Emergency physician's dispatch by a paramedic-staffed emergency medical communication centre: sensitivity, specificity and search for a reference standard.

BACKGROUND: Some emergency medical systems (EMS) use a dispatch centre where nurses or paramedics assess emergency calls and dispatch ambulances. Paramedics may also provide the first tier of care "in the field", with the second tier being an Emergency Physician (EP). In these systems, the appropriateness of the decision to dispatch an EP to the first line at the same time as the ambulance has not often been measured. The main objective of this study was to compare dispatching an EP as part of the first line emergency service with the severity of the patient's condition. The secondary objective was to highlight the need for a recognized reference standard to compare performance analyses across EMS.
METHODS: This prospective observational study included all emergency calls received in Geneva's dispatch centre between January 1st, 2016 and June 30th, 2019. Emergency medical dispatchers (EMD) assigned a level of risk to patients at the time of the initial call. Only the highest level of risk led to the dispatch of an EP. The severity of the patient's condition observed in the field was measured using the National Advisory Committee for Aeronautics (NACA) scale. Two reference standards were proposed by dichotomizing the NACA scale. The first compared NACA≥4 with other conditions and the second compared NACA≥5 with other conditions. The level of risk identified during the initial call was then compared to the dichotomized NACA scales.
RESULTS: 97'861 assessments were included. Overall prevalence of sending an EP as first line was 13.11, 95% CI [12.90-13.32], and second line was 2.94, 95% CI [2.84-3.05]. Including NACA≥4, prevalence was 21.41, 95% CI [21.15-21.67], sensitivity was 36.2, 95% CI [35.5-36.9] and specificity 93.2 95% CI [93-93.4]. The Area Under the Receiver-Operating Characteristics curve (AUROC) of 0.7507, 95% CI [0.74734-0.75397] was acceptable. Looking NACA≥5, prevalence was 3.09, 95% CI [2.98-3.20], sensitivity was 64.4, 95% CI [62.7-66.1] and specificity 88.5, 95% CI [88.3-88.7]. We found an excellent AUROC of 0.8229, 95% CI [0.81623-0.82950].
CONCLUSION: The assessment by Geneva's EMD has good specificity but low sensitivity for sending EPs. The dichotomy between immediate life-threatening and other emergencies could be a valid reference standard for future studies to measure the EP's dispatching performance.