Robert Crouch

NHS emergency response to 999 calls: alternatives for cases that are neither life threatening nor serious

Ambulance services and emergency departments are under increasing pressure as the number of emergency calls continues to rise—but in many cases, patients do not need immediate clinical care. Helen Snooks and colleagues consider the alternatives to the standard NHS response and review the current literature The number of emergency (999) calls received by ambulance services in the United Kingdom has risen consistently over recent years. Ambulance services must respond to calls immediately by sending vehicles staffed by paramedics, with flashing lights and sirens. All patients have to be taken to an accident and emergency department. This response is not always appropriate, and it can resultin inefficient use of resources and unnecessary risks to the general public, patients, and paramedics. The NHS Plan and the recent consultation document Reforming Emergency Care have emphasised the importance of trying new approaches to deliver appropriate care. 1 2 They highlight the need to consider new ways to integrate the ambulance response to 999 calls into the overall system that deals with emergencies. ### Summary points Demands on emergency services and inappropriate requests for emergency ambulances are increasing Ambulance services must respond to calls immediately by sending vehicles with flashing lights and sirens, staffed by paramedics Many ambulance services want to develop alternatives to the standard response to all 999 calls Evidence about the safety and effectiveness of alternatives is weak and few rigorous trials have been reported Studies show that alternative responses are needed but that the work involved in their development is complex In England, demand through the 999 telephone system for services has risen by 40% since 1990.3 Problems of overcrowding and high attendance have also been noted in emergency departments and in primary care. Concerns have been expressed over the number of home visits requested at night and whether all such visits are …

Safety of telephone consultation for “non-serious” emergency ambulance service patients

Objective: To assess the safety of nurses and paramedics offering telephone assessment, triage, and advice as an alternative to immediate ambulance despatch for emergency ambulance service callers classified by lay call takers as presenting with “non-serious” problems (category C calls). Design: Data for this study were collected as part of a pragmatic randomised controlled trial reported elsewhere. The intervention arm of the trial comprised nurse or paramedic telephone consultation using a computerised decision support system to assess, triage, and advise patients whose calls to the emergency ambulance service had been classified as “non-serious” by call takers applying standard priority despatch criteria. A multidisciplinary expert clinical panel reviewed data from ambulance service, accident and emergency department, hospital inpatient and general practice records, and call transcripts for patients triaged by nurses and paramedics into categories that indicated that despatch of an emergency ambulance was unnecessary. All cases for which one or more members of the panel rated that an emergency ambulance should have been despatched were re-reviewed by the entire panel for an assessment of the “life risk” that might have resulted. Setting: Ambulance services in London and the West Midlands, UK. Study population: Of 635 category C patients assessed by nurses and paramedics, 330 (52%) cases that had been triaged as not requiring an emergency ambulance were identified. Main outcome measures: Assessment of safety of triage decisions. Results: Sufficient data were available from the routine clinical records of 239 (72%) subjects to allow review by the specialist panel. For 231 (96.7%) sets of case notes reviewed, the majority of the panel concurred with the nurses’ or paramedics’ triage decision. Following secondary review of the records of the remaining eight patients, only two were rated by the majority as having required an emergency ambulance within 14 minutes. For neither of these did a majority of the panel consider that the patient would have been at “life risk” without an emergency ambulance being immediately despatched. However, the transcripts of these two calls indicated that the correct triage decision had been communicated to the patient, which suggests that the triage decision had been incorrectly entered into the decision support system. Conclusions: Telephone advice may be a safe method of managing many category C callers to 999 ambulance services. A clinical trial of the full implementation of this intervention is needed, large enough to exclude the possibility of rare adverse events.

Computer assisted assessment and advice for "non-serious" 999 ambulance service callers : the potential impact on ambulance despatch

Objective: To investigate the potential impact for ambulance services of telephone assessment and triage for callers who present with non-serious problems (Category C calls) as classified by ambulance service call takers. Design: Pragmatic controlled trial. Calls identified using priority dispatch protocols as non-serious were allocated to intervention and control groups according to time of call. Ambulance dispatch occurred according to existing procedures. During intervention sessions, nurses or paramedics within the control room used a computerised decision support system to provide telephone assessment, triage and, if appropriate, offer advice to permit estimation of the potential impact on ambulance dispatch. Setting: Ambulance services in London and the West Midlands. Subjects: Patients for whom emergency calls were made to the ambulance services between April 1998 and May 1999 during four hour sessions sampled across all days of the week between 0700 and 2300. Main outcome measures: Triage decision, ambulance cancellation, attendance at an emergency department. Results: In total, there were 635 intervention calls and 611 controls. Of those in the intervention group, 330 (52.0%) were triaged as not requiring an emergency ambulance, and 119 (36.6%) of these did not attend an emergency department. This compares with 55 (18.1%) of those triaged by a nurse or paramedic as requiring an ambulance (odds ratio 2.62; 95% CI 1.78 to 3.85). Patients triaged as not requiring an emergency ambulance were less likely to be admitted to an inpatient bed (odds ratio 0.55; 95% CI 0.33 to 0.93), but even so 30 (9.2%) were admitted. Nurses were more likely than paramedics to triage calls into the groups classified as not requiring an ambulance. After controlling for age, case mix, time of day, day of week, season, and ambulance service, the results of a logistic regression analysis revealed that this difference was significant with an odds ratio for nurses:paramedics of 1.28 (95% CI 1.12 to 1.47). Conclusions: The findings indicate that telephone assessment of Category C calls identifies patients who are less likely to require emergency department care and that this could have a significant impact on emergency ambulance dispatch rates. Nurses were more likely than paramedics to assess calls as requiring an alternative response to emergency ambulance despatch, but the extent to which this relates to aspects of training and professional perspective is unclear. However, consideration should be given to the acceptability, reliability, and cost consequences of this intervention before it can be recommended for full evaluation.

Emergency nurse practitioners and doctors consulting with patients in an emergency department : a comparison of communication skills and satisfaction

Background: Emergency nurse practitioners (ENPs) play an increasingly important role in UK emergency departments (EDs), but there is limited evidence about how this affects patient care and outcome. A study was undertaken to compare the content of, and satisfaction with, consultations made with patients presenting with problems of low acuity to an ED. Methods: Patients presenting with “primary care” problems were allocated to senior house officers (SHOs, n = 10), specialist registrars/staff grades (n = 7), sessionally-employed general practitioners (GPs, n = 12) or ENPs (n = 6) randomly rostered to work in a consulting room that had a wall-mounted video camera. At the end of each consultation the doctor/ENP and the patient were asked to complete the Physician/Patient Satisfaction Questionnaire. A stratified sample of videotaped consultations (n = 296) was analysed in depth using the Roter Interaction Analysis System. The main outcome measures were length of consultation; numbers of utterances of doctor/ENP and patient talk related to building a relationship, data gathering, activating/partnering, and patient education/counselling; doctor/ENP and patient consultation satisfaction scores. Results: ENPs and GPs focused more on patient education and counselling about the medical condition or therapeutic regimen than did ED doctors. There were no significant differences in consultation length. ENPs had higher levels of overall self-satisfaction with their consultations than ED doctors. Patient satisfaction with how actively they participated in the consultation was significantly associated with the amount of talk relating to building a relationship and activating and partnering, and patient satisfaction with information giving in the consultation was significantly associated with the amount of talk relating to building a relationship. Conclusion: These findings suggest differences between ENP and ED doctor consultations which are associated with some aspects of patient satisfaction. In contrast to previous reports, consultation length was not greater for ENPs than for doctors. There is a need for further research to test the generalisability of these findings and their impact on clinical outcome.

Satisfaction with telephone advice from an accident and emergency department: Identifying areas for service improvement

OBJECTIVES: Members of the public often telephone general practice, accident and emergency departments, and other health services for advice. However, satisfaction related to telephone consultation has received relatively little attention. This study aimed to describe the views of callers to an accident and emergency department who expressed any element of dissatisfaction about their telephone consultation. This was part of a larger study intended to help identify areas for service improvement. METHODS: A telephone consultation record form was used to document details of advice calls made to the accident and emergency department over a three month period. Callers who provided a telephone number were followed up within 72 hours. The interviews were tape recorded, transcribed, and explored using content analysis for emerging themes related to dissatisfaction. RESULTS: 203 callers were contacted within 72 hours of their call, of which 197 (97%) agreed to participate. 11 (5.6%) expressed global dissatisfaction, and a further 34 (17%) callers expressed at least one element of dissatisfaction at some point during the interview. Sources of dissatisfaction fell into four broad categories, each of which included more specific aspects of dissatisfaction: 36 (80%) callers were dissatisfied with advice issues, 31 (69%) with process aspects, such as the interpersonal skills of the staff member who took the call, 23 (51%) due to lack of acknowledgement of physical or emotional needs, and 11 (24%) due to access problems. CONCLUSIONS: This study supports the findings of other work and identifies three issues for particular consideration in improving the practice of telephone consultation: (a) training of health professionals at both undergraduate and specialist levels should cover telephone communication skills, (b) specific attention needs to be given to ensuring that the information and advice given over the phone is reliable and consistent, and (c) organisational change is required, including the introduction of departmental policies for telephone advice which should become the subject of regular audit.

An analysis of telephone calls to an inner-city accident and emergency department.

The general public in the UK often telephone accident and emergency (A&E) departments for medical advice. Such calls are usually dealt with by nursing staff in an informal manner (often with no written record of the call being made). The specific questions addressed in this study are who was calling for advice, when did they call, what were their presenting complaints, and what was the outcome of the call? In addition, the study provided an opportunity to test the implementation of a new system of record-keeping for telephone consultation. A telephone consultation record (TCR) was developed and used to record details of each call made to the A&E department for medical/health advice. An analysis of 597 consecutive documented calls is presented in this paper. The majority of calls were dealt with by ‘E’ grade nursing staff (42.7%); only four calls (0.7%) were recorded by medical staff. Two hundred and six (43.5%) calls related to patients aged up to 15 years. In 57% of the cases the call was made by a third party. In all, 149 different presenting complaints were recorded on the TCRs. The three most common presenting complaints were dental problems (7.4%), fever (4.3%), and concerns about drug reactions (23%). Seventy-three per cent of callers were advised that a visit to the A&E department was not immediately necessary. The study identifies several important issues for development of a more formal and effective system of telephone advice. The majority of calls made to the A&E department appeared to be of a primary care nature but the extent to which nurses are trained to assess and advise on these problems needs to be questioned. A reluctance to document the calls to A&E was identified, one reason being a concern about accountability. Training and support are clearly required.

Whiplash associated disorder: incidence and natural history over the first month for patients presenting to a UK emergency department.

Objectives: To describe the epidemiology, process of care, and outcomes at 4–6 weeks after injury among patients with whiplash associated disorder attending a UK emergency department. Methods: All patients presenting during the study period with neck pain following a road traffic accident who met the inclusion criteria were assessed. Patients were followed up with a telephone interview at 4–6 weeks after attendance using the Neck Disability Index (NDI). The patient’s general practitioner (GP) was contacted post attendance to ascertain subsequent healthcare use. Results: A total of 200 patients were recruited to the study, of which 30 were lost to follow up. Four variables, midline tenderness (p = 0.008; 95% CI 0.9 to 6.1), x ray request (p = 0.004; 0.9 to 6.1), wearing a seat belt (p = 0.038; 0.2 to 6.2), and having seen their GP post injury (p = 0.001; CI −10.5 to 6.6), were found to be associated with a higher NDI score at follow up. Significant correlation was identified with a high pain score and an increasing age of patient and high NDI scores. No correlation was found between the impact speed, speed of vehicle struck, or time since incident with the NDI. Two thirds of patients had some disability at 4–6 weeks after injury; 91 patients (54.5%) saw their GP in the intervening period between attending the department and telephone follow up, and 87/170 patients had no idea about their prognosis. Conclusions: This study identifies that there is significant disability associated with whiplash associated disorder. Clear prognostic information would be a useful development.

Clinical handovers between prehospital and hospital staff: literature review

Background Clinical handover plays a vital role in patient care and has been investigated in hospital settings, but less attention has been paid to the interface between prehospital and hospital settings. This paper reviews the published research on these handovers. Methods A computerised literature search was conducted for papers published between 2000 and 2013 using combinations of terms: ‘handover’, ‘handoff’, ‘prehospital’, ‘ambulance’, ‘paramedic’ and ‘emergency’ and citation searching. Papers were assessed and included if determined to be at least moderate quality with a primary focus on prehospital to hospital handover. Findings 401 studies were identified, of which 21 met our inclusion criteria. These revealed concerns about communication and information transfer, and themes concerning context, environment and interprofessional relationships. It is clear that handover exchanges are complicated by chaotic and noisy environments, lack of time and resources. Poor communication is linked to behaviours such as not listening, mistrust and misunderstandings between staff. While standardisation is offered as a solution, notably in terms of the use of mnemonics (alphabetical memory aids), evidence for benefit appears inconclusive. Conclusions This review raises concerns about handovers at the interface between prehospital and hospital settings. The quality of existing research in this area is relatively poor and further high-quality research is required to understand this important part of emergency care. We need to understand the complexity of handover better to grasp the challenges of context and interprofessional relationships before we reach for tools and techniques to standardise part of the handover process.

Splinting versus casting of “torus” fractures to the distal radius in the paediatric patient presenting at the emergency department (ED): a literature review

AIM To compare outcomes regarding splinting versus casting of paediatric torus fractures in the ED with the aim of establishing the preferred treatment. METHODS Evidence was collated using electronic databases; Pubmed, Ovid, Medline and Cochrane library. Search terms included [torus fractures; buckle fractures; splinting distal radius fractures; paediatric wrist fractures; paediatric forearm fractures/injuries; cast versus splint]. Searches identified papers published between 1984 and June 2008. RESULTS The review demonstrated that children with removable splints preferred them to casts, in terms of improved physical functioning and lower pain scores reported after initial injury than those with casts. Children demonstrated this by using their wrists in the first week after injury to shower and bathe more easily. The cast group reported unscheduled visits to ED due to problems with the cast, such as discomfort or re-application of the cast from getting it wet. Using a splint will have considerable economic implications, money was found to be saved in terms of time and resource management. Radiographs taken at 4 weeks in both the cast and splint group confirmed that all fractures healed without significant change in alignment, suggesting that neither clinical nor radiographic follow-up is necessary for injury. CONCLUSION Torus splints in all the studies were consistently better than plaster immobilisation in terms of clinical outcome, patient preference and cost, with the exceptions of young children or children with special needs who can easily remove the device. Splinting torus fractures may reduce cost, time and resource management if used instead of casting in the ED.

Doctors and nurses in emergency care: where are the boundaries now?

The current political healthcare economy is blurring traditional professional bound aries, and national agendas are requiring nurses to take on more roles and tasks previously undertaken by doctors. The emergency nurse practitioner’s expanding scope of practice has moved beyond managing the care of patients with minor injuries, to include those with ‘minor’ illnesses and indeed beyond that to the management and care of those with increasingly complex, acute and chronic conditions. The process of conjugation between the two disciplines has been driven by the demands and pressures on the health economy. Given the unprecedented and increasing overlap in practice between the domains of medicine and nursing, it is time to re-examine differences between them and clarify the issues which divide them. There is a need to benchmark infrastructure and standardize the education and development of nurses undertaking advanced practice roles. There is also a need for continued debate on the future of the health care workforce, informed by research, to facilitate correct and cost effective decision making.