Education and debate

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

Helen Snooks, senior lecturer ^a, Susan Williams, research fellow ^b, Robert Crouch, consultant nurse ^b, Theresa Foster, research associate ^c, Chris Hartley-Sharpe, senior operations officer ^c, Jeremy Dale, director ^d. 

^a Centre for Postgraduate Studies, Swansea Clinical School, University of Wales, Swansea SA2 8PP, ^b School of Nursing and Midwifery, University of Southampton, Southampton SO17 1BJ, ^c London Ambulance Service NHS Trust, London SE1 8SD, ^d Centre for Primary Health Care Studies, University of Warwick, Coventry CV4 7AL

Correspondence to: H Snooks h.a.snooks{at}swan.ac.uk

Ambulance services and emergency departments are under increasing pressure as the number of emergency calls continues to risebut 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 result in 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.

	Evidence of the need to change

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 necessary.⁴ Several studies have reported a high proportion of ambulance call outs that do not warrant an emergency ambulancea problem that seems to be common internationally. In the United Kingdom, around 40% of 999 calls are estimated not to need an emergency response.⁵

Lights and sirens are used by ambulance crews to shorten response times to 999 calls, even though a substantial proportion of cases may not subsequently be found to have needed immediate clinical care. Use of lights and sirens places the general public, patients, and ambulance crews at risk of injury or death from collisions and increases financial costs.⁶

	Response to need for change

Some patients do benefit from a rapid response. The benefits of early treatment for patients with myocardial infarction or those in cardiac arrest are reflected in targets set out in the national service framework for the treatment of coronary heart disease.⁷ The Department of Health has set a response target of eight minutes for calls about patients with immediately life threatening conditions in England and Wales.

Recommendations to enable ambulance services to respond quickly to patients who can benefit from early intervention, as well as to provide a more appropriate service to the full range of 999 callers, have been made. These state that "local health authorities and ambulance services should be free to make whatever response is right for the patient's clinical need, by ambulance or otherwise" for calls about patients with conditions that are neither life threatening nor serious (category C).⁸ Some ambulance services in the United Kingdom are trying alternative responses for these patients.⁹

	Sources and selection criteria

We reviewed the literature on alternatives to current emergency ambulance service provisionfrom the initial point of contact with the ambulance service throughout the prehospital phase of care. We searched Medline, BIDS, Healthplan, and Helmis for papers published in English in 1975-2001 (box 1). We also manually searched relevant journals and cross checked with the bibliographies of published reviews and original articles. We appraised papers for relevance, rigour of methods, and validity of findings, on the basis of their results (see table on bmj.com). ^{8 9 12-14 16-22} In general, we did not include preliminary research findings published in the form of abstracts, as they lacked detail and were difficult to appraise fully.

Ten papers described the profile and outcomes of emergency patients who were not transported by the ambulance crew that attended them or evaluated an alternative to the current emergency response (table). We found no papers from countries other than the United Kingdom or United States.

Alternatives in the ambulance control centre

Prioritising 999 calls
Priority dispatch systems have recently been introduced across the United Kingdom to triage calls in ambulance control. These will potentially enable

• Faster responses to calls about patients with life threatening conditions
• Care to start as soon as a call is received
• Lights and sirens to be used in fewer cases.¹⁰

Telephone advice
Telephone consultation seems to be able to provide an alternative response to non-serious 999 callers. Alternatives could include referral to an appropriate primary care agency or self care advice. Systems led by nurses are safe and effective in out of hours settings.¹³ In the United Kingdom, such systems are in use in general practice, in emergency departments, and by NHS Direct (box 2). Many services provided by NHS Direct have been set up within or alongside ambulance services. Opportunities for further integration, including the smooth transfer of calls in each direction, are available. No evidence has yet been published about the safety of passing Category C 999 calls to NHS Direct or whether this service has reduced the number of 999 calls made to ambulance services.¹⁴

Alternative vehicles
A study from the United States reported on the issue of providing alternative responses to patients who ask for an emergency ambulance for minor medical problems.¹⁷ Of 626 patients surveyed, 11% were judged not to have needed ambulance transportation to an emergency department. The most common reason patients gave for asking for an ambulance was lack of any alternative transport, although 82% were willing to use an alternative if one was available. The authors concluded that unnecessary use of emergency ambulances would decline if alternatives were provided. No indication was given of how patients who could safely be offered alternative transportation could be identified before an ambulance is dispatched.

On-scene alternatives

Non-transportation
In 1998-9, the proportion of non-transported patients, those patients attended by an emergency ambulance after a 999 call who were left at the scene, across England and Wales was 17%.³ Despite this, few ambulance services in the United Kingdom have any policies or protocols about non-transportation, and none provide training for crews on whether to leave patients at home.¹⁸ In fact, most ambulance crews in the United Kingdom, as in the United States, may leave patients at the scene only when they refuse to travel.

Field triage and diagnosis by paramedics
Paramedics' abilities to determine patients' need for transportation to emergency departments have been assessed in the United States by retrospective review of case notes. Results from a general population found subsequent events that indicated the need for transportation in at least 3% of cases,²⁴ although findings from a study focusing on hypoglycaemic patients were more encouraging.²⁵

	Discussion

Current developments in the ambulance service provide opportunities for it to work with other healthcare providers to optimise the response to emergency calls about patients with non-serious conditions. Research about the clinical effectiveness and cost effectiveness of prioritised dispatch, telephone advice, and on-scene triage and referral is lacking.

The studies we reviewed were mainly conducted in the United States, although papers and reports from the United Kingdom indicate that concerns about emergency services' workloads and the management of patients are similar for both countries. We found no published studies from other parts of the world, although other systems probably face similar challenges. Many descriptive and exploratory studies were identified; none of the few trials we identified were randomised or controlled. Weaknesses in the methods were apparent in all of the studies, particularly with regard to measurement of appropriateness. Severalabstracts reported the ability of paramedics to triage patients for release from care and stated that doctors disagreed with the decisions made by paramedics in the field about the most appropriate care. We did not include the abstracts because of their brevity and the preliminary nature of the findings.

Research in this area does not identify a "gold standard" of appropriate care. Various methods were used to assess appropriateness, including:

• Identification of treatments subsequently given
• Review against protocol
• Comparison with doctors' opinions.

Each method has its weaknesses, with individual doctors' judgments shown to be unreliable in related research about appropriateness of care. Research leading to full publication rather than the publication of abstracts is clearly needed in this difficult area.

Evidence about the need to develop alternatives that are more appropriate to the current 999 response in the United Kingdom is strong. The benefits of developing more appropriate responses to patients who call 999 with non-emergency problems could accrue to these patients, patients with life threatening conditions, and the NHS. If we view the 999 service as a component of the emergency care system, we could develop a more strategic response, in which people calling about non-emergency situations are diverted to a service that provides more appropriate care. This would allow the ambulance service to respond quickly to patients who would benefit from early intervention. An integrated single point of access to immediate care, such as NHS Direct, may enable an appropriate response to be triggered for the full range of cases. Any exploration of this option, however, must take into account the effect on response times for life threatening emergencies.

	Acknowledgments

We thank Dr Frances Maggs-Rapport and Professor John Williams for providing additional editing advice in the latter stages of preparation of this paper.

Contributors: SW and HS carried out the primary literature searches for this review, although other authors also provided references. All authors contributed to the writing of drafts. HS took the lead in producing the final version submitted for publication and will act as guarantor.

	Footnotes

Funding: NHS Executive Primary/Secondary Care Interface Programme.

Competing interests: JD and RC own shares in and have acted as clinical consultants to the Plain Software Company, which produces clinical decision support software.

A summary of published studies appears on bmj.com

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(Accepted 14 December 2001)