Use of dispatch codes for obvious/expected deaths: maintaining patient safety while reducing the number of lights-and-sirens responses.

Rapid provision of cardiopulmonary resuscitation (CPR) and defibrillation is critical to improving outcomes from out-of-hospital cardiac arrest (OHCA).1Perkins G.D. Gräsner J.-T. Semeraro F. et al.European Resuscitation Council Guidelines 2021: Executive summary.Resuscitation. 2021; 161: 1-60Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar However, in 30–60% of all cases attended by emergency medical services (EMS), resuscitation is not initiated due to the patient meeting clinical criteria for Recognition of Life Extinct - e.g. rigor mortis, lividity and decomposition.2Bray J. Howell S. Ball S. et al.The epidemiology of out-of-hospital cardiac arrest in Australia and New Zealand: A binational report from the Australasian Resuscitation Outcomes Consortium (Aus-ROC).Resuscitation. 2022; 172: 74-83Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 3Berdowski J. Berg R.A. Tijssen J.G. Koster R.W. Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies.Resuscitation. 2010; 81: 1479-1487Abstract Full Text Full Text PDF PubMed Scopus (1352) Google Scholar, 4Brooks S.C. Schmicker R.H. Cheskes S. et al.Variability in the initiation of resuscitation attempts by emergency medical services personnel during out-of-hospital cardiac arrest.Resuscitation. 2017; 117: 102-108Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar For such cases, it is questionable whether a ‘full scale’ EMS response is necessitated. Such a response can divert limited ambulance resources from other incidents,5Whitaker I. Olola C. Toxopeus C. et al.Emergency Medical Dispatchers' Ability to Determine Obvious or Expected Death Outcomes Using a Medical Priority Dispatch® Protocol.Emerg Med J. 2016; 33: e4Crossref PubMed Google Scholar and increase the likelihood of traffic accidents.6Kahn C.A. Pirrallo R.G. Kuhn E.M. Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis.Prehosp Emerg Care. 2001; 5: 261-269Crossref PubMed Scopus (159) Google Scholar The city of Perth (population = 2.2 million),7Australian Bureau of Statistics. Regional population 2021 [cited 14 February 2023]. Available from: https://www.abs.gov.au/statistics/people/population/regional-population/latest-release.Google Scholar Western Australia (WA), has a single emergency road ambulance service, St John Western Australia (SJWA). SJWA call-takers use the Medical Priority Dispatch System (MPDS, Priority Dispatch Corporation) to triage an emergency response. Until recently, all OHCA calls in metropolitan Perth elicited a dual response – of two vehicles staffed by two advanced-life-support paramedics each, and where available, an additional vehicle equipped with the LUCAS® mechanical CPR device, with all vehicles allocated as Priority 1 (lights-and-sirens).8St John Western Australia, Out-of-hospital cardiac arrest report, 2019, St John Western Australia; Belmont, Western Australia. [cited 14 February 2023]. Available from: https://stjohnwa.com.au/about-us/corporate-publications.Google Scholar From 1 December 2020 however, call-takers were authorised to use the complete set of ‘obvious death unquestionable’ and ‘expected death unquestionable’ MPDS codes (09B01a-h and 09Ω01x-z) for eligible OHCA incidents,9Priority Dispatch Corporation The International Academy QA guide – Medical Priority Dispatch System version 13. Priority Dispatch Corporation, Salt Lake City, Utah, USA2020Google Scholar with these codes assigned a single-vehicle Priority 1 response and no call-taker CPR instructions. Here we describe the first 13 months of experience following implementation of these obvious/expected death codes, comparing the code applied and the patient’s presentation as assessed by paramedics. We examined all patients attended by SJWA in Perth between 1 December 2020–31 December 2021 who were dispatched as unquestionable obvious/expected deaths. We linked these data with the WA OHCA database,10Majewski D. Ball S. Bailey P. Bray J. Finn J. Trends in out-of-hospital cardiac arrest incidence, patient characteristics and survival over 18 years in Perth, Western Australia.Resusc Plus. 2022; 9100201Crossref PubMed Scopus (1) Google Scholar noting whether EMS resuscitation was attempted. A resuscitation attempt was considered indicative that patients were potentially viable. We then reviewed the prehospital management and outcomes of any patients who had EMS-attempted resuscitation despite being coded as an obvious/expected death. In total, there were 692 patients coded as obvious/expected death (Fig. 1). Of these, 685 (99%) linked to the WA OHCA database; whilst seven patients were not OHCAs. Of the 685 OHCA cases coded as obvious/expected death, five (0.7%) had resuscitation attempted – four of which had resuscitation discontinued due to paramedics subsequently noting clear indications of death (e.g. rigor mortis). For the remaining case, paramedics initiated resuscitation and called for back-up. No patients survived to 30 days. The median age of OHCA patients dispatched as obvious/expected death was 71 years (interquartile range 57–83), and 67% were male. Our results demonstrate that the dispatch of patients as obvious/expected deaths was highly predictive of those patients being assessed by paramedics as unequivocally deceased. At the same time, the routine use of a single-vehicle lights-and-sirens response for obvious/expected death dispatch represents a reassuring safety net for those rare cases where paramedics did initiate a resuscitation attempt or for cases that were in fact not OHCA. Our findings indicate that SJWA’s expanded use of MPDS obvious/expected death codes has both maintained patient safety and been effective at reducing unnecessary usage of a dual lights-and-sirens response. Mr Austin Whiteside and Mr Jason Belcher are employees of SJWA. Prof Judith Finn and Dr Stephen Ball hold adjunct research positions with SJWA. Dr Milena Talikowska, Prof Judith Finn and Dr Stephen Ball are employees of the Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU) at Curtin University; PRECRU receives research funding from SJWA. There are no other conflicts of interest to declare.