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. 2002 Nov 30;325(7375):1299.

Emergency response to 999 calls

Alternatives to the emergency 999 response can be seen in Europe

Bernard A Foëx 1,2, Darren Walter 1,2
PMCID: PMC1124754  PMID: 12458256

Editor—Snooks et al point out that the current 999 emergency response system has problems: increasing demand from the public and ever shorter response time targets.1 They find a lack of evidence on alternative systems and responses in the English medical literature. By restricting their search, they overlook live examples only a few miles from these shores.

France, since the mid-1960s, has had a system which incorporates many of the alternatives quoted by the authors: the Service d'Aide Medical Urgente (SAMU).2 Calls to the control room are logged by trained telephone operators and then passed on to a “medical dispatcher”: a doctor in emergency medicine, trained by the service. Medical dispatchers may simply provide medical advice to the caller, or they may decide to use one of a range of other responses to a call. These are referral to, or the dispatch of, a primary care doctor; arranging non-urgent transport by a private ambulance; urgent transport by pompiers (emergency technicians working through the fire service); or sending out a mobile intensive care unit with a doctor trained in emergency medicine. Medical dispatchers also coordinate the deployment of additional resources and decide on the most appropriate destination for a patient.

In 2001 the service covering Paris received 300 000 calls (about 820 calls per day). Only 6% of the calls (50 per day) resulted in the dispatch of a mobile intensive care unit. In 16% of cases (130 per day) a primary care doctor was called. Altogether 205 calls per day were managed by the pompiers, by a private ambulance, or by giving medical advice. The remainder were considered not to warrant an emergency medical response.

In contrast, during the same period the greater Manchester ambulance service, which covers an equivalent urban population, received 256 000 calls (700 calls per day), all of which received a standard emergency paramedic response.

In greater Manchester calls are received by non-physician telephone operators using computer based algorithms to determine the time priority of response. Compliance with the pre-set questions is audited as part of a risk management process. In contrast, the doctor in the French service uses clinical training and experience, without computer support, to decide on the urgency and level of the response. We agree that alternatives to the current 999 system need to be explored. Aspects of the French service and other European models of emergency response deserve to be considered in the list of examples.

References

  • 1.Snooks H, Williams S, Crouch R, Foster T, Hartley-Sharpe C, Dale J. NHS emergency response to 999 calls: alternatives for cases that are neither life threatening nor serious. BMJ. 2002;325:330–333. doi: 10.1136/bmj.325.7359.330. . (10 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Carli P. Prehospital care in France, current status and international controversies. Acta Anaesthesiologica Scandinavica. 1997;110(suppl):69–70. doi: 10.1111/j.1399-6576.1997.tb05507.x. [DOI] [PubMed] [Google Scholar]
BMJ. 2002 Nov 30;325(7375):1299.

Safe and reliable alternatives are needed

Andrew Jones 1

Editor—Snooks et al have started a debate on the issue of non-life threatening 999 calls and ways that ambulance services have begun to deal with this.1-1 A sizeable proportion of calls received by ambulance control centres fall into this category, and with increasing demand for emergency ambulances, safe and reliable alternatives have to be adopted.

How should ambulance services respond to someone who has had non-traumatic back pain for 36 hours and to someone who has run out of his or her prescribed drug treatments over the weekend?

Call prioritisation systems, such as the advanced medical priority despatch system (AMPDS), are tools that were designed initially to reduce risk to ambulance crews and the public. Using this system, the call taker can code cases as life threatening, serious, or non-life threatening. The control room manager can then make decisions on how best the ambulance service should respond. He or she could send an ambulance on lights and sirens, delay a response, or refer the call.

Generally, the system is reliable at identifying those most in need of an emergency response but many have use of only elements of the system. For example, when little information is available or there are “unknowns,” the dispatcher has to send a maximal response with lights and sirens. That's sensible enough. But when a patient's case is categorised as non-life threatening, dispatchers will still send an emergency ambulance using lights and sirens. In the light of increasing demand and dwindling resources, this “just in case” mentality is flawed. Sending ambulances using lights and sirens to all calls increases the risk to crews and the public, limiting the availability of resources to respond when a real emergency comes in.

Full use of the system can allow “cold calling” or referral to other agencies, but rarely will a service make use of these options. Some ambulance services might have no alternative links with community care teams or NHS Direct, for example. In practice, the idea of referring callers back to NHS Direct or to their general practitioner fills many control room staff with dread, but this is because services are not using the system fully.

It is easy to justify a rapid response to a chest pain, or acute asthma attack. Can we so easily justify a risky lights and sirens response to that patient with ongoing back problems?

References

  • 1-1.Snooks H, Williams S, Crouch R, Foster T, Hartley-Sharpe C, Dale J. NHS emergency response to 999 calls: alternatives for cases that are neither life threatening nor serious. BMJ. 2002;325:330–333. doi: 10.1136/bmj.325.7359.330. . (10 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2002 Nov 30;325(7375):1299.

Ambulance service is weakest link

Charles Essex 1

Editor—Snooks et al describe the inappropriate use of 999 calls by patients (or their relatives) for non-urgent conditions, which is a huge problem, both numerically and financially.2-1 Much rarer, but with very severe consequences, at the other end of the severity of illness spectrum, is the response of the ambulance service to do not resuscitate instructions when 999 has been called.

Dialling 999 will override an instruction not to resuscitate, even when this has been agreed with the parents. Contrary to the popular view, including that held by Dame Justice Butler Sloss,2-2 decisions about resuscitation are not “doctor knows best” but are discussed fully with parents, and the paramedical crew will attempt resuscitation.

Similarly if a patient is transferred from hospital to home to die with an instruction not to resuscitate, signed by the appropriate consultant, if the patient deteriorates in the ambulance and a relative requests resuscitation, this is deemed to override the instruction, even though this may be against the wishes of the patient or parent; what has been agreed with the medical attendants; and the instruction of the courts. I am not sure how the ambulance service would defend that action if a patient had given an advanced directive that he or she did not want resuscitation, or if a court had ruled that not resuscitating was the correct course of action.

Many ambulance services are now coordinated on a regional basis and claim that they cannot have local knowledge. However, this is a specious argument even with current information technology and will become even less sustainable with technological advances. If, with the parents' permission, I have written to the ambulance service giving details of a patient who is not for resuscitation, it cannot be beyond the wit of humans to devise a computer system such that when a 999 call is received at ambulance headquarters the operator is alerted to special instructions regarding that patient.

Discussing (non-)resuscitation with parents is difficult for parents, doctors, and others involved in a child's care. It is often a slow process, over several months or even years, guiding parents to the inevitable truth about their child—and it can be destroyed in an instant. The ambulance service is the weakest link.

References

  • 2-1.Snooks H, Williams S, Crouch R, Foster T, Hartley-Sharpe C, Dale J. NHS emergency response to 999 calls: alternatives for cases that are neither life threatening nor serious. BMJ. 2002;325:330–333. doi: 10.1136/bmj.325.7359.330. . (10 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Sensky T. Withdrawal of life sustaining treatment. BMJ. 2002;325:175–176. doi: 10.1136/bmj.325.7357.175. . (27 July.) [DOI] [PMC free article] [PubMed] [Google Scholar]

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