Background
The emergency medical communication center (EMCC) is usually the acutely ill patient’s first contact with the emergency medical services (EMS), and the EMCC can be described as the first link in the chain of survival for victims in out-of-hospital medical emergencies [
1]. There is no doubt that the emergency medical dispatchers (EMD) in the EMCC play a crucial role in identifying critical medical conditions and in giving important instructions to the caller if the patient is suffering, for example, from cardiac arrest [
2]. Early identification of the patient’s symptoms result in a better outcome for out- of-hospital cardiac arrest patients [
3], and theoretically early identification may be important in other medical emergencies such as myocardial infarction [
4] or stroke [
5]. Previous studies have described the complexity of assessing an emergency call [
3],[
6],[
7]. There are also studies identifying possible reasons for not identifying the caller’s need of care; language barriers [
8]-[
10] unnecessary questions asked by the EMD during the call [
11], and lack of information from the caller [
7]. Due to some of these difficulties, assessment protocols aiming to support the EMD’s assessment have been developed [
12]-[
14]. Despite continuous development of assessment protocols, studies show that the EMD identifies about 50-70% of patients who are suffering from cardiac arrest, myocardial infarction or stroke [
2],[
4],[
5]. However, most previous studies have focused on the identification of specific conditions such as cardiac arrest and stroke, so it is still unclear whether there are any overall factors that may influence the assessment of the call to the EMCC. Therefore the aim of the study was to identify overall factors influencing the registered nurse’s assessment of calls to the emergency medical communication centre.
Discussion
This study describes both barriers and opportunities related to assessing the call to the EMCC. The main discrepancies appeared in communication strategies used by the RN and symptom descriptions made by the caller. The communication strategies used by the RN could become an opportunity in the best case, but also a barrier in the worst case. Nevertheless, when the barriers are related to the RN there is a possibility for improvement work. It is harder, but maybe not possible, to influence the callers’ ways of expressing themselves.
When assessing the emergency call, an opportunity seems to be use of a closed loop communication strategy by the RN, with conclusions and questions related to the information given by the caller. The use of follow-up questions and conclusions may be a way of making sense of and sorting out the information given by the caller. However, since closed loop communication is described as supporting precise and accurate communication [
22] it may serve as a tool to improve patient safety in the EMCC. Whether the use of closed loop communication is a specific skill developed in an ad hoc way based on the RNs’ professional background and experience in managing interactions with callers as argued by Pettinari & Jessop [
23] is not determined by this study but a question arises; is it possible to develop assessment protocols supporting problematic communication situations?
Knowing the patient’s previous medical history may be an opportunity or a barrier when assessing the call. The information may support the caller’s symptom description and allow the RN to identify the patient’s need of care. It could also be that the previous medical history may be a barrier. If the RN does not select the information given by the caller in a proper way, the information may disappear in the information flow. The use of closed loop communication strategies with conclusions may be a possible way to extract the information under such circumstances. However, as our results indicate, assessing and triaging the patient’s illness by means of a phone call is a complex task.
Salk et al. describe poor agreement between assessments of the same patient in person and over the telephone. In their study, the accuracy of telephone assessment was not enhanced by the use of chief complaint-based protocols or by being informed about the patient’s vital signs [
24]. This result could be congruent with our results
“… a respiratory rate of more than 50…, it may not be a lack of the measured vital signs; other factors influence the assessment. Another barrier in assessing a call seems to be when the RN at the EMCC does not clarify the situation regarding the patient’s breathing and/or consciousness; instead the RN focuses on other matters. This result is congruent with the study of Bång et al. where the EMD asked only 41 percent of the callers if the patient was breathing normally [
11]. Previous studies describe protocol compliance as an important factor for successfully triaging in the EMCC [
3],[
6]. In our study, there were some cases where although the RN followed the assessment protocol and ascertained whether the patient was breathing and/or conscious, nevertheless, the RN did not treat the call as a high priority case. There may be more than just protocol compliance involved in the assessment of the patient over the phone. Our study does not reveal factors outside the call, but factors such as the availability of ambulances, or calls waiting to be answered may also interfere in the decision-making. It could also be that the first call taker misled the RN in their assessment. Further research is needed to identify and explore these factors.
Another opportunity for assessing the emergency call appeared when the symptom descriptions were given by the caller as the literature describes. When the symptom descriptions were vaguer, and were not as the assessment protocol describes, this became a barrier. Whether this means that the assessment protocol needs to be developed or whether there are communication strategies that need to be developed is unclear from this study result but there is a need to develop support tools for the RN assessing the calls. Otherwise, the RNs cannot improve their assessments. Different paradoxes were identified as barriers during the calls - paradoxes that have not been described in previous studies. This result may indicate that there are additional aspects of the calls to the EMCC to be considered. The knowledge of how the caller may express paradoxes during the call can be useful when educating RNs at the EMCC, but these identified paradoxes also need to be examined in future studies. Barriers are commonly described as language and communication problems [
8],[
25],[
26]. In this study, language problems were not identified as a barrier, although a third of the calls were made by a non- native speaker. Another barrier to assessing the call arose if the patient was elderly (older than 80). This result may indicate an issue with geriatric training for the RN at the EMCC or a need to describe the geriatric patients more clearly in the Swedish Medical Index. A previous study has found that increased age and a mental change from an assumed baseline are important clinical factors to consider when identifying a patient’s need of care [
27], and this is not clearly stated in the Swedish medical index [
13]. However, the signs and symptoms available to the RN for assessing the call are reduced to those the caller describes. Maybe we need to increase our understanding of how ill patients communicate with nurses, especially how this is done by phone. The questions to the caller may not always be as clear as we think. Further studies are needed to clarify this.
The results should be interpreted in the context of the following methodological limitations. The purposeful case sampling was intended to provide an insight into factors that influence the assessment, rather than to determine if the assessment made by the RN at the EMCC was right or wrong. The purposeful sample included a variety of calls both from lay persons and calls from various health care providers. Calls to the emergency number and calls for elective ambulance transport were both included for analysis. This can be seen as a limitation since the analysed calls were not a heterogeneous group. Another limitation of this sampling is that the calls for elective ambulance transport or calls to the emergency number may have been assessed differently by the RN at the EMCC. The RN may have different expectations concerning the severity of the call to the different phone numbers. On the other hand, the aim of the purposeful sampling was to achieve a variety of calls (as in reality) to analyse, and all healthcare-related calls to the EMCC should be evaluated by the RNs regardless of phone number used and who makes the calls. However, in order to understand the assessment differences in assessing calls to different phone number at the EMCC, further research is required. Nevertheless, the result shows that there are barriers and opportunities in the calls from both laypersons and health care providers, and further research is needed to explore the reasons. Not including the over triage calls when we conducted the purposeful sampling may have caused a lack of valuable information in the result. The decision not to include these calls was due to the safety margins that should be in EMS systems, and the over triage calls were expected to contain previously described difficulties in assessing certain calls to the EMCC. However, we do not know if this assumption was true. We listened to and transcribed the recorded calls, and in this study it was a limitation that there was no opportunity to ask the caller and RN clarifying questions when clarification was needed to explain what had happened during the call. By using a talk aloud method [
18], listening to the recorded tapes and encouraging the RN to reason about the assessment could have clarified some of the paradoxes. Analysing calls with qualitative content analysis yields an in-depth understanding rather than an empirical generalization of the results [
18]. During the analysis, peer debriefing and member checks were conducted among the authors. To achieve content validity [
28] the identified barriers and opportunities were critically discussed with an experienced RN at the EMCC. The identified generic and main categories were also discussed with approximately 50 of the RNs from different EMCCs around Sweden. The discussions were conducted in smaller groups when the results were presented during the RNs’ annual training arranged by their employer, SOS Alarm. The discussions with RNs at the EMCC confirmed the results, and the nurses agreed with the opportunities and barriers identified in this study.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
VL, MC, KB and ACF conceived the study. VL collected and extracted the data, VL drafted the manuscript. VL & ACF initiated analyzes, KB, MC and KH assessed the analyses and the quality of included data and they reviewed the paper and participated actively throughout the writing of the paper. All authors read and approved the final manuscript.