Managing High Frequency of Ambulance Calls in Hospitals: A Systematic Review

Introduction

The high volume of calls received by emergency ambulance services in standard or high-ranking hospitals is a matter of growing concern in healthcare systems worldwide. Emergency units and healthcare centers have grappled with the challenges posed by the incessant rise in the demand for emergency medical assistance. Despite implementing various strategies to manage this surge, the effectiveness of these measures has remained a critical issue. The impact of this crisis is exemplified by the alarming statistics reported by the Health and Social Care Information Centre, indicating an unsustainable increase in requests for emergency ambulance services.¹ For instance, in England, the number of emergency calls to ambulance dispatch centers more than doubled, soaring from 4.72 million in 2003 to 9.1 million in 2015.² The operational burden on healthcare systems, particularly on emergency services, has reached unprecedented levels.²

The gravity of the situation has not gone unnoticed, and public concern, along with media attention, has intensified. To address this pressing issue, the United Kingdom (UK) has undergone significant reform of its Emergency Departments, seeking to alleviate the mounting pressure on emergency services. The proposed policy advocates a comprehensive system-wide approach, granting greater clinical autonomy and establishing new care pathways within the ambulance service.³

Amidst this healthcare crisis, one key problem that emerged was the recurrent and excessive use of ambulance services by certain patients, commonly referred to as “frequent caller patients”.⁴ The over-reliance on emergency ambulance services by these individuals placed immense strain on the system, compromising its ability to provide timely and efficient care to those with genuine time-critical medical needs. Consequently, the lack of a well-established transfer process for patients and limited availability of services hindered ambulance personnel from directing patients to appropriate care. This situation resulted in longer waiting times at emergency departments, further exacerbating the challenges faced by healthcare facilities.³

In response to this issue, the UK implemented a policy in 2013, classifying citizens who made more than 12 calls within three months as frequent callers.⁵ A similar policy was also introduced in London, where a staggering 1.7 million emergency calls were recorded between 2014 and 2015. Among these calls, 1622 individuals met the criteria for frequent caller patients, resulting in 49,534 ambulance attendances and incurring costs of approximately 4.4 million euros for the London Ambulance Service (LAS).⁶ In addition to the European context, the issue of managing high-frequency ambulance calls is a global challenge, with diverse approaches observed across different countries. In the United States, for example, community paramedicine programs have been recognized for their positive impact on public health. These programs have evolved from traditional emergency medical services (EMS) to include more advanced care and preventative measures. A significant benefit of these programs is the reduction in 911 calls, emergency room visits, and hospital readmission rates, which relieves financial and physical stress on health providers. Current evidence suggests that redirecting 15% of 911 patients to primary care could result in over $500 million in national Medicare cost savings. In many African countries, the existence, distribution, and characteristics of EMS systems are less known. A survey covering 49 out of 54 African countries found that only 30% of these countries had EMS systems, servicing only 8.7% of the African population. The leading causes of EMS transport included injury and obstetric complaints. Most of these systems were basic life support, government-operated, and fee-for-service, highlighting the varied and often limited EMS resources available in Africa. Ambulance Victoria implemented a secondary telephone triage service called the Referral Service (RS) for low-priority patients. This service, which offers alternatives to ambulance dispatch such as doctor or nurse home visits, managed over 107,000 cases from 2009 to 2012, accounting for 10.3% of total ambulance calls. This approach proved effective in managing emergency ambulance demand, demonstrating a successful model of secondary telephone triage in the ambulance setting.

Moreover, ambulance services play a crucial role in catering to the needs of vulnerable patient groups, such as those suffering from self-harming tendencies, chronic illnesses, old age, abnormal mental health conditions, and loneliness. Notably, patients in underserved rural areas often experience a lower quality of life compared to their urban counterparts.^7,8 Consequently, the burden on emergency departments increases, straining the system’s capacity beyond its capabilities.⁹ Addressing the needs of frequent caller patients becomes essential for healthcare facilities to ensure efficient service delivery and patient care, thereby managing the high volume of calls received by emergency departments.¹⁰

In the context of this review, exploring various medical conditions requiring ambulance attention and their impacts on hospitals is crucial. This broad perspective allows for a comprehensive synthesis of management strategies, encompassing not just the direct handling of high-frequency calls but also understanding the underlying medical conditions that contribute to these calls. This approach is vital for developing holistic management methods that are effective across different medical scenarios and hospital contexts.

While some individual hospitals have reported a significant decrease in call rates after implementing case management strategies,⁴ such interventions have not been widely reviewed or examined in systematic reviews. There remains a notable gap in the literature regarding comprehensive investigations into the management of high-frequency hospital calls by emergency departments. The potential consequences of delayed ambulance responses and late emergency department attendance are concerning, as patients may not receive timely medical attention, leading to a deterioration of their condition and increased complications. Hence, this systematic review aimed to fill the existing gap in the literature by critically examining and synthesizing the different management methods employed for handling high-frequency hospital calls.

Methods and Materials

This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA guidelines)¹¹ as shown in Appendix I in the supplementary materials. The methods were guided by the Cochrane Handbook for systematics Reviews.¹²

Inclusion Criteria

We included studies focusing on the management of emergency departments in hospitals those exploring various medical conditions requiring ambulance attention, studies reporting on the impact of a high volume of ambulance calls on hospitals, as well as those investigating the implications and policies regarding ambulance dispatch. Exploring various medical conditions requiring ambulance attention and the impact of a high volume of ambulance calls on hospitals directly informs and enriches the understanding of different management methods utilized for addressing high-frequency hospital calls. These criteria ensure that the review captures a broad spectrum of scenarios and challenges associated with high ambulance call volumes, which is crucial for synthesizing effective management strategies, thus ensures a comprehensive understanding of the challenges and solutions in managing high-frequency ambulance calls., aligning closely with our objectives. Moreover, studies that provide insights into the functions and roles of emergency units in handling emergency cases are part of the review.

We excluded studies that were not in English language. Furthermore, magazine articles and conference abstracts were also excluded from this review.

Data Sources and Searches

Databases including PubMed, Web of Science, and Google scholar were searched from 1st January 2005 to 1st May 2022. Two independent reviewers (AA, AA) searched the databases using search terms such as “Managing”, “ambulanc*” and “hospital*”. Using the search term “ambulanc*” with an asterisk allows for a comprehensive inclusion of all variations related to ambulance services, ensuring a thorough review of literature encompassing various aspects of ambulance usage and management.

Reference lists of all relevant articles and “related citation” search tool of PubMed was checked for any additional eligible publications. Appendix II in supplementary materials details the search terms used.

Screening, Data Extraction and Quality Assessment

Two reviewers (AA, AA) independently screened titles, abstracts and full-texts of all identified records for eligibility using Endnote. Data were extracted independently by two reviewers (AA, AA), including citation details, study characteristics, participant characteristics relevant to the selection criteria, key findings, country, and total calls. We independently assessed the quality of included studies using Critical Appraisal Skills Programme (CASP) Checklist.¹³ Each question has only three answer options: Yes, No and Cannot Say. A study that answered ‘Yes’ to all questions was considered relevant, a study that answered “Can’t” say was regarded as unclear, while a study that answered “No” was considered irrelevant. Disagreements were resolved by consensus in the presence of a third reviewer. A table of the CASP checklist is provided in Appendix III in the supplementary materials.

Results

Study Selection

A total of 2390 citations were identified from the database searched. Of which, 1560 were duplicates and were removed. A further 796 articles were excluded after screening titles and abstracts. We assessed 34 articles for full-text screening and 18 articles met our inclusion criteria and were included in this review and reasons for exclusion were reported. The PRISMA flow diagram for this study is shown in Figure 1.

Figure 1 PRISMA Flow Diagram. Note: Page M J, McKenzie J E, Bossuyt P M, Boutron I, Hoffmann T C, Mulrow C D et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews BMJ 2021; 372:n71 doi:10.1136/bmj.n7114

Study Characteristics

Table 1 presents the characteristics of included studies.

Table 1 Characteristics of Included Studies

Six of the included studies were in the United Kingdom (UK), two were in Japan,^17,20 One study each from Denmark,¹⁵ France,²⁵ Swedish,³² Norway,²⁷ Canada,²⁴ England,²⁹ Korea,¹⁹ Barbados,²³ Rhode Island²¹ and Turkey.²⁸

With regards to the design of the included studies, nine conducted retrospective cohorts, two used observational study designs, two were exploratory and one was a case-study design.

Among all included studies, seven applied a predictive or proposed model for managing frequent calls; seven reported management based on the country’s policy on the emergency department. Four studies reported general methods of management. Figure 2 illustrates the structured approach used in our systematic review, aligning it with the objective of examining and synthesizing various management methods for high-frequency hospital calls.

Figure 2 Systematic Review Analysis Structure.

Management Methods for Handling High-Frequency Hospital Calls

We categorized the management methods for handling high-frequency hospital calls into three distinct research areas for a structured and comprehensive analysis. These are: country policy-based management, modeling approaches, and general studies proposing alternative strategies. This categorization facilitated a focused examination of diverse management methods, reflecting a broad spectrum of strategies employed worldwide to address high-frequency hospital.

Country Policy-Based Management

In examining the impact of country-specific policies on the management of high-frequency ambulance calls, our review identified key practices within national emergency services. For instance, the Pediatrics Medical Emergency Department managed by the Emergency Medical Dispatch Center (EMDC) recorded 7052 calls in a month, implementing an auto-voice recorder system to categorize calls based on severity.¹⁵ Moreover, the UK’s emergency ambulance services policy defines “Frequent calls” with a range of 600–900 calls per month, demonstrating how localized policy variations can influence the management of call frequencies.^23,28

Modeling Approaches

To manage frequent calls, a dynamic decision-making model using a semi-Markov decision process and mini-batch monotone approximate dynamic programming (ADP) algorithm reduced the risk level index (RLI) for all patients by 11.2% compared to the greedy policy.²⁰ Kitamura et al found a positive correlation between call rates and ambulance arrival time The study found that the number of calls increased with the duration of ambulance arrival time (with arrests: 23.2 min to 39.7 min, without arrests: 24.4 min to 36.7 min).²⁰ Another study also classified personal emergency response calls using a mixed methods model. Patients with severe cases had the highest call rates, followed by older individuals.²⁴

General Studies Proposing Alternative Strategies

The review also uncovered a variety of alternative strategies proposed by general studies. Young et al demonstrated that proximity to primary or secondary healthcare in rural areas, increased ambulance availability, and improved service care can reduce frequent calls.¹⁷ Additionally, four emotional management strategies were proposed to control and reduce call frequency, including offering promising ambulance assistance and presenting problem-solving measures for callers’ concerns to instill hope.³² Watson et al analyzed ambulance calls in relation to patient conveyance rates, with a majority being male and aged 60–79 years.¹⁸ We also included Dunca et al’s examination of Scottish ambulance emergency department operations and death records for adults aged 16 years and above, as well as Sterud et al’s study on health problems in ambulance services in Norway.^26,27

Quality Assessment and Risk of Bias

The quality assessment and risk of bias for the synthesis articles in Table 2 indicate that all the included studies, such as Andersen et al (2018), Young et al (2016), Kashima et al (2015), and others, are categorized as “Relevant Studies” with a low risk of bias. This suggests a high level of reliability and validity in the data and findings presented in these studies, supporting the robustness of the systematic review’s conclusions (as shown in Table 2).

Table 2 Risk of Bias for “Relevant” Studies

Discussion

This systematic review is the first to examine the management of high-frequency ambulance calls in hospitals, to the best of our knowledge. Responding promptly to emergency calls is a global priority, guided by various government and local policies. However, our findings demonstrate that the management of high call volumes varies across countries and hospitals. The definition of “frequent calls” depends on factors such as patient condition and proximity to hospitals. Our review also highlights that emergency services personnel face a higher risk of health problems compared to other working populations, with increased call volume observed during weekends, public holidays, and disease outbreaks like influenza and gastroenteritis.

We propose four risk management and four emotional management strategies to improve emergency ambulance services. Effective emergency care requires calmness, interactive empathetic skills, reassurance, and critical reflection to make informed decisions during crises.

Our results indicate that 81% of emergency calls were prioritized, aligning with previous studies (Linell et al,³³ Svensson et al³⁴). Andersen et al found that 73.3% of emergency calls received priority in Denmark, focusing on life-threatening or potentially life-threatening situations and younger children below 15 years. In contrast, Phillips et al²³ utilized the medical priority dispatch system, categorizing calls and dispatching ambulances based on the condition’s prevalence. One of our strategic suggestions is placing ambulance stations in densely populated areas to improve response times, as supported by a UK study showing a high proportion of calls responded to within 10–15 minutes due to proper ambulance station placement. Notably, the definition of a high volume of calls or frequent calls varies across countries. For instance, the UK uses a national definition where patients making 12 calls in a day are considered to have “frequent calls” (Helen et al¹⁶). Multidisciplinary case management is proposed to address the clinical and emotional needs of such patients (Mercer et al³⁵). However, our study lacked information on call reasons or the demographics of callers. Better ambulance maintenance and access to training could also enhance practice methodologies.

While this systematic review provides valuable insights, it has some limitations to consider when interpreting the results. Firstly, the limited number of included studies was a challenge in identifying accurate and reliable sources, with many studies deemed irrelevant or containing insufficient information. Secondly, our focus on management without details on caller categories or reasons for calls may limit the scope of our findings. Lastly, we lack information on differences between responding and non-responding services in managing frequent callers. The absence of meta-analysis further highlights the need for more comprehensive studies.

Conclusion

This systematic review has identified effective management strategies for high-frequency ambulance calls, including country policy-based management, modeling approaches, and innovative alternative strategies. Our findings, derived from studies with a low risk of bias, highlight the importance of diverse, adaptable solutions in emergency healthcare. Continued research and implementation of these methods across varied healthcare contexts remain crucial for.