Priority Dispatching

[Richard B the EMT]

The FDNY EMS EMD uses a system that I think is based on Dr. Jeff Clawson's dispatching principals. I do not recall the exact name of the program.

Most here who follow my postings, know the FDNY EMS EMD uses something like 50 call types, each with BLS, ALS, both, or both with a CFR Engine company, as well as the level of priority the ambulances respond at. A Cardiac Arrest would be a Pri One, with ALS/BLS/CFR, while a vehicle broken down is a priority 8, which is more of a record keeping thing than anything else.

Both Dr. Clawson's and the system used by FDNY EMS EMD also allow for calls to be upped in priority by the call taker, based on patient's age, or other information not covered in the algorithms that the call takers perceive from the callers.

Following getting the call into the Computer Assisted Dispatch system, the call takers then attempt to give the caller instructions of what to do prior to the EMS arrival on the scene, as per the same algorithm charts. I understand the system is now fully computerized with touch screen activation, which is an improvement over the flip page books I was using, back in 1996.

Guess what, people? Folks calling in to 9-1-1 seem to know the "key" words, like "Heart Attack", "Cop Shot", or "My baby isn't breathing, and is turning blue", to get a "quicker" response of an ambulance. Gee, do you think they might be lying?

[Beagle189]

The cons are:

1. No proven benefit to patient outcomes.

1. Rigid protocol results in frequently mis-triaged responses.

If eliminating unnecessary hot responses were the only effect, that would be a good thing. But unfortunately, it also results in a slowing down of responses that are later found to have warranted a higher priority.

As far as I've seen this is the same cons to every Marketable Dispatch Protocol. Things AMPDS does offer is a structured system for dispatchers- people w/o any medical training or knowledge to send help. AMPDS was initially invented to ensure quality dispatch. Care given over the phone was brought in later.

I have experienced Dispatch centers that had no system and dispatching was horrendous, then they implemt AMPDS and improvement was dramatic.

As far as slowing down some responses - well thats true. But centers that conform to the AMPDS system ensure that every call gets dispatched w/ some kind of response apparatus. And yes in some systems missed responses are a problem. A shock I know but...

AMPDS is not perfect. But it beats the Hell out of not having anything

[rock_shoes]

We use AMPDS in BC and speaking from my own experience it is a complete failure. The number of unneccesary "hot" runs to scene has increased dramatically with no relatable increase to positive patient care outcomes. Both crews and the public are being put at risk by this system without any tangible benefit. The majority of dispatchers here are at minimum Primary Care Paramedics (similair scope to EMT-I stateside) before they are ever dispatchers (many of our people who have experienced career ending injuries end up in dispatch). They know the questions that need to be asked without having to follow a computer based flow chart. Society has become so litigious that anything allowing an employer to "blame the computer system" is considered good practise.

[WelshMedic]

As far as I've seen this is the same cons to every Marketable Dispatch Protocol. Things AMPDS does offer is a structured system for dispatchers- people w/o any medical training or knowledge to send help. AMPDS was initially invented to ensure quality dispatch. Care given over the phone was brought in later.

There, in a nutshell, is the problem. Why are untrained personnel allocating resources on the basis of a computer analysis instead of actual need? It will all end in tears.

wm

[Dustdevil]

LOL@tears

I'm a little surprised that we haven't heard from any of the twelve people -- a significant majority -- who voted that they are for priority dispatch systems. Why don't they have anything to say? Is there something overwhelmingly positive about it that the rest of us are missing? Or is this yet another case of an uneducated majority simply parroting what they've always heard or always done, but not having any intelligent insight into why they do it?

[FL_Medic]

I was wanting to hear from those people as well Devil. You know I started this post with the term priority dispatch just meaning what the name implies. I didn't actually mean the company of the same name. I guess at this point it doesn't matter.

I am for a triaged dispatch to a point. What the parameters would be, I don't know. I just feel there should be a way to eliminate L & S responses to every call in my system. That is the main selling point so far here at least.

[Dustdevil]

I'm with ya, bro. I share that desire. I simply have not yet found a commercial system that meets the goal. As intuitive and common sense as it sounds, it just never pans out in actual practice. Same thing with SSM and the PUM. They look great on paper, but they never work out. And all the studies that suggest they do all come from the vendors themselves, or their shills.

Clearly, if the goal is to reduce risky responses, the solution is to address driving habits, not dispatching. Priority dispatching is a pointless and misguided attempt to solve the problem by proxy, and it just doesn't work.

[kevkei]

I just feel there should be a way to eliminate L & S responses to every call in my system. That is the main selling point so far here at least.

Not that you need me to tell you this, but for the purpose of others offering their perspective.

There is a way to accomplish this, develop your own system to do what you want it to do, not what others tell you should be done.

- Have competent, medically trained people (Paramedic) do the call evaluation and dispatch.

- Follow the principles of telehealth to hear and treat (triage), take your time

- not all patients need an ambulance at their door <8:50 90% (actually, the majority don't) so take the time to do a proper evaluation on the phone. There are only a few true critical threats where time sensitivity is an issue.

- send the appropriate resource in the appropriate method, if you need to even send it at all.

- establish appropriate response time benchmarks depending on patient disposition.

- too many systems base how they respond on equality for all patients, which is intuitively wrong.

Too many people buy into the fact that when someone accesses 911, we have to respond L & S as quickly as possible. That we need to stop the clock, the sooner the better. This is a fallacy, we have an inherent issue in wanting to not tell someone that they can wait.

I did some public consultation with different groups and found that they were quite receptive to these kinds of changes.

Does your local are have any type of nursing telehealth system? Have you talked to them at all about the 5 w's and how they do what they do? Is there a way that you can leverage some of their resources or partner with them?

[rock_shoes]

There is a way to accomplish this, develop your own system to do what you want it to do, not what others tell you should be done.

- Have competent, medically trained people (Paramedic) do the call evaluation and dispatch.

- Follow the principles of telehealth to hear and treat (triage), take your time

- not all patients need an ambulance at their door <8:50 90% (actually, the majority don't) so take the time to do a proper evaluation on the phone. There are only a few true critical threats where time sensitivity is an issue.

- send the appropriate resource in the appropriate method, if you need to even send it at all.

- establish appropriate response time benchmarks depending on patient disposition.

- too many systems base how they respond on equality for all patients, which is intuitively wrong.

This is exactly what was done in BC prior to AMPDS. It actually worked far better than AMPDS until management in their wisdom decided we needed to "modernize" and follow trends set by other services. AMPDS opens the door to use lesser trained (read cheaper) people as dispatchers.

By the way I voted for priority dispatching thinking in terms of triaging calls not the use of AMPDS. Regardless of the system or method used a dispatch centre must have a way to prioritize calls.

[Dustdevil]

Does your local are have any type of nursing telehealth system? Have you talked to them at all about the 5 w's and how they do what they do? Is there a way that you can leverage some of their resources or partner with them?

Bad idea. Actual Dallas Fire Department call transcript:

Nurse: And what is the problem there?

Boff: I don't know, if I knew I wouldn't be ...

Nurse: Sir, would you answer my questions, please? What is the problem?

Boff: She's having difficulty breathing.

Nurse: How old is this person?

Boff: She's 60 years old.

Nurse: Where is she now?

Boff: She is in the bedroom right now.

Nurse: Can I speak with her please?

Boff: No, you can't. She seems like she's incoherent.

Nurse: Why is she incoherent?

Boff: How the hell do I know!

Nurse: Sir, don't curse me.

Boff: Well, I don't care. You stupid ... questions you're asking. Give me someone who knows what they're doing. Why don't you send an ambulance out here?

Nurse: Sir, we only come out on life-threatening emergencies.

Boff: Well, this is a life-threatening emergency.

Nurse: Hold on, sir. I'll let you speak with my super ... uh, officer.

Supervisor: Hello?

Boff: What do I have to do to get an ambulance out to this house?

Supervisor: You have to answer the nurse's questions.

Boff: All right! What are they, before she dies will you please tell me what the hell you want?

Supervisor: Well, I tell you what, if you curse one more time I'm gonna hang up the phone.

Boff: Well, I'll tell you what. what if this were your mother in there and can't breathe, what would you do?

Supervisor: You answer that nurse's questions and we'll get you some help.

Boff: She's having difficulty breathing she cannot talk.

Supervisor: OK, she's back on the air. Don't you cuss her again.

Nurse: OK, sir, I need to talk to her still.

Boff: You can't. She is incoherent.

Nurse: Let me talk to her sir.

Boff: (To roommate) Please tell her she's incoherent and cannot talk. (To nurse) She cannot talk at all.

Nurse: Why?

Boff: Well, how am I supposed to know?

Nurse: Well give her the phone.

Boff: (To roommate) Give her the phone in there. Give her the phone. I know she can't talk but they want to talk to her. But she can't talk. (To nurse) Forget it. I'll call the main hospital around here all right?

Nurse: OK. Bye-bye.

Then a follow-up call from the original caller's roommate a couple minutes later:

Nurse: Are you the same man I was talking to earlier?

Fleming: No, that was my roommate.

Nurse: Uh huh. Why can't I talk to the lady?

Fleming: She cannot talk.

Nurse: Why?

Fleming: She's in ... she's just out of it. In fact, he's going in there now. He thinks she's dead.

Nurse: What do you mean by 'out of it?'

Fleming: She is incoherent.

Boff: She's dead now. Thank you, ma'am! Would you please send an ambulance? Would you please send an ambulance here?

That was 1984. The city was found liable for the woman's death, and the system eventually implicated in at least three deaths under similar circumstances. A fire captain and assistant chief were fired or demoted. The nurse was fired, licence revoked, and literally run out of the state by numerous death threats and a malpractice judgement. All the other nurses quit, and it was impossible to find any to take their place. They quietly ended the programme shortly after that. Good riddance. While such phone triage may seem intuitively intelligent, it's a recipe for failure and the worst possible public relations disaster, with zero benefit to the public.

Very few physicians will practise medicine by telephone, and this is why. You cannot competently assess a patient you haven't even seen or touched. Even trying to is do so is a violation of established standards of care. Don't look for ways to pick and choose who you are going to serve and when. You're paid to serve the public. Do it, or be prepared to suffer the consequences.