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THE USE OF CRITERIA BASED DISPATCH IN THE PRIORITISATION OF 999 EMERGENCY AMBULANCE CALLS by Matthew William Cooke

A thesis submitted to The University of Birmingham for the degree of DOCTOR OF PHILOSOPHY

DEPARTMENT OF PRIMARY CARE & GENERAL PRACTICE FACULTY OF MEDICINE THE UNIVERSITY OF BIRMINGHAM AUGUST 2001

Abstract
Criteria Based Dispatch (CBD) is one system used for prioritising 999 emergency ambulance calls. The aim of prioritisation is to deliver a more appropriate and rapid response to those with the most urgent needs. This study aims to assess the safety and effectiveness of CBD in the prioritisation of 999 emergency ambulance calls by detecting where it fails to meet its objectives and to inform wider plans for prioritisation in emergency care in the NHS.

The study consists of many components. These include studies of the opinion of experts on the present coding the present literature clinical state, interventions and outcomes in relation to prioritisation critically ill patients subsidiary studies that look at whether CBD performed well in a period of work overload, the communication problems in 999 calls and a study of those who were not transported to hospital following a 999 call. There is little information in the literature that is applicable to the UK emergency ambulance service system. The studies in this thesis combine to conclude that there is at least a 12.6% under-triage rate, which may mean that critically ill patients are not receiving the fastest and most appropriate response. The use of a guideline system is allowing the dispatchers to improve on the CBD system by use of experience and knowledge. Key groups of critically ill patients, may be unrecognised in 20% of cases. Those with decreased conscious level, those who are bleeding or have suffered fits appear to be at increased risk of under-triage.

CBD does not appear to be used to full advantage by the ambulance service in this study to deploy resources most effectively.

Review of the guidelines is suggested and recommendations are made for change.

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Dedication
To Heather, Hannah and Jenny.

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Acknowledgements
The author would like to acknowledge all of the following for their help in the conduct of this research. I am grateful to all the members of the Emergen Medicine Research Group at the cy University of Birmingham. Teresa Allan, Richard Morrell, Steve Edwards, and particularly to Sue Wilson for her advice and supervision and Pam Bridge for her assistance throughout the project.

West Midlands Ambulance Service Barry Johns, Chief Executive Steve Elliker, Emergency Control Centre Manager All the staff of the Emergency Control Centre Pippa Chalker, IT Department Jeanette Gray, Henrietta Street Ambulance Station Essex Ambulance Service Gron Roberts, Chief Executive Rick Davis City Hospital NHS Trust Jayne Hipkiss, my secretary Joan Holford, A&E Reception Supervisor Reception and Nursing Staff in A&E Medical Records Department and Ward Staff Experts Mr. John Belstead, Mr. Geoffrey Bryant, M. Seaward-Brown, Dr. Timothy Coats, Dr. Rowley Cottingham, Dr. Gareth Davies, Mr. Peter Driscoll, Dr. Richard Fairhurst, Dr. Brenda Fleming, Dr. Graham Gardiner, Dr. Robin Glover, Mr. Paul Grout, Dr. Henry Guly, Mr. Ian Harvey, Major Tim Hodgetts, Dr. Graham Johnson, Dr. Danny MacGeehan, Mr. Kevin Mackway-Jones, Mr. Richard Morrell, Dr. Adrian Noon, Dr. David Parkin, Mr. Patrick Plunkett, Mr. Paul Pritty, Dr. John Ryan, Mr. Brendan Ryan, Dr. Ian Robertson-Steele, Mr. Howard Sheriff, Mr. David Small, Dr. Steve Southworth, Dr. Ian Stewart, Mr. Andrew Swain. I am grateful to Linda Culley (King County, Seattle), Prof. Jeremy Dale, Prof. Richard Hobbs and Prof. Richard Lilford for their constructive comments and Rachel Hewitson for her secretarial support.

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Funding:
The NHS Executive (West Midlands) Research and Development Directorate funded this project.

Ethical considerations:
This study was approved by the West Birmingham Local Research Ethics Committee.

Table of contents
Table of contents List of figures List of tables List of abbreviations Glossary Use of terms relating to urgency of care 1 Introduction vi viii ix xi xii xiii 1 5 5 5 6

2 Aim and Objectives 2.1 Aim 2.2 Objectives 2.3 Methodological overview

3 Overview 3.1 999 call handling 3.2 Triage and prioritisation 4 CBD system 4.1 Criteria Based Dispatch 4.2 History of CBD. 4.3 Review of Expert Opinion Study as an example of a cause for concern. 5 A systematic review of the evidence on the use of priority dispatch of emergency ambulances. 6 7 Clinical outcome study Study of hospital alerts

9 9 11 14 14 19 22 41

54 90 102 102 108 119 127 134 141

8 Other studies 8.1 Study of changes in CBD when introduced to the UK 8.2 Patients not transported from the scene 8.3 Are 999 callers in a position to give triage information and receive first aid advice? 8.4 CBD usage at a time of exceptional workload 9 10 Conclusions Papers published in relation to this thesis

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Appendices 1. The CBD(UK) coding system 2. Objectives of CBD and dispatch categories 3. Sample of recruitment letter 4. Guidance for Study & 5. Instructions for study . 6. Other sources of publications used in the literature search. 7. Proforma for articles undergoing expert appraisal in the Literature Review. 8. Articles undergoing expert appraisal in the Literature Review. 9. Data collection Proforma 10. Recommendations for modifications to CBD References

143 156 157 158 159 160 161 163 165 166 169

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List of Figures
Figure Figure 1.1. Figure 3.1. Figure 4.3.1. Title Trends in the number of emergency 999 ambulance calls and patient journeys provided by NHS ambulance services 19761999. Handling of 999 calls. Summary of changes by panel suggested by 50% or more of the experts in any panel - letters represent panel of experts not CBD codes. Triage Nurse ambulance prioritisation assessment form. Time of 999 call vs. CBD category. Percentage of calls classified as category A per hour. Variation of non-transported 999 calls with day of week. Variation of non-transported 999 calls with time of day. Non transport by CBD code. Total cases not transported. Reasons for not requiring transport. Cases dealt with by another agency. Who calls for the emergency ambulance? Hourly 999 call rate compared to a control time period. Page 2 10 35

Figure 6.1. Figure 6.2. Figure 6.3. Figure 8.2.1. Figure 8.2.2. Figure 8.2.3. Figure 8.2.4. Figure 8.2.5. Figure 8.2.6. Figure 8.3.1. Figure 8.4.1.

57 66 66 111 112 112 113 114 114 123 129

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List of Tables
Table Table 3.1. Table 4.1.1. Title Page Triage category of 999 ambulance cases compared to all A&E 12 attenders at City Hospital, Birmingham in March and April 1998. Emergency calls: response times for services wit hout call 17 prioritisation, by Ambulance Service, 1998-99. Emergency calls: response times for services with call prioritisation, by ambulance service, 1998-99. Example of randomised CBD list as provided for panel . Example of CBD list (in CBD code book order) as provided for panel Participation and response rates. Expert agreement by CBD category. All changes proposed by expert panel Cases where 50% or more of experts in all panels suggested change. Disagreements by 50% or more of experts on a panel for categories involving children under five. Changes induced if decision of each 50% or more of experts on a panel were used. Search strategy for electronic databases Classification of all articles identified. Summary of results of literature search by database. Papers relating to priority dispatch of ambulances and containing original data. Categories used by experts to define urgency. Codes for justification of urgency of care. Sources of data for outcome study. Distribution of study patients by CBD category. CBD coding by sex of patient. Variation of category distribution by age groups. A&E diagnosis of cases in the study. Internal consistency of experts. Analysis of Coding by Dispatchers and Experts. Error rates of CBD Interventions in relation to CBD status Physiological status in relation to CBD code. Discharge from A&E in relation to CBD code. Admission to hospital in relation to CBD code. 18 24 25 26 26 27 36 36 37

Table 4.1.2. Table 4.3.1. Table 4.3.2 Table 4.3.3. Table 4.3.4. Table 4.3.5 Table 4.3.6. Table 4.3.7. Table 4.3.8.

Table Table Table Table

5.1. 5.2. 5.3. 5.4.

42 45 46 48

Table 6.1. Table 6.2. Table 6.3. Table 6.4. Table 6.5. Table 6.6. Table 6.7. Table 6.8. Table 6.9. Table 6.10. Table 6.11. Table 6.12. Table 6.13. Table 6.14.

59 59 64 64 65 65 67 69 71 72 74 75 76 76

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Table Table 6.15. Table 6.16.

Table 6.17.

Table 6.18. Table 6.19.

Title Admission to Coronary care or High dependency in relation to CBD code. Admission to Intensive Care unit in relation to CBD code. A ITU admissions direct from A&E B all ITU admissions, including admissions subsequent to A&E Deaths in relation to CBD code. A Deaths before arrival at or in A&E B Deaths after leaving A&E during hospital stay Duration of complaint in relation to CBD code. Response times by CBD category. A response times by CBD B percentage achieving new 2001 standards Information from ambulance database for alerts study Criteria for determining critical illness on clinical grounds Distribution of diagnoses by the alerting ambulance crew and the dispatchers CBD classification. Comparison of dispatcher and ambulance crew diagnosis. Conscious level on AVPU scale vs. CBD category. The Revised Trauma Scores (RTS) for trauma patients. Glasgow Coma Scale of trauma patients. The changes in coding of CBD when imported into UK. Decreased conscious level coding in UK and US. Variation in bleeding code according to presenting complaint. Coding of reason for non-removal. Search strategy on communications difficulties in 999 ambulance calls. Communication Difficulties Location of person making emergency 999 call Emergency ambulance calls by prioritisation category for New Years Eve and a control period.

Page 72 78

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80 81

Table 7.1. Table7.2. Table 7.3. Table Table Table Table Table Table Table Table Table 7.4. 7.5. 7.6. 7.7. 8.1.1. 8.1.2. 8.1.3. 8.2.1. 8.3.1.

92 92 93 94 96 97 97 103 106 107 110 119 122 122 130

Table 8.3.2. Table 8.3.3. Table 8.4.1.

Table 8.4.2. Table 8.4.3.

Percentage of calls responded within 8 and 14 minutes.

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Average response times and the range of response times by 131 category.

List of abbreviations
A&E AED ALS ANOVA ATLS AVPU BASICS BIDS BLS BP CBD CBD(UK) CINAHL CPR CVA EMD EMS EMT GCS GP ITU MI ORCON standards PHC QS RR RTA RTS SI WMAS Accident and Emergency Accident and Emergency department Advanced Life Support Analysis of Variance Advanced Trauma Life Support Alert-Voice-Pain-Unresponsive scale of unconsciousness British Association for Immediate Care Bath Information Database Service Basic Life Support Blood Pressure Criteria Based Dispatch Criteria Based Dispatch, UK version Cumulated Index of Nursing and Allied Health Literature Cardio-pulmonary resuscitation Cerebro-vascular accident Emergency medical dispatcher Emergency medical services Emergency medical technician Glasgow Coma Score General Practitioner Intensive Therapy Unit Myocardial infarction National standards for ambulance response times. Operational Research Consultants in Health standards Prehospital care Quality Score Respiratory Rate Road traffic accident Revised Trauma Score Shock Index West Midlands Ambulance Service NHS Trust

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GLOSSARY
112 911 The pan European emergency ambulance access number The emergency access telephone number used in many parts of America 999 The emergency services telephone access number in the UK Alert The process of an ambulance service informing a hospital (alerting them) of the imminent arrival of a seriously ill patient Call taker The person in the ambulance control room who initially receives the 999 call and takes details from the caller Control Assistant Person working in ambulance control room ( one of the tasks they undertake is to be a call taker) Dispatcher The person in the ambulance control room who is responsible for mobilising the ambulance. Also used to refer to anyone working in the control room in the dispatch process. Over-triage Where an individual records a triage cate gory higher than the relevant expert. Pre-arrival instructions Instructions given to caller over the telephone after the dispatch of ambulance but prior to it arrival Response time The time from receiving the 999 call in ambulance control to arrival of ambulance personnel next to the patient. Under-triage Where an individual records a triage category lower than the relevant expert.

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Use of terms relating to urgency of care.


The Oxford English dictionary (OED) Immediate Emergency Urgent
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does not differentiate any priority between the

words immediate, emergency and urgent. The OED definitions are: occurring or done at once or without delay a medical condition requiring immediate treatment requiring immediate action or attention

Within the ambulance and emergency services, a different interpretation is used, although it has never been formally defined. In this thesis the terms are used as follows: Immediate Emergency Urgent without any delay with minimal delay (for example, a few minutes) with only a small delay

For example, an urgent ambulance is often requested to arrive within 15 minutes to 2 hours, whereas an emergency ambulance aims to attend within a maximum of 14-16 minutes. If care is needed immediately, this implies that deterioration in the patient's condition will occur from that time or may already be occurring.

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1. INTRODUCTION
The statutory ambulance services in the United Kingdom have responsibility for the provision of the 999 service relating to healthcare2. As such they provide prehospital care and transport of medical emergencies following a 999 emergency ambulance call. They are also responsible for the transport of a patient to hospital following the request of a general practitioner. The ambulance services also have responsibilities relating to emergency planning and major incidents. The provision of transport between hospitals and to non-urgent healthcare is undertaken by both private and statutory ambulance services. There were 1.1 million urgent GP cases transported in 1997-98. These utilise the same resources as 999 calls. The GP urgent calls are not currently prioritised by ambulance control and do not therefore form part of this study. At present 999 ambulance calls receive priority over a GP call unless the general practitioner states that the case needs an immediate ambulance. This study is only concerned with the provision of the emergency 999 service by the ambulance service.

Ambulance services are experiencing a rapidly increasing demand. The number of emergency ambulance journeys reported in 1997-8 was 2.7 million in England. These resulted from 3.6 million ambulance calls, a rise from 3.33 million emergency ambulance calls in 1996-973. The trends since 1976 are demonstrated in Figure 1.1. These figures represent an ambulance call rate of 123 calls per 100,000 population per week in England (92 ambulance journeys /100,000 /week as there is an average of 0.75 journeys per call 3 ). In a study of 25 mid-sized US cities , an ambulance call rate of 158 per 100,000 population per day4 was calculated. A wide variation of call rates has been noted in Europe 5.

Figure 1.1. Trends in the number of emergency 999 ambulance calls and patient journeys provided by NHS ambulance services 1976-1999.

The severity of illness experienced by those for whom a 999 emergency ambulance call is made varies widely. When the hospital care given to those transported to hospital is taken into account, nearly half may b considered retrospectively not to have required an e emergency ambulance. In a review of the international literature, it was demonstrated that, despite a wide range of methodologies being used to estimate appropriateness of use of ambulances, there was surprisingly little variation in the estimates of misuse 6. In nine of the ten studies for emergency ambulances, a figure between 30% and 52% of inappropriate use was reported6. Inappropriate was defined in these studies as not requiring an ambulance because of medical need. However, inappropriate, as defined by medical condition, does not necessarily signify misuse. There may be social reasons why a person cannot obtain transport to hospital (for example, an elderly lady living alone in a violent area) where an ambulance is the only source of transport. The UK system does not have any provision for transport without EMT or paramedic care. Many studies actually assess whether the call was appropriate for paramedic care rather than for ambulance service attendance.

In Birmingham, in 1980, 51.7% of all calls (42.6% of medical and 63.2% of trauma cases) were deemed to be unnecessary7. At least 23.4% of patients needing emergency care (within 10 minutes of arrival in hospital), arrive by means other than emergency ambulance 8. These cases represent those who would be appropriate for 999 ambulance 2

care but decide to use another means of transport to hospital. Improvements in the emergency care system, such as increased usage of NHS Direct and better educational strategies, may encourage these non-ambulance users to utilise the emergency service as well as encouraging inappropriate users not to use an ambulance.

The problem of ambulance misuse is international. In Stockholm, 50% of ambulance cases were reported as low priority following medical assessment by phone and 22% resulted in no patient transport9. In Australia, 23% of calls resulted in no transport and 20% were non urgent 10. In Taiwan 11, 31.7% of calls did not trans port a patient and of those transported, 27.6% did not require even basic EMT care. However, in this study the majority of critically ill (86%) did not arrive by ambulance. In Canada, an inappropriate call rate of 49% has been described12. In a situation where some consider there is inappropriate use of the emergency service, a system is needed that can offer an alternative service to the abusers of the system if emergency ambulance services are to provide a better service to those in true need of medical assistance. There is no work explaining why people call an ambulance when there is no urgent medical need. Inappropriate provision by other services may be the cause. The reasons may include: A perception of urgency because of lack of medical knowledge Inability to contact other sources of health care Non-availability of other transport Poor comprehension of the role of the ambulance service.

Those not requiring an emergency ambulance may require: A non-emergency ambulance service Taxi-type transport to hospital Medical care at home Advice only Care from other health care providers Non medical attention, for example, social services. 3

NHS Direct is a telephone advice line being developed in the UK to work in parallel with the 999 service 13. It aims to p rovide advice on urgent and routine medical problems. One of the aims of the service is to direct people to the most appropriate source of healthcare and to an appropriate route of entry into the health care system. The introduction of this advice line may increase or decrease the ambulance service workload. Present work shows that it has had little impact on ambulance service or A&E department workload14. The increasing demands on ambulance services and the limited resources available suggest that the most cost effective means of providing the service is to prioritise calls (give priority to those cases needing urgent paramedic care or urgent transport to hospital). Referring the abusers to an alternative service or putting them in a queue behind more urgent cases relies on the ability of the system to prospectively and accurately select that group of callers. An inability to detect emergency cases could result in a fatal delay in medical care. The safety of prioritisation and triage systems in prehospital care in the UK has not been assessed. This study aims to assess one of the systems for prioritising 999 emergency ambulance calls that is currently in use in this country.

AIM AND OBJECTIVES

2.1 Aim: To assess the safety and effectiveness of Criteria Based Dispatch (CBD) in the prioritisation of 999 calls.

2.2 Objectives To critically review existing literature relating to prioritisation of emergency ambulance calls To relate prioritisation levels determined by CBD with clinical findings, interventions and outcome To determine the frequency of under-triage of 999 calls, in the light of a medical opinion To identify enhancements to the existing system which will minimise the extent of under-triage To compare expert medical opinion following case revie w with the prioritisation by CBD To study the incidence of critically ill people who are under-triaged by CBD. To identify enhancements to the existing system which may improve the accuracy of CBD To compare the triage of 999 ambulance calls by CBD with other nationally accepted triage systems and guidelines. Parallel studies contributing to this thesis aim: To study the use of CBD for patients who subsequently do not use an ambulance for transportation to hospital To study the communication difficulties which may affect information gathering and have implications on the effectiveness of CBD To study the impact of CBD on ambulance dispatch at times of maximal demand.

2.3

METHODOLOGICAL OVERVIEW

Initially the CBD system is described to ensure the reader understands the system that is being studied. The way in which it was introduced in to the UK is important as a possible cause of changes in the safety and effectiveness of the system.

The author was aware of anecdotal comments that the coding system did not achieve a safe system of coding. When introduced, comments suggested that CBD did not have the support of experts in the field. The expert opinion study was undertaken to determine whether the system coincided with the thoughts of experts and therefore whether the allegations of an unsafe system may be true (see chapter 4). The evidence base of the system was also assessed to determine whether the system was based on evidence and whether CBD had undergone the scrutiny of primary research (see chapter 5). Most work in monitoring effectiveness of emergency medical dispatch looks at quality assurance (namely, adherence to the system, rather than clinical effectiveness)15. Where clinical care has been assessed, work relates only to the prehospital element of care16. Only by studying the complete pathway through the accident and emergency department to definitive diagnosis can all those in need of emergency care, whether prehospital or in hospital, be determined. A clinical outcome study was undertaken to determine the safety and effectiveness of the system (see chapter 6). There is no absolute gold standard against which to measure a prioritisation system. For absolute safety, it should detect all those who could possibly deteriorate if an ambulance response is delayed. To be an effective resource management tool it should optimise use of resources and therefore minimise the number of high priority calls, allowing a lesser response to those who are not needing emergency care by an ambulance crew. This thesis relie s on the premise that in general, those who are at risk of death or serious illness should expect to receive the most urgent treatment. It also relies on the presumption that those with serious illness or injury will benefit from earlier attendance of an emergency ambulance. This has been validated for cardiac arrest and a few other conditions17,18,19 but is an assumption for most conditions since it is not ethical to test the hypothesis by delaying care to the potentially critically ill patient.

Mortality and morbidity are important outcome measures in medical research. However a study of medical dispatch cannot rely solely on these parameters because of the small number of deaths. Dispatch is only one component in a chain of events, from the initial symptoms to eventual outcome, of an emergency situation. It is necessary in many instances to use surrogate outcome measures to evaluate a dispatch centre and the following have been recommended20: Appropriate use of ALS units Prioritisation of calls Accuracy of referral to GPs Information gathering during telephone call Duration of call Adherence to guidelines.

This study looks at the first two of the above, which are the clinically relevant items to the United Kingdom system and looks at the difficulties of information gathering in regard to telephone calls (see chapter 8.3). For that reason, the need for an urgent response was assessed in three ways. Firstly, expert opinion was obtained, secondly clinical indicators were utilised and thirdly outcomes were assesse d. Proxy measures of outcome have to be used, such as length of stay in hospital and admission in conjunction with peer review. The outcome study of this thesis uses measures such as the need for prehospital intervention, physiological parameters and condition on arrival in the accident and emergency department as indicators of need for emergency care. The use of experts remains important for those cases where there is no validated system of determining the urgency of need for an ambulance. The study of the critically ill focuses on those with life-threatening conditions at the time of their arrival in hospital (see chapter 7). Other studies have looked at the global picture or specific diagnostic groups as demonstrated in the literature review in this thesis. With the great majority of patients not requiring intervention, a study that only looks at the whole population (in this case all those who call 999) produces a percentage undertriage rate that may appear very low. But when the numerically small group who could benefit most from a dispatch prioritisation system are studied, the safety of the system can be more effectively analysed. Clinically, the most important safety feature of CBD is its 7

ability to detect the seriously ill who may benefit from more rapid care. In an additional study, this sub-group were studied to determine if CBD was detecting patients who arrived at hospital in a serious condition. Detection of those with serious illness is not a simple matter. In certain conditions such as trauma, there are validated scoring and evaluation systems, which allows confirmation of the severity of the patients condition21. These are, however, designed for analysis of patient groups rather than individual patients. Peer review is equally effective as scoring systems in assessing quality of trauma care22, but they are not available for most medical conditions. If this system is not working perfectly, then it is important to determine why. The study of changes that were made to CBD when it was introduced i to the UK (Chapter 8.1) is n designed to determine whether any of the subsequent problems were caused by these changes. The problems may be related to an inability to obtain information of a sufficient degree of accuracy over the telephone to enable accurate prioritisation. The study of communication difficulties is designed to explore this possibility (Chapter 8.3).

It has been proposed that CBD has other uses as well as the ability to detect those in need of more urgent care. It has been suggested that those in the lowest prioritisation category (category C patients) may not need an ambulance response. Referral to General Practitioners is not undertaken at present direct from the 999 call in the UK, although it has been proposed. This group is analysed in this study to determine whether they could be safely allocated to other care providers. A study of ambulance cases where a patient was not transported is designed to demonstrate whether CBD is effective at detecting this group (see chapter 8.2).

CBD is also designed to help resource allocation, so that those with the most urgent need get an ambulance in preference to those with less urgent needs. A study of the busiest period of the year, New Years Eve, determines whether CBD is used as a means of allocating resources that are limited compared to requirements (see chapter 8.4).

By combining these studies, this thesis obtains a wide picture of the safety and effectiveness of CBD in prioritising emergency ambulance calls, assessed in a variety of ways. 8

3. OVERVIEW
3.1. 999 call handling When a caller makes a 999 call they are initially connected to the telephone company operator, who confirms the number they are calling from and determines which of the emergency services they require. The telephone company operator then connects to the ambulance service, if appropriate, and informs the ambulance service call taker of the phone number of origin. The call taker can check this against the automated call tracking. (This process is summarised in Figure 3.1)

The call taker then obtains the identity of the caller, the location at which the ambulance is required and the main medical problem. This information is then transferred to the dispatcher. The dispatcher then decides on which ambulance to send to this case. The dispatchers computer gives details of all the ambulances available and their estimated travelling time to the incident, aided by automated satellite vehicle tracking. Whilst the ambulance is being dispatched, the call taker undertakes the questioning needed for the Criteria Based Dispatch prioritisation (see chapter 3.2), as well as obtaining other necessary information. This information may include more detail on access (for example, a neighbour has the key) or of other services required (for example, police or fire). These additional details are then passed to the dispatcher who can modify the ambulance response and also inform the responding crew. The call taker then offers to give first aid advice to the caller whilst the ambulance is responding. If necessary, they stay on the line until the ambulance crew arrives. If the call has been made from outside the area or via a mobile phone or the location was not known to be in the West Midlands, then the telephone company may initially direct the call to another ambulance service. That ambulance service will then pass on details to the host ambulance service. The ambulance service receiving the call may not undertake prioritisation of calls and there may therefore be inadequate information to categorise the call. 9

999 caller Mobile or Outside West Midlands

999 caller Land line West Midlands

Telephone Company Operator Other Ambulance control

West Midlands Ambulance Emergency Control Centre (ECC) Call taker Entry on ECC computerised dispatch system

Dispatcher Allocates Ambulance to case

Call taker Determines CBD Priority code Dispatcher informed

Ambulance Crew Mobile on case

Dispatcher Receives CBD Priority code Updates ambulance crew Sends additional resources if required

Call taker Gives First Aid advice

Ambulance Crew Arrive at scene Treat patient, move to ambulance Mobile to hospital

Ambulance Crew Alert hospital if critical cases

Accident and Emergency department Nurse Triage

Figure 3.1

Handling of 999 calls.

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3.2. Triage and prioritisation Any system with limited resources or unpredictable requirements needs to be able to control its response and balance need with demand. Until 1997, the 999 ambulance service in the UK worked on a first come, first served basis. Someone calling 999 for a sprained ankle that had occurred one week ago had priority over a call thirty seconds later from a person with severe chest pains similar to their previous myocardial infarction. The level of demand for ambulances fluctuates by day of the week (for example, Monday is invariably the busiest day of the week) and time of the day (with peaks at lunchtime and in the evening) 23,24. The simultaneous need for several ambulances may lead to a relative lack of resources. A system which can give priority to those with life threatening problems is required, if available resources are to be used most effectively and safely. Such a system must be proven to be safe , reliable and effective in all situations and settings. Triage is used in all the accident and emergency departments in the UK. It is a system of assessment that is attributed to Baron Dominique Jean Larrey, who developed the principle of sorting casualt ies for treatment during the Napoleonic wars 25. The practice of triage has been adopted in A&E departments to ensure that patients with potential critical illness do not wait unnecessarily for assessment and treatment2. However, performance tables based on time before triage have been demonstrated to have no correlation with quality of care26. This may be due to others waiting for triage or because of the failure to develop a system of decision making that rapidly and sensitively detects the most ill. The value of triage has been questioned, and its reliability is in doubt. The decisions for assessment made by doctors, nurses or computer systems are not reproducible on retrospective examination 27. The Manchester triage system (MTS) of triage was introduced in 199628. It uses a series of flow charts for various "presentations" with key " discriminators" to determine the triage category. A multidisciplinary consensus group developed these guidelines. The system has been adopted widely throughout the United Kingdom. There is only one published study suggesting that it is a sensitive tool for detecting the critically ill 8. The majority of A&E attenders do not need emergency c (within 10 minutes of are arrival). The urgency of cases at City Hospital, Birmingham in March/April 1998 is 11

shown in Table 3.1. Triage scale 4 or 5 (could wait two hours or more for treatment) was allocated to 34.9% of ambulance cases and a further 46.1% were triage category 3 (could wait one hour for treatment)
29,30

Table 3.1 Triage category of 999 ambulance cases compared to all A&E attenders at City Hospital, Birmingham in March and April 1998.
Triage category Target time to be seen in AED 1 0 mins 2 10 mins 3 60 mins 4 120 min 5 240 mins Not Specified Grand Total

Ambulance

101 4.4%

330 14.3% 713 7.1%

1066 46.1% 3448 34.2%

780 33.8% 5069 50.3%

25 1.1% 390 3.9%

8 0.3% 287 2.8%

2310 100.0% 10079 100.0%

All cases

172 1.7%

Triage is also needed for emergency ambulance cases. The potential problems in undertaking the triage of a 999 call are even greater than those experienced in the accident and emergency department. These difficulties relate to several factors including: Inability of ambulance service call taker to visualise the patient Anxiety of the caller Language difficulty Anxiety that triage is delaying the arrival of the ambulance Caller may not be with the patient or not have full details The training of the person answering a 999 call compared to A&E nurses The callers lack of medical knowledge. These potential problems must be weighed against the potential advantages of an ambulance triage and dispatch system, which include: Improved response times for critical cases 12

Matching skill level to incident requirement (for example, determining whether an ambulance technician or paramedic or a doctor is required) Opportunity to give advice over the telephone before the arrival of the ambulance.

There are also potential secondary b enefits from 999 call prioritisation, which relate to utilising a category that allows a delayed or less urgent response. These include: Lower accident rate of ambulances responding to 999 calls because of less urgent response driving Better resource alloc ation Improved cost effectiveness. If a category can be defined that is not an emergency or does not require medical assistance, it is possible that these could be diverted to another agency, or be delayed. Mistriage in this situation could have severe consequences, as it removes emergency medical care rather than simply delaying the arrival of the ambulance.

As with any triage or prioritisation system, it is likely that call prioritisation will produce the greatest change in a system that is resource limited. It is unlikely that an ambulance service with ambulances always available and with a highly trained paramedic on each vehicle will gain markedly more from an ambulance dispatch system than could be achieved with pre-arrival advice alone.

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4. EXPLANATION OF CBD SYSTEM


There are two main types of ambulance dispatch system presently in use in the United Kingdom for prioritising 999 calls. The first is driven by strict protocol with mandatory questions and predetermined actions. An example of this is A dvanced Medical Priority Dispatch
31

(AMPDS). The second type is based on guidelines and Criteria Based

Dispatch 31(CBD) is of this type.

4.1 Criteria Based Dispatch


By asking a series of key questions, the ambulance service control assistant prioritises the call and assigns the patient to a CBD category. The dispatcher first determines the chief complaint and moves to the flip chart for that condition. By asking a series of questions the dispatcher can allocate a specific category from the chart.

This category is denoted by a code with three components: The first number signifies the chief complaint The second component is the letter defining the prioritisation category The third component is a numerical code for the specific symptom or circumstances.

For example, code 7A2 signifies: Chief complaint is chest pain (coded 7) Prioritisation is category A Symptom is short of breath, unable to talk coded 2

A full listing of the codes is contained in Appendix One.

The prioritisation categories, as defined by the originators of CBD in King County, are: Category A An immediate life-threatening situation requiring urgent assistance. The objective is to provide immediate aid by telephone advice followed by rapid on scene assistance.

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Category B Category C

A serious condition that is not immediately life-threatening. The objective is to provide intervention as soon as possible. Other non-serious or non-life-threatening conditions that requires conveyance to hospital.

It has been stated that the advantage of a guideline system, such as CBD, is the freedom given to the person taking the call 32. The initial information given by a caller may obviate the need for some questions; for example, there is no need to ask about conscious level if the caller is the patient. Nicholl31 demonstrated that in 50% of cases, the mandatory question about presence of breathing was not asked. Critics would say that this was an omission, protagonists would say that in the other half, it was apparent and did not need to be asked. CBD allows the control assistant to stop questioning as soon as a high priority response is realised. There is no need to ask any further questions about the patient who is unconscious before deciding a priority. An ambulance is required, although more information may then be subsequently gathered to inform the responders of more details, and to allow more accurate pre-arrival instructions to be given The advantage of a protocol system is stated to be that it does not rely on the exercise of good medical judgement and is more amenable to quality assurance32. There have been no comparative studies of the two systems. Much of the literature appears to be clouded by commercial interest having been written by the originators of the systems appraisal.
33, 34 35, 36, 37, 38, 39, 40, 41

rather than as a result of independent scientific

In America, the categorisation determines the level of response, that is whether a paramedic or technician is responded. In the UK, it is used to determine the time, not the level of response. The system aims to ensure that time critical illness and injury are attended by an appropriately trained carer within a set time. In the West Midlands, resources other than an ambulance may be used to ensure rapid response to a category A incident. These include ambulance personnel on motorcycles or in cars, acting as first responders, with an ambulance responding later if necessary. In other areas of the country, non-ambulance personnel may be used for this role, including local doctors, police and firefighters (personal communication, Ambulance Service Association).

15

The Department of Healths review of ambulanc e performance standards (ORCON)42 has proposed the following response time standards for urban ambulance services, such as West Midlands Ambulance Service. Category A Category B Category C 75% of calls within 8 minutes 95% of calls within 14 minutes Currently using the same standards as B

and the following response time standards for rural ambulance services Category A Category B Category C 75% of calls within 8 minutes 95% of calls within 19 minutes At present using the same standards as B

The performance against these standards is documented in Figures 4.1.1 and 4.1.2

The future role of Category C is still being debated. The group should contain those with non-serious or non-life threatening conditions that still require conveyance to hospital. It does however contain several sub-groups including: Those who need minor medical care Those who need non-medical assistance Those who simply need transport Those who do not need to attend hospital, because the condition has resolved or is minor Hoax and inappropriate ambulance calls A proportion who have been mistriaged and who need emergency care. Before a decision is made on how to manage these cases, it must be shown that this category includes the minimum number with serious illness and that the sub-groups can be identified. An informed risk assessment must be made, knowing the level of error and the possible consequences.

The work included in this document is the first study of the UK modification of CBD in operation.

16

Table 4.1.1.

Emergency calls: response times for services without call prioritisation, by Ambulance Service, 1998-99.

Ambulance Service

Total number of emergency calls resulting in ambulance arriving at scene of incident (thousands)

Response within 8 minutes (%)

Response within 19 minutes (Rural) 14 minutes (Urban) (%)

Rural Services Durham County Humberside North Yorkshire Lincolnshire Ambulance Nottinghamshire East Anglian Bedfordshire & Hertfordshire Kent Hampshire Wiltshire Isle of Wight Oxfordshire Gloucestershire Hereford & Worcest er Shropshire Urban Services West Yorkshire. South Yorkshire Surrey. London Ambulance Service Avon Ambulance Service Greater Manchester 155.8 82.4 70.7 685.0 54.0 221.8 59.0 41.3 61.1 38.7 53.5 63.7 94.9 90.7 94.6 86.9 92.2 94.9 36.8 37.5 35.8 52.6 76.2 100.7 90.2 86.3 77.1 22.8 6.4 24.7 24.3 30.4 20.7 38.1 58.2 55.4 57.9 55.6 41.5 51.3 41.7 52.8 51.9 47.0 53.1 50.9 52.1 54.6 93.5 97.3 95.3 95.0 96.4 90.2 95.6 93.2 96.1 94.5 95.8 94.5 95.0 96.4 95.6

17

Table 4.1.2. Emergency calls: response times for services with call prioritisation, by Ambulance Service, 1998-99.
Ambulance Service Category A calls Total number of emergency calls resulting in response/ ambulance arriving at scene of incident (thousands) Response Category B calls Total number of emergency calls resulting in response / ambulance arriving at scene of incident (thousands) Response

within 8 mins (%)

within 19 minutes (Rural) or 14 minutes (Urban) (%)

within 8 minutes (%)

Within 19 minutes (Rural) or 14 minutes (Urban) (%)

Rural Services Cumbria Northumbria Derbyshire Leicestershire Essex Sussex Dorset Royal Berkshire The Two Shires West Country Staffordshire Warwickshire Lancashire Urban Services Cleveland West Midlands Mersey 10.9 54.2 80.2 61.5 68.0 56.9 94.0 96.2 94.2 21.9 134.7 104.7 63.6 58.9 54.0 93.9 94.4 93.4 3.5 20.3 14.7 11.0 21.1 24.8 22.2 5.8 15.0 22.9 19.4 3.6 24.9 59.6 57.1 33.3 42.9 61.9 58.8 60.3 58.1 61.2 41.7 91.2 63.2 68.5 93.7 97.8 82.9 89.1 97.7 98.8 96.8 97.6 97.9 90.0 98.3 97.3 98.3 17.7 83.0 37.9 42.6 84.7 77.9 25.2 37.6 44.2 79.7 35.8 21.0 75.6 59.1 52.7 25.5 36.3 56.5 52.9 59.3 40.9 60.1 40.7 81.8 49.9 63.6 93.5 96.5 81.2 88.3 96.8 95.1 97.4 94.8 97.6 89.6 97.1 94.8 97.3

18

4.2. History of CBD.


The Criteria Based Dispatch system was developed and is licensed by King County Emergency Medical Services in Seattle, Washington, USA. The history of its
16 development in the USA has already been documented . The Association of Chief

Ambulance Officers undertook the modification of CBD for use by ambulance services in the UK. In 1992, Essex Ambulance Service undertook some work relating to prioritisation of 999 calls, resulting in the Anglicisation of the system in 1993. This was primarily a translation of the terminology from American to English. However, the UK Resuscitation guidelines on cardiopulmonary and choking replaced those of the American Heart Association. (personal communication, R Lane)

This system was then submitted to the Joint Royal Colleges Ambulance Liaison Committee whose members unanimously agreed with the need for change and endorsed the continuing need for national standards for A, B and C responses. They also suggested: The need for local audit Need to consider total time to hospital as well as response time Need for better outcome measures to be developed and monitored Standards must be locally clinically acceptable Balance between first response vehicles and patient carrying ability Telephone advice encouraged Medical adviser should adjudicate uncertain Category C calls Need to define Category C before use Use CBD for doctors urgent calls after an education programme

Personal communication (Joint Royal Colleges Ambulance Liaison Committee)

Suggested modifications to coding included the following being promoted to Category A: Acute hypovolaemia Documented hypotension Rhythm disturbances Some road traffic accidents. 19

In March 1994, Prof. Jon Nichol of the Medical Care Research Unit, University of Sheffield studied CBD. These findings have been published as The safety and reliability of priority dispatch systems31

His recommendations included: All head injuries should be high or medium response All children under five should be assigned to medium or high categories Training ne eds to ensure correct identification of the main complaint System should account for other circumstances than clinical state before assigning low priority category Need to assess reliability of information obtained and if in doubt assign a higher category

The above works contributed to the review of ambulance performance standards42. This report identified five groups of patients who were considered to have immediately life threatening conditions. Further consultation amongst ambulance services resulted in two further groups being added when the final report was published.

The five original groups were: Chest pain associated with pallor, sweating, shortness of breath, nausea or vomiting, but excluding those with pain intensified by breathing Individuals identified as unconscious, fitting or unresponsive for any cause Individuals with severe breathing problems who are unable to speak in whole sentences Individuals who have suffered trauma with penetrating injuries to the head or

trunk Any individuals recognised as having anaphylactic shock

20

The subsequent two groups were: Children under two years of age Females suffering severe obstetric haemorrhage.

In December 1996, the NHS Executive circulated a list of dispatch codes to fall within Category A42. From this list, the CBD system was realigned and the system evaluated in this thesis was published - CBD (UK) March 1997 version. The overall changes are outlined in section 8.1.

In only one case was the American code upgraded. In thirty-seven cases the clinical condition had its priority downgraded. The exception to this is the new UK category for children under two years who are all classified as an A response. Every instance of uncontrolled haemorrhage except nosebleed is downgraded. Some anomalies were created with the bleeding and gynaecology sections, which are discussed in chapter 8.1.

The system of CBD currently in use by ambulance services in the UK has been developed from the American system calling upon some evidence but mostly based on the opinion of various experts. It is not known whether CBD can detect the critically ill in the UK system nor is it known whether it is safe to be used as a syste m of prioritising by time of response. This work aims to determine whether the use of CBD is appropriate for determining the timing of emergency ambulance response in the UK.

21

4.3. Review of Expert Opinion Study as an example of a cause for concern.

4.3.1 Introduction The development of the CBD system which has been used in the UK since 1st April 1997 has been described earlier. The processes of consultation and expert committee were not those described as good practice for consensus development 43.

The purpose of this study aimed to determine whether the development process of CBD in the UK resulted in a system that had the agreement of experts. As with many areas, there is controversy over who should be considered an expert, are they the consultants in accident and emergency medicine, dispatchers or the paramedics? The ambulance personnel with greatest clinical knowledge, the paramedics, do not have the same depth of clinical knowledge as the medically trained staff, they rarely practice triage scoring and do not have a detailed knowledge of dispatch systems. They are used to treating only one or two patients to whom they have been dispatched. They therefore do not have to make decisions regarding triage of patients on a regular basis and when this triage is undertaken it is with sight of the patient. The dispatchers in the control room have expert knowledge of the dispatching system, but do not have the medical expertise to determine clinical urgency. Neither paramedics nor dispatchers have any formal sys tem of follow up to enable evaluation of the prioritisation system. Their assessment is likely to be based on anecdote and informal feedback from the subsequent information passed from the attending crew to other personnel via the control room.

Consultants in accident and emergency medicine have expert knowledge of the clinical conditions and they are familiar with the principles of triage as this is universally employed in accident and emergency departments in the UK. However, they may not be familiar wit h the particular difficulties relating to prehospital care and ambulance dispatch. Only a small number of A&E consultants are actively involved in prehospital care. Some of these are involved in training ambulance staff and immediate care doctors; others are involved in strategic planning. Some are operational in prehospital care attending incidents to administer clinical care. It was therefore decided that the most appropriate panel of experts were consultants who are operationally active in 22

prehospital care. They would have an understanding of triage and the depth of clinical knowledge of emergency medicine as well as an understanding of the difficulties of prehospital care. Some may not be aware of the mechanisms of prioritised dispatch, but this was considered a secondary problem. To compensate for this potential knowledge gap, a panel of ambulance dispatchers was also used in the study.

4.3.2 Methods Three methods were employed to assess expert opinion, drawing on three separate panels (, & ). In all three studies, initial contact was made with potential experts. The aim of the study was explained as well as providing an estimate of the time involved, and provided they were asked whether they would be prepared to participate. Those that agreed were provided with the appropriate information and proformata. For the purposes of this study category C was defined as those that are not emergencies and can have a delayed response (as yet not defined by time) and as being not identical in time response to category B. This was to allow assessment of whether category C can be used for an alternative response. PANEL and Experts: Consultants in accident and emergency medicine who are operationally active in prehospital care, who are members of British Association for Immediate Care (BASICS) or members of an active immediate care scheme.

Selection criteria: Identified from BASICS membership lists and the Emergency Services directory. Those who agreed to participate were then randomly assigned between panels and . Method for panel : A copy of the CBD coding system was sent to each expert with instructions briefly outlined the dispatching system (Appendix three is an example of the recruitment letter and appendix four is the instructions for panel ). The experts were aware of the present code and were asked to state whether they believed this was correct, over-triage or under-triage. Non-responders were contacted on two occasions by post or e-mail.

23

Method for panel : The experts were blind to the CBD codes and were asked to assign a prioritisation code (A, B or C) to each presentation. The categories were maintained in their chief complaint groupings of CBD but the order of the groupings and the presentations within the chief complaint was defined by computer generated random number selection. An example of a randomised sheet is included in table 4.3.1 compared to the CBD sheet in table 4.3.2. The order of the chief complaints was also randomised. Two reminders were sent to non-responders by mail or e-mail.

Table 4. 3.1. Example of randomised CBD list as provided for panel Chief complaint category Animal Bites Minor bite below neck nonpoisonous Unconscious or not breathing Uncontrolled bleeding Bite below neck with controlled bleeding Bite from poisonous animal Severe bites to face and / or neck Difficulty in breathing Swelling at bite site Symptom Prioritisation code

24

Table 4.3.2. Example of CBD list (in CBD code book order) as provided for panel . Chief complaint category Animal Bites Unconscious or not breathing Difficulty in breathing Uncontrolled bleeding Severe bites to face and/or neck Bite from poisonous animal Bite below neck with controlled bleeding Minor bite below neck nonpoisonous Swelling at bite site Symptom Prioritisation code

PANEL Experts: 10 Ambulance dispatchers with at least 6 months experience of working with CBD, employed by WMAS.

Selection criteria: Issued to a random sample of dispatchers. Method: Each dispatcher was provided with a listing of the CBD codes and an explanatory letter (see Appendix 5). These were in the order of the CBD book, that is in alphabetical by chief complaint and then in prioritisation order of presentations within the chief complaint (see table 4.3.2.). The dispatcher experts were asked to state

whether they believed this was correct, over-triage or under -triage. Non-responders were contacted on two occasions by personal contact.

4.3.2 Results Response rates The response rates of each panel are demonstrated in table 4.3.3. Participation rates from 25

A&E consultants (panels and ) were significantly higher than from ambulance dispatchers (p<0.05 using fisher's exact test) as were response rates ( 22df =4.11, p<0.05).

Table 4.3.3. Participation and response rates. contacted Panel . Panel Panel
1

18 13 20

agreed to participate (%) 15 (83.3) 12 (92.3) 12 (60.0)

responses 13 11 10

% response 1

86.7 91.7 83.3

calculated as a percentage of those agreeing to participate

In 53 of the 324 (16.4%) categories, none of the members of the expert panels disagreed with the present prioritisation code. Two of these were category C out of a total of 67 category C in CBD (UK). The remaining 51 were category A out of a total of 104 A categories. None of the 163 category Bs had unanimous support. Details are given in table 4.3.4.

Table 4.3.4. Expert agreement by CBD category. CBD code A B C TOTAL total codes in system 104 163 57 324 total agreement 51 0 2 53 50% or more in any group disagreed 13 101 37 151

In 151 (46.6%) categories 50% or more of experts for that method disagreed with the coding. Details of all changes suggested by panel is summarised in table 4.3.5. The distribution of changes suggested by 50% or over of the experts in any panel are shown 26

in figure 4.3.1 and the changes agreed by 50% or more of experts in all three panels are demonstrated in figure 4.3.1.

Table 4.3.5.

All changes proposed by expert panel

13 experts in group ; 11 experts in group ; 10 experts in group Column totals indicate number of experts suggesting change; + indicates expert wanted upgrading (for example, +7, -1 means seven experts suggested upgrading and one suggested downgrading). Abdominal / Back Pain Difficulty in breathing 12 to 50 years with fainting / dizziness Lower abdominal pain, female 12 to 50 years with fainting / dizziness Vomiting red blood Abdominal / back pain, more than 50 years with fainting / dizziness Fainting / dizziness when sitting up Side / back pain Unspecified pain Abdominal / back pain less than 50 years (Non Traumatic) Allergic Reaction Fainting Itching and/or rash with no difficulty breathing Concern about reaction but no history Reaction present for some time with no difficulty breathing Animal Bites Uncontrolled bleeding Severe bites to face and/or neck Bite from poisonous animal Swelling at bite site -1 +3 +5 +7 +4 -3 +1 -3 +10 +9 +11 +7 -1 -4 +6 +7 -5 +2 +2 +2 -1 -7 +3 +5 CBD code 1A2 1B1 1B2 1B5 1B6 1B7 1C1 1C2

-1 +2

-3 +7 +6 +6

-6 +1 +5 +7

2A5 2C1 2C2 2C3

+11 +5 +2 +1

+11 +8 +10 +8

+5 +8 +5 +4

3B1 3B2 3B3 3C2

27

Table 4.3.5.(contd.) Bleeding (Non Trauma) Multiple fainting episodes Fainting or near fainting when sitting Vomiting blood (red / dark red) Lower abdominal pain female 12 to 50 years with associated heavy vaginal bleeding Sweating Black tarry stools Vaginal bleeding more than 20 weeks pregnant Bleeding without 'A' criteria Uncontrolled nose bleed Rectal bleeding without 'A' criteria Breathing Difficulty Recent childbirth / broken leg / hospitalisation within last 2-3 months Drooling / difficulty swallowing Asthma unresponsive to medication Less than 50 years without A criteria Tingling or numbness in extremities or around mouth Chest Pain Male more than 35 years Female more than 40 years 15 to 35 years with shortness of breath / nausea / sweating With drug abuse Male less than 35 years without A or B criteria Female less than 40 years without A or B criteria Rapid heart beat without A or B criteria Chest injury less than 35 years without A or B criteria

+3 +3 +4 +4 +2 -1 +2

+9 +9 +8 +10 +8 +2 1 +6 -1 +6 -1 +6 +6 +7 +9 +8 +1 5 +11

+3 -3 +2 +2 +2 -1 -5 +1 -1

CBD code 4B1 4B2 4B3 4B5 4B6 4B7 4B8 4B9 4B12 4C1 5B2 5B3 5B4 5B5 5C1

+1 +2 +7 +7 -2 +1

+7 +1 +4 +6 -7 +5

+1 +1 +1 +1 +1 +1 +2 +2

+7 +8 +9 +6 +9 +9

+2 +2

7B1 7B2 7B3 7B4 7C1 7C2 7C3 7C4

+2 +6 +7 +6

+7

+7

28

Table 4.3.5.(contd.) Diabetic Decreased level of consciousness Fainting Chest pain Unusual behaviour / acting strange Not feeling well Weakness Fits / Convulsions Diabetic Secondary to drug overdose Fit unknown history Fit / convulsion less than 6 years First time fit more than 6 years Gynaecological / Miscarriage Vaginal bleeding with fainting Fainting or near fainting when sitting up Bleeding more than 20 weeks pregnant Pregnant less than 20 weeks or menstrual with any of the following: cramps pelvic pain spotting Headache Decreased level of consciousness Mental confusion Worst headache ever Sudden onset Headache without A or B criteria

+3 +4 +4 +1 +1 +4 +5 +1 +2 1 +1 -1 -1 +2

+10 +6 +11 +9 -1 +8 +8 +11 +10 +9 +8 +6

+3 +2 +8 +1 +4 +1 0 +5 +2 +5 +1 -5 -8

CBD code 9B1 9B2 9B3 9B4 9C2 9C3 11B1 11B2 11B3 11B4 11B6 12A2 12A3 12B2 12C1

+7 1 +8 +8 +5 +4 +4 +4 +4 -2 -2

+8 +2 +3 +1

+11 +8 +8 +6 +6

13B1 13B2 13B3 13B4 13C1

29

Table 4.3.5.(contd.) Mental / Emotional Unusual behaviour associated with diabetes Known alcohol intoxication Threats to self or others Police request standby Overdose / Poisoning Difficulty in swallowin g Decreased level of consciousness Ingestion of household cleaners Acute alcohol intoxication less than 17 years Drug overdose with chest pain Chemicals ingested splashed on skin Drug use without A or B criteria Alcohol intoxication without drugs more than 17 years Pregnancy / Childbirth Fainting or near fainting when sitting up Delivery Labour pains / contractions: less than 2 mins 1st pregnancy less than 5 mins 2nd pregnancy Bleeding more than 20 weeks pregnant Waters broken Labour pains: more than 2 mins 1st pregnancy more than 5 mins 2nd pregnancy Pregnant less than 20 weeks with abdominal pain spotting

+1 -3 +3 +1 +4 +1 -2 +3

+11 -4 +6 -1 +6 +7 +11 +7 +6 +8 +6 +2 1 +7 +6

-1 -7 -1

CBD code 14B1 14B6 14B7 14C1

+7 +5 -1

15B1 15B2 15B4 15B5 15B7 15B9

+3 -2 -4 +2 +2

15C1 15C2

-2 +6 +1 +1

-1 +10 +6 +6 -1 +7 -1 +6 -1 +8 +8

-7 +7 -2 +2 -2 +2 +1 +1 -2 +5 +5 +3 +4

16A3 16B1 16B2

+2

16B3 16B7 16C1

+1 +1 +8 +7

16C2

30

Table 4.3.5.(contd.) Sick / Unknown Decreased level of consciousness Chest discomfort more than 35 years Generalised weakness Other problems without other criteria High temperature Patient assistance Stroke / CVA Decreased level of consciousness Chest pains Diabetic Severe headache Trouble speaking Unconscious Combined drugs and alcohol overdose Alcohol intoxication less than 17 years Multiple fainting episodes Fainting associated with headache, chest pain / discomfort / palpitation more than 35 years diabetic / GI bleed. vaginal bleed sitting or standing abdominal pain female 12 to 50 years Conscious with minor injuries Obviously dead - decapitated burned beyond recognition cold & stiff unless child less than 1 year

+4 +3

+11 +10 -7 +1 -7 +6 +6 +9 +11 +9 +8 +7 -1 -7 +8 +9 +11 +6 +10 +10 +10

+1 +1 -8 -5 +2 +1 +4 +3 +1 1 -1 -6 -7 +1

CBD code 17B2 17B3 17B6 17B9 17C3 17C4 18B1 18B2 18B3 18B4 18B7 19A3 19A5 19B1 19B2

+2

+4 +4 +1 +2 -1

-5 +2 +4 +4 +3 +4 +3 +3

+5 +3 +4 +1

-1 +1 +1 +1 +1

+1 -1 +1 +1 +3 +8

-7 +2 +1 +2 +9

19B5 19C1

31

Table 4.3.5.(contd.) Miscellaneous Chemical incident stand-by Riot incident Fire Service - standby Police - standby Hoax call children Caller cleared unable to call back Major incident exercise Assault / Trauma Decreased level of consciousness Uncontrolled bleeding Extremity/ femur fracture Minor injuries w ithout weapons Police request standby or check patient Burns Decreased level of consciousness Burns to airway, nose, mouth Electrocution / electrical burns Burns / scalds more than 15% of body surface Battery explosion Chemical burns to eyes Freezer burns Drowning Unconscious or not breathing Confirmed submerged more than 1 minute

+1 2 +1 -1 -2 +2 +1 +1 +5 +9

+3 +7 +3 +8 +8 +8 +6 +11 +11 +3 -2 +2 +6 +6

-5 +2 -3 -6 +4 +2 +5

CBD code 20B4 20B5 20B7 20C2 20C4 20C5 20C6 21B1 21B2 21B6

+10 +10 -6

+2

21C1 21C3

+6 +11 +3 +6 +2 +4 +1

+11 +11 +8 +9 +7 +9 +6

+5 +9 +2 +4

22B1 22B2 22B3 22B4 22B5 22B6 22C2 23A1 23B1

-1 +6

+6

+10

+10

32

Table 4.3.5.(contd.) Falls / Accidents Unconscious or not breathing Severe difficulty breathing Decreased level of consciousness Amputation above fingers or toes Patient paralysed Uncontrolled bleeding Fall more then 10 feet Fall associated with chest pain, dizziness, headache or diabetes Was unconscious but now conscious Multiple extremity fracture or single femur fracture Third party caller not with patient Patient assist / assessment Isolated extremity fracture Neck or back pain Neurological / Head Injury Decreased level of consciousness Fall more than 10 feet Aggressive behaviour Now awake - has been unconscious Confused as to what happened Bump or laceration from fall without loss of consciousness

-8 +1 1 +9 +1 0 +1 1 +7 +6 +6 +1 1 +9 +6 +6 +1 1 +1 0 +1 1 +8 +1 0 +7 -1 +6 +7

+7 +4 +4 +1 0 +3 +2

+5 +5 +2 +6 +4

CBD code 24A1 24A2 24B1 24B2 24B3 24B4 24B5 24B6 24B7 24B9

+3 +3

+2

+3 +5 +7 +3 +1

+2 +7 +1 +3 +2

24B1 0 24C2 24C4 24C5 CBD code 25B1 25B2 25B3 25B4

-2 +2

25B5 25C1

33

Table 4.3.5.(contd.) Road Traffic Accident Decreased level of consciousness Confirmed or unknown injuries with the following mechanism:Vehicle vs. immovable object Vehicle vs. vehicle (head side on) Vehicle vs. pedestrian Vehicle vs. motorcycle / bicycle Victims trapped / ejected Multiple vehicle / casualty incident Chest pain prior to accident Roll over Third party caller not with patient Minor injuries patient up / out / walking Patient assessment required by police Child under 2 years Croup Asthma Epiglottitis Animal bite Sick / unknown / other Mental / emotional Abdominal / back pain

+5

+11

+5

CBD code 26B1

+3 +3 +5 +5 +8 +4 +5 +4

+9 +9 +10 +10 +11 +11 +10 +8 +7

+2 -2 +3 +2 +7 +4 +5 +2 +3

+1 +1

+8 +6 -6 -1

26B2 26B3 26B4 26B5 26B6 26B7 26B8 26B1 0 26B1 1 26C1 26C2 27A4

-4 -2 -4 -2

-9 -5 -10 -10

-2 -6 -3 -5 -4 -6

27A1 3 27A1 8 27A2 0 27A2 3

34

Area of overlap of all three represents where all three panels had 50% or more of experts who agreed a change was appropriate (n=7) Area of overlap represent where at least two panels had 50% or more of experts who thought change was appropriate (n= 4+7+28=309) Non overlapping areas represents where only that panel had 50% or more of experts who thought change was appropriate.

panel

4 7
panel

20 91 28

panel

Figure 4.3.1. Summary of changes by panel suggested by 50% or more of the experts in any panel - letters represent panel of experts not CBD codes

35

Table 4.3.6. Cases where 50% or more of experts in all panels suggested change. CBD code Chief complaint Symptom No experts suggesting change Panel Panel Panel n n n =13 =11 =10 11 11 5 9 10 7 7 11 8 11 11 11 8 11 11 10 6 5 6 9 7

3B1 21B2 24B4 24B1 5B4 22B2 26B6

Animal Bite Trauma Fall Fall Asthma Burns RTA

uncontrolled haemorrhage uncontrolled haemorrhage uncontrolled haemorrhage decreased conscious level unresponsive to treatment to airway, nose, mouth victims trapped / ejected

In panels and there was only one case where 50% or more of the experts suggested a downgrade (Alcohol intoxication less than 17 years - downgrade from A) except in children under two. Panel , the ambulance dispatchers, had 50% or more of these experts suggesting downgrade in 16 cases. The distribution of agreements and disagreements is shown in Figure 4.3.1.

Children under two years are uniformly categorised as A. The experts had 50% or more disagreement with this in five categories (20%) (see table 4.3.7 ).

Table 4.3.7. Disagreements by 50% or more of experts on a panel for categories involving children under five. Child under 2 years Croup Asthma Epiglottitis Animal bite Sick / unknown / other Mental / emotional Abdominal / back pain .
Minus indicates a downgrade suggested

Pan el

Pan el -6 -1

Pan el -2 -6 -3 -5 -4 -6

Present code

27A4

-4 -2 -4 -2 36

-9 -5 -10 -10

27A13 27A18 27A20 27A23

Panel was the only panel who was blinded to the original codes. Only in one (0.3%) adult code did 50% or more of the experts downgrade and in 126 (38.8%) 50% or more of the experts upgraded (34 of which were category C patients).

If 50% or more of each panel of experts were taken the distribution of codes would have been changed as demonstrated in table 4.3.8. Expert panel recommended most changes with the eventual number of codes in each category after suggested changes being 156 codes in category A and only 36 in category C. The other two expert panels opinions resulted in fewer changes, but both increased the number of category A groups.

Table 4.3.8. Changes induced if decision of each 50% or more of experts on a panel were used. Present UK system A B C TOTAL 104 163 57 324 Panel opinion 115 152 57 324 Panel opinion 156 132 36 324 Panel opinion 118 152 54 324

4.3.4 Discussion This study highlights the great variation in opinion of experts regarding the correct coding of identified clinical conditions. Expert opinion from retrospective review has demonstrated a high rate of disagreement about urgency even when working to the same criteria 27. Dispatchers were more likely to downgrade codes. The A&E consultants were less likely to disagree with the coding than the dispatche rs except when blinded to the actual codes (panel );.as demonstrated in figure 4.3.1. All three panels of experts 37

caused an overall upgrading of priority codes, with expert panel causing the most pronounced effect. This panel was blinded to the original codes and therefore represents the expert's pre-existing opinion rather than one influenced by a suggested code. This study suggests that CBD currently under-prioritises many types of patient compared to expert opinion. The panels of experts may be more likely to over-prioritise because they have no incentive to give a low prioritisation, as this is a resource issue whereas allocating high priority codes gives a larger safety net for clinical variation. There is a lack of objective evidence base upon which to inform opinion, as there is an absence of literature on the effects of delay on outcome in medical emergencies. The risk of a presenting symptom being due to a specific condition that may need an urgent response is not accurately known in many cases. Fifty per cent or more of the experts on the panels believed that some changes should occur in the category for children under 2, who are currently all given a category A response. It is acknowledged that young children are difficult to assess and can decompensate very quickly, leading to a rapid deterioration in their condition 44. With relatively low numbers of children under two, and therefore minimal resource implications, (42 in this outcome study of 1598 patients = 2.6% - see chapter 6), the speed o change in a childs condition and the difficulty in the assessment of small f children, the Joint Royal Colleges Ambulance Liaison Committee advised continuing the policy of all children under 2 receiving an A response. This section on children also illustrates the possible risks of using clinically inexperienced experts (who are experts in the process of dispatch) - 6 of 10 experts on panel suggested a downgrading of the category for epiglottitis. This is a condition that is rapidly life threatening and needs the care of specialists in hospital as a matter of extreme urgency. The strongest recommendation from this study is that from when 50% or more of experts in all three panels agree that change is required. This occurred for the presenting complaints of uncontrolled haemorrhage, decreased conscious level, asthma

unresponsive to treatment, burns to the airway and victims of RTAs who are trapped or ejected. This suggests that these should have a higher category. Differing complaints resulting in the uncontrolled haemorrhage or decreased level of consciousness received 38

varying levels of support for change, some where 50% or more of the expert panel did not suggest change. The variations in opinion and the high rate of suggested change of the blinded pa nel suggest that many of the current codes may not have the approval of 50% or more of experts. However the variation in opinion demonstrated by the range of experts used in this study strongly suggests the need to use a more objective method of assessing the safety and effectiveness of CBD, such as the clinical outcome studies described later. The only published work on safety of ambulance service prioritisation systems in the UK, outside of the work undertaken by the author and his colleagues at the University of Birmingham, has relied on expert opinion31. This study suggests that expert opinion may be an unreliable means of assessing the safety of CBD. There is a need to critically appraise methods of guidelines development and ensure that adequate piloting of any system is instituted with outcome assessment before being disseminated for general use. The process for establishing evidence based guidelines has been well described45. Unfortunately this has not been done in the case of CBD with no systematic review of the literature and decisions being made by committees rather than by consensus opinion.

The variation in expert opinion highlights the need for more evidence to inform decisions in developing prioritisation systems. The clinical outcome and criti al illness c studies undertaken in this thesis aim to augment the expert opinion studies already undertaken and inform future developments.

4.3.5 Conclusions Expert opinion can give highly variable results according to how information is supplied to them and their specific areas of expertise. The high response rate of the panel members in the first two groups suggests that the consensus view should be representative of wider opinion by similar specialists.

This study would seem to suggest that certain code s need change. In 7 cases, 50% or more experts on all three panels suggested codes that should have been changed these codes should be considered for change on this basis. In a further 32 codes, two of the 39

three expert panels had 50% or more of experts suggesting change. These categories should be reviewed in association with other evidence to determine the need for change. The 53 categories with complete agreement should continue to be monitored but are unlikely to require change at present. The variability of expert opinion demonstrates the need for outcome studies and other research approaches to determine the correct coding of conditions for ambulance prioritisation.

40

5. A SYSTEMATIC REVIEW OF THE EVIDENCE ON THE USE OF PRIORITY DISPATCH OF EMERGENCY AMBULANCES.

5.1

Introduction

The study of expert opinion of the CBD coding system has highlighted that CBD does not have full support. Only 53 of 324 codes (16.3%) had support of 50% or more of experts in all three expert panels. It is therefore important to determine whether the coding system is based on good evidence and whether the system has undergone formal evaluation.

The volume of primary research that aims to evaluate prehospital based practice continues to increase and in many areas there appear to be several relevant publications, sometimes with contradictory results and conclusions. The practice of evidence-based medicine requires the identification of the majority of relevant articles before decisions are made. Systematic reviews of the literature locate, appraise and synthesise evidence from existing research and their advantages have been well described
49, 50 46,47.

It has been reported that use

of electronic MEDLINE searches alone are unlikely to identify all the relevant literature 48, . The most effective method of identifying appropriate research publications has still not been established.

Emergency medical dispatch systems (EMD) comprise a set of key questions, pre-arrival instructions and dispatch priorities for medical emergencies that am bulance dispatchers provide over the telephone51. Since the early 1990s there have been calls for the implementation of a protocol-based dispatch system in the United Kingdom 52. EMD systems fall into two broad groups; medical priority dispatch and criteria b ased dispatch. Medical priority dispatch systems differ from criteria-based dispatch systems by using algorithms rather than prompts 53. EMD has been utilised by emergency ambulance services in the UK since 1997 to prioritise the allocation of ambulance resources to 999 calls for which the response time is crucial to the patients survival54.

A systematic review of the literature was undertaken to assess the existing literature evaluating the effect of the priority dispatch of emergency ambulances on both clinical outcome and ambulance utilisation. The aim of this study was to assess the sensitivity and 41

specificity of a wide number of potential sources of literature in detecting literature on ambulance dispatch and to describe the relevant literature findings.

5.2

Methods

The literature search was designed to find all publications containing original data, relating to the prioritisation of emergency ambulance calls. No restrictions were placed on the type of study, method of analysis or on the language of the paper.

Three electronic databases were used, all searches commencing with the earliest date available for the respective databases: Medline (using the Ovid interface, from 1963), CINAHL (from 1982) and BIDS (from 1981). Medline is widely used by medical researchers and is recognised to cover most of the high quality medical journals. CINAHL covers an extra area - the nursing and paramedical sciences- not covered by Medline. BIDS includes other scientific non-medical journals. The combination of the three was aimed to cover the expected journals that may contain work relating to ambulance services. The start date for the search on these databases was the earliest available for each. The words ambulance, EMS, prioritisation, dispatch and triage were used in combination to search these indices (Table 5.1). Wild cards were also used ($ signifies a wild card in most search engines). For example searching on prior$ will detect all words starting with the first five letters prior, and therefore includes words such as prioritisation, prioritising. The bibliographies of all relevant publications were searched to identify secondary citations.

Table 5.1 Search strategy for electronic databases

Medline 1963 - 1997


Strategy: EMS (head) + prior$ or dispatch Dispatch Dispatch + EMS (heading) [Ambulance (heading) OR EMS (heading)] + prior$ Ambulance.sh + triage.sh/prior$.th/dispatch$.tw

42

Table 5.1contd

BIDS 1981-1997
Strategy: Ambulance and Dispatch ambulance + prior$ + response ambulance + prior$ ambulance + dispatch ambulance = triage emergencies + dispatch

CINAHL 1982-1997
EMS (head) + prioritise or dispatch Dispatch = 124 references Dispatch + EMS (heading) [Ambulance (heading) OR EMS (heading)] + prior$ Ambulance.sh + triage.sh/prior$.th/dispatch$.tw $ signifies a wild card in the search.

A request for details of any articles that may not have been identified by searching these three bibliographic databases was made to researchers identified as being active in the field. These researchers comprised authors of relevant papers identified from the searches of the electronic databases or members of the National Academy of Emergency Medical Dispatch in America. Requests for relevant articles were posted in the two main UK prehospital care journal (Prehospital Immediate Care and Ambulance UK) and on four s Internet mailing lists (see Appendix 6) that were relevant to prehospital and emergency medical care. The tables of contents of key journals known not to be indexed on electronic databases were, if possible, searched electronically (Emergency Medical Services, Journal of the Emergency Medical Services, Fire Rescue, Prehospital Immediate Care, Prehospital Emergency Care) or if necessary, hand searched (Journal of the British Association of Immediate Care, 911, Ambulance UK).

All publications obtained from these sources were examined independently by 2 reviewers for relevance to the review. 43

All articles were classified to one of four groups: 1 Studies of prioritisation where original data were presented. 2 Manuscripts that related to prioritisation but contained no original data. 3 Manuscripts that did not relate to prioritisation of emergency ambulance calls but did relate to prehospital care. 4 Manuscripts unrelated to prehospital medical care or ambulance dispatch.

In cases where the two reviewers disagreed, a third reviewer also assessed the article to achieve consensus. Articles that did not report original data or were not relevant to the purpose of the review (groups 2 above) were excluded from further analysis. -4

Three independent reviewers (one expert in prehospital care in the UK, one expert in prehospital care non-UK and one academic of at least lecturer status with experience of critical appraisal) then considered the relevant articles against standard appraisal criteria adapted from a previous review (see Appendix seven) 55. The experts in prehospital care were selected from the membership of the British Association for Immediate Care who were of consultant status or equivalent. Experts in prehospital care from outside the UK were identified as authors in prehospital journals of consultant level or equivalent. The academics were senior staff in the authors department. The reviewers were allocated randomly to the papers using a random number se quence; measures were taken to ensure that no reviewer was sent a paper on which they were an author or a paper originating from his department. Non-responders were contacted on one occasion. If there was no reply after this approach, a further reviewer was allocated. The quality of each paper was assessed by seven questions (1-7 on proforma, Appendix seven). Each question was allocated one point for an answer corresponding to a good paper (Yes for all questions except q3, where the preferred answer was no). The total score for each expert was calculated and then averaged over the three reviewers to give a score out of 7 for each paper. This is referred to as the quality score (QS).

Generalisability of the results to the UK ambulance service was assessed by four questions. Question 3 was designed to exclude studies that did not look at either patient outcome or resource usage. A similar scoring system was used as in the quality 44

assessment. A positive answer scored one point, whereas a negative response, don't know or not applicable response scored zero. Precision (the proportion of articles retrieved by a particular search strategy that were relevant to the review) has been defined as the number of relevant papers identified by a single source divided by the total number of references identified by that source. Sensitivity (the proportion of articles relevant to the review retrieved by a particular search strategy) has been defined as the number of relevant references identified by a single source divided by the total number of relevant references.

5.3

Results

The sources searched yielded 326 unique references potentially eligible for inclusion in the review of which 64 (19.6%) related to the prioritisation of emergency ambulances and 20 (6.1%) related to prioritisation and also contained original data (see table 5.2).

Table 5.2.

Classification of all articles identified.

Group
1 2 Studies of prioritisation where original data were presented Manuscripts that related to prioritisation but contained no original data 3 Manuscripts that did not relate to prioritisation of emergency ambulance calls but did relate to pre-hospital care 4 Manuscripts unrelated to pre-hospital medical care or ambulance dispatch
TOTAL

N 20 44

% 6.1 13.4

91

27.9

171 326

52.5 100.0

Table 5.3 shows a breakdown of the number of references identified by source with the number found to be relevant and containing original data (n =20) (see appendix eight for details of articles).

45

Table 5.3. Source

Summary of results of literature search by database. Unique Identifi ed Referenc es Identifie d n n 157 157 0 0 0 0 0 n 10 10 5 5 0 0 0 n 4 4 3 4 0 0 0 % 50 50 25 25 % 4 5 9 18 Eligibl e High Quality Papers Sensitivi ty Precisio n

Electronic Databases MEDLINE BIDS Science Citation Index CINAHL Cochrane Trials register NHS-CRD (DARE) Official databases

242 201 55 28 0 0 0

Web Searches Yahoo Excite

0 0 0

0 0 0

0 0 0

0 0 0

Non-cited journals Electronic searches Hand searches

2 0 2

0 0 0

2 0 2

0 0 0

10 10

N/K N/K

Personal contacts

47

38

11

55

23

Bibliographies Unique references

51 326

42

4 20

2 7

20 -

8 6

Only half of the relevant references were identified by any of the electronic databases, with 55% identified by people working in the field and only two (10%) by hand 46

searching. BIDS and CINAHL did not find any references that had not already been identified by the Medline Search56. No relevant references were identified from generalised Int ernet searches, official document databases, the Cochrane Randomised Controlled Trials Register or the UK NHS Centre for Research and Dissemination database of abstracts of research effectiveness (DARE) (Table 5.3.). Only 7 papers (35% of the 20) were of high quality (average quality score of 4 or more) (see Table 5.4).

47

Table 5.4. Author and year of publication Bailey 199757 Clark 1992 58 Clark 1994 59 Cordi 1997 60 Culley 199137 Culley 199461 Curka 199374

Papers relating to priority dispatch of ambulances and containing original data. Cases included all cardiac arrest Outcome measures number ALS crews dispatched bystander observing breathing performance bystander CPR confirmed death performance bystander CPR paramedic response rates use of ALS skills performance bystander CPR presence of cardiac arrest MI at hospital Country USA USA n 6232 445 Quality score 2.7 4.0 Authors conclusions EMD reduces ALS crew usage. No undertriage rate quoted 46% cardiac arrests have agonal respiration at time of call 5.2% of cases received inappropriate CPR advice; 1.2% received inappropriate cardiac massage 95% accuracy of bystander reporting bystander CPR rate increased from 34% to 54%. 2.3 minutes to give advice CBD decreases paramedic responses time but no Under -triage rate reported 0.5% under-triage rate; 40% of cases only used BLS skills bystander CPR increased from 45% to59% caller >50 yrs or emotional suggests a high risk of MI historical risk factors important when classifying cases, in particular the presence of dyspnoea, vertigo, cold sweat, syncope or severe pain were recognised as high risk factors

cardiac arrest

USA

358

2.3

bystander suspects death cardiac arrest febrile fits & stroke all cardiac arrest cardiac arrest chest pain

USA USA USA USA USA USA Sweden

127 267 NS 14100 414 516 503

2.3 3.7 3.0 4.7 6.0 1.7 4.7

Eisenberg1985 62 Eisenberg 198540 Herlitz (2) 1995 63

Table 5.4 (cont.). Author and year of publication Herlitz 1995 64 Hu 1996 65 Key 199766 Lagaert 1997 67 Lammers 199568 Meron 199669 NAEMSP 199570 Palumbo 199671 Slovis 198572

Papers relating to priority dispatch of ambulances and containing original data. Cases included chest pain all in rural area all cardiac arrest abdominal pain Outcome measures MI at hospital need for ALS ALS intervention presence of cardiac arrest cost evaluation Countr y Sweden China USA Belgium USA n 503 594 12049 311 788 Quality score 5.7 3.7 2.3 2.3 4.0 Authors Conclusions 39 of 143 who EMDs thought low risk had an MI high proportion of ALS cases are dead on arrival. 7 of 12049 missed ALS cases because of failure/refusal to answer questions delay of 3 minutes from collapse to call; 15% of patients had warning symptoms indiscriminate ambulance dispatch cheaper than prioritisation if undertriaged cases cost <$3674 55% callers in contact with patient; 92% able to follow instructions 1.3 % of cases under-triaged 43% agreement in priority coding between EMD and physicians; no undertriage rate reported dispatch decreases the response time for urgent cases, 7% of cases are undertriaged 83-90% of MIs predicted by dispatchers

cardiac arrest intermediate dispatch category all all

location of caller, communication problems ALS interventions coding by EMD and physician response times & EMT diagnosis diagnosis at hospital

AUSTR IA USA USA USA

114 343 320 212

3.0 0.7 3.0 3.3

Sramek199473

chest pain & unconscious

NL

1386

6.0

49

There are few papers containing original data about the use of prioritisation for emergency ambulance calls. The majority of this literature (14 of 20 papers) originates from America. Eight papers (40%) relate to cardiac arrest and 3 (15%) to patients suffering chest pain. Only 5 (25%) study all patients calling the emergency ambulance service. The concept that CBD improves clinical outcome is supported by two papers, which both had a quality score of 4 or more 73,41. Sramek73 showed that bypassing the general practitioner and using the emergency ambulance service may result in less delayed transportation of patients with potentially time dependa nt illness but does produce a higher workload of non-urgent cases. It also showed a 55% rate of over-triage by dispatchers. This was an observational study of calls to the emergency ambulance services in one rural and one urban centre, with follow up to hospital when transported and follow up to the general practitioner when not transported as well as using patient follow up by postal questionnaire. Urgency was assessed by expert opinion of hospital based specialists. The study has several weaknesses and therefore evidence is not strong but indicative. Eisenberg41 showed that after the introduction of a programme of CPR advice from ambulance dispatchers, survival from cardiac arrest improved. This was related to an increase in bystander CPR. This was a prospective study before and after the introduction of CPR advice from dispatchers involving 346 patients. All patients receiving resuscitation were included and survival to discharge from hospital was measured. It appears well constructed without significant cause for bias.
37 Two papers with a QS of 4 or more74 75 and one with a QS of 3 supported the hypothesis

that CBD improves ambulance utilisation. Curka74 demonstrated that dispatch systems could increase the availability of advanced life support units and target their use at more serious cases. Culley61 confirmed this increase in EMS efficiency by improved utilisation of advanced life support units. This study was a before and after study, using data obtained from paramedic report forms. It used febrile convulsion and cerebro-vascular disease as the marker conditions and did not study any other conditions. It did not measure outcome but focused on need for paramedic intervention. This study does therefore look at a small group of patients and excludes some groups with greater needs for emergency care, such as cardiac disease. In the before study some data was not available for when requests for paramedics were from other crews. Results of this study should only be applied to the specified diagnostic groups and may be biased towards increased efficiency of the system

because of missing data. Helitz75 showed that dispatchers suspicion of acute myocardial infarction did not affect outcome but did allow better use of resources. This study of 503 patients assessed dispatcher's suspicion of the presence of acute myocardial infarction, using a questionnaire. The study does not state when this questionnaire was completed. Follow up was via hospital record and evaluation by a single nurse and use of standard criteria for diagnosis of myocardial infarction. There is a lack of detail of how those discharged were followed up. This study may have some bias due to this last factor but it is likely that this effect is small. Only three papers were identified that were generalisable to the UK ambulance service, where prioritisation is used to determine the speed of response rather than the skill level. These three studies provided conflicting evidence; one study74 (Curka- details above) reported that only 0.5% of those tria ged to Basic Life Support subsequently needed an Advanced Life Support intervention (QS=4.7). The second75 (Herlitz- details above) reported that 39 out of 143 patients (27%) with chest pain considered low risk by the dispatcher had a myocardial infarction (QS=5.7). The third76 reported that if the caller is over 50 years or is very emotional this increases the risk of the cardiac arrest (QS=1.6). This study used data collected as part of another study, collecting data from emergency call recordings. The study reveals an association between these factors but cannot be said to be able to explore causal relationships.

5.4

Limitations

Since two of the electronic databases (BIDS and CINAHL) only record publications occurring since the early 1980s it is possible that some relevant publications have not been identified. However, of all the papers retrieved relating to ambulance dispatch, only four were published prior to 1982 and none of these contained original data. The decision not to hand search journals for manuscripts prior to 1982 does not appear to have affected the number of relevant papers retrieved.

5.5

Discussion and Conclusions

Only 20 papers containing original data and relating to the effectiveness of p riority dispatch of emergency ambulances were identified. The overall quality of these publications was poor with only seven (35%) papers having a quality score greater than or equal to 4. Establishing 51

the effectiveness of priority dispatch requires evalua tions that have a control group and that measure outcome at both hospital arrival and discharge. The evidence for improved outcome relates to improved advice to the caller and possibly, the use of the ambulance services rather than a general practitioner. Improved ambulance usage and efficiency results in systems where a choice between level of response (ALS vs. BLS) is made. Most of the papers identified were studies from outside the UK and were not considered to be generalisable to the UK ambulance service, because of differences in how ambulance services operate overseas. Lack of generalisability was related to the populations studied, the location of study and the means of prioritisation assessed.

This study has provided further evidence to demonstrate that electronic databases only identify approximately half of all relevant prehospital literature48,49. The importance of surveying experts when compiling a syste matic review has recently been questioned77. However, almost a quarter ( =47, 23.4%) of all the references considered for inclusion in n this review were identified by people working in the field and eleven of these (23%) were found to be eligible. Two of the four high quality papers identified by people working in the field were not identified by any other source. The lack of sensitivity of the electronic databases may be due to problems with indexing, particularly since priority dispatch systems, in common with many other aspects of prehospital medicine, do not have a unique coding in the databases. In addition, many of the specialist journals are not currently indexed by the mainstream electronic databases. Hand searching these journals was not a productive means of identifying literature relevant to priority dispatch systems. Whether these findings are generalisable to all aspects of prehospital care has yet to be determined. This study supports work undertaken within primary care 78 which also identified that individuals known to be undertaking research in the area of interest are an essential source for identifying literature. However, blanket mailings of professional organisations with standard letters are unlikely to be effective 77. It is probable that, for personal contact to be effective, personalised letters relating to well focused review topics should be sent to persons known to be research active/aware. When performing a systematic review in the area of

52

prehospital care, the sources of literature utilised should include the electronic databases supplemented by contact with appropriate experts. The lack of good quality research relating to the prioritisation of emergency ambulance calls is highlighted in this study. It is now apparent that CBD neither has good support from experts nor from the evidence base. There is no evidence of high quality research of the safety and effectiveness of the CBD system. There is a need for primary research to supports the be nefits, safety and effectiveness of CBD
.

53

CLINICAL OUTCOME STUDY

6.1

Introduction

Earlier work in this thesis has determined the need for a clinical outcome study by demonstrating the lack of expert support for the present coding system and the lack of existing evidence to support the system.

The aim of providing an ambulance or a paramedic quickly is to prevent patient deterioration and to optimise care. Very few prehospital interventions have been proven to be of value79. Urgency of prehospital care can be assessed in many ways, such as potential diagnosis, final diagnosis, use of interventions at scene or interventions on arrival in hospital. The need for an urgent intervention either at scene or on arrival at hospital suggests that an emergency condition exists. Interventions may, however, be undertaken prophylactically rather than as a treatment or may be inappropriate. It then becomes more difficult to assess their importance. Hence, this prospective study looks at outcomes, clinical state, interventions and expert opinion to determine urgency of care.

6.2

Setting

Accident and emergency department, City Hospital NHS Trust (CHT), Birmingham; a large inner city A&E department of a university teaching hospital.

6.3

Inclusions

All 999 emergency ambulance cases presenting to City Hospital NHS Trust accident and emergency department during four one-week study periods were analysed. the time periods were chosen to cover a wide period of year to reduce any seasonal effects. The study periods were: 07.59 hrs. Monday 28th July 07.59 hrs. Monday 18th August 07.59 hrs. Monday 3rd November to 08.00 hrs. Monday 4th August 1997 to 08.00 hrs. Monday 25th August 1997 to 08.00 hrs. Monday 10th November 1997

07.59 hrs. Monday 13th October to 08.00 hrs. Monday 20th October 1997

54

6.4

Exclusions

Those patients being directly conveyed to the Birmingham and Midland Eye Centre. Those patients conveyed directly to the Labour ward. Any cases taken by ambulance from City Hospital catchment area to another hospital.

6.5

Methods

A cohort of emergency ambulance cases that were conveyed to the study hospital were identified from West Midlands Ambulance Service and were then followed up. Outcome data were established from a review of the ambulance service clinical records, hospital notes and retrospective assessment of the dispatch category. Assessment was undertaken in three ways 1. expert opinion 2. interventions used in emergency phase 3. outcome.

Expert opinion was obtained on the correct prioritisation coding of each case in the study using varying levels of information availability for the expert. This multi-level opinion was used to model the effects of the varying levels of information available at various stages in the process to help differentiate between incorrect prioritisation because of lack of information and because of the limitations in the system utilised. Individual case review was undertaken of a sample of cases where the dispatcher was perceived to have undertriaged the case with respect to the expert opin ion. Interventions undertaken by the ambulance crew or immediately on arrival in the accident and emergency department were collated. The use of the various interventions was used on the assumption that if urgent treatment was undertaken then speed of ambulance response would also be important. Outcome measures were also collected and analysed with respect to CBD prioritisation.

Cases were identified from the West Midlands Ambulance Service NHS Trust control room database by searching for 999 calls with C ity Hospital recorded as the destination hospital. Complete case identification was enhanced by also searching the computerised record system of City Hospital accident and emergency department for all cases arriving by

55

ambulance and excluding non-999 calls by review of notes and comparison with the ambulance service database. For all identified cases, data were obtained for analysis from: Ambulance Emergency Control Centre computer records Ambulance patient report form completed by attending ambulance crew Accident and emergency department notes from City Hospital.

Full details of the data collected is given in Appendix 3.

Data collected from the Ambulance patient information record included: Prehospital airway status Prehospital AVPU assessment of conscious level Spinal immobilisation undertaken Prehospital fluid resuscitation administered Prehospital drugs administered Data were retrieved from the hospital records including: Monitoring after arrival in A&E Airway status on arrival in A&E Respiratory status on arrival in A&E AVPU on arrival in A&E The dispatchers CBD category for each case was obtained from the West Midlands Ambulance Service computer system. This is the code assigned under working conditions and utilised for the management of the case by the ambulance service. Also collected from the ambulance control record: Original time of 999 call Attendance time Time at A&E after 999 call All the above information was abstracted and included on a proforma, an example of which is Appendix nine. 56

6.6

Expert opinion

Expert opinion was obtained from four groups Nurse opinion was given by the triage nurse at the time of arrival at the hospital Expert A gave opinion using the CBD system Experts B and C gave opinion using their professional expertise 6.6.1 NURSE OPINION On arrival at the accident and emergency department, following initial assessment, the triage nurse was asked to respond to two questions relating to the case:-

HOW URGENTLY WAS AN AMBULANCE REQUIRED FOR THIS PATIENT? Minutes (please circle) 1. Immediate 2. Under 8 5.

3. Within 14 minutes

4. Within One hour

More than 1 hour

REASON

1. ?airway problem 5. consc level

2. ?spinal injury 6. Fit 7. ?cardiac

3. Short of 8 Degree

breath 4. Bleeding

of pain 9. Chronic problem, no recent change 10. Urgent treatment required 88. Other (specify)

Figure 6.1 Triage Nurse ambulance prioritisation assessment form

6.6.2 EXPERT OPINION Having collected the above data, expert opinion was obtained on various aspects of the prioritisation.

Expert A was the author of this thesis. At the time of data collection, he was an academic in emergency medicine with special interest in prehospital care and experience in prioritisation systems He has received training in ambulance dispatch and had recognised higher qualifications in accident and emergency medicine and prehospital care.

57

Expert B was an experienced higher specialist trainee in accident and emergency medicine with experience of receiving emergency cases from the ambulance service as well as being responsible for the early management of such cases. He received a recognised higher qualification in accident and emergency medicine soon after completion of this study.

Expert C was a general practitioner who undertakes prehospital care and works closely with the ambulance service. He had a recognised higher qualification in prehospital care.

6.6.2.1.

Expert A - On Scene CBD Code

Using only the information available from the control room and the ambulance report form, a prioritisation category was assigned adhering strictly to the guidelines of CBD. The expert used the CBD folder strictly according to the guidelines, in effect using them as protocol rather than guideline. The full CBD code was used for this section. The expert undertaking this coding was fully conversant with the performance of CBD and familiar with the working of the emergency control centre and provision of prehospital care.

6.6.2.2.

Expert A - A&E CBD Code

Using the information from all sources, (including information from hospital notes as well as that available for the On Scene CBD code), expert A undertook a second coding adhering rigidly to the CBD guidelines. Again the full CBD code was recorded. This coding was done by the same person as the previous code but was not undertaken sequentially, to avoid bias of knowledge of the previous code.

6.6.2.3.

Expert B - Dispatchers Expected Code

For this code expert B uses the same sources of information as expert A in his assessment (all those available by the end of the accident and emergency department history taking). It is the prioritisation that expert B would have given had he been the dispatcher and been able to obtain the relevant information via the telephone. The categorisation was made independently of the CBD guidelines and were categorised to the codes in table 6.1. CBD Category A is represented by 1 & 2 combined and Category C by 4 & 5 combined.

58

Table 6.1 Categories used by experts to define urgency. Expert category 1 2 3 4 5 Response time Immediate response time Response time less than 8 minutes Response time within 14 minutes Response time within 1 hour Response time more than one hour Equivalent CBD category A B C

6.6.2.4.

Expert B - On diagnosis code

This was the experts prioritisation based on final diagnosis, ignoring earlier potential diagnoses that have been disproven at any stage. A patient with neck pain after injury would therefore have a high priority for a Dispatchers expected code, but a low code for this category if it proved to be only a neck sprain. The same five point numerical codes were used as for the expert dispatchers expected code.

The justification for the above urgency coding was classified according to table 6. 2 Table 6.2 Codes for justification of urgency of care. Code 1 2 3 4 5 6 7 8 9 10 88 98 99 Triage reason Possible / actual airway problem Possible spinal injury Short of breath Bleeding Loss of consciousness / unconscious / knocked out Fit Possible cardiac / ? myocardial infarction Degree of pain Chronic problem, no recent change Urgent treatment required Other Did not wait / self-discharge Unknown / not specified

59

These categories were used to inform the case review of under-triage cases. 6.6.2.5. Expert C codes on diagnosis

Expert C undertook coding using the same guidelines as expert B for the "on diagnosis" code only. 6.6.3. IMPORTANCE OF DATA COLLECTED 6.6.3.1. Dispatchers code

Any error in the dispatchers code may be due either to failings in the CBD system, dispatcher error, the dispatchers interpretation of the system or communication difficulties. The communication difficulties may include difficulty in obtaining the information given in the 999 call, misinterpretation of the information or false information.

6.6.3.2 Nurse

Opinions

The nurses opinion was considered important as they were the only assessor in the study who saw the patient. Therefore, if the data collection schedule had failed to include some important varia bles or if actually seeing the patient was important, then this assessment would be expected to be at variance with the other expert opinions listed below.

Expert A On Scene CBD Code This reflects the prioritisation that should be achieved with optimal use of CBD using the prehospital information. It presumes that communication difficulties are similar over the telephone and in the A&E department.

Expert A A&E CBD Code This reflects the code that optimal use of CBD would achieve if all the correct questions were asked and with knowledge of the results clinical examination, investigations and diagnosis. This code should therefore reflect the best result achievable by CBD.

Expert B Dispatchers Expected Code This is the prioritisation that the expert would have given had he been the dispatcher and been able to obtain the relevant information via the telephone. This therefore reflects what a 60

perfect system could achieve if it were infinitely flexible in response to individual circumstances and could achieve 100% specificity and sensitivity.

Expert B On Diagnosis Code This can be considered the gold standard. It is a code with the full advantage of retrospection. The information available for this opinion included that from qualified medical personnel following examination and investigation. This extent of information will never be available from a 999 caller. Final diagnosis is defined as the diagnosis at the end of the A&E episode, as recorded in the notes.

Expert C Dispatchers Expected and On diagnosis Codes Use of a second expert to repeat those of Expert B improves the generalisability and reliability of the expert opinion.

6.7

Qualitative case review of under-triage cases

After analysis of the expert opinion study was undertaken, those cases where it appeared there had been under-triage were reviewed. In this study, under -triage was defined as any case where the dispatcher or expert A had recorded a triage category lower than the on diagnosis code of either expert B or C. The author, with full control room information, ambulance patient report form, accident and emergency notes and the experts opinions, reviewed all these cases. Review was undertaken to determine potential causes of the under-triage. This in depth review was undertaken for all under-triage cases in the first week of data collection.

6.8

Interventions

Prehospital treatment is usually limited to that which is urgent and that which prevents deterioration en-route to hospital. All patients with an emergency intervention would be expected to need an A category. The following prehospital interventions were noted: Monitoring Spine immobilisation Fluid resuscitation Drugs 61

Other intervention - Most urgent action. Emergency treatment in the accident and emergency department would also be expected to correlate with needing the ambulance to arrive and transport the patient quickly, (that is those needing a category A response. Hence the following data were obtained from the accident and emergency department notes: Monitoring Urgent drug treatment Other urgent intervention Most urgent action. 6.9 Physiological status

If a patient is critically ill with abnormal physiological recordings then again urgency of care is required. The following physiological data were recorded: Prehospital care Airway clear Prehospital care Breathing present Prehospital care AVPU Accident and emergency department Airway clear Accident and emergency department Breathing present Accident and emergency department AVPU

6.10 Outcome Admission to hospital does not necessarily reflect urgency of care. Admission may be necessary for observation or for treatment or investigation in the next 24 hours. However, one would expect most CBD Category A patients to be admitted. Patients admitted to Intensive Care or other critical care areas would be expected to be CBD Category A. Data were therefore collected on the following outcome measures: A&E outcome (follow up arrangements, admission etc.) Days in-patient Days ITU Death during that hospital admission. 62

6.11 Other aspects Duration of complaint was recorded since it would be expected that if a condition has been present for more than 24 hours without deterioration, urgent response would not be required. The triage score on arrival in A&E reflects the perceived urgency of care on presentation in the accident and emergency department. This should correlate with urgency of prehospital care. The triage category and reason for the categorisation were recorded. This study pre -dates the implementation of the national triage scale and the nationally accepted Manchester triage guidelines at the study hospital28. Prehospital care Triage Urgency Prehospital care Triage Reason Prehospital care 'Other' reason Most senior Doctor.

6.12 Reproducibility of expert opinion In order to verify the consistency of the expert's opinions, a random sample of 20 cases from each week were coded by each expert on two separate occasions. The experts were blind to this procedure with no access to their previous codings.

6.13 Results During the four data collection weeks, 1844 cases were identified on the City Hospital accident and emergency department database that were labelled as having arrived by ambulance. These were then validated initially with hospital records and then on the WMAS database. 268 cases were excluded because they were not 999 emergency calls (118 GP referrals, 11 St John Ambulance, 25 clerical errors or duplicate entries, 105 999 call made outside the study period, 9 transfers or other ambulance services). Analysis of the WMAS database revealed a further 23 cases that were not on the CHT database. No cases were identified and confirmed as 999 calls on the CHT database that were not on the ambulance service database. (See Table 6.3)

63

Table 6.3. Sources of data for outcome study. Detected on CHT database Yes Detected on WMAS database Total Yes No 1576 0 1576 No 23 0 23 1599 0 1599 Total

There were 1599 cases available for this analysis from the four data collection weeks. One of these cases did not have any CBD code assigned by a dispatcher in the emergency control room. In one case there was incomplete dispatcher information; in 21 cases incomplete A&E information; 47 for chief complaint and condition and 46 for priority cases of incomplete information for on scene coding. For the expert expected codes 52 were incomplete but became 58 when coded the same as CBD due to 3 cases where the expert had insufficient information and used an insufficient information code. For the expert on diagnosis there were 121 cases incomplete, which became 133 on conversion to CBD, again due to insufficient preceding information for the expert to make a decision. For expert C on diagnosis codes 19 were incomplete, and for expert C there were 20 incomplete when converted to codes.

Of the 1598 cases for which dispatcher information was available, the CBD coding allocated by the ambulance service dispatcher is shown in table 6.4.

Table 6.4 Distribution of study patients by CBD category. CBD category A B C No. 463 918 217 % 29.0% 57.4% 13.5%

64

There were 688 (43.0%) females and 910 (57.0%)

males in the study. No significant

difference was demonstrated in the CBD classification by sex ( 2 = 2.37; p = NS; see table 6.5).

Table 6.5. CBD coding by sex of patient. CBD category Male Female TOTAL % Category A 257 206 463 28.9% Category B 537 381 918 57.4% Category C 116 101 217 13.6% no code TOTAL

available 0 1 1 0.6% 910 688 1599 100.0%

2 = 2.37. p = NS

The age distribution of the patients in this study is demonstrated in table 6.6. Categories were determined by the data collection system already in place. Variation of CBD code distribution by age category is also shown in table 6.6, this demonstrates a lower percentage of category A in the young adult groups.

Table 6.6. Variation of category distribution by age groups. Age Catego ry A % in age group coded A" 92.9% 28.8% 18.7% 20.6% 28.4% 34.7% 29.0% Category B Catego ry C Total % of total in specified age group 2.60% 5.00% 5.70% 29.40% 30.60% 26.70% 100.0%

Under 2 2-11 12-17 18-34 35-64 65+ Total

39 23 17 97 139 148 463

2 40 61 313 295 207 918

1 17 13 59 55 72 217

42 80 91 470 489 427 1599

65

The mean hourly volume of the 999 calls varies during the d From early morning the ay. level rises to a peak in the late morning, then fluctuates during the working day and falls in the early evening. It rises again in the late evening before falling overnight. Details are given in figure 6.2. The proportion classified as CBD A varies from 15% -45% during the day as demonstrated in figure 6.3.

120 100 80 No cases 60 40 20 0


00 02 04 06 08 10 12 14 16 18 20 22

C B A

Time of day

Figure 6.2.

Time of 999 call vs. CBD category.

50.0%

Percentage of calls

40.0% 30.0% 20.0% 10.0% 0.0% 0 2 4 6 8 10 12 14 16 18 20 22 24 hour of day

Figure Percentage of calls classified as category A per hour.

6.3.

66

885 (55.3%) of the 1599 incidents occurred in the home. A wide range of diagnoses were observed in the study. The diagnoses from the accident and emergency notes are summarised in table 6.7. Soft tissue injuries and ailments and non-lifethreatening head injuries account for nearly a quarter of all 999 calls transported to AEDs (23.5%). Severe trauma accounted for 0.5% of all cases with a further 3.8% of cases having long bone fractures, 31.9% of cases were trauma related. Cardiac conditions accounted for 7.0% of cases with 0.9% of all cases presenting with a cardiac arrest and 4.1% with either myocardial infarction or unstable angina. Respiratory disorders account for 5.8% of cases with asthma being responsible for 1.6%. Other presentations relate to drugs and alcohol (7.8%); abdominal pain (7.0%); fits (5.0%); collapse of unknown cause (4.4%); psychiatric problems (3.1%); acute neurological problems (2.3%); non-trauma musculo-skeletal problems (1.5%) and early pregnancy problems (1.2%). Table 6.7. A&E diagnosis of cases in the study. Chief complaint Abdominal pain acute Abdominal pain minor Allergy Arthropathy Asthma Back pain neuro loss non trauma Back pain no neuro loss non trauma Cardiac acute other Cardiac arrest Cardiac chronic Cardiac MI/unstable angina Collapse/faint Cut/laceration - bleeding Cut/laceration - not blee ding Dehydration - all causes Drug/alcohol overdose - minor Drug/alcohol overdose - significant No. 40 72 3 1 26 2 21 35 14 8 70 71 44 20 8 56 68 67 % of all cases 2.5 4.5 0.2 0.1 1.6 0.1 1.3 2.2 0.9 0.5 4.4 4.4 2.8 1.3 0.5 3.5 4.3 % with diagnosis 2.7 4.8 0.2 0.1 1.7 0.1 1.4 2.3 0.9 0.5 4.7 4.7 2.9 1.3 0.5 3.7 4.5

Table 6.7 (contd.) Chief complaint Facial fracture - no significant head injury Facial injury - no fracture/head injury Fit febrile Fit non-febrile Foreign body non-urgent Foreign body - urgent/complicated Fracture/dislocation - hand/foot Fracture/sprain/dislocation - major limb GI bleeding Head injury moderate minor no x-ray Head injury moderate - needs X-Ray/admission Head injury - severe GCS<8 Infection - life threatening Infection - minor Infection - serious Joint degenerative Multiple - severe/moderate injuries Neurological loss/stroke Pregnancy related problems Psychiatric/behavioural Respiratory - minor Respiratory - moderate Respiratory - severe inc. choking Soft tissue disorder - non trauma Soft tissue injury Trauma - life threatening Other Unknown TOTAL

No. 7 41 25 55 3 1 28 60 15 76 74 2 1 47 27 1 4 37 18 50 22 31 15 77 148 2 74 99 1599 68

% of all cases 0.4 2.6 1.6 3.4 0.2 0.1 1.8 3.8 0.9 4.8 4.6 0.1 0.1 2.9 1.7 0.1 0.3 2.3 1.1 3.1 1.4 1.9 0.9 4.8 9.3 0.1 4.6 6.2 100.0

% with diagnosis 0.5 2.7 1.7 3.7 0.2 0.1 1.9 4.0 1.0 5.1 4.9 0.1 0.1 3.1 1.8 0.1 0.3 2.5 1.2 3.3 1.5 2.1 1.0 5.1 9.9 0.1 4.9

6.13.1 Expert opinion In this section expert opinion determines under or over triage. Under-triage is where an individual records a lower category than the expert. This means the patient receives a lower priority ambulance response than is thought to be required. Over-triage is where an individual records a category higher than the relevant expert. This means that the patient is receiving a level of response higher than is thought to be required by the expert.

Internal consistency of results by experts The consistency of coding by the experts was assessed by them undertaking duplicate coding for 20 cases each week. The experts were blinded, so they were unaware of their previous coding or of which cards were duplicates. Kappa scores were calculated to quantify the consistency of each expert. Expert A has good consistency in both the on scene CBD code (coding by the CBD system using the prehospital information) with a kappa score of 0.671 and in the A&E-CBD code (coding by the CBD system using both accident and emergency department and prehospital information) kappa score 0.676. Expert B had moderate consistency in his codes whether by information from the notes (kappa score 0.524) or on final diagnosis (kappa score 0.481). Expert C had good consistency for his coding based on final diagnosis (kappa 0.730). See table 6.8.

Table 6.8. Internal consistency of experts. Expert Expert A Expert A Expert B Expert B Expert C Code On scene CBD AE-CBD Notes information on diagnosis on diagnosis Kappa 0.671 0.676 0.524 0.481 0.730 Consistency good good moderate moderate good

69

Expert Opinion The analysis of expert opinions is summarised in table 6.9. This demonstrates that compared to the CBD system (as undertaken by expert A; table 6.9 rows 1&2) the dispatcher under-triages by 8-9% and over-triages by 31 %. When compared to expert B who was looking at the information independently the dispatcher under-triages by 33% and over-triages by 22% (table 6.9 row 3); this changes to under-triage of 17-38% and overtriage of 40-54% when compared to the experts opinion based on final diagnosis (table 6.9 rows 4&5).

When looking at the CBD system (as judged by expert A results), it under-triages by 45% and over-triages by 12% compared to expert B using the same information (table 6.9 row 6). When compared to the gold standard of final diagnosis the under-triage rate is 13-25% and the over-triage rate is 27-39% (table 6.9 rows 7&8). If expert A only used the information from ambulance recor ds (on scene), the under-triage rate is unchanged at 45% and the over-triage rate minimally changed to 13% (table 6.9 row 9). The rates against final diagnosis are also very similar with under-triage of 13-26% and over-triage of 27-39% (table 6.9 rows 10 & 11).

The benefit of the final diagnosis is demonstrated by comparing expert B diagnosis using accident and emergency department notes with final diagnosis which shows a 1% undertriage but 53% over-triage (table 6.9 row 13). Looking at expert C in the sa me way gives results of 12% under-triage and 38% over-triage (table 6.9 row 14). When the A&E triage nurses categorisation was compared with that of expert B (notes only) it showed 25% under-triage and 21% over-triage (table 6.9 row 16). Dispatchers under-triaged 16.7% (n = 245) cases when compared to opinion of expert B on final diagnosis and 38.2% (n=604) cases when compared to expert C.

70

Table 6.9. Analysis of Coding by Dispatchers and Experts. Row ref. no. 1 2 3 4 5 % Under -triage 9 8 33 17 38 % Overtriage 31 31 22 54 40
Kappa score
internal consistency

Dispatcher Dispatcher Dispatcher Dispatcher Dispatcher

vs. vs. vs. vs. vs.

A&E CBD system On scene CBD system Expert B notes info Expert B on diagnosis Expert C on diagnosis" Expert B notes info Expert B on diagnosis Expert C on diagnosis" expert B notes info expert B on diagnosis Expert C on diagnosis" A&E CBD system

0.346 0.351 0.164 0.079 0.140

fair fair poor poor poor

6 7 8

A&E CBD system A&E CBD system A&E CBD system

vs. vs. vs.

45 13 25

12 39 27

0.181 0.203 0.251

poor poor fair

9 10 11 12

on scene CBD system on scene CBD system on scene CBD system on scene CBD system Expert B notes info Expert B notes info Expert C on diagnosis" Nurses Nurses

vs. vs. vs. vs.

45 13 26 2

13 39 27 2

0.163 0.195 0.244 0.931

poor poor fair very good fair fair

13 14

vs. vs.

Expert B on diagnosis Expert C on diagnosis" Expert B on diagnosis Expert B notes info Expert B on diagnosis

1 12

53 38

0.255 0.243

15 16* 17*

vs. vs. vs.

9 25 9

36 21 21

0.311 N/A N/A

fair N/A N/A

*week one data only

71

Of the 245 cases under-triaged by the dispatcher, in expert Bs opinion, 93 cases were also undercoded by the CBD system (expert A). The latter u ndercoded a further 185 that were not undercoded by the dispatcher when compared with expert B diagnosis.

Of the 604 cases under-triaged by the dispatcher, in expert Cs opinion, 268 were also undercoded by the A&E CBD coder. The latter undercoded a further 398 cases when compared with expert C diagnosis.

Dispatcher error rate can be defined as the proportion of the total cases that that were under -triaged solely by the dispatcher. The system error rate is the proportion of total cases that are under-tria ged by the system and by the dispatcher using the system. The expert discrepancy rate is the proportion of the total cases that only the expert A under -triaged this represents a summation of expert error plus those cases where the dispatcher improved on the system. The gold standard is the expert's opinion when they had all information available (the opinion as close to actual clinical requirement as can be achieved). These rates can be calculated relative to each of experts B and C and are therefore quoted as a range. (table 6.10)

Table 6.10 Error rates of CBD using Expert B Dispatcher error System error rate Expert discrepancy rate 152/1466 245/1465 185/1465 using Expert C 336/1578 604/1572 398/1572 Rate 10.3% - 21.3% 16.7% - 38.4% 12.6% - 25.3%

6.13.2 REVIEW OF UNDER-TRIAGE CASES In week one, there were 37 under-triage cases, identified by either expert B from their on diagnosis code or C. In only three cases (8.10%) could the under-triage be attributed solely to the dispatchers. This represents a dispatcher error rate of 0.98% (3 of 304 cases). In 12 cases expert A under-triaged cases that were not under-triaged by the dispatcher, representing an additional 3.9% error rate. 72

Under-triage only by dispatchers - case summary Case 1. Case 2 A case of severe left ventricular failure that presented as a hypoxic fit A person choking where it was probably difficult to differentiate

(no specific CBD code available) was miscoded as a fit of unknown origin (11B3). between mild difficulty in breathin g and talking normally. This made no clinical difference as the call was during the recovery phase after back slaps and successful expulsion of the obstructing food. Case 3 A diabetic who was alert but unwell and was therefore classified as

9C2. By the time the ambulance crew arrived 5 minutes later, he was pale and clammy (therefore then 9B5) because of hypoglycaemia. Although theoretically correct at the time of prioritisation, CBD should have a predictive element to allow for deterioration of the patient before the ambulance arrives.

Under-triage by both dispatcher and expert A - case summary by diagnostic group Diabetic patients only accounted for 6 patients in the study but 3 were under-triaged. In one case it was A&E expert error in failing to note the patient was diabetic. One has been described above. The third was a patient with peritonitis who was labelled as diabetic with decreased conscious level (9B1). Two cases were associated with use of the fit unknown history (11B3) category, which was used on only eight occasions. Two further cases were mistriaged by the expert because the fits were continuing at the time of the 999 call but had stopped by the time the crew arrived and were therefore coded by the dispatcher as fitting more than 5 minutes (11A2) or unconscious (11A1).

12.6% of trauma cases were under-triaged. Half of these were classified as C when the experts B & C on diagnosis believed they should have had a Category B. Three road accidents were classified according to mechanism of injury when clinical needs suggested that they were more urgent. Three people had head injuries classified as 25C1 (bump or laceration from fall with no loss of consciousness), although in two head injuries, the dispatcher classed these as 21B7 (assault) and therefore gave it the correct category. One 73

fall of over ten feet (24B5) was graded an "A" by the expert. The final case was a burns victim with an electric shock (22B3). 6.13.3 INTERVENTIONS Only one third of those patients (n =390, 34.5%) being monitored before arrival in A&E were categorised as A, but 58.5% (n = 152) of those monitored in the accident and emergency department were so classified. Only 2 of the 35 (5.7%) patients needing spinal immobilisation were categorised as A, but 67 (78.8%) of those needing drugs and 8 (40%) of those needing fluids received the most urgent category. Of those who received urgent drug treatment on arrival in A&E, 18 (50.0%) had received a category A response. 13 (65%) cases having other urgent interventions in the accident and emergency department were similarly categorised. In the case of fluid resuscitation, drug usage, other interventions and monitoring in A&E, these were not significantly associated with allocation to category A (see Figure 6.11 for details). Significance of the differences between the intervention group and the whole study population (control , line 1 of table 6.11) was tested using the Chi squared test. Testing the hypothesis that patients are coded to A irrespective of any intervention required. In an optimal system, all the patients above would have been categorised A.

Table 6.11. Interventions in relation to CBD status.


Category A Category A % Category B Category C TOTAL 2 P = ***

Control PHC Monitoring PHC Spine immobilisation PHC Fluid resuscitation PHC Drugs PHC other intervention A&E monitoring A&E Urgent drug treatment A&E other urgent intervention

463 390 2 8 67 277 152 18 13

29.0 34.5 5.7 40.0 78.8 46.7 58.5 50.0 65.0

918 608 27 10 17 279 99 16 7 74

217 131 6 2 1 37 9 2

1129 (70.6%) 35 (2.2%) 20 (1.3%) 85 (5.3%) 593 (37.1%) 260 (16.3%) 36 (2.3%) 20 (1.3%)

4.81 p<0.05 9.41 p<0.05 1.196 p = NS 108 p = NS 144 P =NS 131 P =NS 7.9 P<0.01 12.7 P<0.001

6.13.4Physiological status Two thirds (n =11; 68.8%) of patients with obstructed airway or absent breathing noted by the ambulance crew in the prehospital phase were categorised as A by the call taker. However, less than half (n=46.7%) of those with obstructed airways on arrival in A&E had been categorised A. Similar numbers of those with a decreased conscious level in prehospital stage (n =35; 59.3%) and on arrival in the accident and emergency department (n =29; 65.9%) had been coded as A. Of those who were unconscious, but had a clear airway and were breathing, a lower percentage were categorised as A 23 (54.8%) by the prehospital assessment of unconsciousness and 16 (59.3%) by accident and emergency department assessment. In the case of prehospital and accident and emergency department conscious level, these were not significantly associated with allocation to category A. Details are in Table 6.12.

Table 6.12. Physiological status in relation to CBD code.


Category A % with cat A Category B Category C TOTAL 2= p = ***

Control PHC Airway NOT clear PHC Breathing NOT present PHC AVPU = P or U

463 11 11

29.0 68.8 64.7

918 4 5

217 1 1

16 (1%) 17 (1%)

12.4 p <0.001 10.6 p <0.001

35

59.3

23

59 (3.7%)

27.4 p = NS

A-A&E Airway NOT clear B-A&E Breathing NOT present D-A&E AVPU = P or U

7 14

46.7 63.6

8 8

15 (0.9%) 22 (1.4%)

2.3 p <0.05 13.02 p<0.001 29.99 p = NS

29

65.9

15

44 (2.8%)

In an optimal system, all the patients above would have been categorised A. 75

6.13.5

OUTCOME

240 (25.2%) of the patients discharged from A&E were allocated to category A by the dispatcher and 125 (13.5%) by the CBD system used strictly by expert A. Only 153 (16.1%) were categorised C by the dispatcher; 323 (34.7%) by the CBD system. Full details are in Table 6.13.

Table 6.13.

Disc harge from A&E in relation to CBD code. Information used A B C total % B & C"

All cases

463 29.0%

918 57.4% 559

217 13.6% 153 (16.1%) 323 (34.7%)

1599 100% 952

86.4%

Dispatcher 999 call

240

74.8%

(25.2%) (58.7%) CBD system prehospital 125 482

930

86.6%

(13.5%) (51.8%)

10% (n =37) of admissions were categorised C by the dispatcher and 16.9% (n = 60) by the CBD system. Full details are in table 6.14.

Table 6.14.

Admission to hospital in relation to CBD code. Information used A B C total % B & C 463 29.0% 918 57.4% 202 204 217 13.6% 37 (10.0%) 60 (16.9%) 357 73.9% 1599 100% 369 64.8% 86.4%

All cases

Dispatcher CBD system

999 call prehospital

130 93

(35.2%) (54.7%)

(26.0%) (57.1%)

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Category A was only assigned to 36 (41%) o those admitted to coronary care or high f dependency units (32; 35.2% for CBD system; (see Table 6.15) and to 2 (28.5%) of the cases admitted to the intensive care unit from A&E (see Table 6.16). No cases admitted to ITU from A&E were categorised as C. A further 6 patients were subsequently admitted to ITU. Analysis of all admissions reveals that 8 (61.5%) were categorised as A by dispatchers (n =6; 46.2%). Of the 13 patients admitted to ITU, in 4 (30.8%) cases the dispatcher and all three experts agreed on a CBD code A. In one further case (7.7%) only one expert disagreed and the others agreed on a code A. In one case (7.7%) all agreed that he should be coded B or C with a dispatcher code B. In 6 cases there appears to be an error in the CBD system in that expert A (using the CBD system) classified them as category B but experts B & C classified then as a category A. In three cases the dispatcher over -triaged according to CBD giving them the correct category A.

Table 6.15.

Admission to Coronary care or High dependency in relation to CBD code. Information used A B C total % B & C

All cases

463 29.0%

918 57.4% 50

217 13.6% 1

1599 100% 87 91

86.4%

Dispatcher CBD system

999 call prehospital

36 (41.3%) 32 (35.2%)

58.6% 64.8%

(57.5%) (1.1%) 59 (65%) 0 (0%)

77

Table 6.16.

Admission to Intensive Care unit in relation to CBD code.

Table 6.16a ITU admissions direct from A&E Information used All cases Dispatcher 999 call 463 29.0% 2 918 57.4% 5 217 13.6% 0 (0%) 1599 100% 7 71.4% 86.4% A B C total %b&c

(28.5%) (71.4%)

Table 6.16b all ITU admissions, including admissions subsequent to A&E Information used All cases Dispatcher 999 call 217 13.6% 8 1599 100% 5 0 (0%) 1 (7.6%) 13 53.8% 86.4% 1599 100% 13 38.5% 86.4% A B C total %b&c

(61.5%) (38.5%) CBD system prehospital 6 6 (46.2%) (46.2%)

Three quarters (12; 75%) of patients dying in A&E or before arrival, were categorised as A, although this rose to 93.8% using the system strictly applied by expert A. The dispatchers did not categorise any of these early deaths as category C. Details are in table 6.17. Thirty-two patients in the study died after leaving A&E. Subsequent deaths during hospital stay were, however, classified as category C in 3 (9.3%) cases by dispatchers and 3 cases (9.6%) by the CBD system. Half of the patients who subsequently died were classified as A ( =17; 53.15 by dispatchers; n = 14; 45.1% by CBD system). Of those n who died, the average duration of complaint was 12.5 hours (range 0.1-200 hrs., interquartile range 0.18-7). They were in-patients for an average of 14.28 days prior to

78

death (range 1-57 days; interquartile range 3-22 days) and spent 0.88 days on ITU (range 0 21 days; interquartile range 0 days).

Table 6.17.

Deaths in relation to CBD code.

6.17 a Deaths before arrival at or in A&E Information used All cases 463 29.0% Dispatcher 999 call 12 (75%) CBD system prehospital 15 918 57.4% 4 (25%) 0 217 13.6% 0 (0%) 1 (6.3%) 16 6.3% 1599 100% 16 25.0% 86.4% A B C total %b&c

(93.8%) (0%)

6.17 b deaths after leaving A&E during hospital stay Information used All cases 463 29.0% Dispatcher CBD system 999 call prehospital 17 14 918 57.4% 12 14 217 13.6% 3 (9.3%) 3 (9.6%) 31 54.8% 1599 100% 32 46.9% 86.4% A B C total %b&c

(53.1%) (37.5%)

(45.1%) (45.1%)

6.13.6 OTHER ASPECTS 1462 patients (91.48%) had data on the duration of their complaint. The duration of complaint is summarised in Table 6.18. 136 (9.3%) had a duration of complaint of over 12 hours. Of the se 9 (6.6%) were categorised as A, 39 (28.7%) as B and 88 (64.7%) as C.

79

Table 6.18.

Duration of complaint in relation to CBD code. Cat A Cat B 276 80 47 47 18 13 5 3 489 Cat C 493 105 50 32 34 23 18 13 768 TOTAL 886 230 114 96 60 37 23 16 1462 ITU admissions 8 1 2 0 1 0 0 1 13

< 1 hr 1-2 3-6 7-12 13-24 25-48 49-72 72+ Total

117 45 17 17 8 1 0 0 205

6.13.7 RESPONSE TIME RESULTS The standards for response times for urban ambulance services using CBD is: Category A Category B Category C 75% cases within 8 minutes 95% cases within 14 minutes 95% cases within 14 minutes

The response times in this study for each CBD category did not show any statistically significant variation by CBD category ( 2=6.6 (4df), p = NS ) (see table 6.19 for details). The new response standard ( effective from 2001) of 8 minutes for category A calls was achieved in 73.6% of cases and the 14 minute standard was achieved in 98.0% of category B cases and 98.1% of category C cases. Data on response times was available in 1578 (98.74%) of patients in the study. The proportion of this sample that would have achieved the old standard (95% of all calls within 14 minutes ) is 98.1%.

The above give the response times according to the dispatcher's category, as used in performance standards. However, this is only used as a proxy measure for the critically ill. A more reliable measure of the response in relation to clinical need is to look at the figures according to the expert assessment of urgency of ambulance requireme nt. This 80

demonstrated that only 67.0-69.3% of expert "gold standard" category A cases were dealt with in 8 minutes and 98.1-98.4% of expert category B & C cases were responded to in less than 14 minutes. (Ranges reflect experts B and C opinions o categorisation). f

Table 6.19.

Response times by CBD category.

6.19a response times by CBD Category A < 8 mins 8<=14 mins >14 mins TOTAL 338 114 7 459 Category B 623 264 18 905 Category C 138 72 4 214 N= 1099 450 29 1578 % 69.6 28.5 1.8

2=6.6 (4df), p = NS. The response times do not show any significant variation by CBD category. 6.19 b percentage achieving new 2001 standards CBD category Category A Category B Category C Overall within new standards Actual 73.6% 98.0% 98.1% 90.9%
Target 75% in 8 minutes 95% in 14 minutes 95% in 14 minutes

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6.14 Limitations This study relies on various assessments to determine the need for a category A response. No single measure is perfect. By combining expert opinion, physiological abnormality, interventions undertaken and outcome measures, this study aims to produce a full view of the factors that build up a picture of accuracy and safety of CBD. Many of the measures used in this study relate to the state of the patient at a time after the prioritisation had taken place, including at the time the ambulance personnel assessed the patient after their arrival and at the accident and emergency department. It could be argued that the patients condition had changed since the time of the dispatchers assessment. This is not believed to be a significant limitation as CBD must be able to predict any deterioration that may occur in a patient if they did not receive an 8 minute response. Expert opinion is a subjective measure and therefore open to individual variation. The experts were chosen for their knowledge in the field of emergency care. Interventions that were undertaken either at scene or immediately on arrival were used as a proxy measure for urgency of care. Some interventions may have been inappropriate. However, in the majority of cases, one would expect that there was some cause for concern that should have been detected by the dispatcher. Physiological parameters would be expected to be more reliable indicators of severity of illness, although the variation from an individuals normal state can never be assessed in a study such as this. Outcome measures give an indication of the severity of the illness. However, the prehospital state of the patient is only one factor. Outcome will also be affected by the quality of care subsequently received, development of complications and progression of the disease condition. 6.15. Discussion 6.15.1. THE EXPERTS The gold standard adopted in this study is the CBD coding by the expert when he has the full information, including diagnosis. This standard best reflects the patient's actual needs for their clinical condition. However, the variation between experts B and C demonstrates 82

that a true gold standard is not achievable using opinion since a true gold standard is not a fixed point unaffected by external factors. It is acknowledged that the ambulance dispatcher will never have this amount of information available. However, an absolutely safe system would have no under-triage rate compared to the gold standard. An infinitely efficient system would have no over-triage. Safety is the overriding consideration in establishing a prioritisation system, so the aim of a prioritisation system must be to achieve a near zero under -triage rate with as low as possible over -triage rate as a secondary factor.

Analysis of the triaging by the nurses compared to the experts expected category reveals great variation (25% under-triage and 21% over-triage), but equally in both directions (line 16 of Table 6.9). When compared to the gold standard of final diagnosis, the nurses overestimate and underestimate was comparable with that of the experts in the same time period. This initial sample demonstrated that no extra information was obtained by using a nurse assessment. Hence expert opinion based on the information in the notes appears to be as reliable as a nurse who is able to interview the patient and ambulance crew. This suggests that the experts in this study had sufficient information to make their judgements, compared to the nurse who could ask the patient directly. The nurse coding was therefore not used after the first week as it added no extra information and because it may have several inherent disadvantages: Poor compliance rate Inter-observer variability of nurses Variability in understanding of prehospital urgency.

Comparing the expert B expected and on diagnosis codes confirmed reliability (line 12, Table 6.9). Only 1% of cases were under-triaged by him from the notes and subsequently modified when the diagnosis was known. The figures demonstrate that expert B works as would a near optimal system in that there was a low underestimate rate (1%) (only misses 1% serious cases). There was, however, a high over -triage rate (53%). This suggests that it may be impossible to achie ve any increase in efficiency without a decrease in safety.

Expert C is more varied in his categorisation but on more occasions over-triaging with an under -triage rate of 9% relative to expert B and over-triaged rate of 36% was observed (line 14, table 6.9), when information, including diagnosis, was available. (Over -triage results in a higher prioritisation). Expert C also had a higher under-triage rate compared to expert B 83

when their opinions on final diagnosis are compared against expert B's diagnosis from notes information (lines 12 &13, table 6.9), the dispatchers code (lines 4&5, table 6.9) and to the CBD system code on prehospital information (lines 9 & 10, table 6.9) or on accident and emergency department information (lines 6 & 7, table 6.9). This may be due to a different perspective as this expert was actively involved in prehospital care and therefore more accustomed to dealing with the patients before a diagnosis was established. In the scenario of uncertainty, it is best to over-triage and, therefore, to be safe rather than to save on resources. Expert C also demonstrated a highly reproducible opinion with a high kappa score. Expert opinion inevitably gives a spectrum of views. It is therefore important that further analysis includes both experts and that neither are individually considered to be the gold standard.

6.15.2.

CATEGORISATION OF CASES

The dispatchers under -triage by 33 % and over-triage by 22% when compared to expert B on similar information (line 3, fig.6.9). Over-triage is to be expected as dispatchers have less information available to them than the experts. The observed under -triage rate reflects a potential hazard to the patient and could be due to inadequate information via the telephone, communication difficulty, poor perf ormance by the dispatcher or because of the failings of the CBD system. Lines 1 and 2 of table 6.9 demonstrate the performance of dispatchers when compared to the CBD system used using either the prehospital information or the information available in the accident and emergency department. It demonstrates low rates of dispatcher under-triage (9% and 8%) but approximately one third over-triage by dispatchers compared to strict adherence to CBD. This suggests that undertriage is due to incorrect usage of the CBD system (reflecting dispatcher performance) or to lack of information in only a small proportion of cases. It implies that it is the guidelines that are causing the under -triage observed in the previous analysis.

Although the over-triage rate appears large, this is a safety margin. It may be possible to obtain improvement by increasing the information obtained from callers rather than by different use of the system. It is not known whether the extra information can be obtained 84

from the public. The qua lity of information currently obtained is studied in chapter 8.3. In this study, trained ambulance personnel and hospital staff acquired the information for the experts. The dispatcher, however, has to obtain this information from the person on the telephone, without any visual prompt. The minimal difference of 2% under-triage and 2% over-triage between the CBD system results when using the prehospital information or the accident and emergency department notes, confirms that equally reliable information can be obtained from the scene by the ambulance crew in a face-to-face situation. This does not however address the problem with obtaining information via telephone rather than direct observation. It is important to note that this only relates to information required by the current CBD system, not related to the more detailed information required to make a definitive diagnosis.

Whereas expert A, using strictly CBD guidelines, had a high under -triage rate (45%) compared to expert B notes info (line 5, table 6.9), the dispatchers only had a 33% undertriage rate (line3, table 6.9). This implies that the CBD system is the cause of the majority of under-triage cases. The same applies when comparing the under-triage of dispatchers (10% - line 4, table 6.9) and A&E CBD (13% - line 6, table 6.9) with expert B on diagnosis code. The difference is less marked when compared to expert C - dispatchers (21% - line5, Figure6.9) and expert A using the CBD system (25% - line7, table 6.9). This implies that the dispatchers are performing more accurately than would be expected by strict adherence to CBD guidelines. A lower under-triage is mirrored by a higher overtriage rate in all of the above categories. When compared to final diagnosis by expert B or C, the dispatchers appear to have a higher over -triage rate than the CBD system (54% and 40% for dispatchers compared to 39% and 27% for CBD system - lines 4,5,6,7, table 6.9). Hence in this set, the dispatchers appear to upgrade the coding to a greater extent than they downgr ade it. Because of this disparity, it is only possible to conclude that safe practice is being undertaken, The dispatchers are improving on the strict use of CBD system by using their skills.

The improvement in dispatcher performance from expert B notes info (line 3, table 6.9) to expert B on diagnosis (line 4, table 6.9), shows that many cases of under-triage are in high risk patients which subsequently prove to be of less clinical significance. They were apparently potentially serious but were subsequently shown to be less severe. This is also associated with an increased safety margin, as shown by the increased over -triage. The 85

change in expert B's opinion between his assessment from information in the accident and emergency department notes and the final diagnosis suggests that the over-triage of 53% results from the lack of definitive diagnosis and having to assign a higher priority to a case until the most serious diagnosis is excluded.

Cases under-triaged for their final diagnosis represent the failings of the system and a risk to the patient. From this expert opinion, it is concluded that this risk is occurring in 10-20% of cases with current use of CBD. It appears that this is mostly due to the CBD (UK) guidelines rather than their implementation.

6.15.3QUALITATIVE CASE REVIEW The error rate solely attributable to the dispatcher was 0.98%, this appears to be a low rate but no comparative data is available. However, there are errors that are due to a combination of dispatcher and system, so the best estimate of the true error rate is 8% (25 cases in 304). The dispatchers improved on the system in 3.9% of cases. This demonstrates that the dispatchers are using the system, as designed, to guide their decision making, but not to rule it. However, the danger of such a system is that this improvement rate is dependant on individuals and their training. The case review suggests that some individual codes should be changed and these are summarised below with the rationale for the change. Fits of unknown origin (code 11B3) should be allocated as category A in case it is a fit secondary to hypoxia, hypoperfusion or brain injury a case of severe left ventricular failure presented as a fit, two other fits of cardiac origin. Continuing fit should be added to the description of fitting more than 5 minutes (11A2) or unconscious (11A1). Two cases were missed because they were coded simply as fits. It is known that the public do not understand the term unconscious80 and if the fit is still ongoing but less than 5 minutes, its course cannot be predicted. Weakness in a diabetic (9C2) should be presumed to be developing hypoglycaemia unless it is of gradual onset - missed hypoglycaemic in a diabetic with recent onset weakness. Code 9B1 (diabetic, decreased level of consciousness) is upgraded to Category A a patient with peritonitis who was labelled as diabetic with decreased conscious level. 86

Decreased conscious level in a diabetic is often a sinister sign (suggesting hypoglycaemia, sepsis, diabetic ketoacidosis) and needs urgent attention. Code 22B3 (electrocution / electrical burns) upgraded to an A category, because of the risk of cardiac arrhythmia. Falls over 10 feet (24B5) should be priority A because of the high risk of serious injury 25C1 (bump o laceration from fall with no loss of consciousness) should exclude high r risk mechanisms of injury. The same applies to cuts, bumps and bruises (24C1 or 24C2) Road traffic accidents should be upgraded to A if there is insufficient information on the patient in high risk accidents such as rollovers, persons trapped 6.15.4 STUDY OF OUTCOMES Those with physiological abnormalities that are potentially life-threatening are only detected and classified as category A in 45-69% of cases. Those who are unconscious are no more likely to receive a category A response than other patients. Those requiring an urgent intervention are only coded as category A in 5 -80% of cases. These measures all reflect patients who could potentially come to harm from delay in their care. It is in this measure that the highest failure rate of the system is seen. In many cases the use of prioritisation did not even produce a trend towards those needing interventions being more likely to receive a category A. No previous study has looked at this group of critically ill patients in a separate analysis. Other studies have hidden this group in the much larger numbers of well patients for whom time is unlikely to affect their outcome. It is this group of patients who require early assistanc e that prioritisation systems are designed to help when resources are limited and yet they will be frequently missed by the present use of the CBD (UK) system.

Category C patients are those with less serious problems. Although none needed an ITU admission from A&E, category C represented 1.1% of admissions to high dependency areas, 15.5% of the admissions to hospital and 9.3% of the deaths. These figures all suggest that category C contains a significant number of people who need hospital care and ma y have serious illness. It would therefore not be safe to presume that category C equates with minor illness without more detailed evaluation of the patient. However, it is not known 87

whether ambulance response time would affect the outcome, except in those suffering cardiac arrest. It is accepted that Category A will include many patients who are not critically ill or injured as a safety margin. One quarter of all patients categorised A are subsequently discharged from hospital. 6% of patients with category A have had symptoms for more than 12 hours. Further research is required before any recommendations could be made about including duration of complaint in the prioritisation system 6.15.5RESPONSE TIMES It is not possible to determine whether the introduction of CBD has caused a change in response times. Firstly, the categories did not exist before CBD, although they could be retrospectively allocated. More importantly, other changes in the provision of the service have accompanied the introduction of CBD within the West Midlands Ambulance Service. These include the provision of first responders, who are individuals not in an ambulance who respond to an incident to administer first aid. They include trained members of the public, motorcycle paramedics or paramedics in cars. There was also a change in the method of working whereby ambulances were allocated to standby points. In this way the ambulances are evenly spread over an area rather than clustered at ambulance stations.

This study has shown that there is no significant difference in response times between the different CBD categories. In the UK the main aim of the introduction of the system was to improve the response to the seriously ill in a resource limited environment. At present it does not appear that resources are being focused on this issue. However, the old system had only a 14 minute response, so the new system does mean that category A patients are given an improved target. It is possible that the whole system has improved but not specifically for category A patients. Since a paramedic responds to every case, CBD is not used to determine level of response. If times have improved globally, it raises the question of whether the prioritisation systems have benefited the ambulance services and therefore the patient in their present usage or whether other changes have caused the improvement.

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6.16 Conclusions In this study, dispatchers appear to follow CBD guidelines accurately, except in some cases where they override the system and therefore apparently over-triage. This over -triage appears to be beneficial by improving the accuracy. It may be that they are using their experience and concern that a case is more serious than CBD suggests to manipulate the coding to give the priorit isation they want.

Under-triage appears to result mainly from the system rather than the dispatchers. Some of the under-triage is in patients with a high risk story but whose final diagnosis reveals that they were not at risk. Hence it is not of clinical significance. However, 10.3-21.3% of patients appear to be put at clinical risk by undertriaging. Their diagnosis and clinical condition suggest the need for earlier attention than that allocated by the prioritisation of CBD.

There are significant numbers of patients who are physiologically unwell or who require urgent medical interventions but who are not being classified as category A. Potential spinal injuries are particularly poorly detected by CBD. Many with airway obstruction or unconsciousness were not detected. This group of patients is studied further in chapter 7. Equally, category C does not appear to reflect those who are well or could receive a non urgent response, without them having a more detailed evaluation. The patients who could be discharged home are studied in chapter 8.2.

Specific modifications highlighted by case review were suggested in the discussion which may help decrease this risk.

At present the ambulance service does not appear to use the CBD categorisation system to target those individuals with suspected serious illness or injury for a more rapid response. The use of CBD as a resource allocation tool is studied further in chapter 8.4.

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7.

STUDY OF HOSPITAL ALERTS

7.1

Introduction

The initial expert opinion highlighted a cause for concern due to the poor level of agreement with the CBD system. The literature review demonstrated that the system was not founded on a strong evidence base and that there had been no rigorous evaluation of the system. The outcome study has demonstrated an under-triage rate of 12.6% - 25.6% when comparing actual dispatch prioritisation with expert opinion with knowledge of eventual diagnosis. The actual system has a higher rate that is corrected by the intervention of the dispatcher. The patients early or late outcome does not seem to relate accurately to their CBD coding. The outcome study also highlighted that certain seriously ill patients, especially diabetics, those having fits, suffering trauma, with airway obstruction, with potential spinal injury and who are unconscious may be at particular risk. This group of seriously ill or injured patients requires study in more detail, looking at those patients whom the ambulance personnel on scene believe to be critically ill.

An alert describes the situation where an ambulance crew requests that the hospital be notified before their arrival, because they perceive that the patient's clinical condition requires immediate attention on arrival at hospital or a special response (for example, trauma team). Exact criteria may vary between hospitals and between ambulance services. It follows, therefore, that all such patients should have been categorised as A by the dispatching system, providing the crew has made an accurate clinical assessment. Comparison of cases classified as alerts with the ambulance prioritisation of these patients, should therefore, serve as a method of assessing the effectiveness of the dispatch system in detecting the most critically ill or injured patient. A predictive eleme nt is needed in the system, by which any deterioration between telephoning for an ambulance and its arrival could be predicted from the interrogation. A failure to obtain such information should result in a high priority as a failsafe mechanism.

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This study aimed to determine whether Criteria Based Dispatch accurately categorised 999 calls and allocated an A priority for those patients that was later followed by an alert message to the hospital, from the ambulance crew.

7.2

Methods

The study population was identified by a search of the West Midlands Ambulance Service Ambulance Emergency Control computer for the text word alert$ (not case dependant) in any field of the Ambulance Control Database. All cases in the one week study period 24/4/97 30/4/97) were included in the analysis. Alert$ signifies both the word alert and any word with alert as its first 5 letters. Any request for a hospital to be alerted should have two database entries first, a note of the request to alert and, second, the fact that the hospital had been alerted recorded on the Ambulance Control Database. The printout for each case was reviewed and cases where the word alert was detected in another context, for example, bomb alert, were discarded. Information from the a mbulance database is demonstrated in table 7.1. Table 7.1. Information from ambulance database for alerts study Field in database Call identity Location of caller Clinical details CBD coding Timings of response Time of call, ambulance dispatch, ambulance arrival at scene, departure from scene, arrival at hospital Both number and type of response Any messages from crew for example, transcript of radio messages Alert messages Confirmation when informing hospital Pronouncement of death details Contents Individual ID number, date and time Tel. No. and location as given by caller Details as given by caller

Details of ambulance/units responded Additional notes

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Patient report forms were obtained from the ambulance training centre, where a copy of all the report forms are stored.

The dispatch category and ambulance patient report forms were reviewed by the author to determine the clinical grounds for the crew alerting the hospital. Physiological parameters (pulse, respiratory rate, systolic blood pressure and Glasgow Coma score), as well as AVPU consciousness scale 81 were recorded. Revised Trauma Scores82 were calculated, as was the Shock Index83. These scores enable identification of the severity of the injury and therefore cases in this study that may not have warranted an alert can be identified. Other cases could be confirmed as critically ill on clinical grounds, as shown in table 7.2

Table 7.2. Criteria for determining critical illness on clinical grounds Type of abnormality Airway Obstruction Breathing / Respiratory Distress Circulatory Collapse Abnormal result Any Respiratory Rate > 29, Oxygen Saturation 90% BP < 90 systolic, Pulse > 140 or < 40 Burns needing fluid resuscitation Actual blood loss > 1500 mls Disability Fitting continuously Massive uncontrolled bleeding Unconscious with risk to airway (GCS<8, or responding to pain only) Any Any

All cases that had been classified as Category B or C were individually reviewed. Qualitative analysis of all the records relating to under-triage cases was undertaken to determine potential reasons for the under-triage. All cases had retrospective categorisation using CBD (UK) guidelines with the information available as part of this analysis. This review assessed whether the case was a critical illness or injury and the reason for misclassification was deduced from the information available.

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T-tests, Analysis of Variance (ANOVA) and the non-parametric equivalent (Kruskal-Wallis) tests were used as appropriate. After this analysis, modelling was undertaken to determine the effects of the recommended changes and how such changes could be instituted. 7.3 Results

During the seven day study period, West Midlands Ambulance Service dealt with a total of 3,004 emergency 999 calls, relating to 2,563 incide nts. 3,023 operational units (including ambulances, motorcycles, fast response units, and medical teams) responded to these incidents. 104 cases were identified as resulting in a hospital alert call. All occurred in both locations on the database, implying no missed cases. The distributions of diagnoses by alerting ambulance crews and by dispatcher's CBD prioritisation code are shown in Table 7.3.

Table 7.3.

Distribution of diagnoses by the alerting ambulance crew and the dispatchers CBD classification.

Diagnosis alerting crew

by

No of cases

% of total cases

Classified A

% A

Classified B

% B2

Classified C

% C

Unclass -ified..

% Uncl.

Cardiac Arrest Cardiac symptoms Trauma Burns ?CVA Diff Breathing Overdose Fits Non-traumatic Blood loss Hypoglycaemia Others TOT AL
1

37 6 17 2 3 18 7 8 4 1 1 104

36 6 16 2 3 17 7 8 4 1 1 100

34 3 9 0 2 10 5 6 0 1 0 70

92 50 52 0 66 56 71 75 0 100 0 67

3 2 6 (21) 2 1 7 (51) 1 1 4 0 1(11) 28 (81)

8 33 35 100 33 39 14 13 100 0 100 27 1 6

1 1

17 6

1 1 1

6 14 13

Figures in brackets indicate the maximum number where ambulance observations did not justify the alert and

there was a possibility that these cases did not need to be an alert.

Eight cases (indicated by bracketed num bers in Table 7.3) were identified where the information available did not demonstrate critical illness. The comparison between chief complaints ascribed by the dispatcher and by the on scene ambulance crew is demonstrated in Table 7.4.

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Table 7.4.

Compa rison of dispatcher and ambulance crew diagnosis.


No 1 18 Ambulance Diagnosis Blood loss Difficulty Breathing Cardiac Arrest Post ictal Cardiac Arrest Chest Pain Difficulty breathing Cardiac arrest Diabetic emergency Fits Stroke Cardiac Arrest PV Bleed Overdose Stroke Difficulty Breathing Fitting Cardiac arrest Head Injury Stroke Overdose Difficulty breathing Arrthymia Stabbing Burn Fall Arrhythmia Internal bleeding Head Injury RTA Child fits Child trauma Cardiac arrest Bleeding Difficulty Breathing Overdose Unknown No. 1 13 4 1 5 4 1 5 1 4 1 3 1 3 1 1 1 16 2 1 3 1 1 1 2 2 1 1 3 8 2 1 4 1 2 1 1 104

CBD chief complaint by dispatcher Bleeding Difficulty in Breathing

Cardiac arrest Chest pain

5 10

Diabetic emergency Fits

1 8

Gynaecological Overdose Stroke/CVA

1 3 3

Unconscious

24

Assault Burn Fall

1 2 4

Head injury RTA Child fits Child trauma Sick/unknown

3 8 2 1 9

Total

104

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7.3.1. APPROPRIATENESS OF ALERTS It was judged that in a maximum of eight cases (indicated by bracketed numbers in table 7.3) the ambulance crew may have overestimated the severity and the case may not have warranted an alert. Two of these cases were trauma, 5 were difficulty in breathing, and the other was not classified. One of the trauma cases was a head injury who was fully conscious with normal physiology. Four of the cases with shortness of breath had normal physiological parameters One case of shortness of breath had insufficient data to assess. One trauma case and one unclassified case had insufficient data to assess the reason for the alert.

If all alerts were considered appropriate, 27% (29 of 104 cases) were assigned to priority B or C. 8 could not be confirmed as critically ill. If those cases that could not be confirmed as critically ill by expert review are excluded, then 19% (21 of 104 cases) were inappropriately assigned to priority B or C.

7.3.2 Comparisons of alerts with other severity scores Of the 104 patients studied, 101 had a level of consciousness recorded according to the AVPU scale. 25 were alert, 9 responded to vocal command, 12 to pain only and 55 were unresponsive. Table 7.5 demonstrates the categorisation between conscious level measured on the AVPU scale and CBD (UK) priority group. Eleven (52%) of 21 under-triaged cases were either unresponsive or responding only to pain but were not assigned an unconscious code by the dispatcher.

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Table 7.5. AVPU code A = Alert V = Respond to voice P = Respond to pain only U= Unresponsive AVPU not known Total

Conscious level on AVPU scale vs. CBD category. CBD A 12 5 5 47 1 70 CBD B 12 4 5 5 2 28 1 5 CBD C 0 0 0 1 No CBD code 1 0 2 2 Total 25 9 12 55 3 104

The Revised Trauma Scores (RTS) and the Glasgow Coma S cales (GCS) were assessed for the 17 trauma patients There was no significant difference between Category A (mean score 7.8) and Categories B and C (mean score 6.9) patients with respect to RTS (p =0.105, Kruskall-Wallis Test) (see table 7.6).. The differences in GCS (mean scores: Category A = 14.4, B = 12.9, C = 5.0) between the CBD (UK) categories were however statistically significant (p<0.005, ANOVA) (see table 7.7). The distribution of GCS is opposite to what is expected, partly due to the small numbers and the bias of sampling only alert cases.. The category c patient was initially fully conscious and then deteriorated after the 99 call such that his GCS was 5 when the ambulance crew arrived. In the road traffic accident (RTA) subgroup (n =8), three of the four misclassified cases also had a GCS < 12 (AVPU was P in one case and V in the other two). the fourth had insufficient information to conclude the reason for under-triage.

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Table 7.6.

The Revised Trauma Scores (RTS) for trauma patients. n= Range mean Revised Trauma Score 7.8 6.9 -

CBD category

Category A Category B Category C * RTS equal in all cases

4 8 0

7.8* 3.9 - 7.8 -

Table 7.7.

Glasgow Coma Scale of trauma patients. CBD category A B C mean GCS 14.4 12.9 5.0 No. of cases 5 10 1

The four cases of haemorrhage had Shock Indices calculated. The Shock Indices were all greater than 0.83 (range 1.14 2.75). A Shock Index above 0.83 is associated with a high risk of transfusion and ITU admission2,84.

7.3.4 QUALITATIVE C ASE REVIEW FOR CAUSE OF UNDER-TRIAGE There were twenty cases of under-triage, some had more than one reason why they should have been categorised as A. Three cases where fitting was a presenting symptom of cardiac arrest but coded as a fit (code 11B3) The two cardiac related problems in older people both had the same cause of under-triage. A fall from a medical cause (24C3) and a medical collapse (19B3) were classified by the event witnessed rather than the medical cause. One stroke case resulted in under-triage because it presented as a fit which had stopped (11B5) but the patient was still deeply unconscious (GCS=6). One fit was misclassified as a fit of unknown history rather than a continuing fit. 97

One overdose, out of seven in this study, was misclassified and was only responding to pain and therefore should have been classified as unconscious (15A1), but had been classified as 15B3 (intentional/ accidental drug overdose).

Two burns cases were under -triaged because of an underestimation of the extent of the burn. Four cases of severe bleeding had a B category allocated Head injuries were under-triaged because CBD does not relate to the accepted guidelines on the management of head injury85. In the RTA subgroup, the correctly classified cases were all because the patient was unconscious. All others RTA alerts were Category B. Three of the four cases misclassified had a GCS <12, (AVPU was P in one case and V in the other two, indicating a significantly decreased level of consciousness; the fourth was alert). The fourth error appears to be related to using mechanism of injury rather than conscious level as the prime -sorting field.

One fall was classified as a B correctly according to CBD, which classifies a fall from over 20 ft. as a Category B. Minor bump on head, subsequently deteriorated, no identifiable risk factor was found. There were eighteen cases of difficulty in breathing. Assessment of their need for an alert call was difficult, as ability to talk, respiratory rate and oxygen saturation were not recorded in most cases.

A full list of the resulting recommendations is contained in Appendix 10.

7.3.4 EFFECT OF RECOMMENDATIONS When these recommendations for changes in the CBD system and dispatcher training were reapplied to the original data it resulted in a total of 25 of the 28 (89.2%) miscodings being corrected to a category A. The other three cases were all cases of difficulty in breathing where it could not be established that the patient was critically ill.

Fifteen (53.6%) of the se corrections could have been achieved either by a change in the training of dispatchers or a change in the coding system. Ten (35.7%)could only have been brought about by changes in the coding system.

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7.4

Limitations of this study

All cases identified in the study period were included. Although the sample of cases is small, particularly when individual complaints are analysed, the apparently high degree of underprioritisation in a system in active use make this small study important. A larger multiambulance service study is needed to determine under-triage rates with greater precision and to ensure generalisability.

The assessment of severity of most illness is subjective. The only scoring systems that exist and are applicable to the prehospital field are those relating to trauma and haemorrhage. In the other cases the author undertook individual assessment of the need for emergency intervention. This study has excluded all alert cases that may not have had critical illness or injury.

Only those cases where the ambulance services alert the receiving accident and emergency department have been studied. This enables concentration on those cases needing urgent intervention. These are the group who could most benefit from the improved response times of Category A. This alerts methodology is informative because it is the critically ill who are most at risk from a prioritisation system.

If a patient deteriorates after the 999 call, but before arrival of the crew, this will appear as a failure of the system. An effective prioritisation system must have this predictive element as well as simple assessment at the time of a 999 call.

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7.5

Discussion

The methodology of the two studies previously undertaken in the UK was similar but did not specifically look at the most critically ill. The Sheffield31 study reported that only 4 (1%) cases in 571 had serious under-prioritisation, as judged by expert assessment. The London study86 quoted a 2% under-triage rate but also stated that only 2 of these 15 cases could not be resolved by quality improvement. The outcome study in this thesis also highlighted that certain seriously ill patients, especially diabetics, those having fits, those suffering trauma, those with airway obstruction, potential spinal injury and who are unconscious may be at particular risk. This alerts study, alarmingly, suggests at least a 20% under-triage rate.

CBD (UK) appears to fail to detect the immediate emergency in 20-28% of 999 calls which result in a hospital alert call. Improvements must be made to the CBD (UK) system to reduce the level of under-triage. Although only one case was classified as priority C", this highlights the potential danger of a non-ambulance response to the conscious head injury, because of the well recognised delayed deterioration that may occur with an intra-cranial haematoma.

The difference in chief complaint as described by the dispatcher and the on scene ambulance crew is marked in several groups. The difficulty in d etecting cardiac arrest over the telephone is illustrated by it presenting in several different dispatchers' chief complaint categories. This may reflect difficulty in detection, poor observation by the caller or progression of the condition between 999 call and arrival of the ambulance. Early cardio-pulmonary
87 resuscitation is an intervention demonstrated to improve survival . Nineteen (51%) of the

patients in this study who presented as cardiac arrest or possible apnoea would have received advice over the telephone on cardio-pulmonary resuscitation (CPR). The remaining 18 would have had no CPR advice given. Only three of these latter cases were due to failure to recognise a symptom (fitting) related to cardiac arrest. The other cases were due to the cardiac arrest occurring after the call.

Ambulance services undertaking prioritisation of 999 calls should undertake audit to study the categorisation of all alert cases and carefully investigate any that have not been assigned to 100

Category A. This would enable improvement of the system and monitoring of staff performance without creating an excessive auditing workload.

At present, the increase in over-triage or resource requirements that the recommendations of this study may produce cannot be predicted. Ambulance crews may have a lower threshold for alerting because their individual patients welfare is their sole concern. However the prioritisation system has to meet the needs of the population as a whole. The prioritisation system does, however, have to have a high sensitivity for critical cases. Only in this way can appropriate emergency care be delivered to those with time critical illness or injury. Low sensitivity will cause adverse clinical outcomes in the most seriously ill. Low specificity of Category A may mean poor use of resources but does not cause any clinical harm. A review of the United Kingdom CBD guidelines to increase sensitivity should be undertaken, whilst further research looks at increasing specificity.

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8.1. Was CBD changed before use in the UK?

8.1.1. Introduction

This thesis has highlighted some major problems with CBD. The initial expert opinion highlighted a cause for concern due to the poor level of agreement with the CBD system. The literature review demonstrated that the system was not founded on a strong evidence base and that there had been no rigorous evaluation of the system. The outcome study has demonstrated an under -triage rate of 12.6% - 25.6% when comparing actual dispatch prioritisation with expert opinion with knowle dge of eventual diagnosis. It also highlighted that certain seriously ill patients, especially diabetics, those having fits, those suffering trauma, those with airway obstruction, potential spinal injury and who are unconscious may be at particular risk. The particular areas of concern demonstrated by the alerts study are the failure to recognise cardiac arrests. The miscodings are often related to fits, severe bleeding, unconsciousness, falls/faints and the use of mechanism of injury rather than clinical state. This part of the study aims to determine if these specific areas of error may have been caused by the process of change when CBD was adopted in the UK.

The process whereby the CBD system used in Seattle was modified to the format introduced in the West Midlands in April 1997 has been described in chapter 4.2. Part of this process was to reflect the change in the use of CBD. In America it is used to determine the level of response for example, whether to send a technician or paramedic. In the UK its main objective is to determine the speed of response. The objective of this study is to delineate these changes and determine how many clinical conditions have been promoted and how many demoted for their prioritisation.

8.1.2 Methods Copies of the CBD guidelines in use in Seattle at the time of the UK adoption of CBD and the present UK system were manually compared. The wording of the code description was 102

checked to ensure that the clinical description was not changed. All American and UK codes were entered on a database and then merged. This enabled comparison of the coding of identical medical conditions.

8.1.3. Results - The Changes No descriptions associated with codes had been changed. Direct comparison was therefore possible. Children under two years had been separated in the UK system to form a separate group with all codes given a category A response. The UK system had also created a new category (Group 20 -miscellaneous) to cover incidents where clinical details may not be available (for example, bomb alert, fire alarm). The changes in coding are shown in Table 8.1.1.

Table 8.1.1.

The changes in coding of CBD when imported into UK. Description US Code* 1A3 UK Code* Comments March 1997 1B1

Chief complaint

1. Abdominal/Back Pain

Lower abdo pain female 12 to 50 years with fainting and dizziness Vomiting red blood

1A4

1B2 NO CHANGES

2. Allergic reaction 3. Animal Bites Uncontrolled haemorrhage Severe bites to face and/or neck Bite from poisonous animal 3A2 3A4 3A5 3B1 3B2 3B3

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Table 8.1.1. (contd.) Chief complaint

Description

US Code* 4A2 4A3 4A4 4A5 4A6

UK Code* Comments March 1997 4B1 4B2 4B3 4B4 4B5

4. Bleeding Non trauma Multiple fainting episodes Fainting or near fainting Vomiting blood Coughing up blood, more than half a cup full Lower abdo pain female 12 to 50 years if associated with dizziness or heavy vaginal bleeding 5. Breathing difficulty 6. Cardiac Arrest 7. Chest pain 8. Choking 9. Diabetic 10. Environmental 11. Fits/Convulsions Diabetic Secondary to drug overdose 12. Gynaecology /Miscarriage 13. Headache 14. Mental/Emotional

NO CHANGES NO CHANGES NO CHANGES NO CHANGES NO CHANGES NO CHANGES 11A4 11A6 11B1 11B2 NO CHANGES Decreased conscious level 13A2 13B1 NO CHANGES 15A3 16A4 17A2 15B1 16B1 17B1 NO CHANGES ** Delivery Multiple fainting episodes

15. Overdose/Poisoning Difficulty in swallowing 16. Pregnancy 17. Sick/unknown 18. Stroke/CVA 19. Unconscious

Third party caller not with patient Multiple fainting episodes

19B4 19A2

19A7 19B1

20. Miscellaneous 104

No US code 20

Table 8.1.1. (contd.) Chief complaint

Description

US Code* 21A1 21A4 22A2 22A4 22A6 23A3 24A2 24A5 24A6 24A7 24A8 25A3 25A5 26A2

UK Code* Comments March 1997 21B1 21B2 22B1 22B2 22B3 23B1 24B1 24B2 24B3 24B4 24B5 25B1 25B2 26B1

21. Assault trauma

22. Burns

Decreased level of consciousness Uncontrolled bleeding Decreased conscious level Burns to airway, nose, mouth Electrocution/electrical burns. Confirmed submerged more than 1 minute Decreased level of consciousness Amputation above fingers or toes Patient paralysed Uncontrolled bleeding Fall more than 10 feet

23. Drowning 24. Falls/Accidents

25. Neurological/head injury 26. Road traffic accident

Decreased level of consciousness Fall more than 10 feet Decreased conscious level Confirmed or unknown injuries with the following mechanismVehicle Vs immovable object Vehicle Vs vehicle (head on/side on) Vehicle Vs Pedestrian Vehicle. Vs motorcyclist Victims trapped/ejected Multiple vehicle/casualty accident. All

26A3 26A3 26A3 26A3 26A3 26A3 No US code 20

26B2 26B3 26B4 26B5 26B6 26B7 All cases Category A

27. Child under 2

*The middle letter denotes the prioritisation letter ** Upgraded in UK system

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In only one case was the American code upgraded. Unconscious patients reported by a third party caller were assigned a category B in the American system and an A in the UK system. Every instance of uncontrolled haemorrhage except nosebleed was downgraded. However, decreased conscious level is consistently a Category B in the UK system whereas it is variable in the US. See table 8.1.2.

Table 8.1.2.

Decreased conscious level coding in UK and US. US code 9B1 13A2 15B1 17B1 18B1 21A3 22A2 24A2 25A3 26A2 NO SPECIFIC CODE UK code 9B1 13B1 15B2 17B2 18B1 21B1 22B1 24B1 25B1 26B1 27A

Chief complaint Diabetic Headache Overdose Sick/Unknown Stroke/CVA Assault Burns Fall/Accident Neuro/head injury RTA Child under 2

One area of the changes (gynaecological bleeding) also produced some anomalous coding, so that the same condition had different priorities according to which chief complaint was used, as shown in table 8.1.3.

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Table 8.1.3.
BLEEDING UK 4B1 4B2

Variation in bleeding code according to presenting complaint.


GYNAECOLOGY US 4A2 4A3 Multiple fainting episodes Fainting or near fainting when sitting up Lower abdo pain female 12-50 years if associated with dizziness/ fainting or heavy vaginal bleeding UK & US 12A2 12A3 Vaginal bleeding with fainting Fainting or near fainting when sitting up Lower abdo pain 12-50 years if associated with dizziness/ fainting or heavy vaginal bleeding

4B5

4A4

12A5

Many of the areas of concern that have been determined in the outcome st udy and the alerts study could potentially have been prevented by not changing the American system of CBD when it was adopted in the UK.

8.1.4. Resource implications of changes As all but one of the changes are from A to B, the modifications have decreased the resource demand on the UK ambulance services by decreasing those cases needing the most rapid response. To ensure rapid response to Category A patients, some ambulance services are now using first responders. These are an additional resource b ecause they are unable to convey a patient, they simply start treatment and then hand over care to the ambulance crew with a traditional ambulance, or accompany the patient in that ambulance (and have to retrieve their vehicle later). Hence the financial mplications of Category A cases over i Category B are significant.

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8.2 Patients not transported from the scene

8.2.1. Introduction Most of the earlier work in this thesis has concentrated on the ability of CBD to detect the seriously ill and injured. By categorising patients, CBD can also potentially be used to identify those with lesser needs. It has been suggested that CBD can be used to detect those who do not require an ambulance response. If certain cases could be diverted to other sources of care, then the existing ambulance resource could be used more effectively. The outcome study has demonstrated that patients initially categorised as category C are often in need of monitoring in the ambulance or require a prehospital intervention, although they are rarely physiologically disturbed. 10% of all admissions and 9% of deaths are categorised C. It is therefore already apparent that it not safe to automatically state that category C patients are safe to be transferred directly to another source of care. This study looks at those ambulance calls that did not result in transport to hospital as an indicator of where resources could be saved.

8.2.2. Objectives there are two objectives to this study: 1. 2. To determine the reasons for non-transport of 999 call patients. To assist in determining whether CBD can be used to determine which cases do not

require ambulance transport.

8.2.3. Methodology The emergency control centre database for West Midlands Ambulance Service NHS Trust was searched for a one week period (01 Sept 1998 - 07 Sept 1998) for all cases where an ambulance did not transport a patient to hospital following a 999 emergency ambulance call. This week was chosen as being mid point of the outcome study but one year later, so that seasonal effects should be similar, to make data comparable. Duplicate cases were excluded from analysis by comparison of time/date and incident location.

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The reason for non-transport is recorded in the database by the ambulance control room staff as free text. This was classified according to a coding system previously developed and validated in a 100 patient pilot 88. The reasons included were both clinical or operational. The codes for the reason that a 999 call did not result in someone being transported are summarised in table 8.2.1. Most of the groups are self-explanatory. The psychiatric group included only those where the person was not transported to hospital but some would have had the involvement of a community psychiatric team. Deceased indicates the ambulance crews diagnosis, it does not indicate the opinion of the person calling 999. The CBD(UK) code was also noted for each case, as was the time and date of the 999 call.

Analysis was undertaken to determine the extent of the problem of non-transport and to determine if CBD can be used to predict those cases not requiring transport. Specific analysis of CBD category A cases was undertaken as this may reflect a resource wastage, attempting to respond within 8 minutes to cases that eventually did not need an ambulance to transport them. The distribution of CND categories was compared with the distribution in the outcome study ( chapter 6).

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Table 8.2.1. Code No. 1 2 3 4 5 6

Coding of reason for non-removal. Non-Removal Reason Auto Fire Alarm - whether ambulance attended or not Asthma Hoax and malicious calls Psychiatric Minor medical / patient recovered, including fits Social problems, including elderly / disabled patients needing lifting back into bed / wheelchair domestic incidents Intoxicated only Violent No injuries, patient checked by crew (or police) Diabetic, recovered after treatment by self or crew Crew or control requested GP / midwife / social worker visit Patient deceased Refused treatment Smoke detector, no voice contact. False alarm Duplicate cases Patient using other transport to hospital No sign of incident / Patient left scene of incident Patient / caller changed mind - decided ambulance not required after all Case assigned to other service - fire, police, other ambulance service Airport alert - plane landed safely, crew stood down False alarm, good intent Police taken charge at scene Patient will visit own GP later Doctor already in attendance stood crew down. Caller cleared at start of call and control unable to ring back or, call connected / made in error to wrong service conveyed home Other - no code

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 28 99

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8.2.3. Results In the study period (01-07 September 1998) West Midlands Ambulance Service NHS Trust Emergency Control Centre dealt with 4767 999 calls. Of these, 1332 calls, relating to 1066 individual incidents, did not require anybody to be transported to a healthcare provider. Therefore, 27.9% (1332/4767) of all 999 calls received in the study period did not result in the transport of a patient to hospital.

There was some variation by day of week. As shown in figure 8.2.1, there is a rise in the proportion of 999 calls resulting in non-transport through the week with a maximum reached on Friday and then declining over the weekend. There was marked variation by time of day, as shown in figure 8.2.2, with an apparent bimodal distribution with peaks of non-transport cases at 13.00 hrs. and 22.00 hrs. There does not appear to be any difference in the distribution during the day between the category A cases and all cases studied together. The variation in numbers of non-transported cases by time of day reflects the variation of total number of 999 calls.

% of non transported cases by day of the week


40% 35.6% 32.4% 30% 27.0% 28.0% 28.0% 33.2% 31.1%

20%

10%

0%
Mo nd ay Tu es da y Fr ida y W ed ne sd ay Th urs da y Sa tur da y Su nd ay

Figure 8.2.1. Variation of non-transported 999 calls with day of week.

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10.0% 9.0% 8.0% % of daily total 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hour day Category transport of A nonall 999cases

all transport

non

Figure 8.2.2. Variation of non-transported 999 calls with time of day.

The CBD coding of those not transported was category A for 196 calls (18.4%), category B for 533 calls (31.5%) and category C for 336 calls (50%), compared to the distribution from the outcome study of 28.65% A, 59.2% B and 12.1% C. (see figure 8.2.3).

A 18.4% C 31.5%

C 12.1% A 28.7%

B 50.0%

B 59.2%

Not transported Figure 8.2.3. Non transport by CBD code.

Outcome study

The reasons for non transport by CBD category are shown in Figure 8.2.4. The categories have been divided according to potential cause and these are shown in Figure 8.2.5. 400 of t the 1066 cases studied (37.5%) were considered to be due to unnecessary calls. 109 (10.2%) were due to a hoax call, in 57 (5.3%) cases there was no sign of an incident, 29 (2.7%) had used other transport by the time the ambulance had arrived, 33 (3.1%) had changed their mind 112

20

40

60

80

19 (1.8%) were caller errors.

100

120

140

160

Figure 8.2.4. Total cases not transported.


category A

No. cases not transported

about needing an ambulance, 153 (14.4%) refused treatment when the ambulance arrived and

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category B category C

Re Ot fused he tr r tr eat Hoa an m x No spo ent sig rt us n o ed fi Ch ncid an ent ge dm in Au Cale d to r e F r Sm ire A ror ok lar Fa ed m lse ete ala Air ctor rm , g po oo rt a d i le nte rt nt Ps So y cia ch ia l Int prob tric ox lem ica ted s on As ly sig ne Oth dt o o er ca Viole n Po ther rer r t lice ser eq tak vice en ch arg e M As ino th r m ma ed Di ic ab eti No al c, inju rec ri ov es Vis ered Dr it G in P l a a Co tten ter nv dan ey ce ed ho m Ot Dec e he ea r - se no d co de

Decease d3.5%

Other 1.3%

Assessed/Treate d 17.4%

Hoax 38.5% etc.

Other carer required 28.4%

Standb y 10.9%

Figure 8.2.5. Reasons for not requiring transport.

303 (28.4%) of all the non transport cases were dealt with b other agencies. In 61 (5.7%) y cases the ambulance was called for social care (for example, to help someone back into bed) and in 105 cases (9.8%) another carer was requested. An additional 17 (1.6%) cases required the psychiatric team to attend. The police took charge in 32 cases (3.0%) and 40 (3.8%) were assigned to other services before arrival of the ambulance. 43 (4.0%) were intoxicated and 5 (0.5%) were violent without evidence of illness or injury. These are detailed in figure 8.2.6.

Figure 8.2.6. Cases dealt with by another agency.


Police taken charge 11% Psychiatric 6%

Social problems 20% Assigned to other service 13%

Intoxicated only 14% Violent 2%

Other carer req 34%

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In 186 (17.4%) cases patients were medically assessed , treated and discharged from the scene. Of these, 89 (8.3%) were after accidents when no injury was apparent, 10 (0.9%) were diabetics and 8 (0.8%) were asthmatic s, who recovered after treatment.

116 (10.9%) cases were standby situations, accounted for by automatic fire alarms (99;9.3%), smoke detectors (7; 0.7%), airport alerts (2; 0.2%) and 8 (0.8%) other cases. 37 (3.5%) patients were not transported because they were certified dead at home and transported by undertakers.

8.2.4. Discussion Over a quarter of 999 incidents do not result in transport by ambulance. If these represent cases where ambulance care was not needed, then this represents a large waste of resources. The variation of non-transport calls by hour of day reflects the variation in the number of all 999 calls with time. There is an apparent increase in percentage of non transport calls during the week with a peak on Friday. There is a recognised variation in use of ambulance services by day of the week23 but the variation in non-transport cases has not been previously noted. Analysis has not revealed any reason for this increase, in particular there is no apparent increase in any one reason for non-transport. However, the study period was only one week and conclusions cannot therefore be drawn from this. The reasons for non-removal of a patient from the scene are highly variable. 18 (1.7%) patients appear to represent the results of appropriate prehospital ambulance care including asthmatics and diabetics in this group. This figure may be an underestimate as those refusing transport may include some who have been treated and then recovered. Patients who had died and in whom resuscitation was inappropriate accounted for 37 (3.5%) cases. They were all appropriately categorised as A because the lack of need for resuscitation was not known until assessment by the ambulance crew. 43 (3.2%) people were simply drunk. There may be difficulty in determining whether the patient is drunk and safe, or unconscious with an airway risk. Nine of these cases were reported to be unconscious or not breathing from the telephone information. Many of these may be third party calls.

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Those who refused treatment and had minor conditions or did not want treatment represent a quarter (n = 306 ; 28.7%) of the non-transport cases. Those with no injuries represented 8.3% (n =89) of the study population. More study is needed to determine if these can be given telephone advice rather than requiring an ambulance. These cases may result from third party callers with little access to the patient, possible someone passing a road accident and calling an ambulance on their mobile phone.

The GP cases were all cases where a GP had suggested that the caller contact 999 but the ambulance crew thought hospital care was not needed. This study does not show whether the GP subsequently referred the person to hospital and so the accuracy of the paramedics decision cannot be verified. This group suggests the need for more integration of the emergency primary care and ambulance services. Social problems include those who have fallen from bed and need help back into bed and one person who had wet the bed and needed the sheets changing. These 5.7% ( =61) of cases n were dealt with by the ambulance service because of a lack of another out of hours agency to undertake this type of work.

The violent cases ( =5; 0.5%) were removed by the police because of danger to the n ambulance crew. They would have subsequently been assessed by a Forensic Medical Examiner (police surgeon) if required.

Hoax calls are often cited as a major problem but only accounted for 10.2 % (n =102) of the cases. Unnecessary calls for those refusing treatment (n =153, 14.4%) or leaving the scene (n =29; 2.7%) may be deliberate misuse of the system but may be well meaning passers-by, who fail to verify the situation before calling 999. Those who travel to hospital by other means, after calling 999 could avoid this resource waste by informing the ambulance service of their actions. Standby situations account for one in ten non-transports. Regular review is required to see if they need an initial ambulance response. The majority are fire r elated and some attendances may not be immediately necessary, for example, a fire at a hospital may not need an ambulance response as ambulance may not be required even if a fire results.

Category C at present receives the same response as Category B. There are plans to introduce telephone advice to this group and possible transfer to other agencies. Ideally, any 116

case that did not require paramedic treatment or transport to hospital should be classified as a C. Many more non-transport calls were prioritised as category C compared to all calls (50% v 12.1%) the system has the potential to halve the number of non-transport calls if category C cases were dealt with in a different way. Proportions of category A & B cases in various groups of those transported varies and is not isolated to specific diagnostic groups.

Those patients who are intoxicated present a difficult clinical scenario; they are at high risk of having suffered an injury, their decreased conscious level means they are at high risk of airway obstruction or aspiration of vomit and yet they are likely to refuse treatment or leave the scene before the ambulance arrives. Nine patients in this series were reported to be not breathing but were not transported, it mist be presumed that they were breathing but the caller could not judge this. The difficulty in obtaining accurate information is reflected in the 24 different CBD codes that are ascribed to the 34 drunk patients believed to be breathing, the most common code being the other, unclassified code (17B7). This illustrates the difficulty of obtaining information from 999 calls and the need for over prioritisation to have a safe system.

8.2.5. Conclusions Although a quarter of 999 cases do not result in ambulance transport, many are for justifiable reasons. These include patients who are successfully treated, those who cannot be confirmed dead until arrival of the ambulance crew and potential disasters such as airport alerts. Alcohol related incidents account for many non-transport cases. It is unlikely that this group of non transport calls can be reduced. Social reasons for non-transport could be solved by better access to emergency social services for emergency assistance. Public information campaigns may help improve the quality of information received and decrease the number of calls from incidents not requiring an ambulance. This may either be by identifying more serious conditions or recognising cases more appropriate for other services. If people have access to a vehicle they should be encouraged to use this for non life

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threatening problems, rather than use an ambulance. Hoax calls continue to be a problem that should be actively pursued. At present CBD does not provide a useful tool for predicting calls where transport ma y not be required. Although it has been shown that the category C calls could safely be directed to NHS Direct89, the system classifies many cases subsequently not transported to higher categories.

Category C has been shown to be a heterogeneous group. The outcome study demonstrates that it has many patients who are ill, need admission to hospital and will die. This study reveals that many who do not require transport are not classified as category C.

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8.3 Are 999 callers in a position to give tria ge information and receive first aid advice?

8.3.1

Background

The studies in this thesis have already demonstrated that the CBD system has a high error rate. This is partly compensated for by the experience and training of the dispatchers. Further improvement may be achieved by reverting to the American version of CBD. It is unknown how much of the error rate is due to the communications difficulties in obtaining information over the phone from a person who is liable to be upset.

The ability of emergency ambulance services to obtain information from a caller is a key element of their role. Difficulties in identifying the location to send the ambulance has been eased by the introduction of automatic call tracing. However, prioritisation of emergency calls and the delivery of first aid advice are dependent on good two-way communication between caller and ambulance service call taker.

Previous studies have demonstrated that first aid advice can be successfully delivered over the telephone 90, but these studies have not explored whether the location of the caller or language difficulties may prevent these instructions being carried out. One study in China reported that the majority of accidents were reported by passers-by who had little first aid knowledge and
11 did not want to be involved . There has been no study carried out in the UK on the origin of

emergency ambulance calls or any communications problems experienced. The search strategy for this data is shown in table 8.3.1.

Table 8.3.1. Search strategy on communications difficulties in 999 ambulance calls. Databases searched: Medline, BIDS, CINAHL

Search Pattern Ambulance 999 Communication Dispatch 119 Combined with Call Emergency Ambulance Communication

8.3.2. Methods A sample of 999 emergency ambulance calls arriving at the West Midlands Ambulance Service emergency control room was studied. This sample was achieved by listening to consecutive 999 calls taken by one position in the control room during two shifts spanning 08.00 to 00.00 hrs. on a Tuesday and Friday. Incoming calls are allocated to each position according to availability of that line (call takers may have other calls to receive or make as well as receiving 999 calls). The author listened to recordings of the calls, but was not involved in the decision making or call taking. It was determined whether there were any communication difficulties, the identity of the caller and their location in relation to the patient. A communication difficulty was defined as any situation where the call taker had to repeat a question or rephrase it more than once to obtain a reply or where an inappropriate response was received on two or more occasions. They were classified as due to the following causes: emotional / excitable inappropriate use of medical terms by the caller abusive not wanting to answer lack of comprehension child use of a non-English language.

The location of the caller was determined by comparing information provided by the call tracing system with the location of the incident as described by the caller, by the conversation content, by listening for the casualty in the background and by direct questioning of the caller. This was then coded into one of the following categories: a) present within talking distance of patient b) can speak with and assess patient, but needs to leave the phone to do so c) distant from patient, not in contact d) only indirect contact possible, for example, via radio.

The callers relationship was usually apparent from the call content (for example, use of terms such as my husband) but was asked by the call taker if not apparent. 120

95% confidence intervals have been calculated using the method described by Fleiss 91.

8.3.3. Results 104 emergency ( 99 ) ambulance calls were monitored. Three calls were hoax calls, all of 9 which were from children, two of them used abusive language and did not give any location or details, and one gave a false address and ended the call on requests for further details. These cases are excluded from the further analysis. This provided a study population of 101 cases.

In 15 calls (14.9%, 95% CI 8.8-23.6), communications problems were experienced (table 8.3.2). Three cases were due to language difficulties. In one further case the initial caller subsequently handed the phone to the patient who was able to communicate adequately. All four of these cases involved callers in Indian subcontinent languages. In one case, no transfer of information was possible. The location could be verified but further medical details could not be obtained in two other cases and first aid advice could not be given in any of these four cases. In five cases the emotional state of the caller was the key element to the difficulty. However, in all cases, basic details could be obtained but first aid advice was declined or not carried out. One call was from a person who was abusive when asked questions. In three cases, the caller did not understand the questions which were being asked; another one used medical terms inappropriately when answering and one call was a young child who did not understand the questions. One call was on a mobile phone and the distortion made two-way conversations extremely difficult.

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Table 8.3.2. Communication Difficulties Difficulty experienced Emotional/excitable Misuse of medical terms Abusive Not wanting to answer, reason unknown Lack of comprehension Child Line quality (mobile phone) Language TOTAL
1

No. of cases 5 (0) 1 (0) 1 (1) 0 (0) 3 (1) 1 (0) 1 (0) 3 (1) 159(3)
1

% of total calls 5.0 1.0 1.0 0 3.0 1.0 1.0 3.0 14.9

95% CI 1.8-11.7 0.1-6.2 0.1-6.2 0 0.8-9.1 0.1-6.2 0.1-6.2 0.8-9.1 8.8-23.6

The number of cases where communication difficulty was experienced is detailed in column two; the figure in brackets is those cases where no information could be obtained except for location details.

The location of the person making the emergency 999 call in relation to the patient is summarised in table 8.3.3. Only 41.6%, (n =42; 95% CI 32.0-51.8) of callers were close enough to the patient to allow questioning of the patient, assessment or first aid, following advice, to be undertaken without leaving the phone. In only two of these cases was the patient the caller. A further 28 callers (27.7%, 95% CI 19.5 37.7) could get to the pa tient but had to leave the phone to do so. In this group, the caller was a relative in 12 cases, a receptionist in 4 cases and health service related in 5 cases.

Table 8.3.3. Location of person making emergency 999 call Location a) Present within talking distance of patient b) Can speak with/assess patient but needs to leave phone to do so c) Distant from patient, not in contact d) Only indirect contact possible, for example, via radio TOTAL No. 42 28 5 26 101 % 41.6% 27.7% 5.0% 25.7% 100% 95%CI 32.0-51.8 19.5-37.7 1.8-11.7 17.8-35.6

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26 cases (25.7%, 95% CI 17.8-35.6) were in indirect contact with the patient. 10 were police officers via their control, 4 were fire service, 2 were other ambulance services, 3 were site security / reception, 3 were local bus services, 2 were deputising services, one was social services and one was a friend. The identity of the caller is summarised in figure 8.3.1.

104 emergency ambulance calls 3 Hoax calls

101 cases analysed

42 present

28 in vicinity

5 no contact

26 indirect contact

24 relatives 4 health workers* 3 friends 2 patient was caller 9 others

13 relatives 4 receptionists* 3 health workers* 2 home carers* 2 friends 4 others

4 left scene 1 not known

10 police* 4 fire* 3 security/reception* 3 bus company* 2 other ambulance* 2 Doctors deputising* 1 social services* 1 friend

Figure 8.3.1. Who calls for the emergency ambulance? *Indicates those targeted for a call reminder card (see conclusions)

The remaining 5 callers (5%, 95% CI 1.8-11.7) had no means of contacting the patient.

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8.3.4. Limitations No attempt has been made to determine the accuracy of the information obtained from the callers. This study therefore represents the best case scenario presuming All callers gave accurate information and were able to carry out instructions. There is no reason why this sample should not be representative of general calls to the ambulance service studied and the findings should therefore be generalisable. There may be some differences in the extent of communication problems between ambulance services according to the ethnic mix and other demographic features of the community served. Duplicate calls may be underestimated as these invariably occur simultaneously and one assessor can only monitor one call.

8.3.5. Conclusions West Midlands Ambulance Service (WMAS) serves a population of 2.3 million people 92, in a mainly urban environment. The majority (84.8%) are white. However, other self-reported ethnic groups comprise South Asian (9.9%) (including Indian 5.6%, Pakistani 3.6%.and Bangladeshi 0.7%), Chinese (0.6%), Black (3.9%) and Other (0.8%). This population therefore has a higher proportion of South Asian people than Great Britain as a whole (2.8%). Those reporting their ethnic group as white or black generally speak English93,94. Among the South Asian groups, the ability to speak English varies by group. In those aged 16-74, 85% of Indians, 72% of Pakistanis and 59% of Bangladeshis speak English94. If these figures are extrapolated for the population served by WMAS, then 2.3% of the population are not likely to speak English. Applying these figures to the 0.2 million calls received per year by WMAS, then non-English speaking people will make 4,200 calls per year. There will be a further substantial number who do not have English as their first language where communications may therefore be hampered. This calculation also excludes visitors to the area.

It is surprising, with such a high prevalence of non-English speaking people, that in only one case did the call taker not manage to obtain medical details and in only three cases did it delay or restrict the communication. This may be rela ted to the fact that non-English speakers will usually get access to someone speaking English before making an emergency call. It is not known whether this causes any delay in accessing the emergency system. 124

It is to be expected that people making emergency calls will be emotional and excitable. However, a study of cardiac arrests in Vienna had no distraught callers in a series of 59 cases69. In this series, in only 5% of cases did this delay the call taking and in none did it prevent reception of information. This is mainly due to the call takers being trained in the management of such situations. The callers may be able to carry out first aid instructions if calmed down by the call taker. The one abusive caller may reflect alcohol consumption or anxiety and he would not co-operate with information gathering. The three cases of misunderstanding were due to specific terms (medication, conscious) in the prioritisation system and were solved by the use of simpler language. Although 93% of households have a telephone95, many accidents occur outside the home. If the caller does not have direct access to the patient, gathering further information and giving first aid advice is unlikely to be effective. In only 42 cases (41.6%, 95% CI 32.0-51.8), was the caller close to the patient. Any prioritisation and advice system handling emergency ambulance calls will therefore have difficulty. Even those callers in the vicinity of the patient will experience problems as the process is interactive - needing a progression of questions and serial instructions which may take an excessive time if the caller is shuttling between the phone and the patient. The two major prioritisation systems gain much of their information on only four to six questions. At present less than half of emergency ambulance callers are with the patient. This is similar to the 55% noted in cardiac arrest cases in Vienna69. In Seattle, the city of origin of CBD, only 29% of cardiac arrests had advice delayed by the caller not being near the patient 96. This is likely to severely restrict accuracy of prioritisation systems in the UK and the ability to give first aid advice, which often involves many steps. The caller cannot be expected to comprehend and carry out more than two instructions at a time. Going from phone to patient or via a third party is likely to be ineffective. Community first aid programmes and targeting first aid advice on key personnel will continue to be vital when such a large proportion of 999 callers are not with the patient. Those who only need reminding of first aid rather than immediate teaching may be able to absorb more complex or longer instructions and then leave the phone to go to the patient. To assist prioritisation it may be more effective to issue key organisations with a call reminder card, listing key information to be obtained before phoning 999 , than attempting to obtain information indirectly via a third party during the emergency. If such a card were issued to 125

emergency services, travel company controls, health care organisations and home carers (marked * in figure 8.3.1), it would improve the quality of information in 35 of the cases, representing 59% of those not with the patient. This advice could also be included in telephone directories and telephone boxes.

This study demonstrates the inherent difficulties for any prioritisation or advice system associated with the 999 emergency call system, because of the location of the caller and associated communication difficulties. It also highlights important differences between the study area in the UK and Seattle, where CBD originated, and where most of the supportive research has been undertaken. A larger study has now been undertaken and has been published97.

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8.4 CBD usage at a time of exceptional workload

8.4.1. Introduction If all emergency ambulance calls could receive an immediate response from an ambulance travelling in emergency mode then there would be no need for prioritisation. There are two major reasons why this does not occur. Firstly, there are times when the demand for ambulances outstretches the resources available. Secondly, responding in emergency mode is hazardous and therefore should not be undertaken unnecessarily for the safety of the ambulance personnel and the public. The components of this thesis have already raised concerns over whether CBD is safe and effective at categorising patients according to severity of illness. Once cases have been prioritised then that prioritisation must be utilised operationally for CBD to be effective. This element of the study looks at how CBD prioritisation categories are utilised at times when resources are limited compared to the demand.

New Years Eve is a catalyst for large mass gatherings with the potential for high numbers of casualties. It is said to be the busiest period of the year for the ambulance service. In 1997/98 in Edinburgh, a 50% increase in A&E department staffing was insufficient to resolve the problems of increased attendance 98. The New Year of 1997/98 was the first New Year when 999 call prioritisation was operational in the UK. Periods of maximum workload are the ultimate test of this resource allocation system. Category A calls should receive a faster response than Category B or "C". However, no previous research has looked at whether prioritisation achieves its purpose as a tool for managing excessive workload.

The West Midlands Ambulance Service (WMAS) database holds records for every 999 emergency ambulance call received by the control room. Each incoming call is automatically assigned an individual identity number by the control system software. Duplicate calls for the same incident are cross-referenced manually and the records of the ambulance respons e stored with the first call logged. The log also contains details of all the units that were responded to the incident and their time of arrival at scene. The latter time is recorded via the satellite

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tracking system on depression of a button in the ambulance cab. All calls are logged to the nearest second.

8.4.2. Aim of this study The aim of this study was to determine whether the ambulance prioritisation system allows the most urgent cases to receive a priority response at a period when demand massively exceeds the resources available.

8.4.3. Methods Data on all incidents occurring in the first eight hours of 1998 (1st January 00.00 hrs. to 07.59 hrs.) were downloaded from the WMAS control database. The number of calls per hour was compared with the hourly average for the same time period in the first seven days of December 1998. The response time (from the ambulance service telephone answering to the arrival of the first ambulance service response) for each incident was assessed according to the time of day and the prioritisation system category. Adequate data were defined as those incidents with times recorded, to allow calculation of response times, and where the prioritisation system category was recorded.

Analysis was undertaken to determine whether response times varied according to the prioritisation system category. Mean response times were calculated for the eight-hour period, with standard deviations. To allow for isolated exceptionally long response times, the number of incidents responded to within ORCON42 time frames for urban ambulances were calculated. Category A calls have an ORCON target time of 8 minutes and Category B and C calls of 14 minutes. Thirty and sixty minute response times are also included for completeness. These response times were also calculated for each one -hour period of the eight-hour study period.

8.4.4. Results A total of 494 999 calls were received in the eight hour study period, relating to 380 incidents (average 1. 3 calls per incident). This represents an average call reception rate of over one per minute (62 per hour), ranging from 6 calls per hour between 06.00 hrs. and 06.59 hrs. to 88 calls per hour between 01.00 hrs. and 01.59 hrs. (figure 8.4.1.). The number of calls was

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substantially greater than the workload for this time period in the comparator week, which averages 16.4 calls per hour with a peak hourly rate of 30.4.

100 90 80 70 60 50 40 30 20 10 0 00:0 01:0 02:0 03:0 Tim New Years Comparator 04:0 05:0 06:0 07:0

Figure 8.4.1. Hourly 999 call rate compared to a control time period.

Inadequate data were recorded for 126 incidents (all with incomplete time recording, one with no priority code). There was no difference in the distribution of the prioritisation categories between cases with adequate and inadequate data. Adequate data were available for 254 of the 380 incidents and these were included in the following analyses. Of the incidents with adequate data, 69 (27.2%) were Category "A", 136 (53.5%) were Category B and 49 (19.3%) were Category "C". In the one week control period, for patients presenting between 00.00 hrs. and 07.59 hrs., Category A patients accounted for 28.6%, Category B for 59.2% and Category C for 12.1% (see table 8.4.1). There is no significant difference in the proportions of Category A and B patients between the New Year and a control group matched for time of day.

Calls per hour

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Table 8.4.1. Emergency ambulance calls by prioritisation category for New Years Eve and a control period. New Year A B C n= 69 (27.2%) 135 (53.5%) 49 (19.3%) 253 Control 85 (28.6%) 176 (59.2%) 36 (12.1%) 297 p = NS p = NS p<0.05

The percentage of incidents responded to within 8 minutes in category A and within 14 minutes for categories B & C, with variation by time of day is shown in table 8.4.3. No significant difference was observed in the proportion of Category A cases achieving the eight minute response (the new standard for Category A patients) compared to those in Category "B". The same is true for the 14 minute response.

Table 8.4.2. Percentage of ca lls responded within 8 and 14 minutes.


Time (GMT) Response time (mins) 00.00 01.00 02.00 03.00 04.00 05.00 06.00 07.00 All CBD categories 0-8 0-8 p= 38.9% 42.9% NS 21.4% NS 7.7% NS 16.7% 20.0% 50.0% NS NS NS 0.0% NS 75.0% 29.0% A NS NS

25.0% 15.4% 26.9% 38.9% 52.9% 57.1% 30.8% 33.5% B&C

0 - 14 0 - 14 p=

72.2% 76.2% NS

64.3% 46.2% 33.3% 80.0% 87.5% 100.0% 100.0% 66.7% A 52.8% 38.5% 73.1% 88.9% 82.4% 100.0% 84.6% 69.2% B&C NS NS NS NS NS NS NS NS

>14 >14

27.8% 23.8%

35.7% 53.8% 66.7% 20.0% 12.5% 47.2% 61.5% 26.9% 11.1% 17.6%

0.0% 0.0%

0.0%

33.3% A

15.4% 30.8% B&C

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Average response times and the range of response times by category are shown in table 8.4.3. Table 8.4.3. Average response times and the range of respons e times by category. CBD category Category A Category B Category C All cases mean 13 14 14 14 SD 9.6 12.0 10.8 11.2 max. min incidents with adequate data 53 66 55 66 4 0 0 0 69 135 49 253

Exceptional delays (>30 minutes) were experienced in 19 cases. Of these 5 (26%) were Category A calls, 3 occurring between 02.29 hrs. and 02.43 hrs. Thirteen (68%) of the delays occurred between 01.31 hrs. and 02.31 hrs. In this one hour period only 2 of 15 (13.3%) Category A calls were responded to within the target 8 minutes and only 14 of 30 (46.7%) B calls within the target of 14 minutes. Two cases (both category "B") waited over an hour.

8.4.5. Limitations This study only looks at the experience of one ambulance service in one year. One third of incidents have missing data, which probably reflects the excess of demand over resources within the control room. However, the distribution of the prioritisation system codes in the adequate data sample and in the whole population is not significantly different.

The observed results could relate to the use of the prioritisation system by the particular ambulance service studied or the particular people working the shift concerned. However, the conclusions do reflect the prioritisation system in actual use. There is no reason to believe the results should not be representative of ambulance service practice in the UK.

8.4.6. Discussion This study confirms that New Year's Eve is an exceptionally busy period for ambulance services with high hourly call rates. From midnight until 06.00 hrs. demand is markedly increased on this night of the year. The number of calls reaches a peak between 01.00 hrs. and 131

01.59 hrs., with a four -fold increase in 999 call volume over normal for three consecutive hours. The outcome study showed that West Midlands Ambulance Service achieves national targets, however these are not achieved on New Years Eve. During this period response times are markedly delayed, with occasional waits of over an hour occurring for a 999 ambulance.

New Years Eve does not have any special requirements because of any increased severity of illness as predicted by CBD. The popular belief among ambulance services that more low priority cases are seen in this time period is supported by this study, although the proportion of Category A cases is no different.

To ensure that a rapid response is maintained to those whose condition may deteriorate if ambulance arrival is delayed, prioritisation systems should be used when demand exceeds resources. It is worrying to obs erve that response times do not appear to vary according to the prioritisation system category. No variation in response times is demonstrated in either absolute numbers of calls or the percentage of that category (both of which should reflect the prioritisation effect). In all but the final one hour time period, the percentage of cases achieving an eight-minute responses was better in categories B & C than in category A, although the observed differences were not statistically significant. No difference was seen in the fourteen-minute response between prioritisation categories. It appears therefore that either the prioritisation system was not being used to give a more urgent response to those classified as Category A, or the available resources were insufficient even to cope with responding to the Category A cases. Failure to use the system may result from staff changing to the more familiar, traditional and simpler, but not necessarily safer, method of first come, first served allocation of resources. At times when the ambulance service is exceptionally busy, one would expect the prioritisation system to be utilised as a risk management tool.

8.4.7. Conclusions The figures presented suggest that the ambulance service may need to increase its resources on New Years Eve between midnight and 04.00 hrs. to be able to maintain normal response standards. Alternatively, ambulance services need to look at other ways of managing this exceptional workload. This may include use of first responders or doctors to assess the need for an ambulance, use of the voluntary aid societies or use of a non-ambulance response (for example, taxi) for non-urgent cases. An alternative approach may be to decrease turnaround 132

time for ambulance availability by delivering appropriate patients to other local facilities, such as primary health care centres with provision for minor injury care. Category C patients accounted for 19% of cases and will include those who may not need an ambulance immediately. A non-ambulance response may be appropriate for such cases and this is discussed in the conclusions of this thesis.

If the prioritisation system is not being utilised at times of maximum workload, then its use overall is put into question. The time required for dispatchers to ask the extra questions and the cost of the extra training are wasted if no advantage results. It may be better to spend the money that would be invested in prioritisation systems in refining deployment strategy or training and staffing more response units. Alternatively, ambulance services need to assess why the prioritisation system is not being utilised and address those problems. At present the prioritisation system appears to represent a large investment that is failing to deliver benefits in resource utilisation during periods of high demand.

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9. Conclusions
The existing literature that is applicable to the UK in regard to prioritisation of ambulance calls is sparse. What exists has highlighted some of the advantages of prioritising 999 calls by an earlier response and the ability to respond more highly trained crews. In the UK, there is a paramedic in every ambulance and so the latter advantage is not applicable. The literature has also demonstrated that more efficient operational use of ambulance is possible with prioritisation. However, clinical benefits have been only variably demonstrated. Failure to detect serious cases has been recorded in some specific patient groups but has never been closely analysed.

The outcome and ambulance alerts studie s in this thesis have demonstrated that the use of CBD does have some significant safety issues. It must, however, be remembered that prior to the introduction of call prioritisation all ambulance calls were responded to equally with a target time of 14 minutes. Failure of the system to detect serious cases does not therefore confer any disadvantage over the previous system; it simply fails to instigate the improvement of care that was a cornerstone of the argument for the introduction of CBD. The effects of this delay are generally unknown. The time to first medical assistance has been shown to be important in varying scenarios17, 18, 19.

The degree to which CBD fails to detect all the potential time dependant critical illnesses has not been extensively described and is a major finding of this thesis. This failure of the system can be measured in many ways. The opinion of experts in the outcome study suggested that the system failure rate was 16.7% - 38.4% overall. This study has also hypothesised that the dispatchers use the system for guidance rather than as a strict rule book; in this way they improve the system and reduce the under-triage rate of the system. The broad range partly reflects the problems with using expert opinion. There are specific cases where urgent care was required to prevent further deterioration. In these cases where either the ambulance crew or the receiving team in the accident and emergency department commenced urgent treatment, there was a failure to detect the seriousness of the problem by the dispatching system in up to 69% of cases. The other scenario when emergency care can be presumed to be needed is when there is gross physiological abnormality such as airway obstruction, respiratory distress or unconsciousness. In these situations, in up to 55% of occasions the problem was not detected. 134

In cases where the ambulance crew thought the patient was ill enough to require a team standing by at the hospital, the dispatcher using CBD did not detect at least 20% of cases. The error rate appears highest in the most seriously ill, the group which prioritisation is meant to benefit.

It appears from various aspects of the work in this thesis that an over-triage rate of 50% will occur because of the safety margin required. Attempts to reduce the over-triage rate below this should be undertaken cautiously with full evaluation. It is unlikely that information from a 999 call will ever improve on an experts opinion with information from the patient after arrival in hospital, which over-triaged half of cases.

Often the predicted need for emergency intervention was not substantiated when the eventual diagnosis was known. This final diagnosis may only be known after hospital investigation, such as after an x -ray to exclude a neck injury. Nevertheless even when looking with the aid of all diagnostic tests to make the diagnosis, at least 10% of patients who needed a category A response were not triaged as such.

Criteria Based Dispatch cannot therefore be currently stated to be effective at detecting life threatening illness and injury. Expert opinion of the CBD system studied in this thesis has shown that there are many areas of concern. In only 16.4% of codes did a majority of all expert groups agree with the prioritisation. In 46.6% the majority disagreed. When asked to give their opinion of the prioritisation with previous knowledge of the codes, a group of experts gave different priority to 39% of codes. These have been backed up by the other elements of this study. This summary of the conclusions focuses on those issues, which were detected by multiple elements of the study. Individual issues have already been mentioned in the chapter conclusions. It is recommended that a review should be undertaken of all these areas of concern in developing a safer and more effective system of prioritising 999 calls.

Uncontrolled haemorrhage was detected as a major cause of under-triage. Whatever the source of bleeding, if it cannot be controlled then serious consequences will occur. The ambulance services first action to stop this bleeding should be by giving first aid advice. However, the communication difficulties study demonstrated that less than half of callers are 135

within talking distance of the injured party. Hence telephone first aid advice will often not resolve the problem. It is therefore appropriate to respond a person sufficiently skilled to stop the haemorrhage at the earliest time. Hence, all situations with uncontrolled haemorrhage should have a category A response.

Any person with a decreased level of consciousness is at risk. Their airway may be compromised because of their inability to control their own airway. Equally they are unable to protect their own airway, so saliva, vomit or blood may obstruct the airway. This will lead to death or severe neurological injury within minutes. Hence a response within 8 minutes is vital. CBD gives a category A response for people who are unconscious but not those with a decreased conscious level. It is known that the public does not understand the term unconscious80 , let alone the detail of difference between unconscious and decreased conscious level. Any decrease in conscious level is a risk to the patient and also a sign of potential serious impairment or illness. I recommend that all people with any lowering of conscious level should be categorised as "A". This could be achieved by asking whether the person can talk. Other errors resulted from the discrepancy between CBD and nationally accepted guidelines for head injury management85.

Errors were detected in the outcome and alerts studies because of persons reported to be fitting. Fitting is most commonly due to eplileptiform seizures. However, there can be many other causes. Lack of oxygen to the brain because of airway obstruction, inadequate ventilation or poor tissue perfusion can all c ause fits. Usually, the fits of brain hypoxia are short lived, followed by unconsciousness and then death, if no corrective action is undertaken. The majority of these problems could be solved by introducing a new code of fits continuing or not talking since fit and by limiting the use of fit, unknown cause to have the additional statement of now recovered.

The threat to life posed by burns injuries can be difficult to assess. It is well recognised that people with severe burns can initially be walking and talking but die soon after. Burns to the airway can be difficult to detect and can deteriorate very rapidly. All burns to the face or sustained in a closed environment, with the risk of smoke or hot air inhalation, should therefore be categorised as A. The criteria for severe burns by surface area is 15%. This is the nationally accepted level at which resuscitation should be commenced in adults. The body surface area in children for resuscitation is 10%. There is no information to suggest how well 136

this can be estimated on the telephone, so any burn of a whole limb, the front of the chest or equivalent area should be presumed to be over the limit and categorised as A. Burns due to electrocution have the risk of cardiac arrhythmias and those due to chemicals need rapid decontamination and so should receive an urgent response.

Diabetics represent a special group of patients. In particular, the onset of hypoglycaemia can be highly variable in duration and appearance. Hypoglycaemic episodes were missed because the diabetic was classified as being unwell and then deteriorated further. Any fainting, unusual behaviour, sweating or short duration of being unwell should be presumed to be due to hypoglycaemia. At present none of these receive a category A response. The other common metabolic emergency is related to overdoses. Certain overdoses can initially appear well and then suddenly deteriorate often due the drugs cardiotoxic effect. CBD would not detect such high-risk overdoses. A question asking about the type of medication taken should help to resolve this issue.

The elderly often have atypical presentations of common conditions. Falls are often due to an underlying medical cause, such as palpitations or vertigo. Faints can be for more serious reasons than simple vasovagal episodes. Hence the codes for "falls no injury" and "simple faint" should be limited to the younger age group and those in whom it is certain there was no predisposing cause. Children under two years of age are all classified as category "A". Experts thought this could be downgraded in some cases. Because of the difficulty in assessing this age group and the speed with which they can deteriorate, combined with the small numbers involved, it may be better to leave this group uncha nged. Road accidents often have multiple telephone calls and many are reported on mobile phones by people who have passed the incident and have not stopped to see the victim. Hence there is often insufficient information to determine the victim's clinical condition. ATLS gives guidelines for mechanisms of injury that are high risk and these should be all categorised as "A". Falls were also noted in both the alerts and outcome studies to have been under -triaged. Similarly falls greater than 10 feet for adults are known to be high risk and should be reclassified.

Lack of information occurs in 15% of calls because of communication difficulties and when the caller away from the victim this problem is increased. If there is insufficient information, 137

then a higher prioritisation code should be used. In CBD there are several instances where the unknown history is classified as category "C". In the interests of safety this should be changed.

Many of the changes recommended above are consequent on changes made to the American system when it was introduced into the UK. The problems relate to decreased conscious level, haemorrhage and road traffic accidents would not have occurred if the American system had been used without change. CBD needs to be reviewed to ensure that the cases highlighted above will receive a category A response in the future.

Another proposed use of CBD is in detecting those patients who may not need a 999 ambulance response. It has been suggested that category C calls could be dealt with in this way. However, this study has highlighted that category C does not equate exclusively with minor illness or injury. The examples cited above demonstrate that many of the present category C calls may need a category A response. This may be par tially solved by a recoding. The system proposed by Dale and others89 of passing category C calls over to NHS Direct who can then undertake further interrogation to determine the most appropriate and safest response. In his study, Dale demonstrated that half of category C calls did not require an emergency ambulance. The survey of those not transported, in this thesis, has shown that there is a high proportion of patients currently calling 999 who could be u sing other services, if a method of detecting which service could be developed and the resources were made available. This system cannot, however, be used as a safety net for poor initial prioritisation, as it does inevitably result in a delay of the ambul nce response because of the a further interrogation.

If prioritisation is to be effective then action must be taken appropriate to the category ascribed to cases. This study has shown that there is no significant difference in ambulance response times according to CBD category. Even at a time of high workload when the ambulance service were overloaded with cases (New Years Eve), the prioritisation category was not a determinant of the speed of response. It appears that the advantages of call prioritisation for resource usage and patient benefit are being lost. 138

This thesis has demonstrated some major weaknesses in one system of call prioritisation currently used in the UK. No inference can be made as to how the other system performs. At present the syste m has a high failure rate in detecting the seriously ill and much of this is due to system design. There is a need for further work to examine how critically ill and injured patients can be more accurately detected from a 999 call. Until this work has been done people should not presume that 999 call prioritisation codes equate to severity of illness. At present CBD is simply a guide to the possible severity of a persons condition.

Although CBD is only currently used by some ambulance services for prioritisation of 999 calls, the use of prioritisation of emergency workload is increasing. The National Health Service is developing a system of clinical assessment that can be used either by telephone or face-to face. The development of such systems has an initial assessment to exclude serious illness or injury. As this is developed the principles and problems highlighted in this thesis should be taken in to account so that similar problems are not re-invented.

Summary The initial expert opinion highlighted a cause for concern due to the poor level of agreement with the CBD system. The literature review demonstrated that the system was not founded on a strong evidence base and that there had been no rigorous evaluation of the system. The outcome study has demonstrated an under-triage rate of 12.6% - 25.6%, when comparing actual dispatch prioritisation with expert opinion with knowledge of eventual diagnosis. The actual system has a higher rate that is corrected by the intervention of the dispatcher. The patients early or late outcome does not seem to relate accurately to their CBD coding. The outcome study also highlighted that certain seriously ill patients, especially diabetics, those having fits, those suffering trauma, those with airway obstruction, potential spinal injury and who are unconscious may be at particular risk. The alerts study has demonstrated that at least 20% of critically ill patients may not be detected by CBD. The particular areas of concern are the failure to recognise cardiac arrests; the miscodings are often related to fits, severe bleeding, unconsciousness, falls/faints and the use of mechanism of injury rather than clinical state. Many of the areas of concern that have been determined in the outcome study and the alerts study could potentially have been prevented by not changing the American system of CBD when it was adopted in the UK. 139

The outcome study has demonstrated that patients initially categorised as C are often in need of monitoring in the ambulance or require a prehospital intervention, although they are rarely physiologically disturbed. 10% of all admissions and 9% of deaths are categorised C. It is therefore already apparent that it not safe to automatically state that those category C patients are safe to be transferred directly to another source of care. The non-transport study has revealed that many cases that do not need ambulance care are classified other than category C. Category C is therefore neither sensitive nor specific for detecting those with minor conditions that do not require an emergency ambulance response.

Having shown the problems related to prioritisation of emergency ambulance calls using CBD, the New Year's Eve study then demonstrates that the ambulance control centre did not utilise the prioritisation information in determining how to allocate resources. It appears that CBD has major flaws. This research recommends that the American system of categorisation of CBD should be adopted and that specific presenting groups should be reviewed. The use of category "C" to decide whether to send an ambulance, without any further prior assessment, does not appear to be safe at present.

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Papers published in relation to this thesis


PEER REVIEWED PUBLICATIONS

Cooke MW, Wilson S. Are 999 callers in a position to give triage information and receive first aid advice. Pre Hospital Immediate Care 1998;2:193-196. Cooke MW, Morrell R, Wilson S, Allan T, Bridge P, Edwards S. Does Criteria Based Dispatch adequately detect the critically ill and injured? Prehospital Immediate Care 1998;2:52. Wilson S, Edwards S, and Cooke MW. Inappropriate ambulance usage is a retrospective diagnosis. Journal of Accident and Emergency Medicine 1999;16:75. Cooke MW and Jinks S. Planning cannot rely on emergencies arriving by ambulance. Journal of Accident and Emergency Medicine 1999;16:74-75. Cooke MW, Wilson S, Allan T and Bridge P. Will prioritisation of 999 calls help ambulance services cope with the Millennium celebrations? Prehospital Immediate Care 1999;3(4):203205. OFFICIAL REPORTS Cooke MW, Wilson S, Allan T, Bridge P, Edwards S, Morrell R. Safety and effectiveness of criteria based dispatch in the prioritisation of 999 calls. Emergency Medicine Research Group, University of Medicine, Birmingham 1998. OTHER PUBLICATIONS not peer reviewed Cooke MW, Wilson S, Allan T, Bridge P, Edwards S, Morrell R. Safety and effectiveness of criteria based dispatch in the prioritisation of 999 calls. What Matters: Research and Development News West Midlands Region. 1998 Issue 8, p4. INVITED LECTURED AND SEMINARS Cooke MW. Measuring Outcome in Dispatch (invited presentation). Ambulance Service Association, London 24 September 1998. Plenary. CONFERENCE PROCEEDINGS & OTHER PRESENTATIONS Cooke MW, Morrell R, Wilson S, Allan T, Bridge P, Edwards S. Does Criteria Based Dispatch adequately detect the critically ill and injured? (oral presentation) Conference of Pre-hospital Immediate Care, London (5 March 1998). Parallel session.

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Cooke MW, Wilson S, Allan T, Bridge P, et al. Is CBD applicable on an international basis? (Emergency Care Conference, Johannesburg, South Africa 5-10 October 1998) Parallel session. Harrison JF Cooke MW, Early Warning of Accident and Emergency Departments by Ambulance Services. (oral presentation) Conferen of British Association for Accident and ce Emergency Medicine, Birmingham 29 April-1 May 1998 (Abstract in Journal of Accident and Emergency Medicine 1998;15:278).

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Appendix One

The CBD (UK)coding system


Condition Unconscious or not breathing Difficulty in breathing 12 to 50 years with fainting / dizziness Lower abdominal pain, female 12 to 50 years with fainting / dizziness Vomiting red blood Black tarry stools Upper abdominal pain , more than 35 years Abdominal / back pain, more than 50 years with fainting / dizziness Fainting / dizziness when sitting up Side / back pain Pain with vomiting Unspecified pain Abdominal / back pain less than 50 years (Non Traumatic) Chronic back pain Code 1A1 1A2 1B1 1B2 1B3 1B4 1B5 1B6 1B7 1B8 1C1 1C2 1C3 2A1 2A2 2A3 2A4 2A5 2A6 2B1 2B2 2B3 2C1 2C2 2C3

Chief complaint Abdominal / Back P ain

Allergic Reaction

Unconscious or not breathing Difficulty breathing or swallowing Cannot talk in full sentences Swelling in throat Fainting History of severe reaction occurring less than 30 minutes of exposure History of severe reaction but none now Call delayed more than 30 minutes with history of reaction Reaction to medication Itching and / or rash with no difficulty breathing Concern about reaction but no history Reaction present for some time with no difficulty breathing

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Appendix One (contd.) Animal Bites Unconscious or not breathing Difficulty in breathing Uncontrolled bleeding Severe bites to face and/or neck Bite from poisonous animal Bite below neck with controlled bleeding Minor bite below neck non-poisonous Swelling at bite site Bleeding (Non Trauma) Unconscious or not breathing Multiple fainting episodes Fainting or near fainting when sitting Vomiting blood (red / dark red) Coughing up blood (red / dark red) more than 1/2 cup Lower abdominal pain female 12 to 50 years with associated heavy vaginal bleeding Sweating Black tarry stools Vaginal bleeding more than 20 weeks pregnant Bleeding without 'A' criteria Vomiting up coffee ground like substances Weakness Uncontrolled nose bleed Vaginal bleeding without fainting less than 20 weeks pregnant Rectal bleeding without "B" criteria Vaginal spotting Nose bleed without "A" or "B" criteria 3A1 3A2 3B1 3B2 3B3 3B4 3C1 3C2 4A1 4B1 4B2 4B3 4B4 4B5 4B6 4B7 4B8 4B9 4B10 4B11 4B12 4B13 4C1 4C2 4C3

144

Appendix One (contd.) B reathing Difficulty Unconscious or not breathing Inhaled Substances Unable to talk in full sentences Difficulty breathing with chest pains Children less than 12 years with history of asthma or respiratory problems Difficulty breathing more than 50 years Recent childbirth / broken leg / hospitalisation within last 2-3 months Drooling / difficulty swallowing Asthma unresponsive to medication Less than 50 years without 'A' criteria Tingling or numbness in extremities or around mouth Blocked up nose and / or cold symptoms Patient assistance Cardiac Arrest Unconscious or not breathing Suspected sudden death Sudden infant death syndrome Very obviously dead / burned beyond recognition / rigor mortis present Chest Pain Unconscious or not breathing Short of breath cannot talk Fainting Severe chest pains with sweating Rapid heart rate with chest pains or medical history of heart problems Male more than 35 years Female more than 40 years 15 to 35 years with shortness of breath / nausea / sweating With drug abuse Male less than 35 years without 'A' or 'B' criteria Female less than 40 years without 'A' or 'B' criteria Rapid heart beat without 'A' or 'B' criteria Chest injury less than 35 years without 'A' or 'B' criteria 145 5A1 5A2 5A3 5A4 5A5 5B1 5B2 5B3 5B4 5B5 5C1 5C2 5C3 6A1 6A2 6A3 6C1

7A1 7A2 7A3 7A4 7A5 7B1 7B2 7B3 7B4 7C1 7C2 7C3 7C4

Appendix One (contd.) Choking Unconscious or not breathing Unable to talk or cry Turning blue Difficulty / noisy breathing Able to speak or cry No difficulty breathing at time of call Diabetic Unconscious or not breathing Severe difficulty breathing Fitting Decreased level of consciousness Fainting Chest pain Unusual behaviour / acting strange Sweating Awake / alert Not feeling well Weakness Environmental Unconscious or not breathing Severe difficulty breathing Confused / disorientated Fainting Chemical on patient without other criteria Uncontrollable shivering Excessively hot Minor injuries without 'A' or 'B' criteria No injuries but patient has been exposed 8A1 8A2 8A3 8A4 8B1 8B2 9A1 9A2 9A3 9B1 9B2 9B3 9B4 9B5 9C1 9C2 9C3 10A1 10A2 10B1 10B2 10B3 10B4 10B5 10C1 10C2

146

Appendix One (contd.) Fits / Convulsions Not breathing after fit stops Continuous fits more than 5 mins Multiple fits Pregnant Secondary to recent head injury Diabetic Secondary to drug overdose Fit unknown history Fit / convulsion less than 6 years Single fit, known history of fitting disorder First time fit more than 6 years Gynaecological / Miscarriage Unconscious or not breathing Vaginal bleeding with fainting Fainting or near fainting when sitting up Abdominal injury with contractions more than 24 weeks pregnant Lower abdominal pain 12 to 50 years if associated with dizziness / fainting or heavy vaginal bleeding Sweating Bleeding more than 20 weeks pregnant Vaginal bleeding without fainting Abdominal injury without contractions more than 24 weeks pregnant Waters broken Pregnant less than 20 weeks or menstrual with any of the following: cramps pelvic pain spotting 11A1 11A2 11A3 11A4 11A5 11B1 11B2 11B3 11B4 11B5 11B6 12A1 12A2 12A3 12A4 12A5 12B1 12B2 12B3 12B4 12B5 12C1

147

Appendix One (contd.) Headache Unconscious or not breathing Decreased level of consciousness Mental confusion Worst headache ever Sudden onset Physical exertion Head injury without 'A' criteria Headache without 'A' or 'B' criteria Migraines Mental/Emotional Unconscious or not breathing Gunshot wound / stab to head, neck, torso or thigh Unus ual behaviour associated with diabetes Suicidal overdose of medication Lacerated wrist Unusual behaviour associated with psychiatric history Unusual behaviour due to drugs Known alcohol intoxication Threats to self or others Police request standby Overdose / Poisoning Unconscious or not breathing Severe difficulty in breathing (unable to speak in full sentences) Difficulty in swallowing Decreased level of consciousness Intentional / accidental drug overdose Ingestion of household cleaners Acute alcohol intoxication less than 17 years Alcohol or drug overdose Drug overdose with chest pain Third party caller not with patient Chemicals ingested / splashed on skin Drug use without A or B criteria Alcohol intoxication without drugs more than 17 years 148 13A1 13B1 13B2 13B3 13B4 13B5 13B6 13C1 13C2 14A1 14A2 14B1 14B2 14B3 14B4 14B5 14B6 14B7 14C1 15A1 15A2 15B1 15B2 15B3 15B4 15B5 15B6 15B7 15B8 15B9 15C1 15C2

Appendix One (contd.) Pregnancy / Childbirth Unconscious or not breathing Vaginal bleeding with fainting Fainting or near fainting when sitting up Fitting Delivery Labour pains / contractions: less than 2 mins 1st pregnancy less than 5 mins 2nd pregnancy Bleeding more than 20 weeks pregnant Premature labour more than 4 weeks Abdominal injury more than 24 weeks Vaginal bleeding without fainting Waters broken Labour pains: more than 2 mins 1st pregnancy more than 5 mins 2nd pregnancy Pregnant less than 20 weeks with abdominal pain / 16C2 spotting Sick / Unknown Unconscious or not breathing Multiple fainting episodes Decreased level of consciousness Chest discomfort more than 35 years Indigestion more than 35 years Dizziness when standing Generalised weakness Third party caller not with patient Medical alarm from Social Services Other problems without other criteria Flu symptoms High blood pressure High temperature Patient assistance 17A1 17B1 17B2 17B3 17B4 17B5 17B6 17B7 17B8 17B9 17C1 17C2 17C3 17C4 16B3 16B4 16B5 16B6 16B7 16C1 16A1 16A2 16A3 16A4 16B1 16B2

149

Appendix One (contd.) Stroke / CVA Unconscious or not breathing Severe difficulty breathing Fitting Decreased level of consciousness Chest pains Diabetic Severe headache One sided hemiplegia Weakness, numbness Trouble speaking Unconscious Unconscious or not breathing Confirmed unconscious/unresponsive Combined drugs and alcohol overdose Difficulty breathing Alcohol intoxication less than 17 years Unconfirmed slumped over wheel Third party caller not with patient Multiple fainting episodes Fainting associated with headache, chest pain / discomfort / palpitation more than 35 years / diabetic / GI bleed. Vaginal bleed sitting or standing / abdominal pain female 12 to 50 years Single faint Unconscious but now conscious Conscious with minor injuries Alcohol intoxication more than 17 years Obviously dead - decapitated / burned beyond recognition / cold & stiff, unless child less than 1 year 18A1 18A2 18A3 18B1 18B2 18B3 18B4 18B5 18B6 18B7 19A1 19A2 19A3 19A4 19A5 19A6 19A7 19B1 19B2

19B3 19B4 19B5 19B6 19C1

150

Appendix One (contd.) Miscellaneous Airport alert Bomb device detonated Major incident Fire persons reported Explosion Smoke detector no speech contact Firearms incident Prison incident Chemical incident - stand by Riot incident Bomb device unexploded Fire Service - standby Automatic fire alarm Police - standby Hoax call Hoax call children Caller cleared unable to call back Major incident exercise Sporting event 20A1 20A2 20A3 20A4 20A5 20B1 20B2 20B3 20B4 20B5 20B6 20B7 20C1 20C2 20C3 20C4 20C5 20C6 20C7

151

Appendix One (contd.) Assault / Trauma Unconscious or not breathing Crushing or penetrating injury to head, neck, chest, abdomen or thigh Decreased level of consciousness Uncontrolled bleeding Penetrating injury to extremities below shoulder or below knee Unknown injury Minor injuries with weapons Extremity/femur fracture Sexual assault/rape without 'A' criteria Minor injuries without weapons Concerned without apparent injuries Police request standby or check patient Burns Unconscious or not breathing Difficulty breathing Difficulty talking / swallowing Decreased level of consciousness Burns to airway, nose, mouth Electrocution / electrical burns Burns / scalds more than 15% of body surface Battery explosion Chemical burns to eyes Small burns from match or cigarette Freezer burns Drowning Unconscious or not breathing Difficulty breathing Confirmed submerged more than 1 minute Scuba diving accident without 'A' criteria Patient not submerged Patient coughing Other injuries without 'A' criteria Minor injuries (lacerations) 21A1 21A2 21B1 21B2 21B3 21B4 21B5 21B6 21B7 21C1 21C2 21C3 22A1 22A2 22A3 22B1 22B2 22B3 22B4 22B5 22B6 22C1 22C2 23A1 23A2 23B1 23B2 23B3 23B4 23B5 23C1

152

Appendix One (contd.) Falls / Accidents Unconscious or not breathing Severe difficulty breathing Accident with crushing or penetrating injury to head, neck, torso, or thigh or patient trapped Decreased level of consciousness Amputation above fingers or toes Patient paralysed Uncontrolled bleeding Fall more then 10 feet Fall associated with chest pain, dizziness, headache or diabetes Was unconscious but now conscious Amputation / entrapment of fingers / toes with controlled bleeding Multiple extremity fracture or single femur fracture Third party caller not with patient Cuts, bumps and bruises Patient assist / assessment Involved in accident no apparent injuries Isolated extremity fracture Neck or back pain Neurological / Head Injury Unconscious or not breathing Severe breathing difficulties Fit following a head inju ry Decreased level of consciousness Fall more than 10 feet Aggressive behaviour Now awake - has been unconscious Confused as to what happened Bump or laceration from fall without loss of consciousness 24A1 24A2 24A3 24B1 24B2 24B3 24B4 24B5 24B6 24B7 24B8 24B9 24B10 24C1 24C2 24C3 24C4 24C5 25A1 25A2 25A3 25B1 25B2 25B3 25B4 25B5 25C1

153

Appendix One (contd.) Road Traffic Accident Unconscious or not breathing Difficulty in breathing Penetrating injury to head, neck, chest, abdomen or thigh Decreased level of consciousness Confirmed or unknown injuries with the following mechanism:Vehicle vs. immovable object Vehicle vs. vehicle (head side on) Vehicle vs. pedestrian Vehicle vs. motorcycle / bicycle Victims trapped / ejected Multiple vehicle / casualty incident Chest pain prior to accident Injury accident without "A" criteria Roll over Third party caller not with patient Minor injuries patient up / out / walking Patient assessment required by police 26B2 26B3 26B4 26B5 26B6 26B7 26B8 26B9 26B10 26B11 26C1 26C2 26A1 26A2 26A3 26B1

154

Appendix On (contd.) e Child under 2 years Cardiac arrest Unconscious or not breathing Breathing difficulty Croup / Asthma / Epiglottitis Choking Fits / Convulsions Bleeding - Non Trauma Bleeding - Trauma Assault Head injury / Neurological Falls / Accidents RTA related injuries Animal bite Burn Overdose / poisoning Drowning Environmental emergency Sick / unknown / other Headache Mental / emotional Chest pains Stroke / CVA Abdominal / back pain Allergic reaction Diabetic 27A1 27A2 27A3 27A4 27A5 27A6 27A7 27A8 27A9 27A10 27A11 27A12 27A13 27A14 27A15 27A16 27A17 27A18 27A19 27A20 27A21 27A22 27A23 27A24 27A25

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Appendix Two Objectives of CBD as defined by the Association of Chief Ambulance Officers
The objectives of CBD are: To establish critical information from caller (telephone number, chief complaint, location, age, sex, and conscious level). To identify dispatch code. To decide a Priority Level of the call. To offer pre-arrival instructions to the caller. To provide ambulance staff or the responder with more detailed information. To get medical help to every Priority A call within eight minutes. Dispatch Categories (UK) as defined by the Association of Chief Ambulance Officers Priority "A": An immediate life -threatening situation requiring urgent assistance. The objective is to provide immediate aid to apply life saving skills supported by Paramedic intervention. Standard: To reach 75% of priority A cases within 8 minutes.

Priority B & A serious condition which is not immediately life-threatening for example, "C": Standard: controlled haemorrhage. The objective is to provide Paramedic intervention as soon as possible. To reach 95% of cases within 14 minutes.

Dispatch Categories (US) as defined by King County, Seattle, USA, originators of CBD.

Category "A"

An immediate life -threatening situation requiring urgent assistance. The objective is to provide immediate aid by telephone advice, followed by rapid on scene assistance.

Category "B" Category "C"

A serious condition which is not immediately life-threatening. The objective is to provide intervention as soon as possible. Other non-serious or non-life-threatening conditions but which require conveyance to hospital.

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Appendix Three. Sample of recruitment letter.


Please Reply to: Dr M W Cooke Senior Lecturer A&E Department City Hospital Dudley Road Birmingham B18 7QH Tel 0121 507 5522 Fax: 01564 776140 E-mail M.W.COOKE@bham.ac.uk

02 June 1997 Title Initials LastName JobTitle Company Address1 Address2 City State PostalCode Dear FirstName Re: Safety of prioritisation of 999 calls I am undertaking some research relating to the safety of the new systems of prioritising 999 calls. This is being funded by NHS R&D. The main part of the study is related to clinical outcome of the various prioritisation categories. One portion of the study needs the opinion of experts on the system. These experts will all be A&E specialists who are active in pre-hospital care. The crunch- would you be prepared to be one of these experts? The work would involve review a set of criteria for the dispatch categories. You would be provided with the lists that the ambulance control assistants use and asked to mark those you consider that are under or over categorised. This would be simply done by use of two colours of highlighter pen. I would not expect it to take more than 45 minutes. Any other comments would be at your discretion. If you agree, I would ask that the papers are returned within three weeks of receipt. You would of course be acknowledged in the final report/ papers. If you could assist me then either just fax a copy of this letter back to me on 01564 776140 (no need for a cover sheet) with YES written below or phone my secretary on 0121 507 5522. If you would like to speak to me about it further before committing yourself, then call me on 07000 782377. Thanks for considering this Yours sincerely,

Dr Matthew Cooke

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Appendix Four- .Guidance for Study & .


Guidance for expert panel How does the system work?
The control assistant (CA) determines which group the patient belongs to from the initial information received (for example, abdominal pain, allergic reaction etc.). They then look at the appropriate sheet for that condition and work f om the top of the list (i.e. priority one r conditions) and work their way down the list, until they find a symptom/condition that fits the patient. It is important to follow the list in this direction. Example If a patient has an allergic reaction of over 30 minutes duration they will not always go into priority B. If they had any of the symptoms listed in Priority A, that category would be assigned. Therefore patients with over 30 minutes symptoms will only be assigned B if they are not unconscious, have no difficulty breathing or swallowing, can talk full sentences, have no swelling in throat and have had no fainting.

What do the categories mean? Priority A is the immediate response with a standard of 75% reached within 8 minutes. Priority B has a standard of 14 minutes response. Patients in this category can be delayed whilst those in category A are dispatched. Priority C are those that are not emergencies and can have a delayed response (as yet not defined by time).

What do I do? Please can you read through each page of the dispatch criteria. As you read please assess whether you consider that the condition described is in the appropriate group. Please mark those you consider in the incorrect group with the highlighter pen. BLUE if you consider the group assigned is too low, i.e. the case is more urgent than stated. YELLOW if you consider the group is too high, i.e. does not need that degree of urgency. Add an ASTERISK * at the right hand end of the box, if you think that the categorisation is potentially dangerous. If you want, you may add COMMENTS either in the left hand margin or on the reverse of the sheet. In particular, please note any specific diagnoses that would result in mistriage. Please return the sheets in the envelope provided. You can keep the pens! What if I do not understand? Please call Matthew Cooke on either 0121.507.5522 or 07000 782377

Thank You

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Appendix Five.

Instructions for study .

CBD opinion of control room staff.


Guidance for expert panel. Why have I been selected? A panel of control room staff has been selected at random to complete these forms. We need to know the views of those using the system to ensure that the next version of CBD is an improvement.

What do I need to do? Please can you read through each page of the dispatch criteria. As you read please assess the appropriate priority code for the condition (i.e. A, B or C) and write this in the centre (Code) column. This code should be the priority YOU believe the condition deserves, which may differ from what CBD states.

If you wish to add other comments, please write these in the right hand (Comments) column. If there is insufficient space, please use the reverse of the page. I am especially interested to hear of problems you have experienced with particular codes.

How do I return the form? Please return the sheets and this form in the envelope provided. Place this sheet and the forms in the envelope and seal it before giving to the duty officer. The contents of the envelope will only be seen by the researchers at the University and not by any ambulance service personnel. If possible, please return within three weeks of receipt.

What if I do not understand? Please call Matthew Cooke on either 0121-507-5522 or 0468-198028.

Thank You

159

Appendix Six. search.

Other sources of publications used in the literature

Internet Mailing Lists


Acad-AE-Med EMD-L UK emergency medicine mailing list US based international ambulance dispatchers list EMED -L EMS-L US based international emergency medicine list US based international prehospital care list

Other Internet-based searches


DARE (Database of Abstracts of Research Effectiveness), Centre for Research Key words - ambulance dispatch

Dissemination, University of York NHS South West R&D, Wessex Institute The Cochrane Library Yahoo Health Excite Key words - ambulance dispatch Key words - ambulance dispatch Key words - ambulance priority dispatch Key words - ambulance priority dispatch

Official document databases


Department of Health Audit Commission Her Majesty's Stationary Office National Association of Emergency Medical Technicians National Academy of Emergency Medical Dispatch National Institutes of Health http://www.nih.gov/ http://www.naemd.org/ http://www.doh.gov.uk/ http://www.audit-commission.gov.uk/ http://www.hmso.gov.uk/ http://www.naemt.org/

Non-cited journals: electronically searched


Pre-hospital Emergency Care http://www.hanleyandbelfus.com/journals/pec.ht ml Pre-hospital Immediate Care Emergency Medical Services JEMS / Fire Rescue http://www.prehospimmedicare.com/ http://www.emsmagazine.com/artindex.html http://wwwdotcom.com/jems/ffnews/ffnews.html

Non-cited journals: hand searched


Journal of British Association for Immediate Care Ambulance UK 911 Magazine

160

Appendix Seven. Proforma for articles undergoing expert appraisal in the Literature Review.

NAME OF REVIEWER: ..................................................

Paper No...............

A Systematic Review of Ambulance Emergency Call Prioritisation REVIEW PANEL PROFORMA All comments relate to the dispatch system element of the paper only Methodology Type of paper: (Please circle) Retrospective Original Research / Prospective Original / Research / Factual Literature Review / Literatur e Review with Opinion / Editorial / Letter

Yes

No

Dont know

Not applicabl e

1. Was there comparison to any other system? 2. Did the sample include an appropriate spectrum of patients? 3. Were any patients or groups excluded inappropriately? 4. Were the methods described sufficiently to permit replication? 5. Were relevant statistics utilised? 6. Was patient outcome at hospital arrival studied? 7. Was patient outcome at hospital discharge studied? Critique Yes No Dont know Not applicabl e

1. Would the results be reproducible in any U.K. Ambulance Service? 2. Would results be reproducible in a system where prioritisation determines time of response? 3. Does this paper show that the dispatch system improves: i) clinical outcome ii) utilisation of Ambulance Service 4. Are there any particular requirements or special circumstances or limitations relating to this study?

161

NAME OF REVIEWER: ..................................................

Paper No...............

Is there a statistical component that requires expert review? Is there a cost effectiveness component that requires expert review?

YES / NO YES / NO

General Comments 250 words maximum ....................................................................................................................................................................................................... ....................................................................................................................................................................................................... .................................................................................................................................... ................................................................... ........................................................................................ Have you any suggestions as to other people or organisations with an interest in this area? ....................................................................................................................................................................................................... ....................................................................................................................................................................................................... ....................................................................................................................................................................................................... ........................................................................................ Do you have any potential conflict of interest relating to any dispatch system? ....................................................................................................................................................................................................... ....................................................................................................................................................................................................... Please attach extra sheets/information as required. Thank you for your participation. Please return the completed Profor ma to Pam Bridge, Project Officer: either by Fax: or by Air Mail post: +44-121-414-3759 Department of General Practice University of Birmingham Medical School Edgbaston Birmingham B15 2TT

England.

162

Appendix Eight.. Articles undergoing expert appraisal in the Literature Review.


Bailey ED, OConnor RE, Ross RW. The use of an emergency medical dispatch system to reduce the number of inappropriate scene responses made by advanced life support personnel. SAEM 1997. Annual Meeting Abstracts #222 (Page 415). Clark JJ, Culley L, Eisenberg MS, Henwood DK. Accuracy of determining cardiac arrest by emergency medical dispatchers. Annals of Emergency Medicine 1994; 23:1022-1026. Clark JJ, Larsen MP, Culley LL, Graves JR, Eisenberg MS. Incidence of Agonal Respirations in sudden Cardiac Arrest. Annals of Emergency Medicine 1992; 21:12: 14641467. Cordi HP, Persse DE, Key CB, Pepe PE. Ability of a caller to 911 to correctly identify a person as Dead On Scene. Prehospital emergency care 1997; 1 p.173. (3) Culley L, C lark JJ, Eisenberg MS, Larsen MP. Dispatcher-Assisted Telephone CPR: Common Delays and Time Standards for Delivery. Annals of Emergency Medicine 1991; 20:4 362-366. Culley L, Henwood DK, Clark JJ, Eisenberg MS, Horton C. Increasing the Efficiency of Emergency Medical Services by Using Criteria Based Dispatch. Annals of Emergency Medicine. 1994; 24:5 867-872. Curka PA, Pepe PE, Ginger VF, Sherrard RC, Ivy MV, Zachariah BS. Emergency Medical Services Priority Dispatch. Annals of Emergency Medicine 1993; 22:11 46-51. Eisenberg MS, Carter W, Hallstrom A, Cummins R, Litwin P, Hearne T. Identification of cardiac arrest by emergency dispatchers. University of Seattle, Washington 1986; 4:4 299301. Eisenberg MS, Hallstrom AP, Carter WB, Cummins RO, Bergner L, Pierce J. Emergency CPR instruction via telephone. American Journal of Public Health1985; 75:47-50. Herlitz J, Bang A, Isaksson L, Karlsson T. Outcome for patients who call for an ambulance for chest pain in relation to the dispatchers initial suspicion of acute myocardial infarction. European Journal of Emergency Medicine 1995; 2:75-82.

163

Herlitz J, Bang A, Isaksson L, Karlsson T. Ambulance dispatchers estimation of intensity of pain and presence of associated symptoms in relation to outcome in patients who call for an ambulance because of acute chest pain. European Journal of Cardiology 1995; 16:17891794. Hu SC, Kao WF, Tsai J, Chern CH, Yen D, Lo HC, Lee CH. Analysis of prehospital ALS cases in a Rural Community. Chinese Medical Journal. (Taipei). 1996; 58: 171-176. Key CB, Persse DE, Pepe PE, Cordi HP, Ginger VF, Kimball KT. Safety of first-responder only utilisation for motor vehicle incidents when the 911 caller is unable to answer standard medical priority dispatch questions. Academic Emergency Medicine. 1997; 4:5 Abstract No. 220 (page 414). Lagaert L, Calle P, Vanhaute O, Buylaert W. How early and accurate are the calls for out of hospital Cardiopulmonary Arrest (CPA) in Gent? Abstract of a poster at RESUSCITATION 96 in Seville 1997. Lammers RL, Roth BA, Utecht T. Comparison of Ambulance Dispatch Protocols for Nontraumatic Abdominal Pain. Annals of Emergency Medicine 1995; 26:5 579-589. Meron G, Frantz O, Sterz F, Mullner M, Kaff A, Laggner AN. Analysing calls by lay persons reporting cardiac arrest. Resuscitation 1996; 32:23-26. National Association of Emergency Medical Services Physicians 1995. Abstracts of Scientific papers. Prehospital and Disaster Medicine 1995; 10:4 Supp, 51-73. Palumbo L, Kubincanek J, Emerman C, Jouriles N, Cydulka R, Shade B. Performance of a System to Determine EMS Dispatch Priorities. American Journal of Emergency Medicine. 1996; 14:3 388-390. Slovis CM, Carruth TB, Seitz WJ, Thomas CM, Elsea WR. A Priority Dispatch System for Emergency Medical Services. Annals Emergency Medicine. 1985; 14:11 1055-1060. Sramek M, Post W, Koster RW. Telephone triage of emergency calls by dispatchers: a prospective study of 1386 emergency calls. British Heart Journal. 1994; 71: 440-445.

164

Appendix Nine
ID: Age:

Data collection Proforma


Patient surnam e: Sex: Patient forename: Patient Home Postcode: Date 999 call: A&E Notes Hospital: A&E Number: Triage Nurse Name Code: A&E Triage category: A&E Triage urgency: Most Senior Dr: A&E Monitoring: Reason

Home incident: Patient Information Sheet Amb Call sign: Amb Attendant No: Amb Assistant No : Incident Dispatch CBD Code: WMAS Case No: Time 999 call: Time arrival on scene: Time left scene: Time arrival A&E: Original 999 call time: Attendance time (secs) Time at A&E after 999 call (secs) Airway clear: Breathing present: AVPU Duration of complaint (hrs): On scene chief complaint: Amb. crew CBD code. PHC Monitoring PHC Spine immobilisn : PHC Fluid resusc: PHC Drugs: PHC other intervention: PHC other reason urgency: PHC most urgent action MWC On scene CBD code: A&E CBD code: Independent Independent on diagnosis code: Reason independent code:

If no, incident Postcode:

A&E Urgent drug treatment: A&E other urgent intervention: A&E other reason urgency A&E Airway clear: A&E Breathing present: A&E AVPU: A&E Most urgent action A&E Outcome: A&E Diagnosis: Registrar Registrar dispatchers expected code: Registrar on diagnosis' code: Registrar reason: Ambulance Control Dispatcher code: Communicat ion problem: If other, comm problem descr: PAS Hospital Number: Days in-patient Days ITU:

165

Appendix Ten
a) CBD system issues Category Notes

Recommendations for modifications to CBD.

Recommendation

Cardiac Arrest The period of cerebral hypoxia causes a fit in Fits that are continuing or the early stages of a cardiac arrest. when the patient is unresponsive to be classified One of three cases of stroke also resulted in as a Category A. under-triage because it presented as a fit, which had stopped although the patient was still deeply unconscious. Other under-triaged cases of cardiac arrest The default for unknown or were recorded as decreased level of decreased conscious level consciousness and sick - third party caller. must be an A response. Third party callers may have insufficient information and in such cases decisions should err on the side of safety. The two other under-triaged patients with Consider separating faint and cardiac related problems resulting in an alert, fall according to age to allow related to a faint and a fall in elderly men. a higher prioritisation in the older age group where a medical cause is more likely. Trauma CBD(UK) fails to detect serious head injuries in trauma victims Misclassification of RTAs appears to be related to CBD (UK) using mechanism of injury rather than conscious level as the prime -sorting field. RTAs should default to Category A unless there is definite evidence that everyone is conscious.

CBD(UK) classifies a fall from over 20 ft. as A different definition for a Category B, whereas ATLS 81 teaches that children (for example, three this is a high-risk injury times their height) may be appropriate. The final trauma case was initially described as a minor bump to the head and therefore categorised C. This patient later developed fitting. Only those head injuries with a clearly identified low energy accident resulting in minor wounds with no risk factors85 should be ascribed to Category C.

166

Burns

Only two burn cases featured in this alert study and both were under-triaged. National Burns guidelines define shock cases as 10%+ for children and 15%+ for adults 99.

CBD (UK) guidelines should be brought into line with National Burns guidelines. This presumes that such an estimate can be ma de over the phone.

Bleeding

Two patients had uncontrolled external Uncontrolled external haemorrhage. One case was from a third haemorrhage should be a new party caller and again demonstrates the need A category. for an A classification when there is insufficient information. A discrepancy in coding according to how the This inconsistency relating to dispatcher enters the CBD system was noted. how the dispatcher enters the If coded by chief complaint Bleeding", system should be removed. priority B would be assigned whereas vaginal bleeding in the chief complaint Gynaecology generates an A priority.

Unconscious

If all cases with decreased conscious level All cases with decreased (either P or U on AVPU scale) were conscious level should be classified as A", this would have detected at classified as A. least 11 of the total 29 misclassified alert calls.

167

b) Dispatcher training issues Category Notes Dispatcher training should include Consider the possibility of a fit as presentation of hypoxia/cardiac arrest If the fit is continuing , consider this as unconscious. If the fit has stopped, check conscious level. Other under-triaged cases of cardiac arrest were recorded as decreased level of consciousness. The two other under-triaged patients with cardiac related problems resulting in an alert, related to a faint and a fall in elderly men. Trauma Misclassification of RTAs appears to be related to the use of mechanism of injury rather than conscious level as the prime sorting field. The default for unknown or decreased conscious level must be an A response. Consider whether an older person may have collapsed rather than fainted If there is a possibility of anyone being unconscious or having difficulty in breathing use an A category.

Cardiac Arrest The period of cerebral hypoxia causes a fit in the early stages of a cardiac arrest.

CBD(UK) classifies a fall from over 10 ft. as Remember a smaller fall is a Category B, whereas ATLS 81 teaches that dangerous in children. this is a high-risk injury. A patient received minor bump to the head and was therefore categorised C. This patient later developed fitting. Bleeding If there was a high force or any unconsciousness/amnesia or a large cut then do not use Category C.

A discrepancy in coding according to how the Use the gynaecology code in dispatcher enters the CBD system was noted. preference to the bleeding If coded by chief complaint Bleeding", code. priority B would be assigned whereas vaginal bleeding in the chief complaint Gynaecology generates an 'A' priority (Table 7). If all cases with decreased conscious level (either P or U on AVPU scale) were classified as A", this would have detected at least 11 of the total 29 misclassified alert calls. Third party callers may have insufficient information and in such cases decisions should err on the side of safety. If the person cannot be confirmed to be alert or responding to a command, classify as unconscious. Presume the patient is unconscious if the caller cannot give details.

Unconscious

All

168

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