Intended for healthcare professionals


Communication difficulties during 999 ambulance calls: observational study

BMJ 2001; 323 doi: (Published 06 October 2001) Cite this as: BMJ 2001;323:781
  1. J Higgins, research fellowa,
  2. S Wilson, senior research fellow (s.wilson{at},
  3. P Bridge, project officerb,
  4. M W Cooke, senior lecturera
  1. a Emergency Medicine Research Group, Centre for Primary Health Care Studies, School of Health and Social Studies, University of Warwick, Coventry CV4 7AL
  2. b Emergency Medicine Research Group, Department of Primary Care and General Practice, University of Birmingham, Birmingham B15 2TT
  1. Correspondence to: S Wilson
  • Accepted 21 May 2001

One of the key roles of ambulance call receivers is to obtain accurate information concerning the location of the patient and their complaint. The automatic tracing of calls to their source can accurately determine the location of most patients. Obtaining information on the patient's condition, however, depends on effective communication between the call maker and the call receiver. Ambulance services in the United Kingdom now use priority dispatch systems to categorise calls according to the level of urgency for medical treatment and to provide first aid advice (for example, cardiopulmonary resuscitation). 1 2 The safety and effectiveness of priority dispatch has been assessed3; however, whether call receivers are able to procure accurate and reliable information has not been established. This study aimed to determine the nature and extent of communication problems encountered during 999 calls.

Participants, methods, and results

The study population comprised 999 calls received by an urban (West Midlands Ambulance Service) and a rural (Derbyshire Ambulance Service) ambulance service. A stratified systematic sample of the calls received over one week (early December 1998) was selected (n=1830). During this time, the West Midlands Ambulance Service received approximately 830 calls per day and the Derbyshire Ambulance Service received approximately 240 calls per day. An assessor listened to tape recorded calls to determine the caller's identity (for example, husband), location in relation to the patient, type of telephone, and communication difficulties. Cases were excluded if recording quality was very poor.

The method was piloted.4 A conversation was noted as having communication difficulties if the call receiver had to repeat the question, the caller gave an inappropriate response more than once, or misunderstanding occurred between caller and call receiver.

We used univariate analysis to assess the characteristics of callers and compare the two ambulance services, and stepwise discriminant analysis to establish the factors associated with communication problems.

Of 1830 calls, 482 (26.3%) were associated with a communication problem that may delay ambulance dispatch or prevent delivery of first aid advice (table). Fewer problems were observed in Derbyshire than in the West Midlands.

Table 1

Communication difficulties associated with 999 calls to ambulance services. Values are numbers (percentages)

View this table:

The most common reason for communication problems occurring was the emotional state of the caller (161/482, 33.4%). Almost 10% (45/482) of problems were related to the ambulance service call receiver missing information or failing to be understood by the caller. Communication problems were associated more with calls made from payphones or mobile phones (110/221, 49.8%) than with those made from land lines (372/1609, 23.1%) (χ2=71.2, df=1; P<0.001). The type of telephone (land line, payphone, mobile phone) and communication problem were similar in Derbyshire and the West Midlands. Communication problems were less likely if the call was made by a health professional (for example, general practitioner, carer, nurse) rather than by someone else (21/220, 9.5% v 461/1610, 28.6%; χ2=26.4; P<0.001).


More than a quarter of emergency ambulance calls in this study had communication problems. Calls from mobile phones and payphones generated a higher rate of communication problems than those from land lines. Mobile phones, which are used increasingly,5 may help to reduce the time taken to notify the emergency services but the advantages of this must be weighed against the high rate of communication problems.

The occurrence of communication problems related to the emotional state of the caller highlights the need to train call receivers in dealing with people in emotional states. Use of medical/technical terms, some of which can cause considerable confusion (for example, “unconscious”), as well as talking too quickly and without clarity, have been identified as areas in which training of call receivers is needed.

Use of a standard land line, appropriate training of public service personnel, such as police and fire services, and further public education about the information required when making 999 calls may reduce the extent of the communication problem.


We thank all the control room staff at West Midlands Ambulance Service NHS Trust and Derbyshire Ambulance Service NHS Trust for their help in this study; Tracey Cooper, Steve Elliker, Claire Caswell, and the control room supervisors at both ambulance services for their assistance; and Mrs Teresa Allan for her statistical advice during the design and analysis phases of the project.

Contributors: JH undertook the analysis and compiled the first draft of the paper. SW designed the study, assisted in the analysis, gave statistical advice, and helped write the paper. PB was involved in the design of the study, undertook the call monitoring and data entry, and was involved in writing the paper. MWC designed the project, undertook the data validation, and had a substantial role in writing the paper. MWC and SW are joint guarantors of the paper.


  • Funding Laerdal Foundation for Acute Medicine.

  • Competing interests None declared.


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