search terms: Pre-Arrival Instructions (PAIs); Medical Priority Dispatch System (MPDS); the need to increase dispatcher coverage when implementing the MPDS; interrogation time; call processing time; critical (time/life priority) cases; short response times; Dispatch Life Support; Primary (Entry protocol) Survey; Secondary (Key Questions) Survey; importance of following a standard protocol at dispatch; inappropriate and unnecessary PAIs; average response times; "zero minute response time"; patient access time; standard of care.

EMERGENCY MEDICAL DISPATCH!
The Official Journal of the National Academy of EMD
Vol. 3, No. 1 Spring 1992

From the President's Desk:
Jeff J. Clawson, M.D. President, NAEMD

"Isn't the AMPDS an unnecessary burden?"

N ot long ago, a representative from a large EMS agency in California asked me a poignant question. It went something like, "our urban response times average under five minutes, so why do we need to provide Pre-Arrival Instructions? Additionally, if we adopt the MPDS, won’t we have to hire more dispatchers to cover the increased time they will be spending on the phone?" In essence, I was being asked, "why does any agency need the MPDS? Doesn't it just add an additional and unnecessary burden on our dispatchers?" I consider this an intriguing question, the answer to which I feel should be shared with the entire body of NAEMD-certified dispatchers.

"No dispatch center that I am aware of has ever been forced to increase dispatchers as a result of working the MPDS"

Regarding the need to increase dispatcher coverage when implementing the MPDS, I can say unequivocally that no dispatch center I am aware of has ever been forced to increase dispatchers as a result of implementing the MPDS. Once the MPDS is phased into standard dispatch operations, the provision of PAIs will not add an extra time burden to the dispatchers. To use the Los Angeles Fire Department as an example, it was proven during their MPDS implementation that the interrogation time actually dropped enough to allow the inclusion of all PAIs, making the new call processing times equal with their pre-existing average of 72 seconds on all calls. Additionally, the time to dispatch on critical (time/life priority) cases like cardiac arrest, choking, etc., was significantly shortened because the MPDS protocol identifies the most important things first and deals with them. In these cases, a maximum response is dispatched before asking questions that verify the need for telephone treatment sequences. The MPDS in my Los Angeles example did not change the call waiting time (in the queue) either. They averaged 7.0 seconds both before and after implementation.

The associated issue of "short response times" was one of the questions I had to deal with in the implementation of the MPDS in Salt Lake City over 13 years ago. Both dispatchers and administration initially stated essentially that, "We will be there before PAIs can be performed or have any effect". There are four problems with this logic.

First, the national standard of care now states that "Pre-Arrival Instructions are a mandatory function of each EMD in a medical dispatch center. Standard medically approved telephone instructions by trained EMDs are safe to give and in many instances are a moral necessity" according to the NAEMSP and ASTM (copies of both of these standard documents can be obtained by contacting the NAEMD).

"Dispatch centers in their new-found zeal to 'save choking babies' may sometimes give inappropriate, unnecessary, and even dangerous PAIs before establishing a firm idea of the real problem"

Second, the time of response is somewhat irrelevant regarding the use of the MPDS since the provision of PAIs or Dispatch Life Support of any kind is predicated on the fact that one has to determine which cases require telephone intervention or advice and what exactly is the right thing to tell them. In essence, the MPDS is the Primary (Entry protocol) and Secondary (Key Questions) Survey. Proper assessment is always necessary prior to formulating and then delivering appropriate care. It is extremely important to follow a standard protocol at dispatch. Many dispatch centers, in their new-found zeal to "save choking babies" may sometimes give inappropriate, unnecessary, and even dangerous PAIs before establishing a firm idea of the real problem and even before asking any relevant questions at all. Legally, these people are on thin ice if someone questions their judgement, which is likely since crises and deaths are always fair game for disgruntled citizens.

Thirdly, average response times are just that … "average". For every one under five minutes, there is one over. For every near "still alarm", there is a ten or eleven minute response. This is due to availability, time of day, mechanical difficulties with units, etc. The average and below only insure quick responses to the "average" cases. It is the moral responsibility of any dispatch center to provide a "zero minute response time" to all patients. What happens is a first responder gets stopped by a train on a critical case that would have had a 3.5 minute response. Legally, you wouldn't have a leg to stand on in court with the national standard as well defined and tight as it is today. Remember, when a lawsuit happens it's usually an isolated one-time occurrence, but it's for million-dollar stakes.

"when a lawsuit happens it's usually an isolated one-time occurrence, but it's for million-dollar stakes"

Fourth and finally, response times are often not reflective of the time it takes to actually get help at the patient's side. Patient access time might be 1 to 2 minutes longer than the recorded time due to myriad reasons (i.e., trouble locating the patient, patient some distance from place the unit "went out", etc., etc.). It is wise not to rely heavily on response times as they can give a false sense of security in many situations.

Dispatch is the "jewel upon which the watch of EMS turns." In both its manual flip-card version and now fully automated "ProQA" software, the AMPDS provides a systematic and time-proven standard of care, fully supported and maintained by the NAEMD's College of Fellows. It used to be that dispatch was not observed effectively and that EMS dispatch could be disregarded as an equal to law enforcement and fire dispatching in the same center. This is just not the case anymore. Now that there is a proven, reasonably simple way to be state-of-the-art in medical dispatching, it makes no sense not to do it.