9-1-1; What Is Your Emergency?

Wednesday, May 8, 2013

Protocol Use in Emergency Dispatch: An Evolving Standard of Care

Taken from 9-1-1 Magazine.com, 5-13-11, originally published in April, 2008 issue

Written by Brett Patterson, Academics and Standards Associate of the National Academies of Emergency Dispatch (NAED).  Involved in training, curriculum, protocol standards, quality improvement, and research.  He is a senior EMD instructor, a member of the NAED College of Fellows, Standards Council, and Rules Committee, and also serves as Curriculum Board Editor and Research Council Chairman for the NAED.  He became a paramedic in 1981 and began a career in EMS communications in 1987.  Prior to accepting a position with NAED, he spent ten years working in a public utility model EMS system in Pinellas County, Florida.

Protocols have become an integral part of modern day, emergency dispatch operations.  Protocols reduce variance, ensure a continuity of care, reduce liability, standardize response decisions, and provide a basis for performance measurement and quality improvement efforts.  It's not wonder that protocol use has become a rapidly growing standard in a discipline that has, historically, been fraught with inconsistencies in call receipt, processing, interrogation, instruction, and dispatch.

Before the use of protocols in the United States, emergency dispatching involved little more than an individuals interpretation of a complaint, perhaps some ad-libbed questioning to satisfy the dispatcher's curiosity, and the subsequent dispatch of a generalized resource that was left to interpret second-hand, subjective information and fend for themselves.  Mistakes were common because, in the non-visual environment of dispatch, unwritten, vague and varied procedures were forgotten, overlooked, or simply omitted by well-meaning individuals with little or no training.  Quality improvement efforts were either non-existent or in vain because without a standard in which to measure, the best efforts were simply reactionary, occurring only after a mistake was realized.  As a result, addresses and callback numbers went unverified, caller interrogations were incomplete and inconsistent, pre-arrival instructions were ad-libbed or non-existent, and resource allocations were often either wasteful or inadequate.  Concurrently, lawsuits became commonplace, perhaps becoming the saving grace of emergency dispatch, sparking the move to standardize dispatch methods in the same way field operations had years earlier, through the use of well thought out, pre approved protocols.

Although there are many benefits of protocol use in emergency dispatch, the driving force behind their proliferation in EMS involved resource allocation and pre arrival instruction.  While police departments had been using protocols, or at least guidelines, to sort calls according to priority for years, EMS agencies were still fighting turf wars by establishing political and jurisdictional boundaries that often resulted in a reluctance to respond the closest ambulance to an emergency.  Jeffery Clawson, considered by many to be the Father of Emergency Medical Dispatch, became frustrated by the response policies and associated political complications in his hometown of Salt Lake City, Utah in the late 1970s.  When he took action by speaking out and writing letters, he was eventually asked to take a more proactive role by becoming the city's Fire Surgeon.  Dr. Clawson then concentrated on developing protocols to standardize how EMS resources were deployed as related to type (ALS vs. BLS), priority, and location.  The rest, as they say, was history.

The discovery of pre arrival instructions was the next motivating factor in the development of emergency dispatch protocols.  Pre arrival instructions began with well-intentioned field practitioners working or visiting in communication centers.  When a call came in that was perceived as needing immediate attention, these paramedics, EMTs, or CPR certified individuals would provide ad-libbed instructions, before the arrival of responders.  However, because these professionals were trained to assess and treat patients in a visual setting, they often missed important clues to the patients condition due to a lack of non-visual interrogation skills and standardized questioning.  They also provided instructions that were difficult to understand or interpret.  Even so, anecdotal successes were well received and celebrated by communities and professionals alike.  Eventually, as such instructions became a public expectation in a few communities, efforts to standardize and adopt pre arrival instruction methods gained momentum.  As success stories became abundant, the media became more and more interested in the new phenomenon.  In addition to the local news celebrations, television shows, most notably Emergency and then Rescue 9-1-1, played an important role in making pre arrival instructions not only a national, public expectation, but also a standard of care in the industry.

Toward a Consistent Standard of Care
As public expectation evolved the standard of care in emergency dispatch, a duty to act was established in local courts.  This was a very important development because, due to the very fragmented and inconsistent way EMS has developed in the US (town, city, or county based vs. state or national delivery), only a relative few agencies had actually adopted formal protocols for emergency dispatch.  Even so, and probably because of national television coverage, even the smallest of communities had the best of expectations.  These expectations, coupled with the growing national standard of care, prompted lawsuits when pre arrival instructions were not provided in some communities.  Ironically, it was fear of liability that kept many of these agencies from providing the kind of help that their communities actually expected.  Eventually, however, as the growing number of lawsuits clearly involved omission rather than commission, more and more EMS agencies got the message and implemented pre arrival protocols.

While public expectation played a very important role in this evolving standard, written standards and expert opinions concurrently helped to cement it.  In 1983, Utah became the first state to require the use of dispatch protocols and established a curriculum for the certification of dispatchers.  Shortly thereafter, the US Department of Transportation issued a curriculum and a sample protocol for training.  In 1988, the National Academy of Emergency Dispatch was formed and began certifying dispatchers and developing national standards.  Today, the National Academies of Emergency Dispatch (NAED) has evolved to incorporate police and fire protocol standards into their mission.

In 1989, the emergency medical community got involved when the National Association of EMS Physicians (NAEMSP) issued a position paper on the subject.  This paper laid an important foundation for the implementation of emergency medical dispatch protocols because it recommended the elements considered most important in their construction: "The functions of emergency medical dispatching must include the use of predetermined questions, pre-arrival telephone instructions, and pre-assigned response levels and modes.  The EMD must understand the philosophy and psychology of interrogation and telephone interventions, and be expert in dispatch life support.  Minimum training levels must be established, standardized, and all EMDs must be certified by governmental authority."

In 1990, the Americal Society for Testing and Materials (ASTM) published Standard Practice for Emergency Medical Dispatching.  This document defined the functions of emergency medical dispatch including dispatch prioritization and the provision of pre arrival instruction.  It also recommended dispatch-specific medical training and the use of an Emergency Medical Dispatch Priority Reference System (a protocol) to ask key questions about patient condition and incident type, to determine the necessity for and provide pre arrival instruction, and to select predetermined response levels based on information obtained.

Today, it is estimated that more than 90 percent of EMS agencies have implemented the use of some sort of protocol or guideline to provide pre arrival instructions, although this percentage is estimated to be less in agencies controlled by police or fire departments.  The problem is that due to a lack of continuing dispatch education and formal quality improvement programs, compliance to protocol is often poor.  These factors severely limit the effectiveness of protocol use through the introduction of variance and subjective decision-making.  The same problems exist when guidelines are used instead of protocols, as methods are open to interpretation and difficult to measure due to their subjectivity.

Protocols & Quality Improvement
Ironically, protocol compliance issues are often compounded by well-intentioned efforts to improve compliance.  Quality improvement programs are relatively new to emergency services and, unfortunately, are not well evolved.  Too many agencies interpret quality improvement as a simple check and discipline routine that is often more destructive than productive.  When such big-stick methods are employed, dispatchers become frustrated and, eventually, robotic in their actions, because they perceive their agency's goal for them as nothing more than reading a protocol without incorporating human thought, judgment, or feeling.  This inappropriate practice then becomes, on the surface, a standard argument against protocol use with opponents citing that protocols limit, rather than enhance, the natural abilities of good employees.  This could not be further from the truth.

The components of a sound, quality improvement program are too complex to be detailed in this article.  Quality improvement is a philosophy of continuous improvement that must be adopted by the entire agency.  It involves careful attention to initial employee selection, orientation and training, statistically sound processes for randomized call review and analysis, appropriate group vs. individual feedback based on statistical evidence, and continuing dispatch education that is specific to the needs discovered during case review.  When implemented and manage appropriately, quality improvement programs are far more positive in nature than negative and employees actually look forward to feedback, rather than despising it.  When this happens, the protocol becomes an indispensable tool that calltakers rely upon for guidance; a tool that omits guesswork and actually allows individuals to think about a call holistically and incorporate human judgment without being limited by the strain of ad-libbing questions and instructions on a case-by-case basis.  Protocols do not limit decision-making.  When managed appropriately, they actually enhance it.

As national and international standards have developed, more governmental authorities have begun to mandate the use of dispatch protocols and formal training and certification for dispatchers through legislation.  Although extremely varied from state to state, this initiative is clearly on the move.  In Delaware, not only are dispatch protocols mandatory, NAED Accreditation is a requirement of all EMS communication centers.  This process incorporates fundamental quality improvement efforts to make protocol use optimal.  In Massachusetts, a move is in process to require Emergency Telecommunicator Certification and to provide funding for emergency medical protocol software (ProQA) implementation statewide.  Maryland is considering funding the implementation of both fire and police protocols statewide, in addition to the currently funded medical programs.

Although protocol-related legislation is in effect or in the process of being adopted in several states, it is nearly as varied as the delivery systems it is being designed to improve.  In an attempt to help states adopt consistent legislation that promotes protocol use, the NAED has created generic, model legislation for consideration by state lawmakers.  This model can be downloaded at www.emergencydispatch.org under the Document Downloads link.

Internationally, the standardized use of emergency dispatch protocols has evolved very quickly.  With few exceptions, nearly all of the United Kingdom uses the Medical Priority Dispatch System to interrogate callers, allocate a specific response by priority, and provide pre arrival instructions.  The same system is used in Dublin and Belfast, Ireland; Edinburg, Scotland; Berlin, Germany; Innsbruck and Vienna, Austria; Turin, Italy; and all of the major cities of Australia, New Zealand, and Canada.

Protocol use in emergency dispatch has evolved from basic guidelines to sophisticated, software-based programs that benefit communication centers all over the world.  It is no surprise that agencies reaping the efficiency and effectiveness associated with modern-day protocols are the ones with sound, quality improvement programs.  Protocol implementation is a process that involves careful consideration not only to the protocol itself, but also to initial training and certification, statistically sound compliance measurement and feedback methods, appropriate employee interactions and involvement, and continuing dispatch education that relates to dispatch system performance and allows for concurrent recertification.  When implemented and maintained appropriately, and with the full support and buy-in of management, dispatch protocols provide a stable platform from which emergency dispatchers can provide consistent, pre approved help to those in need that meets and exceeds an evolving, standard of care.

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