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

¹ Centre for Primary Health Care Studies, University of Warwick, UK
² Department of General Practice and Primary Care, Guy’s, King’s and St Thomas’s School of Medicine, London, UK
³ London Ambulance Service NHS Trust, UK
⁴ School of Postgraduate Studies in Medical and Health Care, University of Wales, Swansea, UK
⁵ School of Nursing and Midwifery, University of Southampton, UK
⁶ King’s College Hospital NHS Trust, London, UK
⁷ Department of Public Health, Guy’s King’s and St Thomas’s School of Medicine
⁸ Health Care Research Unit, University of Southampton

Correspondence to:
Correspondence to:
Professor J Dale, Centre for Primary Health Care Studies, University of Warwick, Coventry CV4 7AL, UK;
jeremy.dale{at}warwick.ac.uk

ABSTRACT
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.

Keywords: ambulance despatch; telephone advice; nurse triage; decision support

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