Stewarding scarce response capacity: an inductive qualitative interview study of emergency medical dispatchers prioritising ambulance resources

This qualitative interview study of thirteen Swedish emergency medical dispatchers reveals that prioritizing patients under capacity constraints is an active process of "stewarding scarce response capacity," involving the dynamic balancing of individual clinical urgency, geographic coverage, and population-level readiness through anticipation, reassessment, and collaboration.

The Gist

Imagine the Emergency Medical Dispatch center (EMCC) not as a simple switchboard, but as the control tower of a busy airport during a massive storm.

In this storm, the "planes" are ambulances, and the "runways" are the roads leading to patients in need. Usually, the control tower has enough planes to handle every landing request immediately. But sometimes, the storm gets so bad (more calls, fewer ambulances, traffic jams) that the tower runs out of planes.

This study asks: What goes on in the minds of the air traffic controllers (the dispatchers) when they have to decide who lands first, who has to wait in the sky, and how to keep the whole airport from crashing?

Here is the breakdown of their findings, translated into everyday language:

1. The Core Job: Being a "Resource Gardener"

The researchers found that dispatchers don't just act like a vending machine (put a coin in, get a machine out). Instead, they act like gardeners tending a scarce water supply.

• The Problem: They have a limited amount of water (ambulances) and a huge garden of thirsty plants (patients).
• The Job: They can't just water the biggest plant first. If they do, the smaller plants might die, or a new, giant plant might suddenly appear elsewhere that needs water immediately.
• The Metaphor: They are "Stewards." They are constantly moving water around, sometimes letting a thirsty plant wait a little longer so they can save enough water to put out a potential fire that hasn't started yet. They are balancing the needs of the person in front of them with the safety of the whole neighborhood.

2. The Three Main Tools They Use

The study identified three main ways these dispatchers manage this chaos:

A. The "Geographic Chess Game"

Dispatchers aren't just looking at who is sickest; they are playing a game of chess on a map.

• The Move: If they send the closest ambulance to a patient who is "very sick but not dying," they might leave a whole town without a single ambulance. If a heart attack happens in that town five minutes later, there is no one to help.
• The Strategy: Sometimes, they have to send an ambulance that is 30 minutes away, or wait for a closer one to finish a job, just to make sure the "map" stays covered. It's a constant calculation: Is it better to help this person now with a distant unit, or wait a few minutes for a local unit to keep the whole area safe?

B. The "Virtual Waiting Room" (The Invisible Line)

When there are no ambulances available, patients don't just disappear; they go into a "Virtual Waiting Room."

• The Danger: In a real waiting room, you can see people getting worse. In this virtual one, the dispatcher can't see them.
• The Strategy: The dispatchers act like vigilant lifeguards. They don't just put people in the room and forget them. They constantly check in, asking, "Is the situation getting worse?" They have to keep a mental list of everyone waiting and constantly re-evaluate: Is the person with the broken leg now in more danger than the person with the chest pain who was waiting longer?
• The Insight: They realized that the "waiting room" isn't a passive line; it's an active, dangerous place that needs constant management to make sure no one falls through the cracks.

C. The "Swarm of Bees" (Teamwork & Tech)

Dispatchers don't work alone. They rely on a hive mind.

• The Tech: They use computer screens that show where every ambulance is, like a GPS game. But the study found that technology has limits. Computers are great for speed, but they can't "listen" to the fear in a caller's voice or understand a complex family drama.
• The Human Element: When things get crazy, the dispatchers talk to each other. One person handles the calls, another watches the map, and a third talks to the nurses. They pass the "hot potato" of difficult decisions around so no single person burns out. They also have to negotiate with other teams (like police or fire departments) to see if they can borrow resources, like a helicopter, when the ambulances are all tied up.

3. The Big Takeaway: It's Not Just About "First Come, First Served"

The most important lesson from this paper is that fairness in an emergency isn't about who called first.

If a dispatcher follows the rules too strictly (e.g., "Always send the closest car"), they might accidentally leave a whole city vulnerable to a disaster. If they follow the rules too loosely, they might send help too slowly to a dying person.

The "Stewardship" Solution:
The study suggests that hospitals and governments need to stop treating dispatchers like robots who just follow a checklist. Instead, they need to support them as strategic managers.

• Give them better tools to see the "big picture" (who is waiting, where the gaps are).
• Let them talk to each other when they are stressed.
• Accept that sometimes people have to wait, but ensure that while they wait, someone is constantly checking on them to make sure they don't get worse.

In Summary

Think of the emergency dispatcher as the conductor of an orchestra where the musicians (ambulances) are tired, the sheet music is changing, and the audience (patients) is screaming.

The conductor's job isn't just to play the loudest instrument first. It's to make sure the whole orchestra keeps playing, that no section goes silent, and that the music doesn't stop, even when the room is on fire. This study is a thank-you note to those conductors, acknowledging that their job is incredibly hard, deeply ethical, and requires a level of wisdom that no computer can fully replace.

Technical Summary

1. Problem Statement

Emergency Medical Communication Centres (EMCCs) serve as the critical first link in the prehospital care chain, responsible for triaging calls and dispatching ambulances. However, many Emergency Medical Services (EMS) systems face recurrent resource shortages due to rising demand, prolonged ambulance turnaround times, and workforce constraints.

• The Gap: Existing research on scarcity largely relies on quantitative metrics (e.g., response times, unit utilization) or focuses on initial call assessment protocols. There is limited understanding of the practical and ethical reasoning dispatchers employ when they must allocate scarce resources among competing patients, manage "virtual waiting rooms," and maintain system-wide geographic coverage simultaneously.
• The Core Challenge: Dispatchers must balance immediate patient acuity against the need to preserve system readiness for future, unknown high-acuity events. Over-allocating resources to current cases can leave other areas vulnerable, while under-allocating risks patient deterioration.

2. Methodology

The study utilized an inductive qualitative descriptive design to explore dispatcher experiences without imposing predefined theoretical frameworks.

• Setting: Swedish Emergency Medical Communication Centres (EMCCs) operated by SOS Alarm AB (the national provider for 112 calls).
• Participants: 13 purposively sampled Emergency Medical Dispatchers (EMDs) with at least one year of experience. The sample included variation in age (33–62), gender (8 women, 5 men), and geographic location (Northern, Central, Southern Sweden).
• Data Collection: In-depth, semi-structured video interviews (mean duration 48 minutes) conducted via Microsoft Teams in May 2025. The interview guide focused on prioritization during scarcity, queue management, and interprofessional coordination.
• Data Analysis: Inductive qualitative content analysis following the Elo and Kyngäs framework.
  • Process: Open coding $\rightarrow$ Grouping into subcategories $\rightarrow$ Abstraction into generic categories $\rightarrow$ Formulation of a main category.
  • Rigor: Analyst triangulation, reflexive memoing, audit trails, and de-identified translation from Swedish to English ensured trustworthiness.

3. Key Contributions & Conceptual Framework

The study's primary theoretical contribution is the reframing of dispatch under scarcity not merely as "triage" but as "Stewardship."

• Main Category: Stewarding scarce response capacity.
  • This concept captures the dual accountability of dispatchers: ensuring timely care for individual patients while maintaining system readiness for future unknown events.
  • It involves the active redistribution of risk across patients and time.
• Three Generic Categories (Mechanisms of Stewardship):
  1. Allocating care proportionate to acuity within geographic constraints: Balancing clinical urgency with operational realities (distance, travel time) to preserve regional coverage.
  2. Producing availability through anticipation, reassessment, and queue governance: Treating the "virtual waiting room" as an active safety mechanism involving continuous monitoring and reprioritization rather than a passive backlog.
  3. Coordinating response through information infrastructures and interprofessional collaboration: Relying on IT systems for situational awareness and teamwork to manage concurrency and negotiate operational priorities.

4. Detailed Results

A. Allocating Care within Constraints

Dispatchers described prioritization as an ethical-operational task.

• Clinical vs. Operational: While protocols assign priority levels (e.g., Priority 1, 2A), dispatchers must interpret these within geographic constraints.
• Risk Redistribution: Dispatchers often delay lower-priority patients to keep ambulances available for potential life-threatening calls or to maintain geographic coverage.
• Quote Insight: "You have to think what is actually fastest for the patient: assign an ambulance with a 30-minute drive… or wait for a unit that will soon be available nearby."

B. Producing Availability (The "Virtual Waiting Room")

Readiness is viewed as a fragile system property that requires active maintenance.

• Contingency Planning: Dispatchers constantly formulate "Plan B, C, etc.," monitoring when units will become available and preparing alternative resources (e.g., fire services, helicopters).
• Queue Governance: The waiting room is actively managed through reassessment. Dispatchers, often supported by medical advisors, monitor waiting patients for deterioration to trigger escalation.
• Experience as Stabilizer: Experienced dispatchers use pattern recognition to anticipate bottlenecks and avoid reactive over-allocation that destabilizes coverage.

C. Coordination and Information Infrastructures

• Situational Awareness: Real-time IT systems are crucial for tracking unit status. However, dispatchers emphasized the need for selective automation; high-risk or complex calls (e.g., psychiatric, suicide) require human judgment and should not be auto-dispatched.
• Teamwork: Collaboration within the EMCC (the "loop") allows for shared situational awareness during high-demand periods.
• Operational Tensions: Dispatchers reported friction between patient safety and operational routines (e.g., crew breaks), requiring negotiation to ensure allocation decisions remain aligned with safety.

5. Significance and Implications

Theoretical Significance

The study shifts the paradigm from viewing dispatch as a linear, protocol-driven process to a dynamic system-level clinical reasoning process. It highlights that "stewardship" is a form of work that integrates clinical judgment with geographic and temporal risk management.

Practical and Policy Implications

1. Organizational Support: Training and routines must explicitly teach contingency planning, geographic reasoning, and queue governance (reassessment of waiting patients).
2. Safety Mechanisms: Patient safety under scarcity depends on the capacity to sustain follow-up work. Organizations must provide staffing and decision-support tools that make deteriorating risk in the queue visible.
3. Governance of Trade-offs: Management should make the trade-offs between individual response times and geographic coverage explicit to reduce moral distress and provide a shared language for decision-making.
4. Technology Design: Decision-support systems should prioritize "selective automation"—speeding up low-risk dispatches while preserving human judgment for complex or high-risk scenarios.
5. Resilience: Systems need redundancy and rehearsed fallback procedures for IT failures, as coordination relies heavily on information infrastructures.

Conclusion

The paper concludes that effective emergency dispatch under scarcity is best understood as the active stewardship of a safety-critical dispatch queue. Strengthening patient safety requires moving beyond aggregate response-time targets to support the complex, real-time work of redistributing risk, managing queues, and coordinating across interprofessional networks.