New Emergency Medical Dispatch Information for Skilled Medical Environments

In 2021, the Rhode Island Legislature passed General Law § 39-21.1-8, which indicated that Rhode Island E-911 will implement Emergency Medical Dispatch (EMD) by September 1, 2022.  EMD is a structured approach of rapid triage to ensure that ALL medical calls for service within Rhode Island receive standardized acuities and care. The old days of asking for an ambulance then hanging up have ended. EMD requires the 911 Telecommunicator to ask specific questions in a specific sequence relative to the patient or incident. This is accomplished just like a nurse or doctor would do when triaging a patient. The triage occurs rapidly over the phone in the non-visual environment. EMD is utilized in more than 3,500 emergency call centers globally. Just like healthcare providers have protocols such as Advanced Cardiac Life Support, fall protocols, etc., 911 also has protocols that are important.

EMD is used regardless of whether the patient is at home, at work, in public, or in a skilled healthcare environment. EMD reduces the risk of missing critical patient or incident information. EMD allows the trained 911 Telecommunicator the ability to quickly determine the appropriate response and relevant information for medics. Telecommunicators are using a software-based medical triage program called “ProQA”, a decision support tool that contains a logic engine of “If this, then that” to determine the best pathway for the Telecommunicator to navigate and objectively classify the acuity of each call.

For additional information on EMD in general in Rhode Island, see the EMD FAQs at https://ri911.ri.gov

Yes, but it’s different. A “rapid EMD” assessment must still be performed for patients in medical care environments. However, the medical facility pathway called “evaluation” within EMD was designed specifically for skilled medical environments; it is more streamlined. Additionally, the questions are also geared toward the patient care environment and patient management concerns.

The Telecommunicator may inform the caller from a medical facility that they are going to do a quick triage using EMD protocol so that the caller is aware of what’s happening. It is recognized that the process of EMD may not be familiar to some callers.

Every medical caller regardless of location is asked the following questions called “case entry” unless the answers are obvious from initial statements made by the caller. Case entry is the least amount of critical patient information that is needed for the Telecommunicator in the non-visual environment to understand the situation and acuity:

• “Tell me exactly what happened”
  • The reason for the call: factual, objective, relevant information
• Are you with the patient now?
  • Caller party type determines which questions or instructions are appropriate
• How old is the patient?
• What is the sex of the patient?
  • There can be differences between males and females for chief complaints such as chest pain, abdominal pain, fainting, and childbirth/pregnancy.
• Is the patient awake?
  • Critical priority point
• Is the patient breathing?
  • Critical priority point
  • If the patient is ineffective or agonal, let the Telecommunicator know when this question is asked.

All callers calling from qualified medical environment (e.g., nursing homes, clinics, prison infirmaries, school nurse offices, urgent care centers, rehabs, doctors’ offices, etc.) are asked specific questions in a designated pathway for the skilled medical care environment.

The general sequence of questions for skilled medical facility callers is:

1. Has the patient been seen by a nurse or doctor in the last two hours?
   1. If the answer is YES, the Telecommunicator will use the special medical facility protocol called “evaluation” designed specifically for this purpose
   2. If the answer is NO, the Telecommunicator will utilize a “lay person” chief complaint (e.g., chest pain, fall, breathing problem) because the adequacy of the patient care environment is questionable when the patient has not been reliably evaluated locally. In short, patient care needs may not have been met so a more detailed triage becomes necessary.
   3. The caller does not have to have seen the patient--a nurse or doctor, however, must have seen the patient
2. Will the crew need to administer or monitor any medications?
   1. If so, what are they?
3. Will any special equipment be required?
   1. Special equipment includes anything beyond 12-lead or Oxygen. Examples include balloon pumps, isolettes, etc.
4. Are additional personnel required?
   1. For example, if the patient is bariatric or a special team is needed

In some cases, additional questions may be necessary based on the logic engine of “is this, then that” built into the triage protocol software.

Generally, the Telecommunicator will not give or offer instructions when the patient has been seen by a nurse or doctor in the last two hours. In such cases, the Telecommunicator will end the call by informing the caller: rescue is on the way; have any advanced directives ready; call back to 911 immediately if the patient gets worse in any way.

Callers from medical environments are NOT given or offered lay person instructions unless there is an issue with the patient care environment and the protocol use indicates that there is risk in not providing or offering instructions. In the non-visual environment, structured protocol is essential to ensure that all patients are receiving standardized care. EMD seeks to prevent bad outcomes by managing risk with structured protocol.

In some limited cases, the Telecommunicator will offer instructions. For example, the Telecommunicator will ask “Do you need instructions on CPR?” if the patient is in arrest and it’s not yet clear if CPR, AED, airway management, etc is being done. If the answer is no, the Telecommunicator will end the call. If the answer is yes, the Telecommunicator will provide instructions.

1. Cooperate with the Telecommunicator. On average it takes only about 90 seconds to get the needed information when the caller is cooperative. Skilled medical environments are going through an abbreviated version of EMD designed for medical facility environments.
2. Returning to patient care is as important as the Telecommunicator not missing something critical that can create gaps in patient care and dispatch through miscommunication or not recognized an acute condition.
3. There is a printable form that can be put at every phone where staff would call 911 for an ambulance. Having the information ready for the Telecommunicator will speed the process substantially.

Yes. The medical level of training of the caller has no bearing on when the Telecommunicator can use the special rapid EMD protocol for medical environments. If the patient has been seen by a nurse or doctor in the last 2 hours, anyone from the office/facility is eligible for rapid EMD. It is helpful for the caller to know more than just “the doctor wants him/her transported.” The telecommunicator needs to know more than that.  Secretaries, clerks, technicians and administrative staff are encouraged to complete the “Rhode Island E-911 Skilled Medical Environment Checklist” prior to calling 911.  The checklist can be located here.

Tell the Telecommunicator you don’t know. It’s ok to say “unknown” in reference to a pointed question.

Please do not use these terms with 911. There is no consistent application for these ambiguous terms, and they vary from place to place and state to state. If the patient is in ARREST or if CPR is in progress, tell that to the Telecommunicator. A Telecommunicator will ask you what you mean if you use ambiguous terms or medical diagnoses that are not clearly understood. Be prepared to tell the Telecommunicator WHY the patient needs transport:

Examples:

• “The patient has abnormal labs and needs to be evaluated in the ER”
• “The patient fell and has a possible hip fracture”
• “The patient is septic and having altered mental status”
• “The patient is having acute onset of difficulty breathing”

No. The EMD protocol is based on pointed questions such as “Is she awake?” and “Is she breathing?” to move through the protocol. Vital signs are not part of EMD. Medications are not necessary unless the crew needs to administer or monitor the medication.