Ambulance Dispatch Solving Inappropriate Emergency Calls Prof Matthew Cooke Warwick Medical School,

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Ambulance DispatchSolving Inappropriate
Emergency CallsProf Matthew CookeWarwick
Medical School, UK
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The London Experience

• 40 of those living in London admitted that they
  would phone 999 if getting through to their GP
  proved too difficult. The average for the other
  seven cities was 22.

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The London Experience

• 30 of those living in London said they would
  call 999 if they couldn't get a doctor's
  appointment for several days, compared to 16 for
  the other cities.

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The London Experience

• Only 3 of those living in seven other cities
  said they would phone 999 for ambulance if
  suffering from flu-like symptoms, compared to
  more than 10 of London respondents.

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The UK system

• Free National Health Service
• Multiple sources of healthcare

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Open access services

• Emergency department
• GP out of hours system
• Walk-in centres
• Ambulance service

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Phone call

• General Practitioner
• NHS Direct
• 999 (112) emergency ambulance service

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NHS Direct

• Telephone advice from nurses
• Protocol based system
• Popular with patients
• No evidence of changing flow of patients

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Traditional Approach
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Time to change
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999 call

• -Ambulance Services given the right to refuse to
  send an ambulance
• Who do you refuse ?

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The patients perspective

• I need help, who can I call ?

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What is an inappropriate call ?

• You have had several drinks
• Your child has a fall and may have broken her arm
• How do you get to hospital?

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What is an inappropriate call ?

• 24 year old calls emergency ambulance.
• Needs emergency contraception

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What is an inappropriate call ?

• 92 year old falls out of bed and cannot get up

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What is an inappropriate call ?

• 38 year old with indigestion

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What is an inappropriate call ?

• Midnight Friday
• Mother phones emergency ambulance. Child has just
  come home from a party and admits to two month
  history of drug abuse. Wants mum to help her
  before its too late

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How many ?

• 40-60 of all 999 emergency calls
• England
• Population 50 million
• 5.6 million calls per year

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Whats the problem?
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The patients perspective

• I need help, who can I call ?

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Patient Behaviour

• Those who do not call when they should
• They believe it is appropriate

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Education campaigns

• Dont work
• Target medical diagnoses
• Require medical knowledge

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Behaviour

• Need to look at patients reasons for using the
  service

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Change the system

• Callers will not change

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New Approach
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Ambulance Dispatch

• Prioritisation Systems to determine level and
  speed of response
• The Category C call

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ABUSE OF PRIORITISATION SYSTEMS

• Priority does NOT reflect the care needs of the
  patient
• It does reflect the urgency at the time of the
  call

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If do not have an urgent need

• Spend a bit more time
• Find out more
• Decide
• What they need
• Who they need
• When they need
• Where they need

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Who should do it?

• NHS Direct
• Ambulance service
• Others
• Technical issues outweigh clinical issues

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Does it work?

• 52 triaged as not requiring emergency ambulance
• A third of these did require ED
• BUT 9 of those triaged as not requiring
  ambulance were admitted to hospital
• (Dale 2003)

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Does it work?

• US study showed 98 negative predictive value for
  ED attendance

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Does it work?

• NHS Research soon to be published
• 13 of all 999 calls
• 67 returned, of which 25 needed 999
• Callers satisfied (sometimes)
• Adverse events 4 in 1552

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Who they need

• Dispatcher must have access to full array of
  people

• Social work
• Community Nurse
• Palliative Care
• Mental Health
• Pharmacy
• Falls Service
• Primary Care
• Transport

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Where they need

• Dispatcher must have access to full array of
  services
• Access to appointment systems

• Pharmacy
• Minor Injury Unit
• Primary Care
• Home

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The study that is needed

• One contact point
• Access to all services
• Integrated transport system

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New Approach
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New Approach
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ECP Dispatch Procedure
Clinical Assessment Differential Diagnosis
Immediate Removal
Urgent Removal
Refer GP
Treat Refer
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Emergency Care Practitioners

• Nurses and paramedics
• Minor illness and Injury
• Intervention at home
• Wide variety
• Rapidly expanding
• Adequate training

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The future

• Transfer to Advice
• Range of Practitioners
• Case selection improved

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Solving inappropriate calls ?

• Providing an appropriate service
• Providing an urgent care service
• Not providing an ambulance service

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Ambulance DispatchSolving Inappropriate
Emergency CallsProf Matthew CookeWarwick
Medical School, UKwww.warwick.ac.uk/go/ambulance