Chapter 10 Jeff J. Clawson During the last 35 years, it has become apparent that the 9-1-1 dispatcher can rapidly elicit reasonably accurate sign and symptom information from frightened callers, allowing more accurate medical categorization of patients [1,2]. In addition, the dispatcher can activate the configuration of responders optimally suited to deal with the specific emergency. It is not enough to mindlessly send paramedics or first responders on all cases; it is necessary to accurately determine the need for these highly trained individuals [3]. If this is not done for all calls, the number of available providers will be reduced because of their inappropriate use [4]. An available paramedic team located too far from the next patient may be ineffective solely due to excessive response distance. In the 1970s, this dilemma stimulated the development of emergency medical priority dispatching and its essential training process [1,5]. The goals are sending the right resources to the right person, at the right time, in the right way, and doing the right things until help arrives. Because the dispatcher is often the least medically trained provider in the chain of survival, these goals are accomplished through specific training in the careful use of a comprehensive protocol, including the items in Box 10.1. The key role for the dispatcher was defined in 1978 when Salt Lake City Fire/EMS identified the medical dispatcher as the “weak link” in the chain of survival [6]. Until then the average medical dispatcher had less than 1 hour of formal medical training. The emergence of structured emergency medical dispatch (EMD – this acronym is also used for the “emergency medical dispatcher”) protocols and training as vital elements of appropriately functioning EMS systems was a phenomenon of the 1980s. A number of factors contributed to the delay in recognition. Medical directors rarely observed the dispatch function because for most emergency physicians, a prehospital case begins when the radio or phone announces an inbound patient. The dispatcher’s function regarding the mechanics of dispatch and the decision-making process was unknown to the medical community. Whether the closest appropriate unit was sent, or a paramedic unit was unavailable because of previous assignment to a “cat bite” call, or the first-assigned vehicle never arrived because it was involved in an accident in which lights and siren were unnecessarily used, remained hidden and continues to be unaddressed by many medical directors today [7]. There are nine commonly held and virtually universal myths regarding medical dispatch that delay the development of sound programs. These myths are malignant rather than innocent misconceptions (Box 10.2) [8]. One of the more common myths is that most callers are hysterical. In 1986, Eisenberg et al. compared the emotional levels of 640 callers reporting cardiac arrest with those of callers reporting other complaints [9]. A standard emotional scale from 1 to 5 was used, where 1 represented “normal conversational speech” and 5 represented an individual “so emotionally distraught that information (e.g. the address) could be obtained only with great difficulty.” Of the 146 callers in non-cardiac arrest cases, the mean emotional score was 1.4. Contrary to popular belief, the mean emotional score of the 494 callers reporting cardiac arrest was only 2.1. In 1990 a study of 160 random callers in Los Angeles revealed an average Emotional Content/Cooperation Score (ECCS modified) of 1.2 [10]. No callers were rated at 5. More recent studies revealed a mean ECCS of 1.05 in 3,019 cases reviewed in British Columbia and 1.21 in 3,430 cases in Monroe County (Rochester, NY) [11]. A second myth is that the callers do not know the required information. In dispatch, the common classifications for standard callers are first, second, third, and fourth party. A first-party caller is the patient him/herself. A second-party caller is someone with the patient or intimately familiar with the patient’s current condition. A third-party caller is someone who is neither with the patient nor knows the patient (e.g. “I just saw a car accident out the window and it looks really bad!”). Fourth-party callers are related professional personnel who transfer field requests for EMS response (i.e. police dispatchers, airports, security companies, and other public safety agencies). Nearly 60% of callers can be classified as first or second party, and about one-quarter are third party [12]. The high incidence of third-party callers is often the implied reason why dispatchers fail to obtain complete information. An additional 14% of calls may be fourth party, providing little usable information. In reality, this “lack of relevant information” is the result of the dispatcher not asking the right questions rather than lack of knowledge on the part of the caller [13,14]. This can be demonstrated by comparing interrogation sequences using formal protocols with those not using such protocols (see Figure 10.1). Dispatchers left on their own must “invent” questions to ask the caller, who routinely responds, “I don’t know.” When faced with an otherwise “unknown problem,” an ad-libbing dispatcher will not ask a structured series and could fail to ascertain whether the “unknown problem” patient is a talking, moving, or sitting patient who is not in cardiac arrest. Indeed, elimination of a single word or the caller’s misunderstanding of a word or phrase can seriously hamper the effectiveness of the dispatcher’s decision making [15,16]. An example of structured questions is found in Figure 10.1. Figure 10.1 Unknown problem (man-down) protocol. Source: Medical Priority Dispatch System v13.0, ©1979-2014 International Academies of Emergency Dispatch. Reproduced with permission. These myths regarding the medical training of dispatchers and their use of protocols are disproved as EMS systems establish programs for EMD training and use medically approved, scripted protocols [14,17]. Thousands of dispatch systems provide prearrival instructions, with almost universally positive results medically, politically, and legally [18]. The National Association of EMS Physicians stated in its initial consensus document on EMD that “standard medically approved telephone instructions by trained dispatchers are safe to give and in many instances are a moral necessity” [19]. Dispatch prioritization is an essential element in any EMS system, as it establishes the appropriate level of care initially required, including vehicle response configuration and mode of urgency. All medical dispatch centers must institute and monitor adherence to dispatch prioritization protocols that clearly delineate calls that require lights-and-siren use and those that do not. All jurisdictions allowing the use of lights and siren by emergency medical vehicles must require training and professional EMD certification of their dispatchers and mandate the use of priority medical dispatch protocols approved by the local medical director that clearly delineate lights-and-siren use [20]. The role of the dispatcher in a modern EMS system is extensive, with at least seven sub roles [6]: interrogator, radio dispatcher, triager, logistics coordinator, resource provider, psychological calmer, and prearrival aid instructor. A sound basis in generic telecommunication techniques is the first prerequisite for optimal EMD [21]. The dispatcher requires specific training in what is commonly referred to as the dispatch priorities, an oblique cross-section of prehospital medicine unique to dispatch: appropriate interrogation, vehicle allocation, postdispatch instructions (PDIs) and prearrival instructions (PAIs) given to the caller, and concise information regarding the clinical situation and scene conditions given to the responding provider en route. Historically, the types of treatments performed over the telephone are generally more elementary, at least until recently when high-risk pregnancy, early stroke identification, and aspirin administration were added to the dispatcher’s repertoire. The basic components of EMD are chief complaint identification, key question interrogation, dispatch life support instructions, and prehospital medical care dispatch coding and response configuration set-up. They are covered in more detail in subsequent sections of this chapter. The concept of EMD obviously encompasses more than training. In fact, a practice standard has evolved that defines not only the role of the dispatcher but also the supervision, quality management, and risk management that must accompany it [22,23]. Medical oversight at dispatch is essential and is a key element of quality management for medical directors. The implementation process begins with training and certification. The standard instruction period for an EMD course is 24 hours [22]. Dispatch-specific training is a critical basis for the rapid, precise decisions required. NAEMSP described some of the difficulties in EMD education. In order to prioritize calls properly, the EMD must be well versed in the medical conditions and incident types that constitute the daily routine. Training in these priorities must be detailed and dispatch-specific (not EMT or paramedic training per se). Since much of the knowledge and many of the skills required by the EMD are dispatch-specific, a curriculum for their training differs substantially from those used in the preparation of EMTs or paramedics. Training as an EMT or paramedic does not adequately prepare a person for the role of an EMD. Much of the required EMD curriculum cannot be found in standard EMS training curricula. It consists of content and emphasis which differ significantly from that used for the training of all other health professionals and public safety dispatchers [19]. A quality management (QM) program is essential to the successful implementation and maintenance of an EMD program [24–26]. The 11 components of a comprehensive QM program are [24]: The areas falling under the medical director’s purview are as follows. Continuing dispatch education (CDE) is essential to reinforce initial concepts and build on the science of dispatch priorities [24]. As the operational experience of new dispatchers expands, CDE becomes their link with the changing aspects of medicine. Traditionally, the major educational, occupational, and supervisory influences of dispatchers are related to public safety rather than medicine. An active CDE program is required to keep dispatchers current with medical standards and the ideas specific to their daily routine. A minimal CDE investment of 1 hour of education per month is now the national standard [27]. Analogously, the dispatch response protocols are the “messenger RNA” of the EMS system, putting planned desires of medical oversight into play for the desired “replication” of the response and treatment system each time a call is processed. NAEMSP states, “Medical direction and control for the EMD and the dispatch center is part of the prescribed responsibilities of the Medical Director of the EMS system” [19]. This responsibility includes initial training, CDE, medical dispatch case review, and protocol review. The formal reviews should be performed on both the response assignments and the need for lights-and-siren responses. It is essential that the medical director attend a full EMD training course taught by a credentialed instructor with, preferably, significant dispatch training experience. Once physicians understand both the knowledge base required for such training and the medical basis for dispatch priorities, they are significantly more able to provide adequate medical oversight for their dispatchers (Table 10.1). Table 10.1 Effect of protocol compliance on predicting the accuracy of EMD determinant code selection Source: Academy Leadership Course, ©1997-2014 International Academy of Emergency Medical Dispatch. Reproduced with permission. Note: This table shows the correlation between compliance during an evaluation phase (consisting of case entry and key questions) and accuracy of determinant code selection. When protocol compliance drops below 100% for case entry, key questions, or both, the accuracy of determinant code selection also drops. The fundamental issue in the evaluation of dispatcher performance is protocol compliance [25]. The goal of case review is to assist dispatchers in improving performance and protocol compliance. The case reviewer should score each section of the protocol used as the dispatcher navigates through the case. Case entry (primary survey), key question (secondary survey) interrogation, selection of correct dispatch code for appropriate unit response and mode, and correct delivery of PDIs and PAIs, including safety advice, must be carefully assessed. Case reviewers should also be specifically trained in this methodology so that variation among reviewers is minimized [26]. Careful review leads to the identification of the “elements of success” or to case-specific problems of compliance, understanding, policy, or protocol. Without adequate case review, dispatcher compliance to protocol generally falls below 50–80% (depending on the scoring category examined) even when mandatory compliance is a formal policy requirement (Figure 10.2). The level of compliance of every dispatcher should be collected and cumulatively compared with established levels of acceptable practice. Studies have shown that case reviews and the feedback of compliance levels directly to each dispatcher improve compliance dramatically [25]. Figure 10.2 Impact of case review and feedback on compliance to protocol and determinant code selection accuracy. Source: Principles of EMD, 5th edn, ©2000-2014 International Academy of Emergency Medical Dispatch. Reproduced with permission. Disciplinary actions involving dispatchers should be progressive. Formal documentation of deficiencies and corrective actions are basic ingredients for successful remediation of individual dispatcher problems [27]. Trained dispatchers are often the first, first responders. They provide the initial professional intervention, reducing the response time almost to zero for specific problems. There is no better justification for the provision of PAIs than the landmark legal opinion delivered by James O. Page to the Aurora (CO) Fire Department in 1981. After years of arriving “too late” at the scenes of hundreds of life-threatening emergencies, it is difficult for me to offer a detached and unemotional opinion. Throughout the United States, we have spent billions of dollars constructing systems to respond to medical emergencies and we have done little to cure the deadly 4-minute gap at the front of the system. While we race through city traffic to get to the scene, a brain dies from lack of CPR (oxygen). Frankly, I don’t understand how any public safety or health care worker can accept these recurring tragedies without actively seeking a solution to the “response time” problem, which proves fatal in so many cases [28]. There are many recurring and predictable situations that must be uniquely addressed and corrected before terminating a call at dispatch. To the field provider, a cardiac arrest victim is a pulseless, motionless, non-breathing patient; however, the same patient initially presents to the dispatcher in the following fashion. “Is he conscious?” “No!” “Is he breathing?” “Uh, I’m not sure. He’s making funny noises.” The funny noises, a common telephone description of the agonal respirations, must be correctly interpreted [5]. Prearrival instructions are not only an essential dispatcher practice but are a clear public expectation [29]. The failure to provide appropriate PAIs is described as negligent by a growing number of plaintiff attorneys [30]. Although the notion that dispatch agencies will be successfully sued for providing PAIs has been a roadblock to their use, only one dispatcher negligence lawsuit has been filed following the provision of PAIs since that practice took form in 1975. (Ironically, that lawsuit occurred in Phoenix, AZ, where the practice of telephone PAIs was first initiated.) In contrast, an increasing number of recent lawsuits, completed or in progress, cite the omission of PAIs – or dispatcher abandonment, as legal terminology now describes it – as either the primary or the associated allegation. The American Heart Association states: Emergency medical dispatch has evolved over the past 25 years to become a sophisticated and integral component of a comprehensive EMS response. Dispatchers provide the first link between the victim and bystanders and EMS personnel. Trained medical dispatchers may provide pre-arrival instructions to bystanders using standard, medically approved telephone instructions. Dispatchers should receive formal training in emergency medical dispatch, and they should use medical dispatch protocols, including pre-arrival telephone instructions for airway control, CPR, relief of FBAO [foreign body airway obstruction], and use of an AED [31]. Dispatch life support (DLS) provides the basis for defining the actual content and application method of the special treatment protocols used by dispatchers (Figure 10.3) [32]. Figure 10.3 Sample of a prearrival instruction protocol. Source: Medical Priority Dispatch System v13.0, ©1979-2014 International Academies of Emergency Dispatch. Reproduced with permission. In 1989, NAEMSP defined DLS as “the knowledge, procedures, and skills used by trained EMDs in providing care through pre-arrival instructions to callers. It consists of those BLS and ALS principles that are appropriate to application by medical dispatchers” [19]. For example, although the chin lift is not a difficult psychomotor skill to teach in person, over the phone it becomes difficult, time-consuming, and ultimately not effective. However, the head-tilt method of airway control can be easily taught to the caller as follows: “Put one hand on his forehead and your other under his neck. Lift up on the hand under his neck and push down on the hand on his forehead. This will open his airway.” Dispatchers are instructed to be aware of hazards in neck manipulation if the patient has also incurred a significant mechanism of injury; this is rarely present in routinely encountered PAI situations. DLS more realistically incorporates the fact that, although many treatments that dispatchers provide are similar to BLS, they simply must be different in content, process, and real-time instruction. Dispatch life support was formally defined to clearly establish the necessary, functional differences between the dispatcher processes and field care as understandably legitimate. EMD training contains many dispatch-specific methods of description and caller application found in neither field provider training nor protocol. Inherent in DLS is the necessity for medical dispatchers to adhere to scripted protocols for the provision of telephone treatment in a standard reproducible way [10,25]. Although there is growing interest and effort among public safety agencies to provide telephone instruction to callers, only about 5–10% of centers provide correct, non-arbitrary, medically approved PAIs read directly from detailed protocol scripts [33]. In addition, it is not possible to comply with protocols when there are none present. Evenson and colleagues surveyed a relatively progressive state regarding the use of dispatch protocols or algorithms, and found that 45% of North Carolina communication centers had no guide or triage algorithms for dispatch [34]. It is essential for the medical director to understand the difference between PAIs and telephone aid. There are two very different methods of patient care initiated by dispatchers used at present [35]. Telephone aid often provides the illusion of PAIs without consistently delivering high-quality and accurate advice. The following are common errors seen during medical dispatch case reviews in agencies providing telephone aid [35]. The requirement for medical appropriateness within the dispatch center through effective medical oversight is an essential element for assuring the correct, safe, and efficient application of dispatcher telephone evaluation and intervention. Although it may seem to the casual observer that the emotional or hysterical behavior of callers is random or unpredictable, there are very predictable, generic reactions present in most caller interrogation processes and PAI situations [36]. The following are the most common.
EMS dispatch
Introduction
Myths of medical dispatch
Emergency medical dispatcher
Medical oversight of EMD
Quality management
Quality management components
Continuing dispatch education
Medical oversight
% Compliance based on case review Determinant code level selection (% found correct)
Case entry
Key questions
Cleveland 8/92
Montreal 9/92
Los Angeles 9/89
100
100
88
92
93
<100
100
83
86
82
100
< 100
54
51
75
<100
< 100
53
72
37
Performance evaluation and case review
Decertification, suspension, and/or termination
Prearrival instructions
Dispatch life support
Compliance with protocol
Psychological aspects
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