A Quality Improvement Project to Enhance Health Care for Frequent Callers to an Emergency Medical Dispatch Center

Abstract

Background

Frequent callers to emergency medical dispatch centers (EMDC) often have multiple problems, have contact with several care providers, and can be perceived as difficult to help.

Purpose

To describe a quality improvement project aimed at enhancing health care for frequent callers.

Methods

A project registered nurse (RN) was allocated to coordinate individualized care plans based on identified frequent callers’ current problem(s), life situation, and medical history. The outcome was evaluated using an interrupted time series approach and by a review of medical records. Individual interviews were carried out with the project RN and one frequent caller.

Conclusions

Most callers were middle-aged or older, more often male, and often lived alone or in a residence. At the time of intervention, frequent callers contacted the EMDC once per week on average and were transported by ambulance 1.4 times per month. Following the project, EMDC contacts and ambulance responses were reduced to 46% and 33%, respectively, of their peak levels.

Keywords

emergency medical dispatch center frequent caller intervention quality improvement repeated calls

Implications for Practice, Education, Policy, or Research

Contact frequency decreased following the individualized care intervention provided in the project, at least for some time.

Appointing a dedicated registered nurse, creating individual plans for each frequent caller, and documenting the plan in the patient record seemed to help frequent callers.

The project could serve as an inspiration for the care of frequent health-care users in other contexts.

Context

Frequent callers are found in several health-care contexts internationally. Definitions of frequent callers differ between countries and contexts (Skogevall et al., 2022). These patients often have multiple problems and may be perceived as difficult to help (Skogevall et al., 2020, 2022; Wiklund-Gustin, 2011). They may have contact with multiple care providers, possibly representing an inefficient use of scarce resources. However, tracing patients’ use of different health-care services is challenging due to privacy regulations, competition among care providers, incompatibility between information systems, and the significant amount of work required (Maruster et al., 2020). Joint efforts are needed to provide frequent callers with better support and optimize resource utilization.

Frequent callers are also known at emergency medical dispatch centers (EMDCs), where repeated calls from frequent callers are particularly challenging, as the service is designed for handling emergencies and prioritizing ambulance needs under time pressure. Frequent callers calling the emergency number often consume disproportionate amounts of resources (Hildebrandt et al., 2004). Many frequent callers have anxiety and/or depression and pain (Agarwal et al., 2019). The higher occurrence of mental ill-health tends to make calls more complex and consume more time (Björkman & Salzmann-Erikson, 2019).

Interventions aimed at enhancing health care for frequent callers are rare, and efforts to support callers who repeatedly seek help via telephone health-care services such as EMDCs are needed. Such interventions may optimize care for frequent callers, make better use of limited resources, and increase accessibility for other callers. The aim of this quality improvement project was to enhance health care for frequent callers.

Methods

A clinical intervention was initiated to decrease the frequency of frequent callers’ contacts with the EMDC and to alert other care providers to patients’ needs for intensified primary health care or other social arrangements. The intervention was carried out at an EMDC in a region in mid-Sweden between September 1, 2021 and October 7, 2023. The region had a population of 278,967 in 2021. The region employs exclusively registered nurses (RNs) as primary call-takers and uses a self-developed clinical decision support system to prioritize calls (Holmström et al., 2020).

The outcome of the intervention was evaluated quantitatively using an interrupted time series approach and through a review of medical records. In addition, interviews were carried out with the RN coordinating the project and one frequent caller. The Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.9 checklist (Ogrinc et al., 2016) was followed.

Intervention

When RNs at the EMDC identified a frequent caller, they reported this to a designated project coordinator (an experienced EMDC RN), who obtained the patient's informed consent to initiate the intervention. Using information from the patient's medical records, the coordinator collected information regarding the patient`s situation, including living conditions, other health-care contacts, and the patients’ calling patterns over time. Together with the patient and other health-care providers, such as nursing homes and social services (if applicable), an individual plan for each patient was created. The individual plan was approved by the medical director at the EMDC and documented in the patient's EMDC medical record. When an individual plan was implemented, the project coordinator notified other services involved in the plan, raising awareness that the patient had called the EMDC and might need other treatments or arrangements. Table 1 describes the different individual plans employed.

Table 1.

Strategies Employed in the Intervention Project (N = 40).

	n	%
Going through the patient's medical records	19	47.5
Informing other health-care services about the repeated calling to EMDC	12	30
Informing health professionals at EMDC about the patient and strategies taken	10	25
Contacting community care for increased nurse strategies	7	17.5
Establishing an individual plan at EMDC	7	17.5
Calling the patient's residence	5	12.5
Informing and involving other health-care services for increased understanding of the patient's situation	4	10
Contacting psychiatric care services	1	2.5

Abbreviation: EMDC = emergency medical dispatch centers.

Data Collection

The project coordinator collected information from the patients’ medical records, including frequency of calls, frequent callers’ demographics, reasons for calling, and the outcome of the calls. The data for the quantitative evaluation, consisting of contact dates and times for each frequent caller and the outcome of the calls (ambulance dispatch or not), were collected from dispatch system records.

Semi-structured interviews with the project coordinator and one frequent caller were conducted in April and May 2022. The interview guide was developed based on previous research and the authors’ clinical experiences in the field. The interviews were audio-recorded and transcribed. The purpose of these interviews was to capture more in-depth information and “add flesh to the quantitative bones.”

Data Analysis

To understand the impact of the quality improvement project, we compared the number of emergency calls made by the frequent callers and ambulance responses before and after the intervention. Using an interrupted time series approach, we investigated how the number of calls and ambulance responses changed over time before and after the intervention. Poisson regression models estimating the number of EMDC calls and ambulance responses per month in the study cohort were fit using R (v 4.3.2). The models were used to estimate the trend in the number of EMDC calls and ambulance responses per day within the study cohort during the year prior to and following each individual frequent callers’ inclusion in the intervention. It was believed that the intervention might lead to either an immediate change in call/ambulance response rates or a decline in rates over time, and thus models including both intercept and slope coefficients were used. The code used to perform this analysis can be provided on request.

Ethical Considerations

The study was approved by the Swedish Ethical Review Authority (Dnr 2017/085). Patients received information about the project and its purpose from the project coordinator at the EMDC before the intervention started. The information included that they could leave the project at any time without consequences and that data would be presented on a group level only. The possible impact of the project on frequent callers was also considered, as being labelled a frequent caller might impede feelings of guilt and shame. As per the Ethical Review Authority's decision, these potential negative effects were deemed to be outweighed by the potential benefits. Informed consent was obtained verbally and audio recorded. The project coordinator collected information from medical records, and the material was pseudonymized before the authors gained access to it.

Results

There were 43 frequent callers identified at the EMDC; three patients died during the project period, leaving 40 frequent callers in the intervention.

The Frequent Callers

Most frequent callers were middle-aged or older adults, with males being more common than females, and often lived alone or in a residence. Please see Table 2.

Table 2.

Demographic Characteristics of Frequent Callers (N = 40).

Characteristic	n	%
Age (n = 40)
22–40	8	20
41–55	12	30
56–70	8	20
71–93	12	30
Gender (n = 40)
Female	16	40
Male	23	57.5
Not stated	1	2.5
Physical disability (n = 40)
Yes	5	12.5
No	29	72.5
Not stated	6	15
Living situation (n = 40)
Living alone	17	42.5
Living in a residence	10	25
Living with a spouse or in a family	6	15
Receiving home health care	5	12.5
Homeless	1	2.5
Not stated	1	2.5

Reasons for Calling Frequently

Overall, the frequent callers had life situations characterized by anxiety, worry, and physical and mental ill-health. According to the project coordinator, the most common reason for calling was anxiety: “There are patients who have high anxiety and worry; it's almost like the health-care system is designed for them to call several times if they don’t get help in finding a solution that helps and works better in the long run” (RN coordinator). In her experience, the frequent callers perceived their symptoms as acute. However, according to the EMDC criteria, they did not involve life-threatening conditions: “We always make a medical assessment, and many of the frequent callers have illnesses, but most often they don’t need ambulance transport” (RN coordinator). The project coordinator described frequent callers as often calling periodically: sometimes several times a day, and then, when their life was calmer, and they felt better, they didn’t call at all. One of the frequent callers had been calling more or less frequently for a period of 12–13 years, following the pattern of his alcohol addiction. The reasons for calls from frequent callers and their diagnoses are presented in Table 3. Having several diagnoses and contact with various health-care services was common.

Table 3.

Clinical Characteristics of Calls from Frequent Callers (N = 40).

Characteristic	n	%
Reasons for calling
Anxiety	16	42
Worry	12	33
Pain	9	21
Respiratory difficulty	5	14
Fall	5	14
Heart symptoms	3	12
Suicidal thoughts	4	9
Common diagnoses
Anxiety	12	30
Alcohol problems	12	30
Heart disease	6	19
Diabetes	5	14
Depression	5	12
Hypertension	4	14
Personality disorder	4	12
COPD	4	9
Mental ill-health	4	9
Dementia	3	9
ADHD	4	9
Patients’ contact with other health-care services
Psychiatric care services	18	44
Somatic care services	10	26
Primary health-care center	10	26
Emergency care services	6	14
Therapeutic support	5	12

Abbreviations: COPD = chronic obstructive pulmonary disease; ADHD = attention-deficit/hyperactivity disorder.

From a frequent caller's perspective, the reason for calling was an urgent need for medical care. Further, they believed “something bad would happen” if help was delayed, as reported by the project coordinator as well as the frequent caller interviewed. The frequent caller indicated that calling was a result of all other doors being closed: “I was in so much pain and still had to call different places, trying to find a solution” (frequent caller). The frequent caller also stated that in some situations, other health-care professionals had recommended that the frequent caller to contact the EMDC.

Outcome of the Intervention

Some of the frequent callers were immediately helped by individual strategies, for instance, contact with a therapist or help with urgent home care, which led them to stop calling, according to the project coordinator and the patients’ records. Some frequent callers were nursing home residents, and when staff were alerted to the frequent calling, they could provide interventions to the frequent caller. In other cases, collaboration with other emergency services decreased the need for unnecessary examinations at the hospital. However, some frequent callers did not know where to call instead of the EMDC and seemed to fall through the cracks.

Regardless of whether frequent callers continued to call, the project contributed positively to the working environment at EMDC, according to the project coordinator. Solely the fact that the project helped this patient group instilled hope and reassurance in the workplace. Calls from frequent callers otherwise could cause frustration for the RNs, as stated by the project coordinator.

Reactions from the frequent callers included in the project varied. Some expressed positive reactions and gratitude when calling, while others were doubtful that the project would help them, according to the project coordinator. There were also frequent callers who were unreachable or did not remember that they were involved in the project. The project coordinator stated that the greatest challenge in offering frequent callers optimal care was the collaboration with other health-care services: “Psychiatric care is in itself a large organization with its own sections” (RN coordinator). This made it difficult to contact the psychiatrists who were responsible for the frequent callers’ treatment plans at their department.

The quantitative outcomes of the intervention were evaluated in terms of the rate of calls and ambulance responses. One year prior to the project, the 40 frequent callers generated a total of 2.16 calls per day to the EMDC and 0.75 ambulance responses. At the time of the intervention, this had increased to a daily average of 5.9 calls and 1.9 ambulance responses. Following the project, the rate of calls and ambulance responses decreased, with the rate of EMDC calls and ambulance responses being reduced to 46% and 33% of their respective peak levels, essentially returning to the rate of contact found a year prior to the intervention. All findings regarding slope changes were statistically significant (p < .001). While the intervention was found to have an immediate impact on call rates, these results were influenced by an outlier—a single individual who called 35 times in one day at the end of the follow-up period. All robust effects were thus found to be related to decreases in contact rates over time. The results of the interrupted time series analysis are presented in Figure 1.

Figure 1.

Number of emergency medical dispatch centers (EMDC) calls and ambulance responses per day.

Discussion

The present study suggests negative life experiences and emotions among frequent callers, which is congruent with other studies (Agarwal et al., 2019; Skogevall et al., 2022). Their life situation was characterized by physical and mental ill-health, and the most common reason for calling was anxiety. The intervention resulted in a reduction in the rate of calls and ambulance responses, which is in line with findings in previous intervention studies, including frequent users of emergency care (Bergenstal et al., 2020; Tangherlini et al., 2016).

This project can serve as an inspiration to health-care services aiming to improve care for the vulnerable patient group of frequent callers. The essential aspect of the project was closer collaboration between health-care services and social services, making them aware of the frequent callers’ care-seeking patterns and providing more coordinated help. Since the analysis was performed without a control group, it was impossible to establish with certainty that the decrease in contact and ambulance response rates over the one-year follow-up period (46% and 33%, respectively) was due to the intervention. It cannot be excluded that contact rates would have declined even in the absence of intervention. Further studies should thus aim to generate higher-quality quantitative evidence by including a control group, as well as establishing the transferability of the intervention to novel settings.

In parallel with the reduced number of calls, the project resulted in another advantage: It was reported by the project coordinator that the collaboration in the project had led to a better working environment at the EMDC in question. The project coordinator stated that her colleagues expressed less frustration when they knew there was a plan for the frequent callers, and they had greater patience when the frequent callers called. Reducing the number of non-emergency calls from frequent callers can increase accessibility for other callers and optimize the use of limited health-care resources, as EMDCs are considered a “service of last resort” and cannot turn callers away (Wilkinson-Stokes et al., 2024).

The current project points to the benefits of increased collaboration among health-care professionals both within and between health-care services. Given the complexity of frequent callers’ situations and diagnoses, collaboration between emergency departments and other health care and social services needs to be improved. The project provided the RNs at the EMDC with a more comprehensive view of these patients, enabled contact with other health-care and social services, and offered the possibility to provide individualized support in line with person-centered care (Håkansson Eklund et al., 2019). However, a limitation of the study is that the study is small-scale and was conducted at a single EMDC center. Second, the lack of a control group means that we cannot draw strong causal conclusions regarding the reason for the decline in calls post-intervention. Future studies may make use of the present study for sample size estimates. Third, a limitation is also that the study was conducted during the COVID-19 pandemic, which may have acted as a confounding factor.

Conclusions

Call frequency decreased over the year following the intervention, and made EMDC RNs feel less frustrated when frequent callers called. Hence, this project can contribute to a better understanding of how to collaborate with and provide support for frequent callers. Further research is needed to investigate collaboration around frequent callers from the view of other health-care services, such as psychiatric and social health care. More follow-ups on frequent callers’ health and well-being are warranted, as are more studies from the frequent callers’ perspective.

Lessons Learned

A quality improvement project directed at frequent callers to an emergency dispatch center was introduced, including having a dedicated RN who coordinated care, provided individualized care plans, and collaborated between health-care providers, to create tailored and effective support for frequent callers. Call frequency decreased following the intervention, at least for some time, and the effect size can serve to guide larger controlled studies. The approach used could also prove beneficial in other health-care contexts for frequent users.

Footnotes

Acknowledgments

Thanks to all participants who generously provided their time and expertise to make this project possible.

ORCID iD

Inger K. Holmström

Ethical Approval

The Swedish Ethical Review Authority approved the study: Dnr 2017/085.

Consent to Participate

Informed consent to participate was obtained verbally.

Consent to Publication

Not applicable.

Author Contribution(s)

Inger K. Holmström: Conceptualization; Methodology; Supervision; Writing – original draft.

Sofia Skogevall: Conceptualization; Investigation; Methodology; Writing – review & editing.

Hans Blomberg: Conceptualization; Resources; Supervision; Validation; Writing – review & editing.

Marie Pörhö: Conceptualization; Project administration; Writing – review & editing.

Elenor Kaminsky: Conceptualization; Methodology; Supervision; Writing – review & editing.

Douglas Spangler: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing – review & editing.

Jakob Håkansson: Conceptualization; Investigation; Methodology; Supervision; Writing – review & editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The provision of additional data will be considered upon reasonable request.

Author Biographies

Inger K. Holmström, RN, PhD, is a Professor emerita in the Department of Health Sciences, Innovation and Design at Mälardalen University in Västerås, Sweden, and a researcher in the Department of Public Health and Caring Sciences at Uppsala University in Uppsala, Sweden.

Sofia Skogevall, RN, PhD, is a senior lecturer in caring sciences in the Department of Health Sciences, Innovation and Design at Mälardalen University in Västerås, Sweden.

Hans Blomberg, MD, PhD, is a senior consultant in the Uppsala Center for Prehospital Research, Department of Surgical Sciences at Uppsala University, Uppsala, Sweden.

Marie Pörhö, RN, MSc, is a specialist nurse in Region Västmanland, Västerås, Sweden.

Elenor Kaminsky, RN, PhD, associate professor, is a senior lecturer in caring sciences in the Department of Public Health and Caring Sciences at Uppsala University in Uppsala, Sweden.

Douglas Spangler, PhD, is a researcher in the Department of Public Health and Caring Sciences and the Uppsala Center for Prehospital Research, Department of Surgical Sciences, at Uppsala University in Uppsala, Sweden.

Jakob Håkansson, PhD, associate professor, is a senior lecturer in psychology in the Department of Psychology at Stockholm University in Stockholm, Sweden.

References

Agarwal

Lee

McLeod

Mahmuda

Howard

Cockrell

Angeles

(2019). Social factors in frequent callers: A description of isolation, poverty and quality of life in those calling emergency medical services frequently. BMC Public Health, 19(1), 684. https://doi.org/10.1186/s12889-019-6964-1

Bergenstal

T. D.

Reitsema

Heppner

Geerts

Cho

Smallheer

(2020). Personalized care plans: Are they effective in decreasing ED visits and health care expenditure among adult super-utilizers? Journal of Emergency Nursing, 46(1), 83–90. https://doi.org/10.1016/j.jen.2019.09.001

Björkman

Salzmann-Erikson

(2019). Giving advice to callers with mental illness: Adaptation among telenurses at Swedish Healthcare Direct. International Journal of Qualitative Studies in Health and Well-Being, 14(1), 1633174. https://doi.org/10.1080/17482631.2019.1633174

Håkansson Eklund

Holmström

I. K.

Kumlin

Kaminsky

Skoglund

Höglander

Sundler

A. J.

Condén

Summer Meranius

(2019). Same same or different? A review of reviews of person-centered and patient-centered care. Patient Education and Counselling, 102(1), 3–11. pii:S0738-3991(18)30623-2. https://doi.org/10.1016/j.pec.2018.08.029

Hildebrandt

D. E.

Westfall

J. M.

Nicholas

R. A.

Smith

P. C.

Stern

(2004). Are frequent callers to family physicians high utilizers? Annals of Family Medicine, 2(6), 546–548. https://doi.org/10.1370/afm.127

Holmström

I. K.

Kaminsky

Lindberg

Spangler

Winblad

(2020). Registered nurses’ experiences of using a clinical decision support system for triage of emergency calls: A qualitative interview study. Journal of Advanced Nursing, 76(11), 3104–3112. https://doi.org/10.1111/jan.14542

Maruster

van der Zee

D. J.

Hatenboer

Buskens

(2020). Tracing frequent users of regional care services using emergency medical services data: A networked approach. BMJ Open, 10(5), e036139. https://doi.org/10.1136/bmjopen-2019-036139

Ogrinc

Davies

Goodman

Batalden

P. B.

Davidoff

Stevens

(2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality and Safety, 25(12), 986–992. https://doi.org/10.1136/bmjqs-2015-004411

Skogevall

Holmström

I. K.

Kaminsky

Håkansson Eklund

(2020). A survey of telephone nurses’ experiences in their encounters with frequent callers. Journal of Advanced Nursing, 76(4), 1019–1026. https://doi.org/10.1111/jan.14308

10.

Skogevall

Kaminsky

Håkansson

Holmström

I. K.

(2022). One for all or all for one? An integrative review of research on frequent callers. PEC Innovation, 1(1), 1–8. https://doi.org/10.1016/j.pecinn.2022.100070

11.

Tangherlini

Villar

Brown

Rodriguez

R. M.

Yeh

Friedman

B. T.

Wada

(2016). The HOME team: Evaluating the effect of an EMS-based outreach team to decrease the frequency of 911 use among high utilizers of EMS”. Prehospital and Disaster Medicine, 31 (6), 603–607. https://doi.org/10.1017/S1049023X16000790

12.

Wiklund-Gustin

(2011). To intend to but not being able to: Frequent attenders’ experiences of suffering and of their encounter with the health care system. Journal of Holistic Nursing, 29(3), 211–220. https://doi.org/10.1177/0898010110386957

13.

Wilkinson-Stokes

Yap

Crellin

Bange

Braitberg

Gerdtz

(2024). How should non-emergency EMS presentations be managed? A thematic analysis of politicians’, policymakers’, clinicians’ and consumers’ viewpoints. BMJ Open, 14(7), e083866. https://doi.org/10.1136/bmjopen-2024-083866