Implementation of prehospital dispatch protocols that triage low-acuity patients to advice-line nurses.

INTRODUCTION: Although EMS agencies have been designed to efficiently provide medical assistance to individuals, the overuse of 9-1-1 as an alternative to primary medical care has resulted in the need for new methods to respond to this increasing demand. Our study analyzes the efficacy of classifying specific low-acuity calls that can be transferred to an advice-line nurse for further medical instruction. The objectives of our study were to analyze the impact of implementing this protocol and resultant patient feedback regarding the transfer to an advice-line nurse. METHODS: We collected data for retrospective review from April 2011 to April 2012 from a single municipal EMS agency with an average annual call volume of approximately 90,000. Medical Priority Dispatch System response codes were assigned to calls based on patient acuity. Patients classified under Omega response codes were assessed for eligibility of transfer to nurse advice lines. Exclusion criteria included the following: if the call was placed by a third-party caller; if the patient refused to be transferred to the advice-line nurse; anytime the MPDS system was not used; if the patient was referred from a skilled nursing facility, school, or university nursing office, or physician's office. Telephone surveys were conducted for those patients who spoke to an advice-line nurse and did not receive an ambulance response 24 hours after calling 9-1-1 to obtain patient feedback. RESULTS: The database included 1660 patients initially classified as Omega and eligible for transfer to an advice-line nurse. After applying the exclusion criteria, 329 (19.8%) patients were ultimately transferred to an advice-line nurse and 204 (12.3%) received no ambulance response. Of those patients who were not transported by ambulance 118 (57.8%), patients completed telephone follow-up, with 104 (88.1%) reporting the nontransport option met their health-care needs and 108 (91.5%) responding they would accept the transfer again for a similar complaint. CONCLUSION: We identified an average of two patients per day as eligible for transfer to the nurse advice line, with less than one patient successfully completing the Omega protocol per day. While impact was limited, there was a decrease in ambulance response.

Utilization of prehospital dispatch protocols to identify low-acuity patients.

OBJECTIVES: To describe the experience of a U.S. emergency medical services (EMS) agency utilizing a dispatch algorithm to identify low-acuity patients and determine whether secondary telephone triage by a nurse was associated with subsequent hospital admission among those patients. METHODS: This was a retrospective study of all patients meeting the low-acuity Omega classification by the Medical Priority Dispatch System (MPDS) in a large urban EMS system, conducted in two phases. Patients were excluded from the study if a refusal for transport was obtained, the call was received from a third-party caller, the MPDS system was not used, the patient was being referred from a skilled nursing facility, school, or university nursing office or physician's office, or if the call was referred to the Carolina Poison Center. Patients were enrolled over two phases using two different versions of the MPDS protocol, and in phase 2 patients were offered the option of speaking with an advice-line nurse. The outcome of interest was emergency department disposition, classified as hospital admission or discharge home. Admission to an intensive care unit (ICU) bed was also collected as a subcategory of hospital admission. RESULTS: Of the 1,862 patients in phase 1, 69.3% were discharged home from the emergency department, whereas in phase 2, 73.0% of the 1,078 patients were discharged home. Individuals were most frequently admitted to the hospital across both phases if they had a dispatch determinant of pregnancy, psychiatric/behavioral, fall, sick person. Hospital admission was also associated with receiving an EMS or emergency department procedure. There were 530 patients in phase 2 who underwent secondary triage by an advice-line nurse. Among this cohort of patients, 134 (25.3%) required subsequent hospital admission, with a further three (2.2%) requiring an ICU admission. CONCLUSIONS: This study identified a method for classifying patients during the dispatch period as low-acuity while attempting to ensure that those individuals received the medical care that they needed.

Association between patient unconscious or not alert conditions and cardiac arrest or high-acuity outcomes within the Medical Priority Dispatch System "Falls" protocol.

INTRODUCTION: Falls are one of the most common types of complaints received by 9-1-1 emergency medical dispatch centers. They can be accidental or may be caused by underlying medical problems. Though "not alert" falls patients with severe outcomes mostly are "hot" transported to the hospital, some of these cases may be due to other acute medical events (cardiac, respiratory, circulatory, or neurological), which may not always be apparent to the emergency medical dispatcher (EMD) during call processing. OBJECTIVES: The objective of this study was to characterize the risk of cardiac arrest and "hot-transport" outcomes in patients with "not alert" condition, within the Medical Priority Dispatch System (MPDS®) Falls protocol descriptors. METHODS: This retrospective study used 129 months of de-identified, aggregate, dispatch datasets from three US emergency communication centers. The communication centers used the Medical Priority Dispatch System version 11.3-OMEGA type (released in 2006) to interrogate Emergency Medical System callers, select dispatch codes assigned to various response configurations, and provide pre-arrival instructions. The distribution of cases and percentages of cardiac arrest and hot-transport outcomes, categorized by MPDS® code, was profiled. Assessment of the association between MPDS® Delta-level 3 (D-3) "not alert" condition and cardiac arrest and hot-transport outcomes then followed. RESULTS: Overall, patients within the D-3 and D-2 "long fall" conditions had the highest proportions (compared to the other determinants in the "falls" protocol) of cardiac arrest and hot-transport outcomes, respectively. "Not alert" condition was associated significantly with cardiac arrest and hot-transport outcomes (p<0.001). CONCLUSIONS: The "not alert" determinant within the MPDS® "fall" protocol was associated significantly with severe outcomes for short falls (<6 feet; 2 meters) and ground-level falls. As reported to 9-1-1, the complaint of a "fall" may include the presence of underlying conditions that go beyond the obvious traumatic injuries caused by the fall itself.