The Wheel Reinvented

Introducing Version Eleven

By Brett Patterson, Council of Standards Reader & Curriculum Board Editor:Robert Martin, Executive Director

The Medical Priority Dispatch System (MPDS) is always a work-in-progress. Indeed, the Academy has been entrusted to continually reinvent the MPDS. It is the world's most widely used 9-1-1-type Pre-Arrival Instruction and Dispatch Life Support protocol system and has been credited with helping save thousands of lives. Version 11 represents the single most comprehensive upgrade in the history of the protocol. It is easier to use and full of exciting new features designed to ensure safety and take better care of patients.

In the immortal words of pseudo-rocker Nigel Tufnel, "The numbers all go to eleven...it's one louder, isn't it?" Indeed, version 11 is one step louder, and one step clearer, and one step closer to being perfect...again!

The MPDS is truly a worldwide protocol. The Academy has established several International Standards Committees which are responsible for translating, evaluating, approving, and adopting changes approved by the Council of Standards.

There are currently nine different MPDS Version 10.3 language variants available for online use which are now being updated to reflect Version 11: North American English, U.K./European English, N.Z./Australian English, French Canadian, North American Spanish, European Spanish, German, Italian, and Finnish.

The Academy's College of Fellows, through the various International Standards Committees and ultimately the Council of Standards, has the exclusive right to modify the core protocol content; however, licensed users are individually responsible for establishing, maintaining, and reviewing local response assignments, which necessarily vary from agency to agency.

MPDS Version 11 contains nearly 300 "Determinant Descriptors," which are designed to categorize and prioritize emergency situations based upon caller interrogation and the presence or likelihood of priority symptoms and threat to life. It is important to note that scene circumstances may change at any time.

The MPDS is not meant to replace a thinking calltaker and cannot reasonably be expected to predict outcomes or assure EMD compliance in all cases. EMDs always have the option of overriding a recommended choice for patient safety, or of reconfiguring a determinant code based on new information. There are also times when the EMD may have to choose the most appropriate telephone treatment options from several possibilities. These are issues for consideration on a case-by-case basis, through local continuing dispatch education, quality improvement, and medical control.

This article introduces and highlights the significant changes apparent in MPDS Version 11. Anyone interested in better understanding how the MPDS update process works is encouraged to attend an Academy-approved EMD Certification Course or Version 11 Update Course, purchase the Version 11 Update Video and Workbook, as well as participate in the annual Navigator EMD Conference.

Protocol Designations
The MPDS is distributed through the Academy's contract management organization, Medical Priority Consultants, Inc., as either a software expert system (ProQA™) or as a manual flip card system comprised of reference card pairs. For simplicity, in this guide we will refer to the MPDS as it is represented in card form. The ProQA software follows the same numbering schemes and area designations as the cards. There are a total of 90 cards in a complete Version 11 set—a Case Entry pair, three cards for Case Exit (X), 33 numbered Chief Complaint card pairs, six traditional Pre-Arrival Instruction card pairs (designated A through F), a new pair for managing Tracheostomy (Stoma) airway control and CPR (Y), a new series of four cards for AED support (Z), and a "Response Determinant Methodology" instruction card (which also shows the new Legend of Symbols).

For each of the 33 Chief Complaint pairs, one of the cards is referred to as the Dispatch card and the other as the Additional Information card, together comprising a protocol card pair. Each dispatch card consists of Key Questions, Determinant Descriptors, Post-Dispatch Instructions, Critical EMD Information, and Dispatch Life Support (DLS) Links. There is extra space in the determinant area for listing each local response assignment alongside its corresponding MPDS code. Each Additional Information card consists of classifications, definitions, axioms, rules, and laws, pertaining to that specific chief complaint.

Choosing a Chief Complaint Protocol
Due primarily to concerns about scene safety, many of the Chief Complaint Protocols have been augmented to more appropriately address unconscious or arrest situations. The Chief Complaint Protocols that may involve scene safety issues now have specific directives within the Key Question sequence to better accommodate these situations. In addition, specific Determinant Descriptors and DLS Links have been added. Case Entry Rules 1, 2, and 3 clarify the proper selection of a Chief Complaint Protocol.

Using Symbols
Many new symbols have been incorporated into Version 11. These symbols provide visual cues that serve to remind or direct you concerning important issues. The new symbols can be placed in three basic categories: Notifications, Directors, and Warnings. Notification symbols serve as reminders when the needs of the call may require resources other than EMS. Directors visually guide the EMD to accomplish a specific task (i.e. verify an address) or proceed to a specific point in the protocol (i.e. send and return to sequence). Warnings provide visual cues that remind the EMD to consider important issues (i.e. Critical EMD Information or Scene Safety implications). These symbols are located throughout the protocol, and a "Legend of Symbols" is provided with each protocol set and reviewed during each EMD certification course.

Fundamental Benefits
Having an EMD priority reference system is not just about knowing what to say to an emergency caller, but also knowing how and when to say it. Then, it's equally important to know how to appropriately apply the information obtained from the caller. In a nutshell, MPDS Version 11 helps the EMD accomplish all of this and more. It surpasses all previous versions and "generic" variants in four primary ways. It is:

(1) more conversational,

(2) more directive,

(3) more clearly organized, and

(4) more medically correct and current.

All the changes apparent with Version 11 integrate to form a new product that is fundamentally safer, more user-friendly, and easier to learn and apply than previous versions—which quite simply equates to better patient care and outcome.

First, terms and sentence structure throughout the protocol have been changed to make questions and instructions more "conversational" and easier for the layperson to understand (e.g., using "completely awake" rather than "alert" when inquiring about a patient's level of consciousness). In addition, the format of the Pre-Arrival Instruction scripts has changed to break up sentences into logical, more conversational segments. These changes make the instructions easier and more natural to read, which fosters consistency and compliance to protocol. This restructuring goes a long way toward improving specifically "how" to ask potentially delicate questions and in what order.

Second, more specific directives are included regarding protocol navigation and specific instructions for the caller. Through text, symbols, and formatting changes, all Post-Dispatch Instructions are now more specific to the Chief Complaint Protocol on which they are found, and more generic instructions, i.e. "Ensure ABCs", have been enhanced and placed within the new Case Exit protocol (the "X" card) or redesigned Pre-Arrival protocols. The EMD is now linked to these instructions, depending on the patient's condition, via a new DLS Links section provided just below the Post-Dispatch Instruction area of each protocol. Cautions about potentially dangerous situations and scene safety are also incorporated directly within each protocol and linked whenever relevant.

Third, a comprehensive protocol overhaul afforded the Council of Standards the opportunity to reorganize and re-order all the questions, determinants, instructions, definitions, classifications, and other additional information. The order of these components relates to priority, acuity, or protocol navigation requirements. For example, Key Questions involving safety issues are now all listed first, and questions involving priority symptoms or those containing DELTA-level drivers follow. The clinical Determinant Descriptors have been reorganized to list high priority levels first, and, when possible, individual descriptors are ordered to correspond with the order of the Key Questions. At times, specific questions not related to priority or acuity are asked first to determine if a SHUNT is appropriate, (i.e. Protocol 5, Key Questions 1 and 2).

Finally, MPDS Version 11 is more medically correct and current. Indeed, it represents a new standard of care for emergency medical dispatching and call processing. As part of our systematic update and improvement program, the Academy continues to work closely with other associations and organizations to ensure that the MPDS embodies all generally accepted medical and telecommunications industry practice standards.

Recognition of EMD standards have been promulgated by the American Society for Testing and Materials (ASTM), the U.S. Dept. of Transportation, the National Institutes of Health, the American Heart Association, the Canadian Heart and Stroke Foundation, and the European Resuscitation Council, among others. Incorporating all the appropriate international industry standards, the MPDS represents the very core of vital and standardized knowledge for the practicing EMD. Furthermore, the Academy has specifically dedicated itself to continuing to support the MPDS protocol and to maintaining minimum requirements and guidelines to accompany the EMD training, certification, and accreditation processes.

Determinant Descriptors
As mentioned above, each MPDS-licensed agency is individually responsible for establishing, maintaining, and reviewing local response assignments. MPDS Determinant Descriptors (formaly called Sub-Determinants of Response Levels) provide two primary advantages. First, they allow for locally detailed referral and response assignments, making resource allocation efficient and effective. Second, because the codes remain constant, they provide the data that's essential for frequency and outcome studies, regionally, nationally, and internationally.

Expanding and detailing these descriptors in Version 11 has afforded EMS agencies opportunities to further customize their pre-planned assignments and gather the information necessary to conduct related studies. Protocol 29 provides an excellent example of this Determinant Descriptor enhancement. With Version 11, agencies now have the option of assigning a response with "one unit" or "additional units" in situations affecting multiple victims. Also, individual responses can now be assigned to subdescriptors within the definitions of MAJOR INCIDENT and HIGH MECHANISM.

ECHO
One of the most exciting changes to be found in Version 11 is the addition of the ECHO-level Determinant. Because ECHO-level dispatch is utilized directly from Case Entry, this provides the EMD with the means to dispatch earlier in the interrogation sequence—when certain life-threatening conditions are clearly evident. This additional tier also provides each agency with the means to assign response-capable units that would not normally respond to typical EMS calls (i.e., AED-equipped fire or law enforcement vehicles, HAZMAT, snorkel, or ladder crews). For easy reference, the Chief Complaint Protocols which contain an ECHO-level Determinant are highlighted with a purple locator tab.

DLS Links and Case Exit (X)
The Case Exit Protocol provides specific instructions for routine and urgent disconnect situations, as well as instructions for situations where remaining on the line with potentially unstable patients is prudent. These instructions are provided in both 1st and 2nd party caller formats and are accessed via standardized DLS Links from any protocol. The built-in panel logic enables easy navigation from one instruction to the next, depending on the situation or patient condition. Case Exit also provides instructions for bleeding control, amputations, and cooling burns, and flushing chemicals. Instructions for handling as well as avoiding potentially dangerous situations are also provided.

Y & Z Protocols
During the past few years, many protocol change requests were received regarding the provision of specific Pre-Arrival Instructions for "special cases," such as when an Automated External Defibrillator (AED) is present during a cardiac arrest situation or when directing CPR on a patient with an artificial airway (stoma). The new "Y" protocol for stoma patients is a simple modification of Protocol C. The instructions contain script modifications to accommodate differences in airway maintenance and mouth-to-stoma breathing. Similarly, the "Z" protocol serves as a companion to Protocol C whenever an AED is available. The "Z" protocol was developed with the help of representatives from the major AED manufacturers and the American Heart Association and has been beta-tested in communities with a relatively strong AED presence.

Making the Change
There are far too many changes within MPDS Version 11 to detail them all without a formal training experience. The Case Entry Protocol, for example, has changed dramatically with the addition of the ECHO Determinant and Post-Dispatch Instructions. Some of the Additional Information protocols have been almost entirely re-written. Since Version 11 is such a significant advancement, unparalleled in the evolution of the protocol, the Academy requires that each EMD be Version 11 "qualified" by the Academy before initiating its use.

To accomplish this, all EMDs must successfully complete an Update Course taught by a Version 11-qualified EMD Instructor, or complete the Update Course Video Training program. All EMDs must be provided with an Update Course Workbook and submit the included Qualification Application to the Academy. The purchase of the Workbook contains the processing fee, and each qualifying EMD will receive an official document substantiating their Version 11 qualification status. The Academy also recommends that each EMD review every protocol in its entirety, several times, and continue to study its contents until well understood.

In order to better accommodate transitions from previous versions of the MPDS, Medical Priority Consultants, Inc. [now Priority Dispatch Corporation] has developed several training programs and options. For more information, please call toll-free: (800) 363-9127, or (801) 363-9127, fax (801) 363-9144, or send email to: info@prioritydispatch.net

Brett Patterson: Brett is an Academics and Standards Associate for Medical Priority Consultants, Inc. He is also the Editor of the Academy's Curriculum Board and he serves as a member of the College of Fellows and the Council of Standards. He is a 20-year paramedic with 13 years of experience in the communications industry and is an accomplished speaker, educator, and researcher and can be reached at brett.patterson@prioritydispatch.net.

Robert L. Martin: Rob is Executive Director of the Academy and has been involved with publishing and coordinating Academy activities since 1988. He is a district board member for the International Association of Business Communicators. He can be reached at robert.martin@emergencydispatch.org.