R L Lammers1, B A Roth, T Utecht. 1. Department of Emergency Medicine, Michigan State University/Kalamazoo Center for Medical Studies, USA.
Abstract
STUDY OBJECTIVE: To compare rates of undertriage and overtriage of six ambulance dispatch protocols for the presenting complaint of nontraumatic abdominal pain, and to identify the optimal protocol. DESIGN: Retrospective prehospital and emergency department chart review to classify patients' conditions as "emergency" or "nonemergency." Utility analysis was used to identify the preferred protocol and monetary cost-effectiveness analysis to identify the least expensive protocol. SETTING: County emergency medical services (EMS) system with five receiving hospitals serving a mainly urban population of approximately 350,000. PARTICIPANTS: Records of 902 patients who called 911 for nontraumatic abdominal pain were reviewed; patients not transported were excluded. Twenty-seven county EMS medical directors completed questionnaires. RESULTS: Six ambulance dispatch protocols for nontraumatic abdominal pain were developed: indiscriminate-dispatch, four selective protocols, and no-dispatch. A dichotomous classification system was derived prospectively from the prehospital and medical records of patients who had activated the EMS system before the study period to define "emergency" and "nonemergency" conditions associated with nontraumatic abdominal pain. Emergency criteria identified patients with conditions requiring medical treatment within 1 hour. Reviewers determined, for each patient, whether an ambulance would have been dispatched by each of the protocols. Undertriage and overtriage rates were calculated for each protocol. County EMS medical directors assigned utility values to four potential outcomes of ambulance dispatch by the direct scaling method. The outcomes comprised correct and incorrect decisions to dispatch ambulances to patients with and without emergencies. The protocols were compared by decision analysis. A cost analysis was also performed, using an estimated marginal cost per transport of $302. Sensitivity analysis demonstrated the effect of varying the cost of an undertriage error and the cost per response. Of the 788 patients included in the study, 7.8% had conditions defined as emergencies. The four selective ambulance dispatch protocols had overtriage rates ranging from 10% to 51% and undertriage rates of 4% to 7%. None of the protocols was proven superior on the basis of the medical directors' assignment of utility values. The marginal cost of dispatching advanced life support ambulances to all patients with this complaint was $3,838 per emergency. CONCLUSION: The majority of patients with nontraumatic abdominal pain who requested ambulance transport during the study period did not have conditions that were classified as emergencies. In the study model, if an undertriage error costs more than $3,674, indiscriminate ambulance dispatch is the least expensive protocol, and if an undertriage error costs less than $3,674, no ambulance dispatch is the least expensive strategy.
STUDY OBJECTIVE: To compare rates of undertriage and overtriage of six ambulance dispatch protocols for the presenting complaint of nontraumatic abdominal pain, and to identify the optimal protocol. DESIGN: Retrospective prehospital and emergency department chart review to classify patients' conditions as "emergency" or "nonemergency." Utility analysis was used to identify the preferred protocol and monetary cost-effectiveness analysis to identify the least expensive protocol. SETTING: County emergency medical services (EMS) system with five receiving hospitals serving a mainly urban population of approximately 350,000. PARTICIPANTS: Records of 902 patients who called 911 for nontraumatic abdominal pain were reviewed; patients not transported were excluded. Twenty-seven county EMS medical directors completed questionnaires. RESULTS: Six ambulance dispatch protocols for nontraumatic abdominal pain were developed: indiscriminate-dispatch, four selective protocols, and no-dispatch. A dichotomous classification system was derived prospectively from the prehospital and medical records of patients who had activated the EMS system before the study period to define "emergency" and "nonemergency" conditions associated with nontraumatic abdominal pain. Emergency criteria identified patients with conditions requiring medical treatment within 1 hour. Reviewers determined, for each patient, whether an ambulance would have been dispatched by each of the protocols. Undertriage and overtriage rates were calculated for each protocol. County EMS medical directors assigned utility values to four potential outcomes of ambulance dispatch by the direct scaling method. The outcomes comprised correct and incorrect decisions to dispatch ambulances to patients with and without emergencies. The protocols were compared by decision analysis. A cost analysis was also performed, using an estimated marginal cost per transport of $302. Sensitivity analysis demonstrated the effect of varying the cost of an undertriage error and the cost per response. Of the 788 patients included in the study, 7.8% had conditions defined as emergencies. The four selective ambulance dispatch protocols had overtriage rates ranging from 10% to 51% and undertriage rates of 4% to 7%. None of the protocols was proven superior on the basis of the medical directors' assignment of utility values. The marginal cost of dispatching advanced life support ambulances to all patients with this complaint was $3,838 per emergency. CONCLUSION: The majority of patients with nontraumatic abdominal pain who requested ambulance transport during the study period did not have conditions that were classified as emergencies. In the study model, if an undertriage error costs more than $3,674, indiscriminate ambulance dispatch is the least expensive protocol, and if an undertriage error costs less than $3,674, no ambulance dispatch is the least expensive strategy.