Title: 999 R.E.S.P.O.N.D. [emerRgEncy diSPatch decisiONs in coviD-19]
Funder: Health and Care Research Wales (Welsh Government)

Abstract: Improving timely access to appropriate critical care services is a mandate of the Welsh Government and a known global challenge. Emergency Medical Dispatch (EMD) systems are under pressure to provide a rapid, efficient on-site response to medical emergencies and trauma following a 999 call. EMD is directly related to risk assessment, and the result of a decision-making negotiation process between the caller, call-taker and clinical teams. Although the emergency call and its focal role in risk assessment for EMD is well known, there has been no systematic, interdisciplinary study of the multi-actor system behind the call that manages the decision to dispatch critical care resources. A detailed understanding of this process is vital to ensure these scarce, specialist resources are targeted to benefit the patients who need them the most. The COVID-19 pandemic has increased further the complexity of decision-making in relation to critical care deployment. 999 RESPOND proposes a unique design, using the lens of service disruption caused by the pandemic, to study the interrelatedness of public engagement with health services, risk-negotiation and EMD. Our project is the first of its kind in the UK and designed to be translatable to training and policy. We will answer the following research question: When deploying specialist critical care resources, how are risk and severity indicators in 999 -callers utterances identified and brokered amongst those involved in the dispatch decision, and how might dispatch teams be supported to optimize clinically-appropriate deployment to the patients most in need of this scarce resource? We will identify the specific indicators that function as high-risk trigger points in the 999 call and the way in which they are recontextualised in the subsequent inter-/intra- team decision-making process. We will map the information trajectory of risk negotiation and compare against current EMD systems, guidelines and institutionally-set priorities and policy. We use a theoretical approach and methodology that allows the systematic analysis of the ways in which high-acuity medical decision-making is associated with linguistic choices in the 999 call, and teams’ negotiation of risk in situated interaction. We propose a cross-sectional, qualitative study drawing on routinely-collected ambulance datasets to study the trajectories of decisions through the analysis of spoken interaction between all stakeholders (caller, call handler, responders at scene and external agencies) and the written artefacts they produce. Our objectives are to identify and map: • The key interactional practices occurring amongst and within the control room teams, in the determination of cases eligible for critical care dispatch; • The landscape of the decision-making trajectory and the risk indicators brokered between the stages of the dispatch process; • Whether there is evidence that a major disruption (COVID-19) has altered these practices and changed the way critical care resources are targeted within the service; • The role of policy documents and institutional priorities in the ways in which teams operationalise risk negotiation. And use the findings to: • Design a training intervention for Ambulance staff and critical care dispatch staff; • Provide recommendations for national policy.

Lay abstract: Ambulance services around the UK are made up of a variety of emergency care staff, with different skills and capabilities. In addition to the familiar front -line paramedic crewed ambulances, there are a smaller number of specialist teams with extra training, equipment and expertise in treating the very sickest patients. In Wales, the Emergency Medical Retrieval & Transfer Service (EMRTS) Cymru works alongside the Welsh Ambulance Service. EMRTS provides senior hospital doctors (consultants), specialist paramedics and specialist nurses to treat people at the scene of serious accidents, or when they are taken critically ill. EMRTS can respond to the scene of an emergency by road in rapid response cars, or by air on board the Wales Air Ambulance helicopters. There are over 385,000 “999” calls to the ambulance service per year in Wales, but only a relatively small number of these are so serious in nature that they require the advanced critical care skills of the EMRTS team. To help decide which calls to go to the service has two members of staff working in the Welsh ambulance control room looking at all the 999 calls that come in 24 hours a day. They can speak to callers, look at notes on the computer system and speak to ambulance crews and first responders that may already be with a patient. They use this information to decide if they should send a critical care team to help. It is important that the team is dispatched as quickly as possible to the most seriously ill patients. However, as a small specialist team, it is also important that they are only sent to emergencies where they are needed. Getting the right information to make this decision in the heat of the moment can be very difficult. We want to study the way in which the decision to dispatch a cri tical care team is made by the teams in the ambulance control rooms. We will closely study a number of recent cases where a critical care team was dispatched to an emergency. We will use the computer notes, listen to voice recordings of 999 calls, and study any other information that is available about the incident. We will use scientific methods that look in great detail at how members of the dispatch team work together under pressure to make a decision. This involves examining the words and phrases they use between one another, other ways they communicate, and how they make sense of the rapid flow of information from the 999 call. Researchers have done this before for routine ambulance work, but we will be the first to look at this in the UK for the critical care teams. The process is normally a challenge; the COVID-19 pandemic and its aftermath added even more complexities in making these decisions. We will be looking at calls before and during the pandemic. We want to see if COVID-19 has changed the way tthat critical care teams respond to emergency cases. We will be looking at a selection of all 999 calls where a critical care team is sent to the scene. This includes people whose heart has stopped (cardiac arrest) or suffered a major trauma (e.g. a car accident). We hope that we will be able to improve the process of getting critical care to the people who need it most. We will use our research to support training for new staff and ambulance staff that work alongside the service and to influence national policy.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE