for early trauma team activation: Millennial technology in healthcare.

BACKGROUND: Data access through smartphone applications (apps) has reframed procedure and policy in healthcare, but its impact in trauma remains unclear. Citizen is a free app that provides real-time alerts curated from 911 dispatch data. Our primary objective was to determine whether app alerts occurred earlier than recorded times for trauma team activation and emergency department arrival. METHODS: Trauma registry entries were extracted from a level one urban trauma center from January 1, 2018 to June 30, 2019 and compared with app metadata from the center catchment area. We matched entries to metadata according to description, date, time, and location then compared metadata timestamps to trauma team activation and emergency department arrival times. We computed percentage of time the app reported traumatic events earlier than trauma team activation or emergency department arrival along with exact binomial 95% confidence interval; median differences between times were presented along with interquartile ranges. RESULTS: Of 3,684 trauma registry entries, 209 (5.7%) matched app metadata. App alerts were earlier for 96.1% and 96.2% of trauma team activation and emergency department arrival times, respectively, with events reported median 36 (24-53, IQR) minutes earlier than trauma team activation and 32 (25-42, IQR) minutes earlier than emergency department arrival. Registry entries for younger males, motor vehicle-related injuries and penetrating traumas were more likely to match alerts (P < .0001). CONCLUSION: Apps like Citizen may provide earlier notification of traumatic events and therefore earlier mobilization of trauma service resources. Earlier notification may translate into improved patient outcomes. Additional studies into the benefit of apps for trauma care are warranted.

Medical dispatchers' perception of the interaction with the caller during emergency calls - a qualitative study.

BACKGROUND: Medical dispatching is a highly complex procedure and has an impact upon patient outcome. It includes call-taking and triage, prioritization of resources and the provision of guidance and instructions to callers. Whilst emergency medical dispatchers play a key role in the process, their perception of the process is rarely reported. We explored medical dispatchers' perception of the interaction with the caller during emergency calls. Secondly, we aimed to develop a model for emergency call handling based on these findings. METHODS: To provide an in-depth understanding of the dispatching process, an explorative qualitative interview study was designed. A grounded theory design and thematic analysis were applied. RESULTS: A total of 5 paramedics and 6 registered nurses were interviewed. The emerging themes derived from dispatchers' perception of the emergency call process were related to both the callers and the medical dispatchers themselves, from which four and three themes were identified, respectively. Dispatchers reported that for callers, the motive for calling, the situation, the perception and presentation of the problem was influencing factors. For the dispatchers the expertise, teamwork and organization influenced the process. Based on the medical dispatchers´ perception, a model of the workflow and interaction between the caller and the dispatcher was developed based on themes related to the caller and the dispatcher. CONCLUSIONS: According to medical dispatchers, the callers seem to lack knowledge about best utilization of the emergency number and the medical dispatching process, which can be improved by public awareness campaigns and incorporating information into first aid courses. For medical dispatchers the most potent modifiable factors were based upon the continuous professional development of the medical dispatchers and the system that supports them. The model of call handling underlines the complexity of medical dispatching that embraces the context of the call beyond clinical presentation of the problem.