Are We Speaking The Same Language?

Edel Burton

Edel Burton

David Willis

Best Practices

Editor’s Note: You might be used to finding the latest research in the Annals of Emergency Dispatch & Response (AEDR). This article seeks to make the findings of a recent research study published in AEDR 11.1 more accessible to a wider audience.

Are we speaking the same language? If I said “response time” to someone in Austria or Australia, would they know what I meant? Would they use the same words? Would it refer to the same time period?

These are the questions we set out to answer when beginning this work. Which terms and definitions do countries use and are they the same or different?

Why did we do this research?
In order to benchmark, i.e., compare processes and outcomes between international ambulance services, we need to be able to compare like with like. Due to the current level of variation in both the terminology and definitions of international ambulance times and time intervals we need to align these terms and definitions. If standardized terms were applied, ambulance times and definitions could then be used to compare aspects of prehospital care on a global level.

What is in a word? Terminology versus definition
The line between terminology and a definition may seem semantic or ambiguous. However, language is important. We need to know what word is used to describe a time or time interval but also what period of time that word describes. In our work, the Prehospital Care of Stroke (PHoCoS) consortium defined “terminology” as the word used to describe the ambulance time or time interval. The related “definition” describes the variables in the computer-aided dispatch (CAD) system that constitutes the time or interval.

Ambulance times and ambulance time intervals
Ambulance times and time intervals are objective key performance indicators used in prehospital care across the globe. However, their corresponding terminology and definitions used globally are more subjective.

We investigated the international definitions and terminology surrounding ambulance times and ambulance time intervals from the patient perspective.1 We started the patient journey from the point the emergency services call begins until arrival at the hospital.

An ambulance time refers to a discrete point in the patient journey, e.g., “at scene time.”2 However, an ambulance time interval refers to the temporal distance between two ambulance times, e.g., “response time interval."

We used the terminology and definitions of the Republic of Ireland National Ambulance Service as the benchmark in this study.3

Figure 1 displays the five ambulance times and four ambulance time intervals we compared internationally.

Stakeholder involvement
It is important to us as a research team that the research we carry out is shaped by those it affects the most. Thus, we engaged with two main groups of stakeholders in this research: 
1. Patient and public involvement contributors
2. Prehospital clinicians and policy stakeholders

1. Patient and public involvement contributors
Patient and public involvement in research is defined as “research being carried out ‘with’ or ‘by’ members of the public rather than ‘to’, ‘about,’ or ‘for’ them.”4 We engaged with 13 stroke and transient ischemic attack (TIA) survivors, family members, and caregivers from the beginning of this research.

Patient and public involvement contributors co-created the research question with the research team. The aim was to compare the international definitions and terminology surrounding ambulance times and ambulance time intervals on the patient journey. The group believed this exercise would give insight into how emergency medical services operate in other regions. The patient and public involvement contributors were also involved in selecting which countries would be relevant to compare in this context.

The group discussed the importance of being able to compare key performance indicators between countries in order to facilitate continuous improvement for patients. They further emphasized the importance of shared learning between countries. The group commented on the differences in international terminology and definitions. They all believed that standardized definitions and terminology are required in order to compare like with like.

Furthermore, they suggested that current challenges when comparing and contrasting data from different countries could be overcome if language was harmonized. They believed it would be useful if the same terminology was used on a global scale. As a result, international trends and patterns of ambulance times and time intervals could be investigated and compared. In turn, this would aid researchers, policymakers, and clinicians in setting priorities and making decisions.

Calling emergency medical services for help is a crucial starting point of the patient journey. This becomes even more important in time-dependent conditions as time is brain where stroke and transient ischemic attack (TIA) or mini stroke are concerned.5 Thus, it is important to include the voice of those with lived experience in work like this. The patient and public involvement panel was involved in composing this article and will be involved in sharing this research further with wider audiences.

2. Prehospital clinicians and policy stakeholders
Stakeholder involvement has been a key focus of this body of work from the beginning. The motivation and conceptualization of this topic was co-designed by members of the Republic of Ireland National Ambulance Service. All of the comparisons and methods for this work were co-designed and co-created with this expert group. Input on the conceptualization and methodology was also sought from representatives of international ambulance services.

Furthermore, the questionnaire used to collect information on the terminology and definitions was composed in collaboration with domestic and international ambulance services. Subsequently, the questionnaire was pilot tested by two members of international emergency services organizations.

On an international level, members of an international consortium focused on prehospital care of stroke patients were involved in the comparison of terminology and definitions. The PHoCoS consortium comprises an international group of prehospital researchers and practitioners from 10 ambulance services,  nine countries, and three continents. This group was involved in aligning the definitions and terminology of the ambulance times and time intervals in Figure 1. As this is a specialized area within prehospital response, we believed we needed constant engagement with members of these services to ensure accurate and precise alignment.

The group of prehospital care professionals involved in this body of work were involved in all stages of the process. They all imparted their clinical and research expertise to contribute to this international project. A Dispatch in Depth podcast on this topic was released earlier this year, and the group have co-created a policy brief about our results. The findings were also published in Issue 11.1 of the Annals of Emergency Dispatch & Response (AEDR).

What did we find?
We gathered information from 10 international ambulance services, representing nine countries and three continents. In the majority of cases, terminology differed greatly between countries, and at times within countries and even between reports. Services can have different terms for the same ambulance times and time intervals depending on the context and use. Some countries, such as those in the United Kingdom, have worked to standardize their ambulance times terminology and definitions.6 However, the variation in terminology across this cross-section of countries is evident. Variation also exists between definitions. However, this is not as apparent or frequent as terminology variation. Notably some services/countries do not collect data on the same time periods. 

Also, as English is not the first language of some of these countries, terminology, and definitions were translated into English from their native language.

What does this mean?
Some may think that this work is a semantic exercise comparing words and meanings. However, language matters. This was emphasized when translating from a country’s native language to English. At times it was challenging to translate local assumptions and meaning. 

The current level of variation in international ambulance times terminology and definitions poses a challenge for international benchmarking and research. Currently, in academia, these differences can be dealt with by journals recommending authors adapt a certain set of definitions.7 However, international consensus or harmonization of language and definitions would result in more efficient and accurate global comparison. On a smaller scale, defining terms in publications and reports would begin facilitating this process.

We need to work together to align and harmonize these terms and definitions. It is time we spoke the same language. 

1. Krafft T, García Castrillo-Riesgo L, Edwards S, Fischer M, Overton J, Robertson-Steel I, König A. “European Emergency Data Project (EED Project): EMS data-based health surveillance system.” European Journal of Public Health. 2003; 13 (3 Suppl): 85-90.
2. Spaite DW, Valenzuela TD, Meislin HW, Criss EA, Hinsberg P. “Prospective validation of a new model for evaluating emergency medical services systems by in-field observation of specific time intervals in prehospital care.” Annals of Emergency Medicine. 1993; 22 (4): 638-45.
3. “Pre-hospital Emergency Care Key Performance Indicators for Emergency Response Times Version 1.1.” Ireland: Health Information and Quality Authority. 2012; Oct. 5. hiqa.ie/reports-and-publications/key-reports-and-investigations/pre-hospital-emergency-care-key-performance (accessed Jan. 5, 2023).
4. “What is public involvement in research?” National Institute for Health and Care Research. nihr.ac.uk/patients-carers-and-the-public/i-want-to-help-with-research (accessed May 1, 2023).
5. Saver JL. “Time is brain--quantified.” Stroke. 2006; 37 (1): 263-6.
6. “Ambulance Quality Indicators: Clinical Outcomes specification.” NHS. 2020; Jan. 10. digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-collections/ambco/ambulance-quality-indicators-clinical-outcomes-specification#top (accessed May 1, 2023).
7. See note 2.