Ambulance Response Times in Developing Emergency Health Care Systems

Outline

Thesis: Dispatcher training can improve ambulance response times in EMS systems in low income countries

I. Statement of the problem
A. Introduction
1. Why was the research started
2. We need to improve health care in 3rd world countries
3. In order to do this, we need to improve emergency care
A. Why emergency care?
B. Why focus on this?
C. Ambulance response time plays an important role in improving the outcome of patients in health emergencies
4. Ambulance response time has impact on short-term survival
5. Need for sustainable approaches in low- and middle- income countries in order to improve emergency health care. One approach could be ambulance response time.

II. Survey of the literature
A. How do we improve emergency care in an area with limited resources?
B. Training is one way to do this
C. Dispatcher Training can be effective
1. What training programs are available for dispatchers?
D. How do we evaluate the effectiveness of our training?
1. Look at ambulance response times
a. Is this a good method?
i. Some say yes - why?
1. Ambulance response has been area of interest in recent years
2. Ambulance response is prone to perceptions, demands and utilization of emergency medical services
3. Changes are necessary in order to improve response time
4. Example of changes from Canada
5. Study that changes in developing countries should focus on ambulance response. Support of pilot projects and research
ii. Some say no - why?
1. Arguments against focus on ambulance response time
2. Widespread development of indicators is needed
3. No universal approach to emergency medical service performance indicators has been developed so far
4. Traditional approach to performance measurement should be questioned
5. The right development of indicators is questioned
b. Counter argument
1. Example of Addis Ababa shows that a case sensitive assessment of performance indicators and focus of change should be developed - in individual case can this be ambulance response time

III. Research design and data collection
A. Study design and protocol:
i. Experimental research design
ii. Collect data for ambulance response times before and after implementation of training program
B. Subjects
i. Osh Ambulance description
ii. Dispatchers in that system - description and level of education
iii. Ambulance workers - description
C. Interventions
i. Training program - description
ii. Tone system - description
D. Measurements and other observations
E. Explanation of results and relation to examples from the literature. V. Conclusion
A. Result supports thesis and importance of topic
B. Further research in this area is needed

Abstract

Dispatcher training can improve ambulance response times in emergency medical service (EMS) systems in low income countries. Emergency health care systems are of increasing concern in international healthcare developments and the global fight against the burdens of disease. Studies show that emergency health care improvements in developing countries should focus on ambulance response. Low-cost changes including emergency medical dispatch training in developing urban emergency health care systems can improve ambulance response times. Concerns about focusing on ambulance response time as a single indicator are addressed by showing a case sensitive approach for developing emergency health care systems that in return can identify ambulance response as main indicator for a particular system. This approach has been chosen for the subject of study, the Osh Ambulance Service, a municipal EMS in Kyrgyzstan. This particular service, the implemented research, the study design and, the data analysis are presented. The data show that there has been a change from an average response time of 23, 18 minutes to 20, 15 minutes. This data is statistically significant and indicates that the implemented changes, despite severe challenges, likely have an effect, but it is unclear if this change will have a large clinical impact. Further research on emergency medical dispatch and emergency medical response in low- and middle- income countries is encouraged. With increased opportunities and further globalization emergency health care professionals could play a greater role in research and development of emergency medical service systems in resource-limited countries.

1. Statement of the problem

This research was based on the experience of the authors in emergency medical service (EMS) development and training in low-income countries. As one would expect, the problems with ambulance response are many and varied. They range from poor road conditions, lack of equipment and vehicles, overspecialization of the ambulance units, lack of training for dispatchers, frequent power outages which limit the radio usage and a limited supply of gasoline for the ambulances themselves. When thinking about what vast resources are necessary to address the complex web of problems, the question surfaced; if dispatcher training can improve ambulance response times in low income countries?

Health care systems in low- and middle income countries need improvement and support in order to ease the global burden of disease and enable human development. A lot of financial resources are poring into third world countries in order to accomplish this.

Emergency health care is becoming an important focus in international health care development. Emergency medical services are seen as a critical component of health care in developing countries (Kobusingye, 2005). It has been recognized as an important horizontal approach to improve living conditions, burdens of disease and long-lasting economic effects due to improved disease adjusted life years (DALYs) in industrialized nations and developing countries alike (Davis, 2004; Kellermann, 2002). Rather than focusing on a vertical (disease oriented) approach a horizontal approach like on emergency medical services provides benefits to the population suffering from various medical conditions.

If we define EMS systems based on experiences from industrialized nations system development and improvements will fail in the Third World because resources in low- and middle- income countries (LIMC) are limited and sustainable approaches are needed in order to develop an emergency health care system with a lasting effect for the population (Kobusingye, 2005).

Changes need to be made that are able to be maintained by the health care system long after international aid has vanished. Otherwise there are a lot of resources and time that is wasted. Indeed many people in third world countries still do not have access to proper emergency care and equipment. This results from a lack of infrastructure and financial resources (Jamison 2006; Kobusingye 2005).

2. Survey of the literature

How can we improve emergency care in a region with limited resources and maintain a sustainable approach? Before changes are implemented and further investments are made into the area of emergency medical services in developing countries it is important to find support for this approach. Hauswald and Yeoh (1997) have studied this issue and came to the conclusion that the benefits of an EMS system for a developing country are small if it is based on western models. The authors support the search for alternative approaches to a North American EMS model in low- and middle-income countries. Also Kobusingye (2005) concludes that EMS system development must be carefully designed to the countries needs.

Practice and research in emergency health care and in particular in ambulance services have focused in the last 30 to 40 years on health care system in developed and industrialized nations. The focus of research often was to improve emergency health care delivery in these regions. How important are emergency medical services for developing countries, and how important is the improvement of ambulance response for low- and middle- income countries? These questions need to be asked in the light of low levels of infrastructure, health care services, income and education in these regions — factors that influence ambulance response and the overall performance of emergency health care systems.

In 1995 a comparative study of Ghana and Mexico (Arreola-Risa) found out that in order to improve trauma care (as part of emergency health care) in urban areas of developing countries the focus should be on ambulance service and emergency room development rather than on intensive care unit development and other levels and areas of care.

Razzak and Kellermann (2002) support research and pilot projects in the area of emergency health care development in low and middle income countries. They show that the incorporation of a basic level of emergency medical care into a health system ha a significant impact on the well-being of the populations.

This view is also shared by a recent publications of the World Bank: "Disease Control Priorities in Developing Countries — 2nd Edition" provides data that shows that 36% of all disability adjusted life years (DALYs) in low- and middle- income countries could benefit from emergency medical service systems if they would be available (Jamison (Ed.), 2006).

In resource limited settings it is important to determine what kind of changes can possibly have a positive impact on emergency medical service performance. The authors of a case study on developing countries found the following: "Prevention, as well as improvements in prehospital care are likely priorities for developing countries" (Mock, 2003, p.45). The paper identifies three different categories that should be addressed: Administration and organization, human resources including staffing and training, physical resources like equipment, supplies and infrastructure. The authors show that improvements in organizational measures like the introduction of improved dispatch schemes can have an impact in the essential health service delivery of emergency care.

Strengthening organizational means are a method how an EMS system can be influenced. One way to influence such organizational capacities is training, and a crucial point in ambulance response is the mechanism of ambulance dispatch. Therefore a dispatch training program likely can influence the process of ambulance dispatch. As a consequence this paper asks if dispatcher training can improve ambulance response times in EMS systems in low income countries.

What kinds of training programs are available for emergency medical service dispatchers? The most widespread used training program is the emergency medical dispatch curriculum of the National Highway Traffic Safety Administration (Wallace (Ed.), 1995). This program has been adopted by many emergency medical service systems and changed to their specific needs. Currently dispatch training based on this program is not only performed in the USA, it serves as a template and emergency medical dispatch programs in Germany, the UK, as well as other countries are based on this curriculum.

In an attempt to evaluate the effectiveness of dispatch training ambulance response times can serve as an indicator. Ambulance response times play an important role in improving the outcome of patients in health emergencies (Pell, 2001). Response times and response time regulation is therefore a topic that not only affects developing emergency health care systems but also systems that are already firmly in place.

Is ambulance response time a good indicator for EMS system performance? Ambulance response time has often been an area of interest with those concerned with the development of emergency health care systems. A paper by Kellermann & Razzak shows that improved ambulance times in developing countries can limit mortality and morbidity, and have a positive impact on injury complication, infection and early rehabilitation of sick and injured patients (2002). Mayer (1979) shows that ambulance response times have an impact on short-term survival and that ambulance response is influenced by the patients delay to seek care, by dispatch time and the ambulance travel time to the scene of the emergency. Especially the dispatch time and the ambulance travel time are factors that can be influenced through organizational means.

The Irish Association of Ambulance Personnel claims that as many as 700 people die each year because of long ambulance response times in rural areas (Payne, 2000). It can take up to 20 minutes to dispatch an ambulance after a call in these places. This poor response time is due to lack of funding and organizational errors within the Irish EMS systems. All problems are not solved by training alone, and are not limited to the developing world.

In specific emergency cases, this response time is often perceived as taking longer than it actually does (which would make sense from a psychological point of view), however the public's general perception of the timeliness of EMS response plays an important role in the utilization of such a system (Finch, 1999). This demonstrates that the public is interested in improved response times and the picture the ambulance service portrays also influences its utilization and therefore its capability to respond in time at the event of a health emergency.

The question that needs to be asked is what is the most efficient use of resources to make change regarding emergency medical service delivery. Stiell and colleagues (1999) have shown that low cost improvements in a Canadian emergency medical service system can have a positive impact on ambulance response times. His paper shows that a multifaceted optimization approach focusing on improving the dispatch process, and continuous quality improvement can lead to significant improvements in survival rates in a large Basic Life Support (BLS) and defibrillation based emergency medical service system. Stiell, et al shows that low cost improvements can have an effect on response times. In this particular study the 8 minute response goal has improved from 76.7 % times of all calls before changes got introduced to 92, 5 % after changes were in place.

A similar study was conducted in the city of Monterrey in Mexico also focusing on low cost changes. The data from this study was published in 2000. In this study focusing on the emergency medical service system in Monterrey the response time decreased from a mean of 15, 5 minutes while there where two dispatch sites to 9, 5 minutes when there where four dispatch sites. The increase in sites of dispatch and other low cost measurements (in this case it was prehospital trauma life support training) resulted in improved response times and lower mortality rates. The authors conclude that the changes where low cost and should be considered for use in other developing countries. This study emphasizes the point that low-cost changes can have a positive impact on health care delivery and outcome (Arreola-Risa, 2000).

Short ambulance times are important, but a goal of a 5-minute response time for acute cases is not realistic in a low- income country. Pell (2001) from the UK states that an ambulance response time of 5 minutes could almost double the survival rate for unwitnessed cardiac arrest. This 5 minute response time needs a very well developed infrastructure. With the limited resources available in low income countries such an effort would not be sustainable. Resources should be spent on a sustainable response system as well as on improvements in facility based emergency health care.

There are many voices that question the use of ambulance response time as a performance indicator. O'Meara (2005) in his paper expresses concern about focusing solely on response times as an indicator of good emergency response. He asks that there would be a widespread development of other indicators for ambulance service delivery. More concerns are expressed by Moore (1999). Moore asked if evaluation and research of emergency medical service systems has any importance as long as there are no universally accepted systems or approaches for evaluation of emergency medical services. The author particularly questions traditional approaches and recognizes the diverse circumstances under which emergency medical services operate. Farlane (2003) emphasizes in his work the difficulty that occurs when evaluating and comparing ambulance service systems. They ask if global indicators could be developed and if the right indicators have been developed.

Some papers show that a single focus on a simple indicator like ambulance response time might not correctly evaluate an emergency health care system but yet despite these concerns there still needs to be a way to evaluate an EMS system. A study on the EMS system of the city of Addis Ababa in Ethiopia concludes that the capacities for EMS need to be assessed in every single situation in order to prioritize needs and develop a sustainable concept for improvement (Pozner, 2003). It is shown that in each case with a focus on a particular system the ambulance response time can be the main indicator and focus of change in order to improve the overall system performance. This approach was chosen in the particular case of the ambulance service in Osh, Kyrgyz Republic.

3. Research design and data collection

A prospective observational study with an experimental design was designed to compare ambulance response times before and after the implementation of an ambulance dispatch training program.

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