Search terms: Capability of the current EMD system to meet the needs of children No need for a specific pediatric dispatch card set The greatest needs for further improvement of the Nation's EMD system The barriers to further development of the Nation's EMD system Necessity of ongoing commitment to continuous quality improvement, research, and training Limitations in the effectiveness of EMD across the country by variations in local implementation Criticality of a comprehensive EMD system that conforms to national consensus standards

EMERGENCY MEDICAL DISPATCH FOR CHILDREN WHERE ARE WE AND WHERE DO WE GO?

O n June 16-17, 1998 a distinguished panel of Emergency Medical Dispatch (EMD) experts met in Washington, D.C. to discuss emergency medical dispatch for children. The meeting was jointly sponsored by the Emergency Medical Services for Children Program of the Health Resources and Services Administration (HRSA), the National Highway Traffic Safety Administration (NHTSA), and the Georgia Department of Human Resources, Office of Emergency Medical Services. The purpose of the gathering was to solicit expert opinion on the current status of EMD for children and directions for further development.

Objectives The objective of this meeting was to consolidate the experiences of a number of nationally recognized EMD experts, together with data from a recent survey conducted by the Georgia Office of EMS, to address a number of questions about the ability of the nation's EMD system to respond to the needs of children. Specifically, the questions posed to the group included:

  • Is our current EMD system capable of responding appropriately to 9-1-1 calls made by children and 9-1-1 calls about a sick or injured child?
  • Is there a need for a specific pediatric dispatch card set?
  • What are the greatest needs for further improvement of the nation's EMD system?
  • What are the barriers to further development of the EMD system?

The Experts The panel of EMD experts included pediatric emergency physicians, EMD educators, producers of EMD programs and card sets, representatives of the American Society for Testing and Materials, members of the National Academy of Emergency Medical Dispatch, and Federal and state program representatives.

Background and Significance Organized emergency medical dispatch is a recent phenomenon in the United States. Twenty years ago less than 20 percent of the nation's population was covered by the emergency access system that we take for granted today -- the 9-1-1 system. Today, nearly 90 percent of the nation is covered by this life-saving link to emergency care. And over these 20 years, our emergency access and dispatch system has grown as much in sophistication as it has in coverage. HRSA and NHTSA recognize that access and dispatch are the first links in the chain of emergency response and that the strength of our EMS system is dependent on rapid access to a skilled emergency medical dispatcher. This is especially true in responding to emergencies involving children, where special accommodations and skills may be needed to prevent or reduce a tragedy.

One of the first steps toward national recognition of the criticality of EMD was the development of a dispatcher training program for emergency medical technicians in 1976 by NHTSA. This was revised in 1983 and published as the Emergency Medical Dispatch: National Standard Curriculum.1 During this same period, cities such as Phoenix, Arizona and Salt Lake City, Utah, began to develop structured protocol systems for providing pre-arrival information to callers requesting emergency medical assistance. The field grew rapidly in the early 1980s and in many locales, emergency medical services, and specifically emergency medical dispatch, joined fire and police services in the 9-1-1 public safety program.

The national consistency provided by the NHTSA Emergency Medical Dispatch: National Standard Curriculum was augmented in 1994 by the introduction of the American Society for Testing and Materials (ASTM) national standard for EMD programs. These standards were the product of the ASTM Committee on Emergency Medical Services (ASTM Committee F-30).2

Medical protocols were introduced to the EMD system early in its development. These commonly took the form of a structured set of reference cards for the dispatcher. Several proprietary card sets have been developed, addressing the 32 commonly occurring complaints identified in the Emergency Medical Dispatch: National Standards Curriculum. In addition, local systems have developed and employed additional protocols to meet local needs.

Survey on Pediatric Emergency Medical Dispatch With support from the HRSA Emergency Medical Services for Children (EMSC) program, the Georgia Office of EMS conducted a national survey of public service emergency communications directors to learn more about the current status of pediatric EMD.

This survey was conducted in 1997 to provide basic information about the perceptions of local system administrators concerning their capability to respond to pediatric emergencies. The surveys were sent to the Emergency Medical Services Director in each state and achieved a 50 percent response rate, with 25 of the 50 states completing the survey instrument. The survey contained four statements about the comfort level of communications officers in responding to calls from or concerning children:

  • Agencies in 17 of 25 states (68%) "Strongly Agreed" or "Agreed" that their communications officers were comfortable dealing with adults calling for medical help concerning adult patients.
  • Agencies in 17 of 25 states (68%) also "Strongly Agreed" or "Agreed" that their communications officers were comfortable dealing with adults calling for medical help concerning child patients.
  • Four agencies "Strongly Agreed" and 10 "Agreed" (56%) that their communications officers were comfortable dealing with children calling for medical help concerning adult patients.
  • Agencies in 10 states "Strongly Agreed" or "Agreed" (40%) that their communications officers would feel comfortable dealing with children calling for medical help concerning child patients.

A majority of respondents also agreed with the following statements:

"A pediatric dispatch system designed to assist communications officers with injured or ill children in need of medical assistance would be of value to (their) system."

"A pediatric dispatch system designed to assist communications officers with child callers needing help for themselves or others would be of value to (their) system."

These findings suggest that while administrators feel that their communications officers are comfortable dealing with adult callers, they feel that their officers are much less comfortable when dealing with child callers. The cause of this concern appears to be centered not on the age of the emergent victim, but on the age the caller. Not surprisingly, respondents also felt that technical assistance would be useful both for improving skills in handling cases involving pediatric victims, and for developing greater competence in handling child callers.

Expert Considerations and Recommendations

Is our current EMD system capable of responding appropriately to 9-1-1 calls made by children and 9-1-1 calls about a sick or injured child?

Expert Opinion: Consistent with the findings of the pediatric dispatch survey, the expert panel generally felt that the current system is adequately addressing the special dispatch needs related to children. The group emphatically recognized the criticality of accommodating the needs of children, citing a recent unpublished study by New York University Medical Center which focuses on the role of EMD on the outcomes of pediatric patients and includes information on the influence of EMD on system resource utilization.

Specific comments from the group included:

"No one has been able to identify a pediatric problem to fix: EMD is working for children."

"I am not aware of a problem with the card sets, a pediatric-related inadequacy with them, or changes that would better facilitate pediatric care."

"We have heard nothing so far to suggest that there is a problem with the way EMD functions for children, no data, no stories, not even innuendo."

While expressing some confidence that the current system appears to adequately address the needs of children, the expert panel also stressed that continuous improvement in this area is critical. The panel also recommended that research be conducted to further assess the efficacy of pediatric EMD and offered a commitment to examine any evidence of problems that might arise.

Is there a need for a specific pediatric dispatch card set?

Expert Opinion: The question of the need for a specific pediatric dispatch card elicited a strong response from the expert panel. The experts generally believed that the currently available card sets covering 32 common medical complaints are adequately meeting pediatric needs.

The panel felt that ongoing refinement of the protocol is necessary, and one expert pointed out that there have been 12 revisions to the National Academy of Emergency Medical Dispatch (NAEMD) protocols over the past 19 years to keep them current with state-of-the-art practice.3 However, the group felt that developing an additional set of cards without specific evidence of need, might unnecessarily complicate the protocols and result in a net negative effect on system performance. The panel also expressed a willingness to consider change or the addition of specific pediatric cards if any problems with EMD for children are identified.

What are the greatest needs for further improvement of the Nation's EMD system?

Expert Opinion: The expert panel identified two priority needs for further improvement of the EMD system. These relate to the consistency of local adherence to established protocols and the utilization of a continuous quality improvement program. The group pointed out that national standards have been developed to identify the essential elements of an effective EMD system. The ASTM Standard for EMD Management is explicit in calling for:

"…a comprehensive plan for managing the quality of care in the emergency medical dispatch system (that) must include careful planning, EMD program selection, proper system implementation, employee selection, training, certification, QA/QI, performance evaluation, continuing dispatch education, re-certification, and risk management activities…"4

The experts stressed that the overall quality of the national EMD system is dependent on the manner and degree to which these voluntary standards are implemented across the nation. Panelists felt that current implementation is highly variable. It was the observation of one participant that as few as 10 percent of EMD systems are fully and rigorously adhering to all EMD policies, practices, procedures, and protocols, and have a continuous quality improvement system in place that actively monitors and assesses a statistically significant percentage of EMD calls.

What are the barriers to further development of the EMD system?

Expert Opinion: The expert panel felt that one of the most serious barriers to further progress in EMD is a widespread assumption that strict adherence to standards is unnecessary. That is, system administrators and the communities they serve may believe that because they have adopted some of the elements of the EMD standard, they have adequately addressed this part of their system. Panelists felt that this false confidence may be preventing many system administrators from allocating sufficient attention and resources to EMD. The experts stressed that system administrators and the public need to be reminded of the importance of a comprehensive EMD system that adheres to the consensus-developed protocols and includes an effective continuous quality improvement program.

Another area for improvement identified by the expert panel is EMD training. The panel felt that while the Emergency Medical Dispatch: National Standard Curriculum has been widely accepted as the basic EMD training standard, its local application is variable. The experts felt that, in general, more attention needs to be directed at EMD training nationwide, and further, that the most appropriate way to identify specific local training needs is through an effective continuous quality improvement program.

Specific comments from the group included:

"Training and the purchase of cards are little more than events in the life of communications and dispatch."

"If you do not have a Q1 program in place assessing 3-5 percent of calls, you are not adhering to protocol. Not only must you create the protocol, you must see that it is followed."

1Emergency Medical Dispatch: National Standard Curriculum: Government Printing Office

2Annual Book of ASTM Standards, Vol 13.01

3Medical Priority Dispatch System, 10.3, Salt Lake City, Utah

4Annual Book Of ASTM Standards, Vol 13.01, F1560-94

Summary The expert panel gathered to provide insights on the current status of EMD for children and directions for further development of EMD. The panel offered the following observations and recommendations:

The expert panel believes that in general, the EMD system now in place across the country is meeting the needs of children.

  • The panel recommends that maintaining adequate coverage for children and the community at-large will require an ongoing commitment to continuous quality improvement, research, and training.
  • Based on available evidence, the panel does not believe that a specific pediatric dispatch card set is needed or appropriate.
  • The panel believes that further research and continuous quality improvement is needed to determine if any problems with EMD for children might exist. The panel recommends that any evidence of problems be thoroughly addressed.
  • The expert panel believes that the effectiveness of EMD across the nation is currently limited by variation in local implementation. The panel recommends that system administrators and the public be reminded of the criticality of a comprehensive EMD system, that conforms to national consensus standards.
  • The panel recommends that local systems implement effective continuous quality improvement programs to identify performance problems, training needs, and areas for system refinement.
  • The panel recommends that EMD training be more consistently implemented across the country.

Consensus Statement A consensus position statement was prepared by the expert panel. The statement sets the stage for important and continued work that the panel believes needs to be pursued to maintain and improve the quality of the national EMD system.

We believe that appropriate emergency care for the Nation's children should be among the highest priority of those issues currently affecting our public safety medical dispatch systems. A major threat to children (and indeed to all 9-1-1 emergency callers) is the failure of public safety communications centers to implement and utilize medically approved, standardized protocols that clearly delineate the evaluation, dispatch services, information, and pre-arrival instructions provided to callers. This means that compliance to these protocols should be enforced. Only with continuous evaluative case review of EMD performance in dealing with children both as callers and patients will the definitive issues regarding children's special health needs and treatment issues be better understood and dealt with by medical dispatch protocol and training standards organizations.

The content of the protocols can only be assessed when correctly used and when cases are carefully monitored and evaluated by qualified medical personnel. This information is vital to determine whether the current content of these protocols meets the needs of the Nation's children. The content of these protocols must be reviewed by expertly staffed standards groups that contain public safety experts and physicians with medical dispatch expertise, including pediatricians. Local and untested modification of protocols should be discouraged, as the complexity of the protocols is often significantly underestimated. Medical dispatch organizations should be encouraged to place children's needs and priorities high on the list of ongoing concerns within their standards groups.

Public safety communications has long been understood to be a special hybrid between the medical community and the public safety establishment. The control of these dispatch pre-arrival systems is predominantly within the public safety arena. The medical control responsibility within EMD systems has been clearly identified as residing within the medical physician's realm. This dichotomy creates many of the traditional road blocks to assuring that individual EMD programs are functioning in a safe, efficient, and effective manner. Public safety management in concert with medical oversight physicians groups must embrace total quality management practices with adequate numbers of quality assurance case reviews as the core of this performance evaluation system.

Research support should be provided by appropriate governmental divisions, managed care organizations, or other funding sources to facilitate careful examination of issues facing children as prehospital patients. Emergency medical dispatch is a critical element of the emergency medical services system. Health and safety professionals, together with community members and children's advocates, must continue to work to ensure that our emergency medical dispatch system is providing the best possible care for our children.

Participants Jean Athey, Ph.D. Director Emergency Medical Services for Children; Charles D. Carter Executive Director National Communications Institute (NCI); Jennifer Clarke Communications Specialist Georgia EMS for Children Office of EMS and Injury Prevention; Jeff Clawson, MD National Academy of Emergency Medical Dispatch; Captain Garry Criddle, R.N. EMS Specialist National Highway Traffic Safety Administration; Ej Dailey Project Coordinator Georgia EMS for Children Office of EMS and Injury Prevention; Captain Brian Dale Salt Lake City Fire Department & National Academy of Emergency Medical Dispatch; David H. Fagin, MD Director, Emergency Medicine Emergency Department; Scottish Rite Children's Medical Center; Chuck Glass EMD Consultant American Society for Testing and Materials; Leigh Haislip EMD Consultant; Patrick Lanzetta, MD Medical Director PowerPhone, Inc.; Patty Maher EMD Program Manager APCO; Paul Rasch Manager Training and Development PowerPhone, Inc.; Paul Roman EMD Consultant American Society for Testing and Materials; Michael G. Tunik, MD Assistant Professor of Clinical Pediatrics Bellevue Hospital Center; Carl VanCott Office of EMS North Carolina Department of Health and Human Services