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      Ambulance dispatch of older patients following primary and secondary telephone triage in metropolitan Melbourne, Australia: a retrospective cohort study

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          Abstract

          Background

          Most calls to ambulance result in emergency ambulance dispatch (direct dispatch) following primary telephone triage. Ambulance Victoria uses clinician-led secondary telephone triage for patients identified as low-acuity during primary triage to refer them to alternative care pathways; however, some are returned for ambulance dispatch (secondary dispatch). Older adult patients are frequent users of ambulance services; however, little is known about the appropriateness of subsequent secondary dispatches.

          Objectives

          To examine the appropriateness of secondary dispatch through a comparison of the characteristics and ambulance outcomes of older patients dispatched an emergency ambulance via direct or secondary dispatch.

          Design

          A retrospective cohort study of ambulance patient data between September 2009 and June 2012 was conducted.

          Setting

          The secondary telephone triage service operated in metropolitan Melbourne, Victoria, Australia during the study period.

          Participants

          There were 90 086 patients included aged 65 years and over who had an emergency ambulance dispatch via direct or secondary dispatch with one of the five most common secondary dispatch paramedic diagnoses.

          Main outcome measures

          Descriptive analyses compared characteristics, treatment and transportation rates between direct and secondary dispatch patients.

          Results

          The dispatch groups were similar in demographics, vital signs and hospital transportation rates. However, secondary dispatch patients were half as likely to be treated by paramedics (OR 0.51; CI 0.48 to 0.55; p<0.001). Increasing age was associated with decreasing treatment (p<0.005) and increasing transportation rates (p<0.005).

          Conclusion

          Secondary triage could identify patients who would ultimately be transported to an emergency department. However, the lower paramedic treatment rates suggest many secondary dispatch patients may have been suitable for referral to alternative low-acuity transport or referral options.

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          Most cited references 21

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          Validation of a combined comorbidity index

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            The challenges of population ageing: accelerating demand for emergency ambulance services by older patients, 1995-2015.

            To measure the growth in emergency ambulance use across metropolitan Melbourne since 1995, to measure the impact of population growth and ageing on these services, and to forecast demand for these services in 2015. A population-based retrospective analysis of Ambulance Victoria's metropolitan emergency ambulance transportation data for the period from financial year 1994-95 to 2007-08, and modelling of demand in the financial year 2014-15. Numbers and rates of emergency ambulance transportations. The crude annual rate of emergency transportations across all age groups increased from 32 per 1000 people in 1994-95 to 58 per 1000 people in 2007-08. The rate of transportation for all ages increased by 75% (95% CI, 62%-89%) over the 14-year study period, representing an average annual growth rate of 4.8% (95% CI, 4.3%-5.3%) beyond that explained by demographic changes. Patients aged ≥ 85 years were eight times (incident rate ratio, 7.9 [95% CI, 7.6-8.3]) as likely to be transported than those aged 45-69 years over this period. Forecast models suggest that the number of transportations will increase by 46%-69% between 2007-08 and 2014-15, disproportionately driven by increasing usage by patients aged ≥ 85 years. These findings confirm a dramatic rise in emergency transportations over the study period, beyond that expected from demographic changes. Rates increased across all age groups, but more so in older patients. In the future, such acceleration is likely to have major effects on ambulance services and acute hospital capacity. This calls for further investigation of underlying causes and alternative models of care.
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              Emergency (999) calls to the ambulance service that do not result in the patient being transported to hospital: an epidemiological study.

              To describe the demographic and clinical characteristics of patients who are not transported to hospital after an emergency (999) call to the East Midlands Ambulance Service, the reason for non-transportation, and the priority assigned when the ambulance is dispatched. The first 500 consecutive non-transported patients from 1 March 2000 were identified from the ambulance service command and control data. Epidemiological and clinical data were then obtained from the patient report form completed by the attending ambulance crew and compared with the initial priority dispatch (AMPDS) code that determined the urgency of the ambulance response. Data were obtained for 498 patients. Twenty six per cent of these calls were assigned an AMPDS delta code (the most urgent category) at the time the call was received. Falls accounted for 34% of all non-transported calls. This group of patients were predominantly elderly people (over 70 years old) and the majority (89%) were identified as less urgent (coded AMPDS alpha or bravo) at telephone triage. The mean time that an ambulance was committed to each non-transported call was 34 minutes. This study shows that falls in elderly people account for a significant proportion of non-transported 999 calls and are often assigned a low priority when the call is first received. There could be major gains if some of these patients could be triaged to an alternative response, both in terms of increasing the ability of the ambulance service to respond faster to clinically more urgent calls and improving the cost effectiveness of the health service. The AMPDS priority dispatch system has been shown to be sensitive but this study suggests that its specificity may be poor, resulting in rapid responses to relatively minor problems. More research is required to determine whether AMPDS prioritisation can reliably and safely identify 999 calls where an alternative to an emergency ambulance would be a more appropriate response.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2020
                6 November 2020
                : 10
                : 11
                Affiliations
                [1 ]departmentDepartment of Epidemiology and Preventive Medicine , Monash University , Melbourne, Victoria, Australia
                [2 ]departmentCentre for Research and Evaluation , Ambulance Victoria , Doncaster, Victoria, Australia
                [3 ]departmentBolton Clarke Research Institute , Bolton Clarke , Bentleigh, Victoria, Australia
                Author notes
                [Correspondence to ] Dr Kathryn Eastwood; kathryn.eastwood@ 123456monash.edu
                Article
                bmjopen-2020-042351
                10.1136/bmjopen-2020-042351
                7651717
                33158837
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

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                Health Services Research
                1506
                1704
                Original research
                Custom metadata
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                Medicine

                epidemiology, quality in health care, rationing, telemedicine, geriatric medicine

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