Discussion

The 119 Emergency Control Center started in June 1990 as a presidential election pledge to promptly complete the emergency medical service system. In 1990, the fundamental plans were established and the 129 Emergency Patient Information Center was launched and operated by the Korean Red Cross as of July 1991 to actively begin the emergency medical service system. Moreover, the government announced the Managerial Regulations of Emergency Medical Services (1991.6.22. Order 869 from the Ministry of Health and Social Affairs) to improve emergency medical services for the general population. In addition, the 129 Emergency Medical Information Center was established by the Korean Red Cross (July 1991), as a result of which the “emergency medical service system,” including the maintenance of emergency medical centers and ambulances, was established and implemented.

Furthermore, in 1994, the Emergency Medical Service Act (No. 4730) was enacted and announced as foundational legislation for emergency medical services. Detailed supplemental legislation on emergency medical services (No.

14494) was made in December 1994, and enforcement rules were made in 1994. However, since the reporting and registration of emergency patients could be made at both 119 (operated by the fire department under the Ministry of Government Administration and Home Affairs) and the 129 Emergency Medical Information Center, operated by the Korean Red Cross under the Ministry of Health and Welfare, the number was changed from 129 to 1339 in 1997 to avoid potential confusion for the reporters. After this, the transportation of emergency patients was performed by the 119 EMS, while 1339 provided consultation and guidance for emergency patients and first aid guidance for EMTs.

In 2000, as a part of improvement measures for emergency medical services to ensure that the general public could receive prompt and fair emergency medical service in case of disasters or accidents, the rights and obligations of both the EMS recipient (citizens) and the service providers (EMS workers) were strengthened. In addition, the Emergency Patient Information Center was renamed the Emergency Medical Information Center to supplement the limitations of the current emergency medical services system. The management authority of these renamed Emergency Medical Information Centers was transferred from the Korean Red Cross to local emergency medical centers.

In December 2011, at the 4^th Meeting on the Life and Safety of the General Public under the chairmanship of the Prime Minister, it was decided that the emergency telephone numbers separately operated by the fire department (119) and the Ministry of Health and Welfare (1339) would be consolidated into a single number (119) in attempt to provide a “one-stop”

service for patients, including the reporting and registration of emergency patients, guidance and consultation, first aid guidance, and hospital guidance.

In March 2012, with the amendment of the Act on the 119 Rescue and Emergency Medical Services by the National Assembly of the Republic of Korea, the 1339 Emergency Medical Information Center was closed. Instead, in order to efficiently provide information to 119 EMS staff regarding transporting the patients, 119 Emergency Control Centers have been established at the fire department headquarters of different cities and provinces.

In this study, the usage of the emergency telephone number (119) after its consolidation has been assessed. Emergency medical consultation via telephone can reduce the frequency of unnecessary emergency center visits,

thereby reducing the chances of emergency rooms becoming overcrowded. In addition, the general public can rapidly and easily access the information to obtain information on health issues and diseases (Kernohan et al., 1992;

Crouch and Dale, 1998; Lattimer et al., 2000). Emergency room overcrowding is a common worldwide phenomenon, lengthening the waiting period for patients in the emergency room and forcing ambulances to look for vacant emergency centers, consequently delaying medical treatment and yielding poorer prognoses for patients (Trzeciak and Rivers, 2003). Emergency room overcrowding in Korea is thought to be due to the accumulation of non-emergency patients and to-be-hospitalized patients. An increased number of non-emergency patients was determined to be a cause of emergency room overcrowding (You et al., 2007).

The most common reason for using the 119 Emergency Control Center was hospital guidance (743,799 cases), followed by first aid guidance including CPR (397,620 cases), disease consultation (150,128 cases), and inter-facility transfer (5,123 cases). These findings were somewhat different from those of a previous study assessing the usage of the 1339 Emergency Medical Information Center by the citizens of Seoul and nearby regions (Lee and Lim, 2002). Appropriate utilization of hospital guidance provided by the 119 Emergency Control Center can result in multiple positive outcomes, including shortened travel times and waiting times for emergency patients as well as the improved efficiency of the emergency medical service by dispersing emergency patients instead of collecting them at a single center. However, there is a difference between hospital guidance and first aid guidance, as hospital guidance can improve the efficiency of emergency medical service but is not directly useful for emergency medical care. Providing these different kinds of information together will likely result in problems during the

establishment of an effective information delivery system, and this will serve as evidence of the need for a mandatory distinction between emergency and non-emergency calls in the future from the perspective of direct first aid. In order to resolve these issues, the U.S. and Japan operate separate telephone numbers for emergencies (911 in the U.S. and 119 in Japan) and non-emergencies (311 in the U.S. and #7119 in Japan). By providing non-emergency services such as medical consultation for relatively mild symptoms or hospital guidance through a separate number, these countries minimize the waste of emergency medical resources and loss of professionalism (Richard et al., 2009; Morimura et al., 2011). Furthermore, considering that information regarding inter-facility transfer is an important issue at actual clinical sites, additional measures need to be taken to expand the usage or establish a separate department for this issue. Lastly, a quantitative study assessing the effectiveness of the medical information provided by the 119 Emergency Control Center in resolving the issue of emergency room overcrowding should be performed in the future.

In comparison to 2011, prior to the consolidation of 119 and 1339, the usage of emergency telephone number in 2016 after consolidation was lower by 27.8%. Although the usage for first aid guidance had increased by 91.0%, all other usages such as hospital guidance and disease consultation had decreased by 46.5% and 42.5%, respectively. By type of client, the usage by the general public decreased by 28.8%. Despite the increased usage by the 119 EMS (66.0%), all other types of clients, including medical institutions (65.2%), ambulance companies (87.9%), related organizations (77.2%), foreigners (99.0%), and others (75.1%), exhibited remarkably reduced numbers of emergency telephone calls. In the operational performance of the 119 Emergency Control Center in 2016, first aid guidance for emergency patient

accounted for 28.5%. The remaining 71.5% included non-emergency hospital (pharmacy) guidance, disease consultation, and inter-facility transfers. The majority of the calls were made for hospital guidance (53.4%), followed by first aid guidance (28.5%), disease consultation (10.8%), and inter-facility transfers (0.4%). Although the most frequent reason for using the 119 Emergency Control Center was hospital guidance, there was a noticeable difference with the operational performance of the Emergency Medical Information Center (72.1%), according to the 2011 Emergency Medical Service Statistical Yearbook (Yoon et al., 2012). Considering that the operational objectives/purpose and proportion of first aid guidance at 119 Emergency Control Centers are increasing, additional effort and studies by the 119 Emergency Control Center are needed so that high-quality and professional first aid guidance can be constantly provided for the patients under emergency situations.

Based on the daily usage during the week of the emergency telephone number, the most frequent usage was on Sundays (26.5%), followed by Saturdays (15.9%) and Mondays (13.0%). These findings were similar to those of a previous study, “Does the general public follow the hospital guidance provided by the Emergency Medical Information Center?” (Han et al., 2011), where the frequency of calls was highest on Sundays (43.7%), followed by Saturdays (13.4%) and Mondays (11.5%). For the frequency of calls by time of day, although a previous study, “Study of the usage of the 1339 Emergency Medical Information Center by the citizens of Seoul and nearby region” (Lee and Lim, 2002), showed that the greatest frequency of calls (22.4%) was between 9:00 PM and 12:00 AM, our study demonstrated a consistent increase in usage from 9:00 AM to 7:00 PM. The active hours of the general public, who frequently use the 119 Emergency Control Center, and

the business (operating) hours of medical institutions may be reflected in this difference.

The mean age of patients with cardiac arrest was 68.3 years. The majority of patients were in their 80’s (5,188 cases, 26.7%), followed by those in their 70s (4,179 cases, 21.5%) and 60s (2,730 cases, 14.0%). There were more male patients (11,710 cases, 60.2%) than female patients (7,729 cases, 39.8%). In comparison with a previous by Cho et al. (2009), the mean age of patients was slightly different (56.7 years in the study by Cho et al.) while the gender ratio of patients was similar (65.8% male and 34.2% female in the study by Cho et al.). The majority of cardiac arrest events occur in the pre-hospital phase (e.g., household, work, or street), and it is known that the time period between cardiac arrest and CPR is one of the most important factors deciding the recovery of spontaneous circulation and prognosis of the patient (Steen et al., 2003). Since most witnesses of cardiac arrest events are the patient’s family members, immediate and effective CPR performed by the first witness is essential for improving survivability of pre-hospital phase CA patient in addition to basic life support by EMTs (Stiell et al., 2004). Thus, a witness of cardiac arrest must perform CPR as soon as possible. However, because it is not easy for people to provide immediate and accurate emergency medical care for the patient, dispatcher-assisted CPR performed by the witness is crucial.

As was found in previous studies, most cardiac arrest events occurred in the house, and in most cases the first witness who performed CPR was a family member (73.4%), followed by friends or acquaintances (9.1%) and facility participator (5.9%). These findings were slightly different from those of a previous study by Eun et al. (2011), which assessed the validity of CPR termination guidelines for pre-hospital phase cardiac arrest patients and

showed that 58.1% of cardiac arrests happened within the patient’s house.

However, another study by Oh et al. (2010) that assessed the awareness of CPR in CA patient’s witnesses (or companions) via interview survey reported that 75.0% of cardiac arrest occurs within the patient’s house, which is similar to the findings of our study. In order to promote CPR performed at the pre-hospital phase by a witness, the Ministry of Health and Welfare, the Korean National Fire Agency, and the Korean Red Cross are working together to provide CPR training for the general public. However, previous studies suggest that increasing the survivability of CA patients two-fold by providing CPR training to the general public will take 20–30 years (Stromsoe et al., 2010). Therefore, until CPR training becomes more widely available to the general public, the current operation of DA-CPR by the 119 Emergency Control Center should become a more important key task in the future in order to improve the survivability of CA patients with immediate CPR from witnesses with no previous CPR training or uncomfortable with CPR despite their previous training.

In this study, the mean time period between reporting an incident of cardiac arrest and receiving CPR guidance from the 119 Emergency Control Center and performing chest compression was 182.3 ± 89.8 seconds. For CPR providers with previous training, the mean time period was 173.9 ± 88.6 seconds, which is ~10 seconds faster than those without previous training (184.0 ± 88.2 seconds), a statistically significant (p < 0.001) difference. Ben Bobrow (SHARE, 2018) has emphasized the importance of prompt CPR performed by a witness of cardiac arrest, and stated that the witness ideally should perform CPR within one minute from reporting the incident to the emergency medical service system. The survivability of patients with cardiac arrest decreases by 7–10% every minute that CPR is delayed, while

immediate CPR performed by the witness improves the patient’s survivability.

Dispatcher-assisted (guided) CPR improves the probability of a witness performing immediate CPR, thereby shortening the time period between the onset of cardiac arrest and CPR (Lewis et al., 2013). Therefore, EMDs working at the 119 Emergency Control Center must quickly recognize the situation (cardiac arrest) based on the report of the witness and provide adequate guidance for the witness to perform immediate CPR. To provide sufficient training for EMDs to provide proper guidance for witnesses making emergency phone calls, additional studies should be performed.

Despite these intriguing findings, there are a few limitations in this study. First, due to the retrospective nature of the analysis of CPR and first aid guidance call logs, the accuracy of the data is limited. Second, data on dispatcher-assisted (guided) CPR outcomes prior to the consolidation of emergency telephone numbers was unavailable. Even for the data after consolidation, medical records stored at other institutions could not be assessed, and thus the prognosis or treatment outcome of CA patients could not be determined. More specifically, whether or not accurate CPR was provided to the patient after dispatcher’s guidance and the patient exhibited recovery of spontaneous circulation after hospitalization could not be determined. Therefore, a comprehensive system that can follow-up from emergency telephone call and ambulance dispatch until the patient’s endpoint (e.g., survival) should be established, and a prospective study on this topic needs to be performed. Last but not least, the data from 2011 and 2016 were compared regarding the operational performance of the 119 Emergency Control Center. However, the data from these years may not fully represent the data before and after consolidation, which may have affected the study outcome.