By Geoff Cady, Consultant and EMT-P
TABLE OF CONTENT LINKS
The MPDS An Emergency MedicalDispatch System Design
EMD Activity Prioritization
What Makes the MPDS Protocol Different?
The MPDS ProQA Software an EMDExpert Software System
Advanced Quality Assurance Measuringand Improving EMD Performance
Anticipating Changing Demands and Expectationson 911
Flexibility in Solution Design
Medical Priority Consultants, Inc. and the National Academyof EMD (NAEMD), a nonprofit organization with more than 27,000members and 2,300 agencies, respectfully submits the followingmaterials for review and consideration. We believe that the safeand effective delivery of emergency medical services (EMS) startswith the consistent and professional provision of emergency medicaldispatch. Its delivery through professionally trained emergencymedical dispatchers (EMD) ensures the timely delivery of life-savingand impacting care. The consistent and predictable use of a uniformedmedically managed and supported EMD protocol ensures each 911caller receives EMD that is consistent with current standardsof care. However, it is important to point out that EMD trainingand protocols alone will not guarantee the delivery of this vitalcomponent of the EMS system. Only through EMD compliance to theprotocol and the ability of the communications center administrationto measure and correct EMD performance can the objectives of EMDbe obtained.
The Medical Priority Dispatch System (MPDS), originally developedby Dr. Jeff Clawson and now controlled by the National Academyof EMD, is the most advanced and comprehensive EMD system available.By virtue of its design, the MPDS is unparalleled in its abilityto provide system administrators with complete information onEMD performance as it relates to compliance to the protocol. TheMPDS applies a systems approach to quality management of emergencymedical dispatch activities that exceeds all national standardsand industry position statements. To understand the importanceof adherence to national EMD practice standards as a form of "malpractice"insurance, a quick review of standards and position statementsthat are specific to EMD has been included.
At the inception of EMS, as with many other new professionsand industries that have emerged, there were few, if any, standardsor position statements that established minimum performance expectations.Since that time, however, there has been an effort by many professionalorganizations and academic institutions to establish a body ofinformation regarding acceptable EMD performance. These effortswere directed toward insuring that the public is provided witha minimum level of service that is both safe and effective. Withthese two directives in mind, the American Society for Testingand Materials (ASTM), a voluntary consensus building organization;the National Institute of Health; the National Association ofEmergency Medical Services Physicians (NAEMSP), a professionalassociation of EMS medical directors; and, the National Associationof State Emergency Medical Services Directors (NASEMSD) have publishedstandards and position statements that address EMD and EMS systemdesign, safety and effectiveness.
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The NAEMD's EMD certification course curriculum is maintainedby the Board of Curriculum of the NAEMD. EMD instructors are certifiedthrough a process that consists of attendance and co-instructingat no less than five EMD courses following successful completionand certification as an NAEMD certified EMD. The instructor candidatemust be signed off by an NAEMD "Master Instructor" priorto independent instructing. Each EMD instructor is provided withan instructor manual and NAEMD maintained training materials.The NAEMD requires attendance at its instructor update at leastonce every two years to ensure instructors remain up-to-date onthe EMD curriculum. All instructors receive feedback through courseevaluations and through other sources of direct observation. TheNAEMD believes that instructor competency is key to the appropriateand consistent use of the MPDS.
EMD certification course attendees will learn how to handledifficult callers, identify the correct chief complaint, assignappropriate resources, effectively communicate between respondersand callers and provide life-saving support. EMD certificationoccurs following the completion of 24 hours of training, CPR certificationand obtaining a passing score on the final exam. Course contentsconsist of:
EMD: The science of prioritized dispatch
Course attendees are provided with an overview of basic telecommunicationsskills and activities, history of EMD (and some of the misconceptions),and the EMDs duties and responsibilities in today's telecommunicationsenvironment.
Ethical and medical-legal: The shaping of modern EMD
Attendees are presented with the ethical and medical-legalissues that have shape EMD. Issues related to the developmentof an EMD standard of care are reviewed and their subsequent incorporationinto the MPDS protocol. Participants are presented with informationon the risks of an inadequate understanding of EMD and where the"EMD danger zones exist."
Dispatch life-support: The "zero minute" responsetime
Attendees are taught the skills that will enable them to takecontrol of the call, effectively interrogate the caller , andprovide life-saving instructions. They are provided with insightsinto how to anticipate and respond to predictable caller behavior.Attendees are then presented a series of actual cases that illustratethe techniques previously discussed.
MPDS protocols: Principles of operation
Attendees are presented with specific information regardinghow the MPDS protocol is designed to assist them in making betterdecisions. From case entry to top case completion, attendees areprovided with step-by-step instruction regarding the use of theMPDS. Information regarding remote patient access, resource assignment,and providing responder assistance is all discussed. The day finisheswith MPDS hands-on practice using scenario drills.
Instructed practice: Learn by doing and reviewing
Attendees continue to drill using the protocol in small groupswith one-on-one instructor review. Each call type is walked throughby the attendees, from time-life priority situations needing dispatchlife support, to multiple patient calls.
Course conclusion: Preparing for certification
Attendees have an opportunity to review and question the instructorabout any aspect of the previous three days of training beforetaking the certification test. Final results of the test are processedby the NAEMD, who mails the results with Certification documentsand 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 theoperation of EMD while optimizing safe and effective patient carethrough dispatch life support and EMS system response. The MPDSprotocol uses a system of interrogation and time-life symptomdetermination that enables the EMD to prioritize system responseaccording to user-defined response configurations. Its uniquedesign results in:
While the most visible features of an EMD system is its abilityto identify the need for pre-arrival instruction and prioritizean EMS response, the MPDS protocol's ability to assist the EMDin identifying safety issues is often overlooked. The safety andcare of the patient, bystanders and responding rescuers are essentialto maintaining the "Do no harm" doctrine in medicine.The first responder and transportation safety issue is relatedto the use of lights and sirens and the inherent risk associatedwith 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 andbystanders. In order to minimize the risk of EMVCs to bystandersand EMS responders, ASTM Standard F 1258-95, Subsection 18.104.22.168(a)states that the EMD process "Adequately establish the correctlevel of [EMS] response."
Other safety issues that must be addressed in an emergencymedical dispatch protocol include questions regarding the presenceof scene hazards such hazardous materials, electrical shock, violence,etc. Thus, questioning the caller serves to establish what theappropriate level of response should be to address the patient'smedical condition and to provide for the safety of respondingrescuers. The MPDS carefully directs the EMD to determine thepresence of scene hazards based on the patient's presenting conditionsand other indicators to determine the existence of hazards. Forexample, 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 informationmay be missed in the initial caller interrogation. Assuring complianceto the protocol is the only method for insuring that a completescene safety assessment is conducted. Without this information,the bystander could take the initiative to begin treating thepatient without first assessing the safety of the scene. Withthe right protocol, training and compliance to the protocol, bystanderscan safely be used to provide life-saving support.
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The ability to safely prioritize EMS responses in communitiesthat have chosen to use the MPDS to more effectively allocatelimited resources, ensures the availability of these resourcesfor medical conditions that require short response time and thehighest levels of clinical capability. Many systems have identifiedthat minor injuries such as cat bites do not require lights andsiren ALS response and may be more appropriately managed by alower level of system response. In systems with limited resourcesand nonexistent or extended mutual-aid responses, the use of theMPDS ensures that limited resources are optimized.
In addition to the prioritization of system response, the MPDSprioritizes the actions of the dispatcher and bystanders to ensurethat life-threatening conditions are identified and respondedto immediately. The "first" first responder, individual(s)having the shortest response time, is the caller who is actingon behalf of the patient. The ability of the EMD to provide life-savinginstructions to someone who can provide supportive care is dependenton 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 "CaseEntry" questions. Case Entry questions are design to determinein the first 20 to 30 seconds of the EMD interrogation whetheror not a life-threatening condition exists and where the responseis needed. The importance of establishing whether or not the calleris conscious and breathing offers the first opportunity to begindispatch life support (DLS).
In the NAEMSP position paper titled "Emergency MedicalDispatching," the association points out that, "pre-arrivalinstructions are a mandatory function of each EMD in a medicaldispatch center. Such instructions are safe, and in many instances,are a moral necessity." There is a frequently repeated cautionthat perhaps best illustrates the need to always determine thestatus of consciousness and breathing: 'Something never lookedfor is seldom found.' Illustrative of this point is the recentrelease 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 Universityof Sheffield. While not originally designed to study the importanceof compliance to the protocol, some of the study findings shedconsiderable light on the
topic of compliance to protocol. The following figure bestillustrates the issue of protocol compliance and identificationof life-threatening conditions.
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STRATIFIED RANDOM SAMPLE OF 124 CALL TRANSCRIPTS
ESSEX= (CBD) VS. DERBYSHIRE=(AMPDS), UK
Position statements from the NAEMSP and NIH, as well as, publishedstandards by the ASTM further elaborate on the need to have scriptedpre-arrival instructions and specialized training in their use.Furthermore, the NAEMSP points out that: "Training as EMDsis required for all dispatchers functioning in medical dispatchagencies[EMD training] contains significant content and competencewhich differs substantially from that standardly provided to EMTsand paramedics." In addition to the implementation of a medicallyapproved protocol (caller questions, pre-arrival instructionsand response determinants) and EMD training, medical dispatchagencies must also implement a quality management process thatis consistent with current ASTM Standard F 1560 "EmergencyMedical Dispatch Management." The importance of quality managementactivities that monitor EMD activity, involve medical control,and provide performance feedback to EMDs is described in the ASTMdocument. The ASTM document points out that: "Since the EMDis now clearly defined as a pre-hospital medical professional,it is necessary to establish sound medical management processesthrough a multi-component QA/QI program administered by the EMD'sagency in conjunction with the physician medical director."EMD protocol and training, as well as, standard operating policiesand procedures are not enough to ensure consistent and appropriateuse of an EMD system. A comprehensive quality management processthat performs regular reviews of performance and provides feedbackto EMDs is the only means of minimizing risk from errors and omissions.
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WHAT MAKESTHE MPDS PROTOCOL DIFFERENT?
There is a clear distinction between other currently marketedEMD algorithms/protocol and the MPDS protocol. That distinctionis the "uniformed protocol" concept and a systems approachto managing EMD activity, which ensures consistent applicationand verification of EMD compliance to the protocol. Only throughpredictable use (compliance to protocol) and multiple-site replicationcan cause and effect relationships be validated. The ability toengage in multiple-site studies, the strongest study design, isonly possible through the use of a uniformed protocol, a protocolwhich is exactly the same in all locations it is used. An analogyexists in the use of the American Heart Association's AdvancedCardiac Life Support (ACLS) protocol. There is only one ACLS protocolto ensure the consistent and most efficacious treatment of cardiacarrest. The "customization" of an EMD protocol and itsselective use by dispatchers significantly reduces or eliminatesthe ability of any organization to externally validate the safetyand effectiveness of the protocol.
Although objections are periodically raised regarding the inabilityof users to "customize" or randomly change the MPDS,it has undergone more than 1000 changes since its inception. TheNAEMD, through its "College of Fellows," uses a systematicchange process to ensure that changes to the protocol create thedesired results relative to outcomes. No other protocol has acomparable body of content experts, which includes more than 40physicians, legal experts, EMS industry experts, state and federaladministrators, educators and opinion leaders to examine and approveprotocol 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 interrogationis completely user defined. Once the dispatcher interrogationis completed, the acquired data is processed resulting in a recommended"Determinant Code." The user agency pre-assigns a specificsystem response to each Determinant Code (protocol end point),resulting in a rational assignment of system resources tailoredto the specific needs of the patient.
The capture and analysis of communications center activitydata, permits the external validation of communications centercompliance to the protocol or a standard of practice. Communicationscenter Accreditation by the National Academy of EMD provides externalvalidation of center compliance to ASTM standards and positionstatements from NHTSA, NAEMSP, NIH and other national agenciesand organizations. The growing dependence by managed care organizationsand other payor sources on external validation and bench-markingprocesses substantially increases the value of MPDS, since noother protocol has a process for center accreditation or a processin place for external validation of quality. Implementing theMPDS is the first step toward center accreditation by the NAEMD.
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THE MPDSPROQA SOFTWARE-AND EMD EXPERT SOFTWARE SYSTEM
The MPDS ProQA software is a decision support system that providesthe EMD with an advanced caller-interrogation script; raises andnearly guarantees EMD compliance to protocol; time-stamps protocolactivation; provides online pre-arrival and post-dispatch instructions;and provides quicker and more appropriate response and referralrecommendations. Data gathered throughout the interrogation processis analyzed and output from ProQA to create EMD comparative histories.This data permits a comparison of interrogation process-timesbetween operators; "Determinant Code" histories permitfrequency analysis of caller chief complaints by time of day,day of week, month or against all recorded cases; or, data canbe exported to other databases for further analysis. No otherEMD software product uses a "logic" system that analyzesresponses to each of the questions presented by the EMD and producesa recommend response determinant.
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ADVANCEDQUALITY ASSURANCE (AQUA) SOFTWARE-MEASURING AND IMPROVING EMDPERFORMANCE
AQUA is a unique public safety software tool created by MedicalPriority Consultants and approved by the NAEMD that automatesmost functions of EMD case review. AQUA simplifies the processof case review, data collection, analyzing and retrieval, whiledecreasing 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-recordingof the case.
AQUA provides quality management staff with the tools to turnraw data into meaningful information on EMD performance.AQUA provides easy to understand information, so trainingpersonnel can be kept abreast on areas of needed performance improvementwith reports that pin point problems. AQUA provides informationthat minimizes EMD risk while maximizing service delivery to yourcustomers. AQUA:
AQUA's powerful statistical formulas crunch operational dataand present it in easy to understand tables and graphs, that enablescommunications center staff to find and correct performance problemswith point and click simplicity. AQUA ensures key staff have enoughinformation to manage change processes that will result in optimalEMD performance improvement. AQUA provides the proof of managementcommitment to improved performance. AQUA:
Professional managers understand that every activity has inherentrisk. The successful ones understand that the trick is managingand reducing risk through continually improving performance. AQUAprovides the most effective tool set for reducing risk and improvingservice delivery by ensuring control over the quality of the servicedelivered. All names, dispatcher ID numbers, topics and hoursare easily entered and cumulative totals simply retrieved. Therequirements for successful two-year EMD recertification are keptactive and easily accessible. This feature keeps managers andsupervisors free of the excessive paperwork often required tomaintain certification records of dozens of EMDs in the averagecenter.
AQUA's Powerful Statistical Package
The Medical Dispatch Case Review Template presents compliancedata in the format required by the National Academy of EMD forAccreditation as a center of excellence. This report presentsperformance information in the traditional check sheet presentationthat that your EMDs may be already familiar with and thus easesthe transition to the AQUA reporting system. EMDs and qualitymanagement personnel can quickly review performance data in thisreport.
AQUA's Protocol Compliance Report is a summary reportthat presents the average compliance to protocol performance scoresfor 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, ChiefComplaint, Final Coding, Total Average Compliance). A quick reviewof the results in effortless identification of top-and bottom-performersor EMDs who fall below established lower control limits.
AQUA's Evaluation Record is a permanent record of EMDactivity on each reviewed case. Case entry along with all possiblekey questions, post dispatch instructions and pre-arrival instructionsare listed with the corresponding findings of the case reviewerregarding the EMD's performance. Compliance to protocol scoringis subtotaled for each section and highlighted for quick referenceto problem areas, with amble room for written reviewer comments.
AQUA's Determinant Drift Report presents a graphicalview of the impact of EMD compliance to protocol by reportingincidents of over-and under-response. Within minutes you knowhow well your center is meeting the needs of its customers (callersand responders). Just as under-response (sending an Alpha responsewhen it should have been Delta) puts patient's at risk, an over-responseputs responders needlessly at risk. Meeting the goal of 100 percentideal response optimizes system resources.
AQUA's Noncompliance reports demand immediate attentionby requiring input from reviewer and dispatcher, minimizing riskof litigation associated with management inaction/action. Thisreport succinctly describes the process and required action neededfrom each participant in the quality management process, thusmeeting or exceeding all risk management requirements.
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ANTICIPATINGCHANGING DEMANDS AND EXPECTATIONS ON 911
As managed care organizations continue to reengineer healthcarethrough the realignment of economic incentives and delivery systemdesign, MPC in concert with the NAEMD has created and is activelydeveloping products and services that have and will continue toconstitute the foundation of "access management" systemsolutions. These products and services are essential for the safeand successful operation of access management activities from911/EMS communications centers and medical call centers. MPC recognizesthat each mode of operation poses unique challenges to management,with respect to caller needs and center missions.
Medical Priority Consultant's process for creating seamlessaccess management solutions consists of a series of strategicalliances with producers of telecommunications and software technology,thus ensuring the highest degree of compatibility, reliability,scalability and affordability. The first component of the referralprocess begins with the identification of the caller's healthplan. Using available technology, the caller's ANI/ALI informationcan be used to query a membership database that identifies thecaller's health plan status. Following the completion of caller/patientinterrogation or questioning using the MPDS-Omega ProQAsoftware, a recommended determinant resulting in a response orreferral results. If the recommendation is to refer the patient,the information regarding the patient's health plan is used toselect the appropriate disposition. In some instances, contractrequirements may result in the caller being referred to a medicalcall center (nurse advice line) that is operated and staffed bythe health plan. In other cases, the caller may be referred toan in-house medical call center. In either case, the MPDS-OmegaProQA software, in combination with a nurse-triage algorithm,ensures seamless transfer of the caller with data acquired duringthe ProQA interrogation, as well as the accurate measurement ofsystem activity and outcomes.
The determinant coding scheme of the MPDS-Omega protocol createsa standardized interface for the seamless referral of callers,not requiring an immediate EMS response, to a nurse triage processor medical call center. The Determinant Code or end-point of theMPDS provides an interface with the medical call center or servicebureau. The interrogation of callers, using in-house or off-sitenurse triage algorithms, assists in further clarifying callerneeds and therefore ensures the assignment of the most appropriatesystem response.
With more than 18 years of implementation experience and supportof the MPDS in government operated 911 centers, as well as privateEMS providers, MPC is in an unequaled position to facilitate theimplementation and integration of front-end protocols for accessmanagement services providers.
The MPDS-Omega ProQA software in conjunction with nurse-triagealgorithms creates the optimal combination of sensitivity,specificity and accountability, or quantifiableoutcomes in a seamless access management solution.
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FLEXIBILITYIN SOLUTION DESIGN
The configuration of MPDS-Omega access management solutionscan be structured to accommodate a variety of health care deliverysystem needs. Some examples include:
To ensure consistent and medically prudent management of caller/customers,access management systems must install and maintain a comprehensivequality management (QM) infrastructure. MPC has developed andimplements QM structures as an integral part of the comprehensiveimplementation of the MPDS. The MPDS is a systems approach toEMD that includes a fully integrated QM process that is unequaledin its ability to provide statistical data regarding system anduser activity. In combination, the MPDS QM process, ProQA andAQUA (Advance Quality Assurance) software provide users and managedcare customers with levels of accountability unattainable by competitors.The MPDS-Omega protocol in combination with medical call centertechnology stands alone in its ability to ensure the safe andefficient management of all callers to 911.
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The Medical Priority Dispatch System is the most advanced medicallymanaged EMD system available today. Its installation and consistentuse ensures each 911 caller will receive a professional and completeassessment, resulting an optimal system response. No other EMDprogram (training and algorithm/protocol) offers a comparablesystems approach to the delivery of EMD. No other EMD programoffers the strength and backing of the National Academy of EMD,with more than 27,000 members and 2,300 agencies. No other EMDprogram can offer the connectivity and safety that will be necessaryto effectively work within future managed care environments.
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® Copyright, 1999 MPC, Salt Lake City,Utah, 84111 USA. All rights reserved