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Journal of Emergency Medical Services (JEMS), February 1983
Jeff Clawson, MD

Medical Priority Dispatch: It Works!!

In the February 1981 edition of this journal, we published a report on an innovative dispatch system being put to use in Salt Lake City. Dr. Jeff Clawson, fire surgeon for the Salt Lake City Fire Department, explained the system he devised of training dispatchers how to medically interrogate a caller, give life-saving pre-arrival instructions, prioritize symptoms, and select appropriate preplanned unit configuration and response modes. The article elicited an unexpectedly enthusiastic response-Dr. Clawson received over 250 requests for more information with some 160 municipalities eventually implementing or adapting the system locally. Two years later we now present an update of the program as it is being applied in Salt Lake City. Statistical data gathered since the first publication appear to support our readers' enthusiasm-the system is working!

The inception of medical dispatch training and dispatch screening in this country has vaguely traceable roots into the mid-1970's. While the Salt Lake City program is unique in that it first combined as a single package the basic ingredients of dispatch-specific medical training, call screening, response mode assignment, and pre-arrival instructions-many of these ideas were initiated by others prior to our distillation and modification. These ideas have been difficult to trace due to a lack of nationally published material.

The Phoenix Fire Department's "Lifeline" program, started in 1974, was the first organized attempt to provide pre-arrival or "self-help" instructions to callers prior to the mobile responding team's arrival. The tape recordings of dramatic telephone "saves" that we, and now many others, use for training and in selling the merits of dispatcher training to politicians and medical providers, comes from this lifesaving program that we and many thankful victims are indebted to.

Although I was not personally aware of it at the time, the Illinois Division of Emergency Medical Services was using a card reference approach similar to ours as early as 1977. Called the "911 Medical Advisory Flip Chart" and co-authored by Karen M Kabat, RN, and Daniel VonBerg, P.E., it provided indexed questions and general instructions for callers in need. While its organization was not as pure in adherence to the symptom/incident-type philosophy that we recommend both for rapid reference and for avoidance of caller and dispatcher reliance on "diagnosis," the system was definitely ahead of its time. The third revision of the Medical Dispatch Priority Card System has incorporated a number of Kabat's and VonBerg's ideas that were not known to me in 1976.

In September 1978, a group from the Dallas Fire Department, led by dispatch screening advocate Chief Bill Roberts, conducted a research project entitled "EMS Dispatching-Its Use and Misuse." The project contained a "dispatch screening study" by Debra Cason, RN. This was expanded into her much more comprehensive master's thesis, "Telephone Triage of Emergency Patients By a Nurse," completed in December 1979. Cason's work hallmarked use and skill of trained nursing personnel in accurately screening medical calls for appropriate prehospital response. Leilani Starks, RN, began in 1980 as the first regular nurse screener for the Dallas Fire Department and has developed specific interrogation, screening and treatment protocols based somewhat on our original card system and index (1).

The concept of nurse dispatch screening has been proven successful not only in Dallas but also in New York City. The New York program began about 1972.

The nurse screening approach appears to be the "Cadillac" of selective dispatch philosophies. But considering current economic restraints, nurse screening will probably be instituted only in large, progressive-thinking municipalities. The expertise, effectiveness and confidence of nurses in selective dispatch screening appears to be, we must admit, the best and most logical approach to the overall concept of medical dispatch screening. However, since the vast majority of medical dispatch operations today cannot afford to add any extra personnel, much less a registered nurse, the approach to overall improvement of medical dispatch on a national level must be aimed at the dispatch specialist.

In 1974, Salt Lake City instituted an ALS system with a single paramedic unit. Shortly thereafter, a first responder program was initiated. In the past eight years the number of ALS units has increased to four and currently consists of two paramedic/engines and two two-man non-transport teams.

Prior to 1974, medical responses in Salt Lake City were made by Gold Cross Ambulance, a private EMT ambulance service. A computer survey of their runs from 1970 to 1974 showed that, excluding all non-emergency transfers, etc., the percentage of Īred-light-and-siren runs" to the scene for this period was only 62 percent (2). In the initial absence of written protocols, vehicle response configuration was the option of each individual dispatcher. The one exception to this freedom was that, until only recently, fire department apparatus responded with the ambulance on all runs unless the caller need was a "request for transportation" only. Because of these dual and even triple response configurations, the total number of emergency vehicles responding as well as the total responding "red-light-and-siren" increased dramatically from the pre-1974 levels.

The Utah Emergency Medical Dispatcher (EMD) training program (described in JEMS, February 1981) began on a statewide voluntary basis in September 1979 and included training and certifying dispatchers of the Salt Lake City Fire Department.

The complete implementation of the system was not to occur until after the arrival of Salt Lake City's new fire chief, Peter O. Pederson, a progressive, lettered fire administrator from Los Angeles County. Under Chief Pederson's direction, the Medical Dispatch Priority System, along with a locally revolutionary paramedic/engine program, was instituted on February 5th , 1982. The persistence of medical control combined with the arrival of a progressive fire administration eventually made possible the application of a comprehensive medical dispatch screening system earlier this year.

The history of emergency medical response for Salt Lake since 1978 is statistically depicted in Figure 1. In the first six months of the system's full implementation, the percentage of paramedic (ALS unit) responses dropped by 11.5 percent compared to the same six months in 1981 and dropped 11.0 percent since 1978. Conversely, as expected, the ratio of paramedic runs to total fire department responses (i.e., total calls minus solitary ambulance responses) increased 3.5 percent from 1981 and 13.7 percent since 1978 (see Figure 2).

The greatest change in response level occurred in the number of runs assigned a basic life support response only (see Figure 3). The number of calls assigned to Gold Cross Ambulance Service, an excellent private BLS provider, has increase over 1,000 percent from 1978 through June 1982. Since the "unofficial" introduction of the screening system wasn't until September 1979, another factor was obviously responsible for the increase in solitary non-fire department ambulance responses between 1978 and 1979.

In 1978, Gold Cross moved its second base station very near the busiest paramedic station located in downtown Salt Lake. It was our recommendation that, in order to spare the paramedic units and first response engine crews unnecessary runs, solitary ambulance first response districts for both stations could be established safely with appropriate dispatch modification. After significant internal opposition, SLCFD Operating Procedure #271-EMT Ambulance Run District-was instituted in October, 1978, although only for the original ambulance base station located in the southwest periphery of the city. This procedure, although modified from our original recommendation, in effect gave the dispatchers the option of sending the ambulance alone as a sole responder. Since the protocol was not enforced at the dispatch level by the fire department administration at the time, predictable, this usually occur-red late at night while firefighters, and occasionally paramedics, slept.

The 1979 "ambulance alone" percentage of 7.8 changed only slightly in 1980 to 9.2 percent, but in 1981 jumped to 18.0 percent. Familiarity with the system, medical control pressure and the late 1981 change in fire administrations are the main reasons suggested as contributing to this dramatic shift. The first six months of 1982 (excluding January) were under the fully implemented system and show another significant rise in solitary ambulance responses to 33.9 percent. This amounts to a near doubling again in transferring basic life support calls from the fire department to the private ambulance service. The estimated costs savings of the program appear to be substantial, especially considering that one-third of Salt Lake City's medical calls now require no response by the fire department at all!

We anticipate that as dispatchers become more familiar with and proficient in the full use of the system, the percentage trends described will continue. It is very important to note that, contrary to some local fears, no serious problems or citizen complaints have been received to date,

At this point we can make some general recommendation concerning the implementation of medical dispatch priority systems. They are:

  1. A progressive provider administration;
  2. Strong, persistent medical control;
  3. Department and municipal government support of priority dispatch concepts and goals prior to implementation;
  4. Emergency Medical Dispatcher training and certification prior to program implementation;
  5. The use of medical dispatch feedback report to report problems, recommend modifications in protocols, and monitor dispatcher compliance to screening procedures;
  6. Assigning code numbers and letters to each priority card and response configuration respectively (This allows the rapid relay of the selected response from the interrogating agency to other agencies that may send an associated or solitary response and also aids the relay of assignment between the interrogator and the radio dispatcher in multiple personnel centers, and is especially useful in computer-aided systems. Additionally, card coding reduces compliance problems by requiring the dispatcher to initially reference the card during questioning and visual referencing decreased the inherent temptation to guess on response configuration and mode. It thereby achieves one of the original goals, that of assuring consistency in dispatching technique.);
  7. Emphasis on positive feedback and introduction of rewards for dispatchers to stress their vital role in the overall prehospital care system;
  8. Careful collecting and monitoring of relevant statistics both before and after the system initiation.

The use of selective dispatch screening via the Medical Dispatch Priority concept is safe, effective and economically appropriate. The Salt Lake City experience, although statistically brief, has reinforced the fact that medical dispatching should be one of the prime areas of national EMS attention and improvement in the 1980's.

Footnotes

  1. Robinson, V: "Call Screening Targets False Emergencies." The International Fire Chief (Vol. 47, No. 6: 16-18, June 1981).
  2. Clawson, J: "Salt Lake City Emergency Ambulance Analysis." PP. 41-42, 1975.

Figure 1: History of Medical Response

1978 1979 1980 1981 1982

Total Medical 11,820 10,681 10,304 10,836 5009

Runs

Apparatus only 3886 3056 2819 2540 798

% Apparatus/

Total 32.8% 28.6% 27.4% 23.4% 15.9%

Rescue &

Apparatus 2690 2293 2542 2262 1021

% Resc & App

Total 22.8% 21.5% 24.7% 20.9% 20.4%

Rescue only 4928 4490 3999 4079 1517

% Rescue only/

Total 41.7% 42.0% 38.8% 37.6% 30.3%

All Rescue 7618 6783 6541 6341 2538

% All Rescue/

Total 64.5% 63.5% 63.4% 58.5% 50.6%

Gold Cross

Ambulance only 316 842 944 1955 1673

% Gold Cross/

Total 2.7% 7.8% 9.2% 18.0% 33.4%

Total BLS

responses 4204 3898 3763 4495 2471

% BLS

responses/total 35.5% 36.5% 36.5% 41.5% 49.3%

six month totals-----All fire department runs include a Gold Cross EMT ambulance response

Apparatus = first response (BLS) fire unit

Figure 2:Call Ratio

Jan. thru June 1978 Jan. thru June 1981 Jan. thru June 1982

Rescue Unit Responses 3,667 2,676 2.121

% of F.D. responses 64.8% 73.0% 76.5%

% of total calls 64.8% 62.1% 50.6%

Fire Department Responses 5,659 3.665 2,773

Total medical responses 5,762 4,310 4,195

 

Figure 3: Basic Life Support Response

1978 1979 1980 1981 1982*

# Solitary EMT 316 842 944 1,955 (1,673)

Ambulance

Responses

% Solitary EMT 2.7% 7.8% 9.2% 18.0% (33.4%)

Ambulance

Responses

Total Medical

Runs 11,820 10,681 10,304 10,836 (5,009)

*six month totals