THE MEDICAL PRIORITY DISPATCH SYSTEM-A SYSTEM AND PRODUCT OVERVIEW

By Geoff Cady, Consultant and EMT-P

TABLE OF CONTENT LINKS

Introduction

EMD Training

The MPDS ­ An Emergency Medical Dispatch System Design

EMD Activity Prioritization

What Makes the MPDS Protocol Different?

The MPDS ProQA Software ­ an EMD Expert Software System

Advanced Quality Assurance ­ Measuring and Improving EMD Performance

Anticipating Changing Demands and Expectations on 911

Flexibility in Solution Design

Conclusion

INTRODUCTION

Medical Priority Consultants, Inc. and the National Academy of EMD (NAEMD), a nonprofit organization with more than 27,000 members and 2,300 agencies, respectfully submits the following materials for review and consideration. We believe that the safe and effective delivery of emergency medical services (EMS) starts with the consistent and professional provision of emergency medical dispatch. Its delivery through professionally trained emergency medical dispatchers (EMD) ensures the timely delivery of life-saving and impacting care. The consistent and predictable use of a uniformed medically managed and supported EMD protocol ensures each 911 caller receives EMD that is consistent with current standards of care. However, it is important to point out that EMD training and protocols alone will not guarantee the delivery of this vital component of the EMS system. Only through EMD compliance to the protocol and the ability of the communications center administration to measure and correct EMD performance can the objectives of EMD be obtained.

The Medical Priority Dispatch System (MPDS), originally developed by Dr. Jeff Clawson and now controlled by the National Academy of EMD, is the most advanced and comprehensive EMD system available. By virtue of its design, the MPDS is unparalleled in its ability to provide system administrators with complete information on EMD performance as it relates to compliance to the protocol. The MPDS applies a systems approach to quality management of emergency medical dispatch activities that exceeds all national standards and industry position statements. To understand the importance of adherence to national EMD practice standards as a form of "malpractice" insurance, a quick review of standards and position statements that are specific to EMD has been included.

At the inception of EMS, as with many other new professions and industries that have emerged, there were few, if any, standards or position statements that established minimum performance expectations. Since that time, however, there has been an effort by many professional organizations and academic institutions to establish a body of information regarding acceptable EMD performance. These efforts were directed toward insuring that the public is provided with a minimum level of service that is both safe and effective. With these two directives in mind, the American Society for Testing and Materials (ASTM), a voluntary consensus building organization; the National Institute of Health; the National Association of Emergency Medical Services Physicians (NAEMSP), a professional association of EMS medical directors; and, the National Association of State Emergency Medical Services Directors (NASEMSD) have published standards and position statements that address EMD and EMS system design, safety and effectiveness.

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EMD TRAINING

The NAEMD's EMD certification course curriculum is maintained by the Board of Curriculum of the NAEMD. EMD instructors are certified through a process that consists of attendance and co-instructing at no less than five EMD courses following successful completion and certification as an NAEMD certified EMD. The instructor candidate must be signed off by an NAEMD "Master Instructor" prior to independent instructing. Each EMD instructor is provided with an instructor manual and NAEMD maintained training materials. The NAEMD requires attendance at its instructor update at least once every two years to ensure instructors remain up-to-date on the EMD curriculum. All instructors receive feedback through course evaluations and through other sources of direct observation. The NAEMD believes that instructor competency is key to the appropriate and consistent use of the MPDS.

EMD certification course attendees will learn how to handle difficult callers, identify the correct chief complaint, assign appropriate resources, effectively communicate between responders and callers and provide life-saving support. EMD certification occurs following the completion of 24 hours of training, CPR certification and obtaining a passing score on the final exam. Course contents consist of:

EMD: The science of prioritized dispatch

Course attendees are provided with an overview of basic telecommunications skills and activities, history of EMD (and some of the misconceptions), and the EMDs duties and responsibilities in today's telecommunications environment.

Ethical and medical-legal: The shaping of modern EMD

Attendees are presented with the ethical and medical-legal issues that have shape EMD. Issues related to the development of an EMD standard of care are reviewed and their subsequent incorporation into the MPDS protocol. Participants are presented with information on the risks of an inadequate understanding of EMD and where the "EMD danger zones exist."

Dispatch life-support: The "zero minute" response time

Attendees are taught the skills that will enable them to take control of the call, effectively interrogate the caller , and provide life-saving instructions. They are provided with insights into how to anticipate and respond to predictable caller behavior. Attendees are then presented a series of actual cases that illustrate the techniques previously discussed.

MPDS protocols: Principles of operation

Attendees are presented with specific information regarding how the MPDS protocol is designed to assist them in making better decisions. From case entry to top case completion, attendees are provided with step-by-step instruction regarding the use of the MPDS. Information regarding remote patient access, resource assignment, and providing responder assistance is all discussed. The day finishes with MPDS hands-on practice using scenario drills.

Instructed practice: Learn by doing and reviewing

Attendees continue to drill using the protocol in small groups with one-on-one instructor review. Each call type is walked through by the attendees, from time-life priority situations needing dispatch life support, to multiple patient calls.

Course conclusion: Preparing for certification

Attendees have an opportunity to review and question the instructor about any aspect of the previous three days of training before taking the certification test. Final results of the test are processed by the NAEMD, who mails the results with Certification documents and other NAEMD materials to the attendee.

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THE MPDS™;AN EMERGENCY MEDICAL DISPATCH SYSTEM DESIGN

The MPDS protocol is designed to standardize and codify the operation of EMD while optimizing safe and effective patient care through dispatch life support and EMS system response. The MPDS protocol uses a system of interrogation and time-life symptom determination that enables the EMD to prioritize system response according to user-defined response configurations. Its unique design results in:

While the most visible features of an EMD system is its ability to identify the need for pre-arrival instruction and prioritize an EMS response, the MPDS protocol's ability to assist the EMD in identifying safety issues is often overlooked. The safety and care of the patient, bystanders and responding rescuers are essential to maintaining the "Do no harm" doctrine in medicine. The first responder and transportation safety issue is related to the use of lights and sirens and the inherent risk associated with their use, as it relates to emergency medical vehicle collisions (EMVCs). It is estimated that nearly 12,000 EMVCs occur annually, resulting in an estimated 120 fatalities of EMS responders and bystanders. In order to minimize the risk of EMVCs to bystanders and EMS responders, ASTM Standard F 1258-95, Subsection 6.1.1.1(a) states that the EMD process "Adequately establish the correct level of [EMS] response."

Other safety issues that must be addressed in an emergency medical dispatch protocol include questions regarding the presence of scene hazards such hazardous materials, electrical shock, violence, etc. Thus, questioning the caller serves to establish what the appropriate level of response should be to address the patient's medical condition and to provide for the safety of responding rescuers. The MPDS carefully directs the EMD to determine the presence of scene hazards based on the patient's presenting conditions and other indicators to determine the existence of hazards. For example, the MPDS' chief complaint card #15 "Electrocution" questions the caller regarding:

1. Where is s/he [patient] now?

2. Is s/he disconnected from the power?

3. Has the power been turned off?

However, without compliance to the protocol key information may be missed in the initial caller interrogation. Assuring compliance to the protocol is the only method for insuring that a complete scene safety assessment is conducted. Without this information, the bystander could take the initiative to begin treating the patient without first assessing the safety of the scene. With the right protocol, training and compliance to the protocol, bystanders can safely be used to provide life-saving support.

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EMD ACTIVITY PRIORITIZATION

The ability to safely prioritize EMS responses in communities that have chosen to use the MPDS to more effectively allocate limited resources, ensures the availability of these resources for medical conditions that require short response time and the highest levels of clinical capability. Many systems have identified that minor injuries such as cat bites do not require lights and siren ALS response and may be more appropriately managed by a lower level of system response. In systems with limited resources and nonexistent or extended mutual-aid responses, the use of the MPDS ensures that limited resources are optimized.

In addition to the prioritization of system response, the MPDS prioritizes the actions of the dispatcher and bystanders to ensure that life-threatening conditions are identified and responded to immediately. The "first" first responder, individual(s) having the shortest response time, is the caller who is acting on behalf of the patient. The ability of the EMD to provide life-saving instructions to someone who can provide supportive care is dependent on the identification that a life-threatening condition (i.e., cardiac arrest, choking, respiratory arrest, or emergency childbirth) exists. The MPDS directs the EMD to first perform an initial assessment, similar to the field provider's primary assessment, through "Case Entry" questions. Case Entry questions are design to determine in the first 20 to 30 seconds of the EMD interrogation whether or not a life-threatening condition exists and where the response is needed. The importance of establishing whether or not the caller is conscious and breathing offers the first opportunity to begin dispatch life support (DLS).

In the NAEMSP position paper titled "Emergency Medical Dispatching," the association points out that, "pre-arrival instructions are a mandatory function of each EMD in a medical dispatch center. Such instructions are safe, and in many instances, are a moral necessity." There is a frequently repeated caution that perhaps best illustrates the need to always determine the status of consciousness and breathing: 'Something never looked for is seldom found.' Illustrative of this point is the recent release of a study comparing the MPDS (Derbyshire Ambulance Service ) with criteria-based dispatching (CBD) (Essex Ambulance Service) published in 1996 by the Medical Care Research Unit of the University of Sheffield. While not originally designed to study the importance of compliance to the protocol, some of the study findings shed considerable light on the

topic of compliance to protocol. The following figure best illustrates the issue of protocol compliance and identification of life-threatening conditions.

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SHEFFIELD STUDY

STRATIFIED RANDOM SAMPLE OF 124 CALL TRANSCRIPTS

ESSEX= (CBD) VS. DERBYSHIRE=(AMPDS), UK

Position statements from the NAEMSP and NIH, as well as, published standards by the ASTM further elaborate on the need to have scripted pre-arrival instructions and specialized training in their use. Furthermore, the NAEMSP points out that: "Training as EMDs is required for all dispatchers functioning in medical dispatch agencies[EMD training] contains significant content and competence which differs substantially from that standardly provided to EMTs and paramedics." In addition to the implementation of a medically approved protocol (caller questions, pre-arrival instructions and response determinants) and EMD training, medical dispatch agencies must also implement a quality management process that is consistent with current ASTM Standard F 1560 "Emergency Medical Dispatch Management." The importance of quality management activities that monitor EMD activity, involve medical control, and provide performance feedback to EMDs is described in the ASTM document. The ASTM document points out that: "Since the EMD is now clearly defined as a pre-hospital medical professional, it is necessary to establish sound medical management processes through a multi-component QA/QI program administered by the EMD's agency in conjunction with the physician medical director." EMD protocol and training, as well as, standard operating policies and procedures are not enough to ensure consistent and appropriate use of an EMD system. A comprehensive quality management process that performs regular reviews of performance and provides feedback to EMDs is the only means of minimizing risk from errors and omissions.

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WHAT MAKES THE MPDS PROTOCOL DIFFERENT?

There is a clear distinction between other currently marketed EMD algorithms/protocol and the MPDS protocol. That distinction is the "uniformed protocol" concept and a systems approach to managing EMD activity, which ensures consistent application and verification of EMD compliance to the protocol. Only through predictable use (compliance to protocol) and multiple-site replication can cause and effect relationships be validated. The ability to engage in multiple-site studies, the strongest study design, is only possible through the use of a uniformed protocol, a protocol which is exactly the same in all locations it is used. An analogy exists in the use of the American Heart Association's Advanced Cardiac Life Support (ACLS) protocol. There is only one ACLS protocol to ensure the consistent and most efficacious treatment of cardiac arrest. The "customization" of an EMD protocol and its selective use by dispatchers significantly reduces or eliminates the ability of any organization to externally validate the safety and effectiveness of the protocol.

Although objections are periodically raised regarding the inability of users to "customize" or randomly change the MPDS, it has undergone more than 1000 changes since its inception. The NAEMD, through its "College of Fellows," uses a systematic change process to ensure that changes to the protocol create the desired results relative to outcomes. No other protocol has a comparable body of content experts, which includes more than 40 physicians, legal experts, EMS industry experts, state and federal administrators, educators and opinion leaders to examine and approve protocol changes.

Although the protocol itself is not user "customizable," a characteristic that ensures outcome accountability and stability, the EMS response or referral that occurs as a result of the interrogation is completely user defined. Once the dispatcher interrogation is completed, the acquired data is processed resulting in a recommended "Determinant Code." The user agency pre-assigns a specific system response to each Determinant Code (protocol end point), resulting in a rational assignment of system resources tailored to the specific needs of the patient.

The capture and analysis of communications center activity data, permits the external validation of communications center compliance to the protocol or a standard of practice. Communications center Accreditation by the National Academy of EMD provides external validation of center compliance to ASTM standards and position statements from NHTSA, NAEMSP, NIH and other national agencies and organizations. The growing dependence by managed care organizations and other payor sources on external validation and bench-marking processes substantially increases the value of MPDS, since no other protocol has a process for center accreditation or a process in place for external validation of quality. Implementing the MPDS is the first step toward center accreditation by the NAEMD.

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THE MPDS PROQA SOFTWARE-AND EMD EXPERT SOFTWARE SYSTEM

The MPDS ProQA software is a decision support system that provides the EMD with an advanced caller-interrogation script; raises and nearly guarantees EMD compliance to protocol; time-stamps protocol activation; provides online pre-arrival and post-dispatch instructions; and provides quicker and more appropriate response and referral recommendations. Data gathered throughout the interrogation process is analyzed and output from ProQA to create EMD comparative histories. This data permits a comparison of interrogation process-times between operators; "Determinant Code" histories permit frequency analysis of caller chief complaints by time of day, day of week, month or against all recorded cases; or, data can be exported to other databases for further analysis. No other EMD software product uses a "logic" system that analyzes responses to each of the questions presented by the EMD and produces a recommend response determinant.

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ADVANCED QUALITY ASSURANCE (AQUA) SOFTWARE-MEASURING AND IMPROVING EMD PERFORMANCE

AQUA is a unique public safety software tool created by Medical Priority Consultants and approved by the NAEMD that automates most functions of EMD case review. AQUA simplifies the process of case review, data collection, analyzing and retrieval, while decreasing the time and personnel requirements these efforts take. Through the export of ProQA data files and their input into AQUA, the activities of the EMD are captured and compared to the audio-recording of the case.

AQUA provides quality management staff with the tools to turn raw data into meaningful information on EMD performance. AQUA provides easy to understand information, so training personnel can be kept abreast on areas of needed performance improvement with reports that pin point problems. AQUA provides information that minimizes EMD risk while maximizing service delivery to your customers. AQUA:

• Turns raw data into useful information
• Presents information in understandable format
• Information that improves effectiveness

AQUA's powerful statistical formulas crunch operational data and present it in easy to understand tables and graphs, that enables communications center staff to find and correct performance problems with point and click simplicity. AQUA ensures key staff have enough information to manage change processes that will result in optimal EMD performance improvement. AQUA provides the proof of management commitment to improved performance. AQUA:

• Identifies performance problems
• Provides information needed to successfully manage change processes
• Quantifies efforts to improve performance

Professional managers understand that every activity has inherent risk. The successful ones understand that the trick is managing and reducing risk through continually improving performance. AQUA provides the most effective tool set for reducing risk and improving service delivery by ensuring control over the quality of the service delivered. All names, dispatcher ID numbers, topics and hours are easily entered and cumulative totals simply retrieved. The requirements for successful two-year EMD recertification are kept active and easily accessible. This feature keeps managers and supervisors free of the excessive paperwork often required to maintain certification records of dozens of EMDs in the average center.

AQUA's Powerful Statistical Package

The Medical Dispatch Case Review Template presents compliance data in the format required by the National Academy of EMD for Accreditation as a center of excellence. This report presents performance information in the traditional check sheet presentation that that your EMDs may be already familiar with and thus eases the transition to the AQUA reporting system. EMDs and quality management personnel can quickly review performance data in this report.

AQUA's Protocol Compliance Report is a summary report that presents the average compliance to protocol performance scores for the communication center by: the entire center as a whole, or shift, or individual in each of the six compliance categories (Case Entry, Key Questions, PAI Compliance, PDI Compliance, Chief Complaint, Final Coding, Total Average Compliance). A quick review of the results in effortless identification of top-and bottom-performers or EMDs who fall below established lower control limits.

AQUA's Evaluation Record is a permanent record of EMD activity on each reviewed case. Case entry along with all possible key questions, post dispatch instructions and pre-arrival instructions are listed with the corresponding findings of the case reviewer regarding the EMD's performance. Compliance to protocol scoring is subtotaled for each section and highlighted for quick reference to problem areas, with amble room for written reviewer comments.

AQUA's Determinant Drift Report presents a graphical view of the impact of EMD compliance to protocol by reporting incidents of over-and under-response. Within minutes you know how well your center is meeting the needs of its customers (callers and responders). Just as under-response (sending an Alpha response when it should have been Delta) puts patient's at risk, an over-response puts responders needlessly at risk. Meeting the goal of 100 percent ideal response optimizes system resources.

AQUA's Noncompliance reports demand immediate attention by requiring input from reviewer and dispatcher, minimizing risk of litigation associated with management inaction/action. This report succinctly describes the process and required action needed from each participant in the quality management process, thus meeting or exceeding all risk management requirements.

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ANTICIPATING CHANGING DEMANDS AND EXPECTATIONS ON 911

As managed care organizations continue to reengineer healthcare through the realignment of economic incentives and delivery system design, MPC in concert with the NAEMD has created and is actively developing products and services that have and will continue to constitute the foundation of "access management" system solutions. These products and services are essential for the safe and successful operation of access management activities from 911/EMS communications centers and medical call centers. MPC recognizes that each mode of operation poses unique challenges to management, with respect to caller needs and center missions.

Medical Priority Consultant's process for creating seamless access management solutions consists of a series of strategic alliances with producers of telecommunications and software technology, thus ensuring the highest degree of compatibility, reliability, scalability and affordability. The first component of the referral process begins with the identification of the caller's health plan. Using available technology, the caller's ANI/ALI information can be used to query a membership database that identifies the caller's health plan status. Following the completion of caller/patient interrogation or questioning using the MPDS-Omega ProQA software, a recommended determinant resulting in a response or referral results. If the recommendation is to refer the patient, the information regarding the patient's health plan is used to select the appropriate disposition. In some instances, contract requirements may result in the caller being referred to a medical call center (nurse advice line) that is operated and staffed by the health plan. In other cases, the caller may be referred to an in-house medical call center. In either case, the MPDS-Omega ProQA software, in combination with a nurse-triage algorithm, ensures seamless transfer of the caller with data acquired during the ProQA interrogation, as well as the accurate measurement of system activity and outcomes.

The determinant coding scheme of the MPDS-Omega protocol creates a standardized interface for the seamless referral of callers, not requiring an immediate EMS response, to a nurse triage process or medical call center. The Determinant Code or end-point of the MPDS provides an interface with the medical call center or service bureau. The interrogation of callers, using in-house or off-site nurse triage algorithms, assists in further clarifying caller needs and therefore ensures the assignment of the most appropriate system response.

With more than 18 years of implementation experience and support of the MPDS in government operated 911 centers, as well as private EMS providers, MPC is in an unequaled position to facilitate the implementation and integration of front-end protocols for access management services providers.

The MPDS-Omega ProQA software in conjunction with nurse-triage algorithms creates the optimal combination of sensitivity, specificity and accountability, or quantifiable outcomes in a seamless access management solution.

• Sensitivity ensures that callers with conditions that warrant an immediate response do not "fall through the cracks" or have the delivery of medical care inappropriately delayed.
• Specificity ensures the ability to succinctly define the nature of the medical complaint or member service need.
• Accountability, or the ability to quantify outcomes, permits the protocol user to study the ability of the protocol to aid in the determination of the most appropriate system response and permits external validation of the process.

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FLEXIBILITY IN SOLUTION DESIGN

The configuration of MPDS-Omega access management solutions can be structured to accommodate a variety of health care delivery system needs. Some examples include:

• Multiple 911 center (front-end/EMD) handoff to a regional medical call center (back-end/nurse triage algorithm)
• Combined 911 /medical call center (front-end/EMD and back-end/nurse-triage algorithm)
• Single or multiple 911 center (front-end/EMD) handoff to multiple medical call centers (back-end/triage-nurse algorithm)
• Combined 911/medical call center handoff to membership medical call center

To ensure consistent and medically prudent management of caller/customers, access management systems must install and maintain a comprehensive quality management (QM) infrastructure. MPC has developed and implements QM structures as an integral part of the comprehensive implementation of the MPDS. The MPDS is a systems approach to EMD that includes a fully integrated QM process that is unequaled in its ability to provide statistical data regarding system and user activity. In combination, the MPDS QM process, ProQA and AQUA (Advance Quality Assurance) software provide users and managed care customers with levels of accountability unattainable by competitors. The MPDS-Omega protocol in combination with medical call center technology stands alone in its ability to ensure the safe and efficient management of all callers to 911.

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CONCLUSION

The Medical Priority Dispatch System is the most advanced medically managed EMD system available today. Its installation and consistent use ensures each 911 caller will receive a professional and complete assessment, resulting an optimal system response. No other EMD program (training and algorithm/protocol) offers a comparable systems approach to the delivery of EMD. No other EMD program offers the strength and backing of the National Academy of EMD, with more than 27,000 members and 2,300 agencies. No other EMD program can offer the connectivity and safety that will be necessary to effectively work within future managed care environments.

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