This retrospective cohort study aimed to describe the characteristics and response plan of a large amount of UTI patients calling the EMS in Copenhagen. Descriptive statistics for age and gender showed a higher proportion of calls from women in their late teens and twenties, as well as in elderly people, which was in line with the evidence on UTI incidence among different age groups that was found in the literature (2). Additionally, a previous study on OOH contacts in Denmark found that females and age groups above 81 years old and between 0 and 18 years old were more likely to contact the services than males and other age groups (31), which possibly partially explains the similar results that were found in this study. Similarly, the distribution of calls during the day and during the week reflected the fact that most UTIs do not require an emergency response and are therefore in line with the total amount of calls answered by the OOH 1813-medical helpline in the Copenhagen. This shows a higher number of calls during the GPs OOH, which is between 16:00 and 8:00, as well as during the weekend when GPs in Denmark are closed.
Furthermore, a significant proportion of patients calling 1-1-2 received a non-emergency (F) response, whereas only a small proportion of patients calling 1813 received an emergency response. This means that dispatchers are successfully able to switch between both systems, leading to the most accurate response for the patient. These findings contribute to the evidence that having two systems in a joint dispatch center is in favor of the patients’ wellbeing and the precision in their received response.
After assessing the dispatch response to UTI calls over the years, the overall number of 1-1-2 calls was found to have increased, particularly the A and B response categories, which means that there is an increasing amount of people with UTI who received an emergency or urgent response. Furthermore, the 1813 response showed some changes over time, particularly in the referral to ED and prescription categories. While the number of patients receiving antibiotic treatment over telephone consultation showed an immense decrease from 2015 onwards, more patients were being referred to the ED as what is assumed to be a response to that trend. This means that instead of immediately being given a receipt for antibiotics by the dispatcher, patients are instead being sent to the ED to be evaluated first, receive a urinary dipstick to assess the strain of bacteria causing the UTI, and might be treated with specific and targeted medication. This trend is in line with the increased emphasis on antimicrobial stewardship, as well as an executive order on antibiotic treatment from the Danish Health Authorities to all GPs in Denmark in 2012 (32), which implicated that GPs were only allowed to prescribe a select number of antibiotics to their patients. This guideline was not fully implemented at the 1813-medical helpline until a year after the start of its operation, which explains the vast decrease of UTI prescription over the telephone between 2015 and 2016. Currently, only elderly patients with recurrent UTI and demonstrable access to results of a previous urinary dipstick with subsequent treatment are receiving antibiotic prescription over telephone consultation, given they are not seriously ill with symptoms such as fever or nausea and there is no blood in their urine (4). Also, the decrease in referral to the ED response in 2020 is hypothesized to be a result of downscaled care in the ED due to the COVID-19 pandemic. This is in line with previous reports on decreased diagnoses of cancer and cardiac disease in Denmark (33, 34).
Compared to GP IH, patients are less likely to be referred to the ED during OOH than any other response. A possible explanation for this observation is that during IH, patients are supposed to call their GP first, instead of immediately contacting the 1813-medical helpline. During OOH, proportionally more people call the OOH 1813 number. This means that the situation is either more severe, that the patient cannot wait until the next day and needs to be admitted immediately, or the situation is evaluated by the dispatcher as less severe than the patient originally thought, which means the patients are more likely to receive a telephone consultation with the advice of self-care or to go to their GP the next day.
The opposite effect was found for weekend calls compared to a call during the week, which means that patients are more likely to be referred to the ED than to receive any other response. This can possibly be explained by the fact that on Saturday, patients cannot be told to visit their GP the next day and consequently, they are more often sent to the ED for evaluation. Finally, the use of a urinary catheter is considered a comorbidity, which means it requires a different and personalized response. Therefore, patients were more likely to receive the ‘other’ category, which is a compilation of the more uncommon response categories. The second highest response category was that of antibiotic prescription, which is in line with our expectations, as catheter users often experience complicated UTIs and are therefore at a higher chance of having recurrent UTIs (2). This also explains why patients with catheters are more likely to be admitted to the hospital than being referred to the ED compared to patients without a urinary catheter.
Furthermore, the finding that there are more emergency (A) responses dispatched during OOH calls might be due to coincidence, but it might also be caused by the fact that some people want to wait until the next day to visit their GP first, but get more severely ill in the meantime. On the other hand, the fact that more people receive a non-emergency (F) response, might be related to the 1813-medical helpline. More people might call 1-1-2 instead of 1813 during their GPs OOH, which more often results in a non-emergency response. In contrast, D responses are less likely to be given than B responses in OOH compared to IH, because this type of transport is planned and does not require any medical supervision, which can possibly wait until the next day.
After comparing weekday and weekend calls, surprisingly similar numbers in terms of A and F response were found, which might be explained in the same manner as described in the previous paragraph. However, an increased likeliness to receive a C or D response during the weekend compared to weekday was also found, which might underlie the increased need for planned transport, both monitored and unmonitored during the weekend compared to the week. Patients with a urinary catheter were more likely to receive a planned transport response (C and D) compared to an urgent response (B). This is potentially caused by the patients’ underlying comorbidities for which they need a catheter, which can immobilize them which makes them require (monitored) transport to the hospital for evaluation.
Implications for the EMS in Copenhagen
To the authors’ knowledge, this is the first study looking at data on the response to people calling with symptoms of UTI of both the emergency medical number and the OOH-medical helpline of a region. The EMS in Copenhagen has its exceptional structure of operating both those number in the same dispatch center, which means that the data was retrieved from one place with all telephone records. This provides many opportunities for the research department at the EMS in Copenhagen to study other types of incidents and diseases which are often handled at the dispatch center.
This study was particularly explorative in its nature and the outcomes gave us more understanding about the patients with UTI calling the EMS and the prehospital response given to these patients. This data can be used to monitor the demand of patients calling with UTI symptoms and whether they got an accurate response. It can also be used to evaluate areas of improvement. It is important to evaluate current trends, but also changes over time to assess the need for different resources for patients suffering from UTI. Further research is needed to appraise these numbers compared to the accumulated data on the 1-1-2 and 1813 medical helplines, and to appraise the public health needs of prehospital treatment and care of UTIs.