Dispatch centres: what is the right population catchment size?

Literature on medical dispatch is growing, focusing mainly on efficiency (under and overtriage) and dispatch-assisted CPR. But the issue of population catchment size, functional costs and rationalization is rarely addressed. If we can observe a trend toward a decreasing number of dispatch centres in many European countries, there is today no evidence on what is the right catchment size to reach the best balance between quality of services and costs.

An ambulance referral network improves access to emergency obstetric and neonatal care in a district of rural Burundi with high maternal mortality.

OBJECTIVES: In 2006, Médecins sans Frontières (MSF) established an emergency obstetric and neonatal care (EmONC) referral facility linked to an ambulance referral system for the transfer of women with obstetric complications from peripheral maternity units in Kabezi district, rural Burundi. This study aimed to (i) describe the communication and ambulance service together with the cost; (ii) examine the association between referral times and maternal and early neonatal deaths; and (iii) assess the impact of the referral service on coverage of complicated obstetric cases and caesarean sections. METHODS: Data were collected for the period January to December 2011, using ambulance log books, patient registers and logistics records. RESULTS: In 2011, there were 1478 ambulance call-outs. The median referral time (time from maternity calling for an ambulance to the time the patient arrived at the MSF referral facility) was 78 min (interquartile range, 52-130 min). The total annual cost of the referral system (comprising 1.6 ambulances linked with nine maternity units) was € 85 586 (€ 61/obstetric case transferred or € 0.43/capita/year). Referral times exceeding 3 h were associated with a significantly higher risk of early neonatal deaths (OR, 1.9; 95% CI, 1.1-3.2). MSF coverage of complicated obstetric cases and caesarean sections was estimated to be 80% and 92%, respectively. CONCLUSION: This study demonstrates that it is possible to implement an effective communication and transport system to ensure access to EmONC and also highlights some of the important operational factors to consider, particularly in relation to minimising referral delays.

Introducing systematic dispatcher-assisted cardiopulmonary resuscitation (telephone-CPR) in a non-Advanced Medical Priority Dispatch System (AMPDS): implementation process and costs.

OBJECTIVE: In order to improve the quality of our Emergency Medical Services (EMS), to raise bystander cardiopulmonary resuscitation rates and thereby meet what is becoming a universal standard in terms of quality of emergency services, we decided to implement systematic dispatcher-assisted or telephone-CPR (T-CPR) in our medical dispatch center, a non-Advanced Medical Priority Dispatch System. The aim of this article is to describe the implementation process, costs and results following the introduction of this new "quality" procedure. METHODS: This was a prospective study. Over an 8-week period, our EMS dispatchers were given new procedures to provide T-CPR. We then collected data on all non-traumatic cardiac arrests within our state (Vaud, Switzerland) for the following 12 months. For each event, the dispatchers had to record in writing the reason they either ruled out cardiac arrest (CA) or did not propose T-CPR in the event they did suspect CA. All emergency call recordings were reviewed by the medical director of the EMS. The analysis of the recordings and the dispatchers' written explanations were then compared. RESULTS: During the 12-month study period, a total of 497 patients (both adults and children) were identified as having a non-traumatic cardiac arrest. Out of this total, 203 cases were excluded and 294 cases were eligible for T-CPR. Out of these eligible cases, dispatchers proposed T-CPR on 202 occasions (or 69% of eligible cases). They also erroneously proposed T-CPR on 17 occasions when a CA was wrongly identified (false positive). This represents 7.8% of all T-CPR. No costs were incurred to implement our study protocol and procedures. CONCLUSIONS: This study demonstrates it is possible, using a brief campaign of sensitization but without any specific training, to implement systematic dispatcher-assisted cardiopulmonary resuscitation in a non-Advanced Medical Priority Dispatch System such as our EMS that had no prior experience with systematic T-CPR. The results in terms of T-CPR delivery rate and false positive are similar to those found in previous studies. We found our results satisfying the given short time frame of this study. Our results demonstrate that it is possible to improve the quality of emergency services at moderate or even no additional costs and this should be of interest to all EMS that do not presently benefit from using T-CPR procedures. EMS that currently do not offer T-CPR should consider implementing this technique as soon as possible, and we expect our experience may provide answers to those planning to incorporate T-CPR in their daily practice.

A comprehensive framework for determining the cost of an emergency medical services system.

To determine the cost of an emergency medical services (EMS) system, researchers, policymakers, and EMS providers need a framework with which to identify the components of the system that must be included in any cost calculations. Such a framework will allow for cost comparisons across studies, communities, and interventions. The objective of this article is to present an EMS cost framework. This framework was developed by a consensus panel after analysis of existing peer-reviewed and non-peer-reviewed resources, as well as independent expert input. The components of the framework include administrative overhead, bystander response, communications, equipment, human resources, information systems, medical oversight, physical plant, training, and vehicles. There is no hierarchical rank to these components; they are all necessary. Within each component, there are subcomponents that must be considered. This framework can be used to standardize the calculation of EMS system costs to a community. Standardizing the calculation of EMS cost will allow for comparisons of costs between studies, communities, and interventions.

Cost-effectiveness analysis of telemedical devices for pre-clinical traffic accident emergency rescue in Germany.

OBJECTIVES: The purpose of this study is to assess the cost-effectiveness (net costs per life year gained) of telemedical devices for pre-clinical traffic accident emergency rescue in Germany. METHODS: Two equipment versions of a telemedical device are compared from a societal perspective with the baseline in Germany, i.e. the non-application of telemedicine in emergency rescues. The analysis is based on retrospective statistical data covering a period of 10 years with discounted costs not adjusted for inflation. Due to the uncertainty of data, certain assumptions and estimates were necessary. The outcome is measured in terms of "life years gained" by reducing therapy-free intervals and improvements in first-aid provided by laypersons. RESULTS: The introduction of the basic equipment version, "Automatic Accident Alert", is associated with net costs per life year gained of euro 247,977 (at baseline assumptions). The full equipment version of the telemedical device would lead to estimated net costs of euro 239,524 per life year gained. Multi-way sensitivity-analysis with best and worst case scenarios suggests that decreasing system costs would disproportionately reduce total costs, and that rapid market penetration would largely increase the system's benefit, while simultaneously reducing costs. CONCLUSION: The net costs per life year gained in the application of the two versions of the telemedical device for pre-clinical emergency rescue of traffic accidents are estimated as quite high. However, the implementation of the device as part of a larger European co-ordinated initiative is more realistic.

The potential impact of rural mayday systems on vehicular crash fatalities.

Rural mayday systems can reduce the time between the occurrence of an accident and the notification of emergency medical services--called the accident notification time. Reductions in this time, in turn, may affect the numbers of fatalities. A statistical analysis is used to estimate the quantitative relationship between fatalities and the accident notification time. The elasticity of rural fatalities with respect to the accident notification time was found to be 0.14. If a rural mayday system were fully implemented (i.e. a 100% market penetration) and the service availability were 100%, then we would expect monetary benefits of about $1.83 billion per year and comprehensive benefits (which includes the monetary value attached to the lost quality of life) of $6.37 billion per year.

Diversion of 911 poisoning calls to a poison center.

OBJECTIVE: To determine the impact and safety of diverting poisoning calls from 911 to a regional poison center. METHODS: A prospective six-month review was performed of all calls transferred from 911 dispatchers to a regional poison center for management. Recommendations for management and transport were made by the poison center using existing protocols. Patients were followed with telephone contact by poison center staff until symptoms resolved or until hospital discharge. Medical outcomes were categorized using the American Association of Poison Control Center guidelines for medical outcome. RESULTS: A total of 262 cases were reviewed; four were excluded. The poison center was contacted prior to ambulance dispatch in 210 cases (81%). An ambulance was sent before the poison center was contacted 48 times (19%). The majority of patients originally calling 911 were managed at home (175/258; 68%). Patients experienced either no effect or minor effects in 254 cases (98%). Two patients developed moderate effects (0.8%), one developed a major effect (0.4%), and one died (0.04)%. No adverse effects or treatment delays resulted from diversion of calls to the poison center. CONCLUSIONS: Appropriate poisoning and toxic exposure cases may be diverted safely from emergency medical services dispatch to a regional poison center for management, reducing unnecessary responses, with substantial cost savings.

Advantages and limitations of medical dispatching: the French view.

One of the main features of the French emergency medical services (EMS) system as it has been developed during the last 40 years is the participation of a physician in each stage of the EMS organization. Thus, in the 100 French emergency medical dispatch centres, all calls received on 15, the national medical emergency phone number, are medically dispatched. The main advantages are: (i) better security for the caller; (ii) proper adaptation of the response to the emergency; (iii) a quicker and more efficient intervention time; (iv) the hospital is informed of the arrival of an emergency; (v) the respect of medical secrecy; (vi) a good cost-efficiency ratio in the use of intervention means. The main limitations are connected with: (i) the inaccuracy of certain calls and problems of dialogue with the caller; (ii) the poor acceptance of the system's obligations by some of the callers, patients, physicians or any other partners of the EMS organization. In the future the implementation of the multi-purpose European emergency number 112 will probably require the system's adaptation to it.

The effectiveness of personal emergency response systems in meeting the safety monitoring needs of home care clients.

Personal emergency response systems (PERS) are electronic communication devices placed in the home to summon help in an emergency. In 1988, New York enacted legislation providing for Medicaid reimbursement for patients of certified home health agencies (CHHAs) whose PERS substituted for hours of safety monitoring by a personal care worker as part of the plan of care. Before the implementation of the new legislation, the Visiting Nurse Service of New York initiated a grant-funded demonstration project in February 1992, which showed that PERS save lives, reduce healthcare costs, and are well received by patients. The authors discuss the issues and outcomes surrounding the use of PERS within a CHHA.