Jeff Clawson

Accuracy of emergency medical dispatchers’ subjective ability to identify when higher dispatch levels are warranted over a Medical Priority Dispatch System automated protocol’s recommended coding based on paramedic outcome data

Objectives: To establish the accuracy of the emergency medical dispatcher’s (EMD’s) decisions to override the automated Medical Priority Dispatch System (MPDS) logic-based response code recommendations based on at-scene paramedic-applied transport acuity determinations (blue-in) and cardiac arrest (CA) findings. Methods: A retrospective study of a 1 year dataset from the London Ambulance Service (LAS) National Health Service (NHS) Trust was undertaken. We compared all LAS “bluing in” frequency (BIQ) and cardiac arrest quotient (CAQ) outcomes of the incidents automatically recommended and accepted as CHARLIE-level codes, to those receiving EMD DELTA-overrides from the auto-recommended CHARLIE-level. We also compared the recommended DELTA-level outcomes to those in the higher ECHO-override cases. Results: There was no significant association between outcome (CA/Blue-in) and the determinant codes (DELTA-override and CHARLIE-level) for both CA (odds ratio (OR) 0, 95% confidence interval (CI) 0 to 41.14; p = 1.000) and Blue-in categories (OR 0.89, 95% CI 0.34 to 2.33; p = 1.000). Similar patterns were observed between outcome and all DELTA-level and ECHO-override codes for both CA (OR 0, 95% CI 0 to 70.05; p = 1.000) and Blue-in categories (OR 1.17, 95% CI 0 to 7.12; p = 0.597). Conclusion: This study contradicts the belief that EMDs can accurately perceive when a patient or situation requires more resources than the MPDS’s structured interrogation process logically indicates. This further strengthens the concept that automated, protocol-based call taking is more accurate and consistent than the subjective, anecdotal or experience-based determinations made by individual EMDs.

Ability of the medical priority dispatch system protocol to predict the acuity of "unknown problem" dispatch response levels.

Objective. To determine if Medical Priority Dispatch Systems (MPDSs) Protocol 32–Unknown Problem interrogation-based differential dispatch coding distinguishes the acuity of patients as found at the scene by responders, when little (if any) clinical information is known. Methods. “Unknown problem” situations (i.e., all cases not fitting into any other chief complaint group) constitute 5–8% of all calls to dispatch centers. From the total patient encounters (n = 599,107) in the aggregate data of one year (September 2005 to August 2006), we examined 3,947 (0.7%) encounters initially coded as “unknown problem” by the London Ambulance Service Communications Center for the scene presence of cardiac arrest (CA) andparamedic-determined high-acuity (blue-in [BI]/“lights andsiren”) findings. Odds ratios (ORs) with 95% confidence intervals (95% CIs) andp-values were used to assess the degree of associations between determinant codes andcase outcomes (i.e., CA/BI). Results. Statistically significant association between clinical dispatch determinant codes andcase outcomes was observed in the “life status questionable” (LSQ; DELTA-1 [D-1]) andthe “standing, sitting, moving, or talking” (BRAVO-1 [B-1]) code pair for the CA outcome (OR [95% CI]: 0.11 [0, 0.63], p = 0.005) andfor the BI outcome (OR [95% CI]: 0.47 [0.28, 0.77], p = 0.003). The LSQ andall three code pairs (i.e., B-1; “community alarm notifications” [B-2]; and“unknown status” [B-3]) also demonstrated significant associations both with the CA outcome (OR [95% CI]: 0.43 [0.23, 0.81], p = 0.010) andwith the BI outcome (OR [95% CI]: 0.74 [0.56, 0.97], p = 0.033). All the determinant code levels yielded significant association between BI andCA cases. Conclusion. This dispatch protocol for unknown problems successfully differentiates dispatch coding of low-acuity andnon-CA patients only when specific situational information such as the patients standing, sitting, moving, or talking can be determined during the interrogation process. Also, emergency medical dispatcher (EMD) reliance on caller-volunteered information to identify predefined critical situations does not appear to add to the protocols ability to differentiate high-acuity andCA patients. LSQ proved to be a better predictor of both CA andBI outcomes, when compared with the BRAVO-level determinant codes within the “unknown problem” chief complaint. The B-3 (completely unknown) determinant code is a better predictor of severe outcomes than nearly all of the clinically similar BRAVO determinant codes in the entire MPDS protocol. Hence, the B-3 coding should be considered—in terms of its predictability for severe outcome—as falling somewhere between a typical DELTA anda typical BRAVO determinant code.

The accuracy of emergency medical dispatcher-assisted layperson-caller pulse check using the medical priority dispatch system protocol.

INTRODUCTION Knowing the pulse rate of a patient in a medical emergency can help to determine patient acuity and the level of medical care required. Little evidence exists regarding the ability of a 911 layperson-caller to accurately determine a conscious patients pulse rate. Hypothesis The hypothesis of this study was that, when instructed by a trained emergency medical dispatcher (EMD) using the scripted Medical Priority Dispatch System (MPDS) protocol Pulse Check Diagnostic Tool (PCDxT), a layperson-caller can detect a carotid pulse and accurately determine the pulse rate in a conscious person. METHODS This non-randomized and non-controlled prospective study was conducted at three different public locations in the state of Utah (USA). A healthy, mock patients pulse rate was obtained using an electrocardiogram (ECG) monitor. Layperson-callers, in turn, initiated a simulated 911 phone call to an EMD call-taker who provided instructions for determining the pulse rate of the patient. Layperson accuracy was assessed using correlations between the layperson-callers finding and the ECG reading. RESULTS Two hundred sixty-eight layperson-callers participated; 248 (92.5%) found the pulse of the mock patient. There was a high correlation between pulse rates obtained using the ECG monitor and those found by the layperson-callers, overall (94.6%, P < .001), and by site, gender, and age. CONCLUSIONS Layperson-callers, when provided with expert, scripted instructions by a trained 911 dispatcher over the phone, can accurately determine the pulse rate of a conscious and healthy person. Improvements to the 911 instructions may further increase layperson accuracy.

Medical Miranda--improved emergency medical dispatch information from police officers.

INTRODUCTION Medical Miranda, also called Secondary Emergency Notification of Dispatch (SEND), is a low cost, effective, and welcome addition to emergency medical dispatching systems. The benefits are recognized by emergency medical dispatchers who receive feeder calls from associated public safety agencies that have trained both their field staff and call-takers in the Medical Miranda protocol. HYPOTHESIS The dispatchers would be more satisfied with feeder agencies that used the SEND protocol. METHODS A survey was conducted and analyzed, taking advantage of a situation in which two agencies (one used SEND) fed calls to the same communication center. RESULTS Dispatchers were more satisfied with the information gained from the feeder agency that used the SEND protocol and believed that the officers and dispatchers of that agency had a far better understanding of the emergency medical dispatchers needs. CONCLUSIONS When the emergency medical dispatcher does not talk directly with the reporting scene personnel or caller, Medical Miranda increases the usefulness of the information the dispatcher receives, helps the dispatcher better understand the reported medical emergency, and improves response appropriateness in emergency medical service (EMS) systems where responses routinely are prioritized.

Past, Present, and Future of Emergency Dispatch Research: A Systematic Literature Review

Abstract previously published in Annals of Emergency Dispatch and Response.

Hospital-Confirmed Acute Myocardial Infarction: Prehospital Identification Using the Medical Priority Dispatch System

Introduction Early recognition of an acute myocardial infarction (AMI) can increase the patients likelihood of survival. As the first point of contact for patients accessing medical care through emergency services, emergency medical dispatchers (EMDs) represent the earliest potential identification point for AMIs. The objective of the study was to determine how AMI cases were coded and prioritized at the dispatch point, and also to describe the distribution of these cases by patient age and gender. Hypothesis/Problem No studies currently exist that describe the EMDs ability to correctly triage AMIs into Advanced Life Support (ALS) response tiers. METHODS The retrospective descriptive study utilized data from three sources: emergency medical dispatch, Emergency Medical Services (EMS), and emergency departments (EDs)/hospitals. The primary outcome measure was the distributions of AMI cases, as categorized by Chief Complaint Protocol, dispatch priority code and level, and patient age and gender. The EMS and ED/hospital data came from the Utah Department of Health (UDoH), Salt Lake City, Utah. Dispatch data came from two emergency communication centers covering the entirety of Salt Lake City and Salt Lake County, Utah. RESULTS Overall, 89.9% of all the AMIs (n=606) were coded in one of the three highest dispatch priority levels, all of which call for ALS response (called CHARLIE, DELTA, and ECHO in the studied system). The percentage of AMIs significantly increased for patients aged 35 years and older, and varied significantly by gender, dispatch level, and chief complaint. A total of 85.7% of all deaths occurred among patients aged 55 years and older, and 88.9% of the deaths were handled in the ALS-recommended priority levels. CONCLUSION Acute myocardial infarctions may present as a variety of clinical symptoms, and the study findings demonstrated that more than one-half were identified as having chief complaints of Chest Pain or Breathing Problems at the dispatch point, followed by Sick Person and Unconscious/Fainting. The 35-year age cutoff for assignment to higher priority levels is strongly supported. The Falls and Sick Person Protocols offer opportunities to capture atypical AMI presentations. Clawson JJ , Gardett I , Scott G , Fivaz C , Barron T , Broadbent M , Olola C . Hospital-confirmed acute myocardial infarction: prehospital identification using the Medical Priority Dispatch System. Prehosp Disaster Med. 2018;33(1):29-35.

9-1-1 Triage of Non-Traumatic Chest Pain: Association with Hospital Diagnosis

Abstract Objective: Chest pain is one of the most common reasons people seek emergency care—and one of the most critical. In the United States, chest pain is the second most common reason for emergency department (ED) visits. A patients primary complaint of “chest pain” may reflect a broad range of underlying causes; therefore, it is important that emergency medical service (EMS) agencies gain a thorough understanding of these cases, beginning with the initial management of chest pain in the 9-1-1 center. The primary objective of this study was to compare hospital-confirmed patient discharge diagnoses to all calls handled by emergency medical dispatchers (EMDs) using the Chest Pain/Chest Discomfort (Non-Traumatic) Chief Complaint Protocol. Methods: The retrospective descriptive study utilized emergency medical dispatch, EMS, and hospital datasets, collected at two emergency communication centers in North America, from January 1, 2013 to December 31, 2014. Patients who were dispatched using the Chest Pain/Chest Discomfort Chief Complaint Protocol and matched to hospital datasets were included. The primary outcome was the number and percentage of cases classified as ischemic heart disease (IHD), other cardiac-related conditions, or non-cardiac-related conditions associated with chest pain. We also evaluated the distribution of causes of chest pain across demographic indicators and dispatch determinants. Results: 3,007 cases were identified as “chest pain” at dispatch for which corresponding hospital records were identified. Cases in the study were obtained by linking EMS/Hospital and Emergency Medical Dispatch datasets. Of these cases, 47.1% (n = 1,417) were due to cardiac-related causes of chest pain, 61.5% of which were Ischemic Heart Disease (IHD), while the rest had other cardiac-related causes. Of the IHDs, 32.1% were Acute Myocardial Infarction (AMI). Conclusions: Underlying causes of non-traumatic chest pain reported to 9-1-1 demonstrate a wide range of etiologies, with a mix similar to that of chest pain patients in several other healthcare settings, including hospital emergency departments. Most IHD events are triaged by EMDs to the (highest) DELTA priority level, while the CHARLIE level captures nearly all of the remaining IHD cases.

EMERGENCY MEDICAL DISPATCHERS' ABILITY TO DETERMINE OBVIOUS OR EXPECTED DEATH OUTCOMES USING A MEDICAL PRIORITY DISPATCH PROTOCOL.

Abstract previously published in Annals of Emergency Dispatch and Response

Outcome accuracy of the Emergency Medical Dispatcher's initial selection of a diabetic problems protocol.

INTRODUCTION Diabetes mellitus, although a chronic disease, also can cause acute, sudden symptoms requiring emergency intervention. In these cases, Emergency Medical Dispatchers (EMDs) must identify true diabetic complaints in order to determine the correct care. In 911 systems utilizing the Medical Priority Dispatch System (MPDS), International Academies of Emergency Dispatch-certified EMDs determine a patients chief complaint by matching the callers response to an initial pre-scripted question to one of 37 possible chief complaints protocols. The ability of EMDs to identify true diabetic-triggered events reported through 911 has not been studied. OBJECTIVE The primary objective of this study was to determine the percentage of EMD-recorded patient cases (using the Diabetic Problems protocol in the MPDS) that were confirmed by either attending paramedics or the hospital as experiencing a diabetic-triggered event. METHODS This was a retrospective study involving six hospitals, one fire department, and one ambulance service in Salt Lake City, Utah USA. Dispatch data for one year recorded under the Diabetic Problems protocol, along with the associated paramedic and hospital outcome data, were reviewed/analyzed. The outcome measures were: the percentage of cases that had diabetic history, percentage of EMD-identified diabetic problems cases that were confirmed by Emergency Medical Services (EMS) and/or hospital records as true diabetic-triggered events, and percentage of EMD-identified diabetic patients who also had other medical conditions. A diabetic-triggered event was defined as one in which the patients emergency was directly caused by diabetes or its medical management. Descriptive statistics were used for categorical measures and parametric statistical methods assessed the differences between study groups, for continuous measures. RESULTS Three-hundred ninety-three patient cases were assigned to the Diabetic Problems Chief Complaint protocol. Of the 367 (93.4%) patients who had a documented history of diabetes, 279 (76%) were determined to have had a diabetic-triggered event. However, only 12 (3.6%) initially assigned to this protocol did not have a confirmed history of diabetes. CONCLUSIONS Using the MPDS to select the Diabetic Problems Chief Complaint protocol, the EMDs correctly identified a true diabetic-triggered event the majority of the time. However, many patients had other medical conditions, which complicated the initial classification of true diabetic-triggered events. Future studies should examine the associations between the five specific Diabetic Problems Chief Complaint protocol determinant codes (triage priority levels) and severity measures, eg, blood sugar level and Glasgow Coma Score.