Monitoring Emergency Medical Services Frequent Use: Protocol for a Mixed-Methods Study Using Routinely-Collected Data

Introduction

Aging populations are placing increasing pressure on Emergency Medical Services (EMS) providers to address the potentially suboptimal use of scarce resources. EMS utilization that falls outside the established deployment framework, referred to here as ‘non-indicated use’, may constitute an important source of such suboptimal resource use. Frequent users of EMS represent a key target group in efforts to reduce non-indicated utilization. The focus on frequent users is driven by the substantial workload and costs associated with their use of EMS, as well as by the need to address potential underlying quality-of-care issues reflected in high, persistent, or intensive EMS utilization.

Addressing possible non-indicated EMS use among frequent users requires the development of monitoring systems that can be applied in both clinical practice and research to identify such use and support appropriate action once it has been detected. This study aims to explore the relationships between the drivers of frequent EMS use, potential remedies for non-indicated use, and subsequent reductions in utilization. Based on these insights, the study seeks to develop, through prototyping, a framework to guide the design of monitoring systems for research and clinical practice.

Methods and analysis

We will employ a mixed-methods observational study design. A systematic literature review and interviews with stakeholders who play key roles in the EMS referral process will be conducted to identify the drivers of frequent use and ‘non-indicated’ EMS use and their potential remedies. Pseudonymized routinely collected data covering 2013-2026 from three Dutch EMS providers will be analyzed using machine learning (ML) and artificial Intelligence (AI) techniques to develop a typology of drivers and trustworthy, interpretable models for identifying frequent use and non-indicated use.

A prototype monitoring system will be developed to demonstrate the online and the offline functionalities of the proposed framework for use in both clinical practice and research. The prototype’s usability, trustworthiness, and interpretability will be evaluated in collaboration with relevant stakeholders involved in the EMS referral process.

Ethics and dissemination

The data is routinely collected for administrative purposes only. Accordingly, the data will be completely pseudonymized, and as such this study falls outside the scope of the Dutch Medical Research Involving Human Subjects Act. After assessment we obtained a full waiver for using pseudonymized data from the EMS services from the Medical Ethics Review Board of the University Medical Center Groningen, The Netherlands. Patients and/or the public are not involved in the design, conduct, reporting, or dissemination plans of this research. Interviewees and participants in evaluating prototype monitoring systems (e.g. EMS clinicians, medical directors, ambulance nurses, emergency physicians, general practitioners (GP’s), policy makers and police officers) will provide informed verbal consent prior to their participation in the study. The study findings will be disseminated through peer-reviewed publications, presentations at conferences, and in social media. Also, summary reports will be made available to participating institutions and relevant stakeholders.

Strengths and limitations of this study

• The study will provide comprehensive insights into underlying drivers of frequent and ‘non-indicated’ EMS use (i.e. EMS care utilization that falls outside the agreed upon deployment framework), potential remedies, and the resulting implications for patients, EMS providers, and other healthcare providers.

• A framework for the systematic design of EMS monitoring systems will be developed to identify and support action on frequent and non-indicated EMS use. The framework is firmly grounded in both the scientific literature and clinical practice.

• An AI-based approach using routinely collected EMS records will be proposed to model frequent and non-indicated EMS use, that fosters trustworthiness and interpretability for relevant stakeholders.

• The prototype monitoring system will demonstrate the on-line and off-line functionalities of the proposed framework and evaluates their usability, trustworthiness, interpretability, and relevance for clinical practice.

• The use of routinely collected EMS data from three provinces of Northern Netherlands operating within the same geographical area and healthcare system may limit the generalizability of the findings.