Search Terms: SearEmergency medical services, EMS dispatch, response, EMS dispatching, sound medical evaluation, screening calls, priority dispatching, tiered response, maximal response dispatching, advantages, disadvantages, alternatives, medical priority dispatch training, certification, concept of priority dispatching, level of EMS response, strong medical control, implementation, new programs, Fire Chief magazine, 1983, common dispatch practices

Fire Chief Magazine, August 1983
Dorothea R. St. John, Assistant Director, EMS Division, Alexandria Fire Department Alexandria, Virginia; and Captain Reggie D. Shephard, Jr., Manager, Emergency Medical Services, Baltimore County Fire Department Towson, Maryland

Emergency Medical Services-EMS dispatch and response

In this era of tight fiscal restraints, are fire service managers making the most efficient use of their human and material resources in EMS dispatch and response? Is EMS dispatching (and consequent unit response) done with regard to sound medical evaluation, or the desire to "cover the department's tail"? New programs in screening calls, priority dispatching, and tiered response challenge traditional, maximal response dispatching.

Common practices

Before reviewing newer alternatives, it may be wise to review more common dispatch/response practices. Although the size of the agency and the level of service affect EMS response, in most agencies all requests for aid receive some response. Those agencies providing advanced life support (ALS) will often dispatch an ALS unit on all EMS incidents. In addition, most response procedures require the use of red lights and sirens en route to the scene for all incidents, and many still call for the use of red lights and sirens for all transports.

Advantages

There are advantages to this all-out system of dispatch and response. Most notable is the contention that those in dire need will receive not only the most basic help as quickly as possible but also the most advanced help as quickly as possible. And so will everyone else.

There are other advantages. By dispatching for and responding maximally to all requests, run volume increases. This is seen as desirable for many reasons:

    • Increased visibility for the agency (theoretically good public relations)
    • Possible increased justification for additional personnel and vehicles (and everything that goes with them-training personnel, supplies, facilities)
    • Increased productivity of present personnel (translated from less "idle time")

As the incidence and severity of fires continues to decrease in many areas, an increased EMS response continues to mean the survivability of many fire departments.

Disadvantages

For many departments, however, increased call volume, coupled with fiscal restraints, is severely taxing restricted resources. Not only are most agencies denied additional new positions, but many are faced with actual reductions in force, either through dismissals or, at best, attrition. Consequently, the fire service manager must be able to justify the positions he or she already has and use these human resources as efficiently as possible to meet ever-increasing demands for service.

Increased call volume, without increased numbers of EMS units and personnel, ultimately begins to severely strain the agency providing EMS service. Wear and tear on the units and equipment become increasingly apparent, and stress begins to take its toll on the EMS personnel.

What is the impact of these restraints on the patients we are supposed to be serving? Is it medically feasible, for instance, to dispatch less than an ALS unit on many EMS incidents and to drive without red lights and sirens not only during transport but during initial response? The answer is yes.

In departments where the number of ALS units are limited, if an ALS unit is dispatched on all EMS calls, a unit may not be available during times of peak demand. This lack of an available unit may be handled by a mutual aid response (and consequent time delay) or, worse yet, by "stacking" calls (holding the call until a unit is available).

A department may decide initially to provide ALS response to all incidents for purposes of legal protection. However, it may be unable to defend the delayed or unavailable response of an ALS unit to a victim of chest pain or severe trauma if even one ALS unit is tied up responding to a simple fractured arm.

In addition, it is a sound safety practice to require emergency response (red lights and siren) to all incidents, exposing crews to the additional hazards of an emergency response, just to arrive one to two minutes earlier for a nonemergency patient? Perhaps it is time for fire service EMS managers to include physician medical control, so important in patient care, as an integral part of the definition of EMS dispatch protocols. For example, should a 17-year-old male with abdominal pain and fever (felt to be appendicitis) be treated as a prehospital emergency requiring red lights, siren, and paramedic response? Probably not (1).

It is time to question whether we are serving the best interests of all our patients by providing large numbers of costly ALS units when 80%-90% of EMS incidents require only basic life support (BLS). Using fewer people to serve the ALS patients translates into greater efficiency and effectiveness because the ALS personnel have more opportunities to practice their ALS skills. This means decreased skill degradation and increased patient care. Benefits to the manager include decreased staffing and training costs.

Alternatives

Necessity is the mother of invention. This is certainly true in EMS, and present-day fire service managers have several new and promising alternatives to consider and adapt for local use.

"Dallas, like other big cities, is faced with one of the most serious obstacles to effective emergency medical services: abuse and misuse of the system by callers demanding services in nonemergency situations (2)." Dallas initially attacked the problem by launching an expensive public education program. This only served to make the public more aware of the services available and, in consequence, the number of nonemergency calls increased even more.

Further analysis of dispatch procedures led Dallas to develop its nurse call-screening program. The nurse, located in the dispatch center, primarily performs two functions:

    1. In life-threatening medical emergencies, the nurse gives medical self-help advice until the ALS unit arrives.
    2. In nonemergency situations, the nurse gives medical self-help advice, and, if an ALS unit is not dispatched, provide follow-up, including referrals to other agencies.

The Dallas Fire Department gave two major reasons for using registered nurses to screen calls, both reasons based on the extensive medical education nurses receive: the risk of misjudging the seriousness of a medical emergency is reduced, and the caller is reassured by talking to a medical professional (3).

Salt Lake City's development of medical priority dispatch training and certification of Emergency Medical Dispatchers (EMD), further defines the concept of call screening, allows for more formal medical control, and may prove more economically feasible to the fire service.

In addition to basic dispatch techniques, the EMD is trained in the use of a medical dispatch priority card system. This system is structured around the concept of key questions, prearrival instructions, and dispatch priorities (4).

Strong medical control is built into the key questions, which emphasize the importance of obtaining symptoms (e.g., chest pain) rather than diagnosis (heart attack), in addition to the patient's age and state of consciousness and breathing. The answers to these key questions lead the appropriate prearrival instructions and also establish the correct (standardized) level of emergency medical response (dispatch priority). While maximal response is permitted "when in doubt," the number of such situations is greatly reduced, simplifying dispatch decision making.

What is the advantage to the fire service manager to have certified EMDs? First, it eliminates the need to hire, in addition to regular dispatchers, registered nurses to perform medical call screening. In addition, the call screening provided by EMDs, using a medical dispatch priority card system, may be more standard and consistent-comparable to the standard operating procedures followed by firefighters and paramedics. In terms of time and money costs, the 25-hour EMD course, adopted by the Department of Transportation as a national standard, is certainly less expensive to provide than EMT training (minimum, 81 hours), which is of less use to the dispatcher.

The concept of priority dispatching can easily go hand in hand with systems of tiered response, that is, dispatching only what is needed. To date, tiered response-first responder, BLS unit, ALS unit-is most frequently used in larger systems where multiple levels of EMS response is possible, such as Baltimore County, Maryland.

To illustrate the idea of a tiered response, let's examine two situations of patients complaining of chest pain. In situation A, an 18-year-old female complains of chest pain but has no shortness of breath and not history of previous chest pain or heart problems. In situation B, a 46-year-old male complains of chest pain, shortness of breath, and acknowledges previous incidents of chest pain.

Do these situations need the same level of EMS response? No. Yet in most departments, the mere mention of "chest pain" or "shortness of breath" would automatically elicit a full response of engine company first responder, BLS unit, and ALS unit to both of these situations. Not only is the medical necessity of such all-out response questionable in situation A, but such large numbers of vehicles responding under emergency conditions (red lights and sirens) greatly enhances the hazards to both vehicle operators and citizens.

A system of tiered response would allow for a full response (first responder, BLS unit, ALS unit) in situation B (46-year-old male) and the dispatch of only a BLS unit with no first responder to situation A (18-year-old female). Additionally, a tiered response system is structured to permit the shutdown of the response at any point. For example, if the first responder arrives on the scene of situation B and finds that the 46-year-old male has been hit in the chest by a softball and has since "regained his breath," the first responder can stop the response of the ALS unit and perhaps even change the response of the BLS unit to nonemergency status (no red lights and siren).

The advantages of such a response system to a busy EMS agency should be readily apparent. Medical control of dispatch is more clearly defined. As a consequence, fewer unnecessary emergency response are made, which in turn reduces the time spent on hazardous emergency responses, lessens stress to personnel, and cuts down on wear and tear to vehicles and equipment.

With the reduction in ALS responses, the agency is able to be more efficient in terms of the number of ALS personnel and vehicles. Since fewer people handle the truly life-threatening calls requiring invasive procedures, skill quality remains high, and the patient benefits from the care of more experienced emergency medical personnel.

Tiered response can only work, however, if multiple levels of care can be provided. What option is available to the smaller agency that has only first responder units (engine and truck companies) and transporting ALS units? Where can these agencies reduce cost and minimize the hazard of emergency response without compromising the care provided to the citizens?

Perhaps it is time to review and even revise policies calling for emergency response to all incidents. The use of strong medical control in defining dispatch/response procedures may ultimately determine that "in a sizable number of incidents the use of red lights and sirens is unnecessary (5)." In establishing procedures for the use of routine vs. emergency response, the following questions should be considered prior to implementation:

    1. Will time make a difference in the outcome?
    2. How much time leeway do you have?
    3. How much time can you save (really) driving with red lights and sirens?
    4. When the victim gets to the hospital, will the time saved be significant with the time spent waiting for care (X-rays, lab tests, and so forth)? (6)

Obviously, the same questions can be used to decide between emergency or nonemergency transport. Again it is important to emphasize the need for medical control in developing alternate response and transport policies. However, the savings in the amount of fuel used, in vehicle wear and tear, in stress to personnel and hazards to the public on the road will prove well worth the initial investment of time and effort in developing more realistic, reasonable, and clearly defined procedures.

Implementation

How can the fire service manager implement any of the alternatives discussed here? As with any management action, sound planning is the key to success.

Once the decision is made to make the change, a thorough system evaluation should be the first step. Collecting and reviewing present and past information about the system not only clearly defines where the system is presently but provides the justification for change.

The design of the new procedures should include input from all appropriate source: operations managers, EMS manager, dispatchers, field providers, training personnel, and physician medical control. Plans, including timetables for training and startup, should be detailed. Each step of the implementation process should be clearly defined in terms of objectives, action plans for meeting objectives, and identification of responsible persons.

Equally important, but often forgotten, is the need to research not only the legal authority to make such changes but the possible political impact. Any implementation plan should therefore also include objectives aimed a public education, including public service announcements, written press releases, and press conferences. Any public education maneuver should emphasize that the new procedures, especially if they include more questioning at dispatch, are designed to make sure the patient gets the right help.

Finally, the implementation plans should include the means to collect data during a reasonable trial period. Adequate data feedback may support the continued existence of the new procedures as well as suggest modifications for greater effectiveness. System data provide additional information/public relations programs.

If EMS is going to continue to be dynamic and responsive to the citizens it serves, continued reassessment is necessary and may require the use of innovative, and possibly radical, approaches to EMS dispatch and response. New programs in call screening, priority dispatch, and tiered dispatch will allow the fire service manager to maximize the efficient use of human and material resources in the provision of quality, effective patient care.

References

  1. Clawson, Jeff, "Dispatch priority training: Strengthening the weak link." JEMS 6 (February 1981):34.
  2. Starks, Leilani, "Call screening in Dallas." JEMS 8(February 1983):30.
  3. Ibid.
  4. Clawson, "Dispatch priority training," p.33.
  5. Clawson, Jeff, "The red-light-and-siren response." JEMS 6(February 1981):34.
  6. Ibid., p.35.