EMD for Dispatchers

EMD requires operational changes to the way 911 has always worked with dispatcher centers. The call workflow must change to balance the needs of patient care with those of early notification to dispatch. Instead of the old way of “transferring” the caller, the 911 telecommunicator will “conference in” the PSAP dispatcher, providing information to the dispatcher but allowing the dispatcher to speak directly to the caller to troubleshoot issues with the location/address. Emergency Medical Dispatch at the 911 level removes the burden from dispatch centers to provide EMD based on state statute.

• Time/Life Critical Medical Call: The caller will be conferenced in as soon as the telecommunicator recognizes the life threat. 911 takes lead in managing the caller so that interruptions to EMD flow are minimized (pre-arrival instructions).
• Non-Time/Life Critical Medical Call (No Safety Issues): The caller will be conferenced in after the telecommunicator has obtained Age, Sex, Awake status, Breathing status, and “what happened” (chief complaint.) 911 takes lead in managing the caller. Non-essential interruptions from the dispatcher will adversely impact EMD workflow and patient care.
• Incident involves scene safety issues (e.g., shooting, stabbing, assault, psychiatric): The caller will be conferenced in immediately upon recognizing the safety/law enforcement issue. The dispatcher will ask whatever is necessary relative to suspect information, safety issues, etc. EMD will be suspended until the dispatcher is finished and the scene is secure enough to do EMD without endangering the caller/bystanders. Dispatcher takes lead.

For most “non-life-threatening” calls, 911 conferences in the dispatcher at the end of “case entry”; this is the earliest opportunity with the least amount of important information needed to understand the event. After notification to the dispatcher, the telecommunicator will segue into other areas of protocol such as key questions, post-dispatch instructions, pre-arrival instructions, and diagnostic tools as the situation requires.

All Medical Priority Dispatch System (MPDS) protocol questions and instructions have been developed by expert consensus by the Medical Council of Standards at the International Academies of Emergency Dispatch. The MPDS is used in more than 3,500 emergency call centers worldwide and is translated into more than 35 languages. Additionally, the MPDS protocol is endorsed by the Rhode Island Department of Health. Dispatchers who are EMTs/Paramedics and/or have been doing a form of medical questioning over the years will note that the questions and instructions in the MPDS that you hear 911 going through may vary significantly from their personal style or rule of thumb. In the non-visual environment, questions and instructions are very carefully sequenced and scripted to prevent leading the caller, to seek precise information at the right time, or to give an instruction in a way that works the best over the phone. Moreover, the ProQA software uses a dynamic logic engine that re-sequences questions based on many factors, such as the patient’s age and sex which can prompt different types of questions and instructions. All questions and instructions are clinically valid and were developed by international consensus and thus cannot be changed by the telecommunicator on the fly unless the caller does not understand them.

In order for standardized care to occur, the 911 telecommunicator must use protocol the way it was designed. Interruption to the flow must be kept to a minimum. Interruptions or interjections into the call will throw the 911 telecommunicator off protocol, delay other questions or instructions in the sequence, and will adversely impact patient care. It is expected that on a routine medical call the dispatcher will interject only to verify/troubleshoot a location/address, and once that is done will tell the caller that 911 is going to provide instructions. This will streamline the workflow and have the least impact on the caller. Unsafe scene calls such as shootings, stabbings, assaults, psychiatric, will remain with the dispatcher to ask questions. EMD will be suspended until the dispatcher is done AND the scene is safe to have the telecommunicator do EMD with the caller.

Once the location, callback, and brief case entry information is relayed by 911 to the dispatcher, the dispatcher can release the line and let 911 continue to EMD the call. It is recommended that dispatchers say to the caller “911 is going to give you some instructions” after acknowledging the address and indicating that responders have been/will be dispatched. Or, the dispatcher may stay on the line to listen to the EMD interview. If a significant change to the scene or patient occurs after the dispatcher disconnects, 911 will attempt to update the PSAP by return call as timely as possible. Medical calls with an overriding scene safety (law enforcement) issue will be transferred to the dispatcher first; EMD will be suspended until the dispatcher is done asking scene safety/police-related questions and the scene is safe. These include assaults, shootings, stabbings, & psychiatrics.

Every dispatch center’s leadership has been informed about EMD, the go live date, and significant changes to workflow. Each telecommunicator completed 24 hours of Emergency Medical Dispatch classroom training followed by 8 hours of workshop training, operational policy reviews, and the completion of 75 simulation exercises. Additionally, oversight committees have been established to ensure that the system is launched successfully and that operational changes identified based on feedback after go-live are swiftly evaluated. These committees include an Executive Steering Committee, EMD Users Group, Quality Assurance Team, and Statewide Dispatchers Committee. The International Academies of Emergency Dispatch and Priority Dispatch Corp. of Salt Lake City, Utah provided the training, certification, and project coordination. EMD was developed 40 years ago by Dr. Jeff Clawson as a way to standardize medical care in the non-visual environment of 911.

The success of EMD long term in Rhode Island requires feedback and pivoting as needed to address issues and challenges. There are several areas where anticipated challenges may arise and thus operational changes to the program will need to be made. Dispatchers who are solutions oriented are encouraged to participate in the oversight and feedback via the Statewide Dispatchers Committee.

There are four EMD oversight committees:

1. Statewide Dispatchers Committee: All Rhode Island dispatchers employed by a dispatch center are invited to participate in quarterly meetings to share feedback, ask questions, and get updates on the system’s progress. For the first 6 months following go-live, this committee will meet monthly.
2. Executive Steering Committee: 911 leadership and high-level leaders from around the State
3. EMD Users Group: 911 Telecommunicators and Supervisors
4. Quality Assurance Team: 911 Quality Assurance experts from within 911, Department of Health, 911 leadership, and Quality Performance Review (independent contractor)

Moreover, questions about EMD or the management of a specific call can be emailed to emdfeedback@rie911.gov. If related to a call, include the call date, time, nature, and dispatch center name so the call can be reviewed.

Each week, approximately 80 medical calls will be reviewed from beginning to end to identify trends where telecommunicator education and development are needed to improve use of the protocol and delivery of care over the phone. Trained quality assurance team members will focus on call flow, caller management techniques, and compliance to protocol. The goal of quality assurance is to “catch them doing it right” and to celebrate the telecommunicator’s efforts to provide care in the challenging non-visual environment where the telecommunicator often has to overcome many barriers such as caller emotion, language barriers, and inability to see what the caller is describing. The initial focus on quality assurance feedback will also target areas of deviation from protocol that present a high impact or high risk to the outcome of the call. Peer support, coaching, feedback, and continuing education are an integral part of quality improvement. Moreover, EMD data will allow the Department of Health to better understand how bystander CPR instructed by the 911 telecommunicator in the early minutes of a cardiac arrest impacts patient outcomes. The majority of quality assurance case reviews will be provided by an independent contractor called Quality Performance Review.

While EMD is primarily focused on 911 callers, it is recognized that a small number of calls may be direct dialed into the dispatch center. In such cases, the dispatcher should transfer the caller to 911. To reduce misunderstandings, the dispatcher should state upon call pickup that the call was received on a 7-digit line and the caller needs EMD. If it is not possible to transfer the caller, obtain a callback phone number and notify 911. 911 will make an outbound call to the caller and provide EMD if possible.

911 will attempt to stay on the line with a caller when the situation falls into one of the following categories:

• Pre-Arrival instructions are needed (e.g., CPR, choking, childbirth, sinking vehicle)
• Unconscious
• Priority Symptoms (Significant chest pain, significant difficulty breathing, etc.)
• Not alert
• Suicidal/Domestic Violence
• Elderly or child alone
• Serious injury or hemorrhage

High call volume overwhelming the 911 center may impact 911's ability to do complete EMD on non-life-threatening medical calls. Moreover, a telecommunicator may choose to stay on the line where the caller/incident is stable but there are other valid reasons to stay on the line.

There are many diagnostic tools that help the telecommunicator gather medical information and provide care. Some of the most frequently used tools include:

• Aspirin Diagnostic: For patients 16 and older with chest pain, the EMD may instruct the patient to chew aspirin if they qualify and have it. There are safety questions built into the protocol to ensure that aspirin would not be instructed if the patient has stroke symptoms, is not functionally alert, is pregnant, or has an upper of lower GI bleed (vomiting or defecating blood)
• Breathing verification tool: For unconscious patients whose breathing is questionable, the TC will have the caller observe the patient’s chest rise and fall then count the number of breaths observed. The ProQA software helps the telecommunicator determine if the breathing is normal or ineffective, which could lead into airway management or hands on chest through protocol instructions.
• Pulse Diagnostic: For patients reporting a pulse or implanted device issue, the telecommunicator may have the patient count beats. The tool allows the telecommunicator to accept patients’ electronic monitoring devices.
• Stroke Diagnostic: This tool is used to gauge the likelihood that the patient is having a cerebrovascular accident (CVA). Based on the Cincinnati Stroke Scale, the diagnostic provides a level of confidence that what the caller is reporting is actually a stroke.