J Med Syst (2012) 36:3917–3923 DOI 10.1007/s10916-012-9863-x
ORIGINAL PAPER
An Emergency System to Improve Ambulance Dispatching, Ambulance Diversion and Clinical Handover Communication—A Proposed Model Samir El-Masri & Basema Saddik
Received: 18 February 2012 / Accepted: 29 May 2012 / Published online: 7 June 2012 # Springer Science+Business Media, LLC 2012
Abstract Effective communication in healthcare is important and especially critical in emergency situations. In this paper we propose a new comprehensive emergency system which facilitates the communication process in emergency cases from ambulance dispatch to the patient’s arrival and handover in the hospital. The proposed system has been designed to facilitate and computerize all the processes involved in an accident from finding the nearest ambulance through to accessing a patient’s online health record which can assist in pre-hospital treatments. The proposed system also locates the nearest hospital specializing in the patient’s condition and will communicate patient identification to the emergency department. The components of the proposed system and the technologies used in building this system are outlined in this paper as well as the challenges expected and proposed solutions to these challenges. Keywords Emergency department . Emergency medical system . Ambulance . Ambulance dispatch . Online health record . Mobile web services . GPS . Clinical handover
S. El-Masri College of Computer and Information Systems, King Saud University, Riyadh, Saudi Arabia B. Saddik (*) Department of Health Informatics, College of Public Health and Health Informatics, King Saud Bin Abdulaziz University for Health Sciences, Mail Code: 2350, P.O. Box 22490, Riyadh 11426, Kingdom of Saudi Arabia e-mail:
[email protected]
Introduction An effective emergency medical system should not only provide emergency care, but also integrate and link all the interdependent components from the initial mayday call, to ambulance dispatch, ambulance transportation, pre-hospital ambulance care and arrival at the healthcare facility. Emergency response times will inevitably be linked to telecommunication systems, geographic location of the emergency and ambulance deployment, and hospital availability. This paper describes the Comprehensive Medical Emergency System (CMES) which has been developed with a view to link the different and essential components of emergency medical systems. It highlights the need for such a system and discusses how it addresses the gaps arising from existing systems as well as the challenges expected and proposed solutions to these challenges.
Background In recent years, the role of ambulance services has evolved significantly. Ambulance services have become venues for initiating life-saving treatments prior to arrival at a health care facility as well as providing a range of healthcare needs such as fracture management, hemorrhage control and wound care including urgent primary care, emergency and non-emergency patient transport, and referrals to alternative healthcare professionals [1]. Factors such as delayed ambulance dispatch, incorrect pre-hospital treatments, incomplete and inaccurate clinical handover, emergency department overcrowding and ambulance diversion can delay and impact on effective outcomes of care. Our proposed system will contribute to reducing ambulance dispatch times, facilitate pre-hospital treatments and enhance communication in the clinical handover process, and
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contribute to reducing emergency department overcrowding and ambulance diversion. Ambulance dispatch The crucial moments in dispatching an ambulance correctly with the least response time in cases of trauma or other lifethreatening situations will contribute and determine patient survival. Many studies have highlighted the importance and possible advantages gained from reducing response time, and initiating early specialized pre-hospital patient management [2–4] Moreover, it is realized that quick response time of prehospital patient management decreases the percentage of death and improves patient outcomes [5]. The communication system by which ambulances are dispatched needs to facilitate the process of saving lives. Every moment of delay in an emergency can significantly reduce a patient’s chance of survival. Traditionally, and with current ambulance systems, ambulance dispatch has mainly relied on radio communications in which an ambulance is dispatched, following a request which is entered by an operator via information often from a caller at the scene providing information about the accident and its approximate location. Newer Computer Aided Dispatch systems have been reported in the literature however, various problems have been reported with these systems such as the inability of the dispatch system to be able to track the locations of ambulance units outside their station; making it impossible to determine the closest unit to dispatch in an emergency call [6–9]. Ambulance diversion In recent years, ambulance diversion in response to emergency department overcrowding has become a widespread public health concern as well as leading to substantial loss in revenues. Ambulance diversion is defined as the patient not being transported to their initially intended hospital because the hospital is unable to accept patients because of temporary emergency department overcrowding or closure [10]. Ambulance diversion can lead to delayed emergency medical care and affect overall clinical outcomes, patient and provider satisfaction, quality of life measures and economic outcomes [11]. A study by McConnell et al., found that avoiding diversion can generate substantial revenues for a hospital, approximately $1,100 per hour of diversion avoided. Furthermore, the study reports that a two thirds decrease in ambulance diversion was followed by increased revenues for ambulance patients of approximately $175,000 per month [12]. Clinical handover communication Effective communication between staff in healthcare is important and particularly critical in the emergency department. The
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communication process between the ambulance and the emergency department in particular is a complex process with many opportunities for breakdown and error. A study examining communication in the emergency department, found high levels of communication failure in the transfer of written information from ambulance crew [13]. The illegibility of the ambulance transfer form, the lack of real-time information, the misinterpretation of the handover information, and long delays with the transfer of vital information are some of the communication failures which have been documented in the literature [14]. Another study showed that 26 % of emergency department records had at least one instance where information recorded by the ambulance crew was either omitted or altered during transfer. These fell into various categories including the previous medical history of the patient, the timings of the event bringing them to hospital, frequency of the event occurring, allergies and medications [15]. The loss and breakdown of communication in emergency situations, and in healthcare overall is chaotic and can lead to significant implications for patient care as well as causing negative experiences to the patient.. Organizations and governments have realized the importance of building better systems to address these issues and have utilized tools to assist in the overall management of communication in healthcare [16–21]; however no system has yet been able to effectively address all of the above factors. The Comprehensive Medical Emergency system we are proposing is a wireless Internet web based integrated system. The main advantage of this system is the use of Mobile Web Services technology which overcomes problems of interoperability between systems running on different applications based on different programming languages on different platforms [22]. The proposed comprehensive medical emergency system (CMES) 1. System components and functions The proposed CMES is composed of five integrated subsystems as shown in Fig. 1. The subsystems and their functions include: 1.1. An Emergency requester device: (Emergency application for mobile devices). This constitutes of a mobile phone equipped with a Global Positioning System (GPS) and simple emergency application. The system will initially be triggered by the emergency requester device reporting an accident. Through this simple mobile application, the caller can quickly and easily enter details about the accident such as the number of injured people and number of cars involved in the accident. The
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Fig. 1 Proposed comprehensive medical emergency system components. The request is made by mobile phone which is received by the MCS and an automatic request and allocation for an ambulance is made through the MCS
application will also automatically send the coordinates of the mobile phone to the main central system. 1.2. Main Central System (MCS): This is the main server for the whole system which controls and manages collaborative operations between the systems components. MCS receives the emergency request from the requester without human intervention. It sends a request to all available ambulances to report their GPS coordinates (other algorithms will also be available where the ambulance continually reports its coordinates to the MCS. The selection of a specific algorithm will be based on how busy the environment is). MCS will then compare the accident and all ambulance coordinates and send a job request to the nearest ambulance based on the navigation system map rather than on direct distance. 1.3. Ambulance System: Each ambulance is equipped with a GPS and navigation system. The system utilizes touch screen (to indicate ambulance availability). Once the MCS locates the nearest ambulance it will send a request to the ambulance. Ambulance crew will have 10 s to accept or reject the request. Once an ambulance accepts the request (through a touch screen computer in the ambulance), MCS will send the accident’s coordinates to the ambulance and automatically the ambulance system will show the road map to the accident location. If ambulance crew reject the job or do not reply within 10 s, the MCS will locate the second nearest ambulance to the accident, assuming that the positions of ambulances do not change
much in 10 s. In cases of longer delay, MCS will restart the process from the beginning. The ambulance system, based on the patient’s conditions, distance, availability and specialty of hospitals, will locate the nearest and most appropriate hospital for the patient’s conditions and the roadmap on the navigation system will automatically be displayed. The identity of the patient will be communicated to the Hospital Emergency Department System (HEDS). All hospital GPS coordinates will be available on the database of the ambulance system. 1.4. Online Health Record (OHR): This is the patient’s online health record. The OHR will be created to transfer patient’s data to the hospital in real-time using online wireless communication. As well as having the ability to be linked with the patient’s electronic medical record to assist in retrieving the patient’s medical history, the OHR system will also function as a decision support system which will support the ambulance crew and recommend the best form of treatment based on the patient’s medical history and existing medical conditions. 1.5. Hospital Emergency Department System (HEDS): The HEDS in each hospital has the ability to receive patient information directly entered by the incoming ambulance crew. Once the ambulance locates the right hospital, the HEDS will book a bed or cubicle for the incoming patient and will access the patient’s health record. The ambulance system continues to send the ambulance coordinates to HEDS so that the department’s medical staff can monitor the incoming ambulance on the system. HEDS will
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show in real-time all the incoming ambulances on a map with a list of information on the distances and estimated time of arrival. Department staff will prepare what they require for the incoming patient based on the information transmitted through the ambulance system. Through HEDS, staff can update the availability of beds or operation theatre availability based on the discharge or transfer of patients.
System communication processes The proposed system has two main communication processes divided into two phases as shown in Fig. 2. Phase1: Ambulance and MCS The communication process between the ambulance and the MCS is complex in that it includes a number of processes. This begins with the capture of the accident information through the mobile requestor device and the interaction between the MCS and the ambulance server to retrieve all available ambulance locations via its GPS system. MCS interacts with the ambulance server which interacts directly with ambulance vehicles to retrieve their availability information. Each ambulance displays their vehicle status as either, available, non-available or in mission. When the MCS server finds the appropriate ambulance based on availability and location, Fig. 2 The CMES has two main communication processes, Phase 1 between the ambulance and MCS and Phase 2 between the ambulance and HEDS
it defines its ID and sends a request to the defined ambulance system. The ambulance crew are able to respond to the MCS request via their installed laptop touch screen, and choose to accept, or reject the requested mission. Once the request is accepted, the ambulance’s status will be reset through MCS from available to on mission and a roadmap of the incident location will be displayed on the respective ambulance system screen through MCS. If the ambulance rejects the mission, then MCS will restart the process of finding the next nearest and available ambulance. Once the patient is inside the ambulance vehicle, the crew enters the patient’s information through the OHR system. This information and the accident location will be sent to the ambulance server which will interact with HEDS.
Phase 2: Ambulance and HEDS The Ambulance server will already have the locations of all the hospitals in all areas. The ambulance server will select the hospital based on three values: 1. The hospital’s location (nearest to accident). 2. The hospital’s specialty (according to the patient injury type). 3. The hospital’s bed and resource availability, through which information is transmitted through HEDS.
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Once the ambulance locates and confirms availability for the hospital, a road map for that hospital will be displayed on the ambulance system screen and information is directly transmitted to HEDS. Information transferred includes: the ambulance identification (ID) number, the ambulance road map, and the estimated time of arrival (ETA) which will all be displayed on the HEDS screen. Ambulance alert colors will be used to reflect the estimated time of arrival (i.e., red will reflect arrival within 15 min whilst blue will reflect an ETA of between 30 and 60 min). Prior to the arrival of the ambulance to the hospital, a communication link is established between HEDS and the ambulance to allow the transmission of data, voice and text patient information. Moreover, the OHR will allow the HEDS team to access online updated information from the ambulance en-route to the hospital. This will be done automatically when the ambulance crew uses the OHR to transfer the patient identification number (PID) and all medical details concerning the patient. As mentioned earlier, the OHR also supports the ambulance crew in making the correct decisions concerning the patient’s pre-hospital treatment based on their existing medical conditions and previous medical history. In case the patient does not have an OHR, the ambulance crew will still transmit the patient’s details and the current condition details to the hospital in order that preparations are made to treat the patient accordingly and to avoid any breakdown in communication upon arrival. Technologies and standards used All system components and inter-communications are based on mobile web services and the emerging technology of Service Oriented Architecture (SOA). The technologies which have been used in the system have been described in more detail by El-Masri [22]. It is presumed that all ambulances will have fast wireless Internet access through a General Packed Radio Service (GPRS) or Worldwide Interoperability for Microwave Access (WiMAX). It is also presumed that emergency requestors will have access to the Internet and their mobile phone will be equipped with a GPS receiver. The system can also receive normal voice calls to a human operator whereby the operator will enter accident details into the system as well as provide support to the caller if needed. All the components of the system use the communication standard protocol HL7 version 3.0 and healthcare approved security and privacy standards to communicate with each other.
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the hospital; which in turn improve overall patient care. Whilst the literature shows that current emergency systems are automating their functionalities and are using wireless links in their communication, our proposed system has many advantages over existing systems which include: The system utilizes a fully computerized dispatch system based on new technology which will allocate and deploy ambulances to an incident in the least response time. This eliminates the potential for human error and reduces the time required to find and send an ambulance to an incident. The system will utilize new advanced technologies such as GPS, Mobile Web Services, Service Oriented Architecture and Wireless Communications which will improve ambulance dispatch services in comparison to the computer aided dispatch systems which have been reported in the literature [9] The proposed system ensures that best resource allocation decisions are made. This is achieved by the system computation capability to decide the nearest and appropriate ambulance care and hence the most appropriate hospital for the patient, taking into consideration issues such as location, specialty and emergency department availability. Furthermore, by communicating with HEDS the system is able to identify which emergency departments are overcrowded and allows the system to identify the next available hospital in the least amount of time, thus minimizing the time for ambulance diversion. A study in 2005, found that the implementation of pre-emptive ambulance distribution using internet-accessible ED information and pre-hospital ATS allocations was associated with reduced ambulance diversion, due to the redistribution of ambulances [23]. We believe that our system will contribute to the reduction of these issues. The system accesses the patient’s OHR, allowing ambulance crew to efficiently provide pre-hospital treatment to the patient based on their past medical history whilst at the same time the OHR supports crew in making the right decisions for patient care. The availability of the OHR will also reduce the communication gaps reported in the literature in the handover of patient care between the ambulance and the emergency department and the potential for loss of information [24]. Our proposed system will overcome the barriers to effective clinical handover between the ambulance and the emergency department reported in the literature such as inattention to handover and lack of active listening skills [25] and improve the quality and quantity of information exchanged during handover [26].
Discussion
Challenges and proposed solutions
The aim of our proposed system is to improve the process performance and management of dispatching ambulances, to decrease time wasted on ambulance diversion, and to improve communication links between the ambulance and
The proposed system is a system for the future in which we foresee the complete uptake of technologies in healthcare. In case of delayed uptake of specific technologies, the proposed system can still function in the absence of one or more of its
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components. In addition to the emergency requester device on mobile phones, the system can also receive normal emergency calls, through an operator who will enter details about the emergency and the rest of the system’s processes will continue. The operator can also provide support to the caller such as cardiac arrest support or reduction of blood loss support until the ambulance arrives to the scene. Our proposed system can also function in the absence of OHR access in the ambulance. In this case the ambulance system provides an alternative way of communicating the patient’s details and conditions to the hospital using web-based communication. We are also aware of the challenges of duplicate calls which are common to traditional and advanced systems. The proposed system will have an automatic function to eliminate or reduce duplicate calls profiting from information provided by callers and by comparing distances between callers. The challenge of deciding the number of ambulances to dispatch to the same accident has also been addressed. The system’s components have been developed and are being tested individually and collectively to overcome potential problems. Various consultations and interviews with end users have been conducted to address the specific needs for each component and to overcome any potential challenges. A pilot system will be deployed and tested. The system will be evaluated and results and performance will be studied and compared with existing systems.
Conclusion Using advanced technology such as Mobile Web Services and Service Oriented Architecture, a new advanced medical emergency system has been proposed and developed. The new system will respond to the needs of an efficient and comprehensive emergency medical system from the initial emergency request and ambulance dispatch, until the admission of the patient to the emergency department of the hospital. This system includes components that to the best of our knowledge no previous systems have proposed and aims to improve existing problems in ambulance diversion and clinical handover communication. Further studies will evaluate the CMES systems’ reliability of the communication, integration and interoperability between all the components of the system. Acknowledgement This work is part of a two year research project which has been fully funded by a grant through King Abdul-Aziz City for Science and Technology (KACST)/National Plan for Science and Technology (NPST) in the Kingdom of Saudi Arabia. Grant number: 09-INF880-02 Conflict of interest No conflict of interest declared.
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Authorship: S.El-Masri developed and conceived the proposed system and reviewed final drafts of this manuscript. B. Saddik drafted and reviewed this manuscript.
