Jan 14, 2014 ... 1/14/2014. 3. PSAP/EMS Dispatch Options. • Combined PSAP / EMD. – All
functions co-located in single center. – May internally transfer for ...
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Fundamentals of EMS Dispatch William Fales, MD, FACEP Western Michigan University School of Medicine and Kalamazoo County Medical Control Authority
[email protected]
Yes, there really is a Kalamazoo • Countywide EMS System – 250,000 population / 550 sq. miles – All ALS with BLS 1st Response • 4 ALS / 1 Air / 15 BLS (1st response) • Performance based contract
– ~80 Paramedics – ~700 EMT/EMR First Responders
• WMed Emergency Medicine – 20 residents/yr x 3 yrs – Houses Medical Control Authority – EMS Resident Response Vehicle – 1st Accredited EMS Fellowship Program
Disclosures and Supplemental Material • Disclosures and Conflicts – None to Report
• Supplemental Material – Principles of Emergency Medical Dispatch – EMD Research PPT – EMS Radio 101 and Disaster Communications PPT – 2012 New Jersey EMD Guidecards PDF – EMD Program Implementation PDF – Next Generation 911 Report
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Core Content of EMS Medicine 2.2 EMS SYSTEMS • 2.2.1 Public Safety Answering Points – 2.2.1.1 Pre-arrival instructions – 2.2.1.2 Dispatch • 2.2.1.2.1 Use of lights and sirens • 2.2.1.2.2 Prioritization of response (e.g., determining local needs based on local resources) • 2.2.1.2.3 Tiered-response Source: American Board of Emergency Medicine
Attitudes of Medical Directors about EMS Dispatch • That’s something that someone else does. • It’s not really clinically related, therefore it’s not a medical director thing. • It involves a separate agency that I have no control over. • Dispatch just sort of happens and there’s nothing I can do to impact it. • Dispatch is the entry point to the EMS system. If dispatch fails the system fails!
EMS Dispatch Components • PSAP = Public Safety Answering Point – 911 Center – Receives call / determines service needs – May perform EMD function or transfer caller – May dispatch EMS unit(s)
• EMD = Emergency Medical Dispatch – Prioritizes Call – Dispatches EMS unit(s) – Pre-Arrival / PostDispatch Instructions – May be co-located with PSAP or seperate
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PSAP/EMS Dispatch Options • Combined PSAP / EMD – All functions co-located in single center – May internally transfer for EMD
• Single PSAP / Multiple EMD Centers – Multi-jurisdictional (or county) centralized PSAP – Multiple ambulance services
• Multiple PSAPs / Single EMD Center – Individual jurisdictional PSAPs – Single EMS agency
• Multiple PSAPs / Multiple EMD Centers
PSAP Operations • 6,000 PSAPs nationally • Call Taking – Via landline, Via cellular voice, Via VoIP
• Automated Number Identification (ANI) • Automated Location Identification (ALI) – Typically based on account address for land lines • Provide EMD services thru (EMD) call taker – or Transfer caller to separate EMD center
• Dispatch all or some EMS/Public Safety units
911 Calls by Phone Type
http://transition.fcc.gov/bureaus/pshs/911/Phase%202/WA/07-114_09-252013_Marlys_Davis_75209453741.pdf
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PSAPs and Cell Phones • ~70% of 911 calls from cellular • Cellular – 1996 Wireless 911 Mandate
• Phase 1: PSAP receives call back number and location of cell tower • Phase 2: PSAP receives caller’s # and location via GPS or triangulation – Cellular providers to be ready by 2006 (2012) – Local PSAP must request and be able to receive info – Locate within 300 m
http://nena.ddti.net/
Problems with Cell Phone Caller Location (Phase 2) FCC Information • California • Oregon • North Carolina • Pennsylvania • Texas • Utah • Washington
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Find Me 911 Coalition
Source: http://findme911.org/
Voice over Internet Protocol (VoIP) and 911 • Small percent of 911 calls • FCC Mandate May 2005…VoIP Providers Must: – Deliver all 911 calls to local PSAP – Advise of capabilities / limitations of VoIP 911 service – Deliver the call back number and location information • Location is pre-set by caller • The PSAP must be capable of receiving address
• Caller must maintain up-to-date address – Problem with travelers – Automatic prompts for new URL address
Next Generation 911 (NG9-11) • Integrate all communications modalities into cloud environment • Exploit smart phone technology – Text messaging, photos, videos
• Emergency Services Internet Protocol (ESInet) • Many challenges • Pilot projects underway • Full implementation >5 years
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PSAP WARNING! • Many PSAPs are under the control of police agencies. • EMS may not be their priority – We need to make it their priority
• Frequent praise (when due)
Emergency Medical Dispatch • Responsibilities – – – –
Non-911 Calls (scheduled transfers) Call Prioritization EMS Unit Dispatch Pre-Arrival / Post Dispatch Instructions PRN
• Formal EMD System – Protocol Driven • Guidecard versus computer – Avoids dispatcher free-lancing – Various national / other EMD systems • Certifiable programs
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EMD Call Prioritization • Purpose – Send “right resource in right mode in right time” • ALS vs BLS vs BLS+ALS • 1st responders, as needed • Decrease emergency (lights/siren) responses
• Use structured, protocol-driven caller interrogation • Call Prioritization vs. Call Screening – Call Screening – EMS response optional – Call Prioritization – EMS response assured
Why we don’t screen calls….
EMS Unit Dispatch • Confirm incident location – Must re-confirm from PSAP – Secondary PSAP: EMD receives ANI/ALI
• Computer-Assisted Dispatch (CAD) – Tracks status of all EMS units • Integrates into vehicle GPS tracking system
– Documents all EMD activities
• Alert responding unit(s)
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EMS “Control Center” Console
GPS Vehicle Tracking
Call Coverage Map
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Pre-Arrival / Post-Dispatch Instructions • Provide “Dispatch Life Support” – “Zero response time” – Dispatcher-Assisted CPR • Where’s the public AED?
– Obstructed Airway Management – Hemorrhage Control – Assist in Childbirth
• High public expectations – Limited published evidence showing safety and efficacy – Liability for not offering?
• Use EMD Protocol Reference System
EMD Protocol Reference System • Key Questions – Universal all caller interrogation – Goal: Identify Chief Complaint
• Chief Complaint Categories – Generally 32 Chief Complaints – Uses key questions – Allows for Call Prioritization
• Scripted Medical Protocol – Provides clear, simple instructions to caller
Sample Guidecard
Source: New Jersey EMS
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Sample Guidecard
Source: New Jersey EMS
Sample Guidecard
Source: New Jersey EMS
ProQA Computer-Based System
Source: Life EMS Ambulance -ProQA/MPDSTM
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2010 AHA Guidelines for CPR & Emergency Cardiovascular Care • EMS dispatchers should provide telephone instruction in chest compression-only CPR for untrained rescuers.
2010 AHA Guidelines for CPR & Emergency Cardiovascular Care • Dispatchers should be specifically educated about identification of no normal breathing in order to improve recognition of adult cardiac arrest • Quality improvement efforts should assess the accuracy and timeliness of dispatcher recognition of cardiac arrest and the delivery of CPR instructions.
2012 AHA Scientific Statement
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Dispatcher CPR Instructions
http://circ.ahajournals.org/content/125/4/648.full?sid=f6d9350a-9df2-411f-a4a0-cf982df1dd07
• King County, WA •
Excluding Seattle
• 416 arrests had PSAP recording reviewed •
80% identified as arrests • •
Median time 75 seconds 62% had DA-CPR
• Time to 1st compressions •
176 sec (range: 141-242)
Lewis M et al. Circulation. 2013;128:1522-1530
• Less likely to ID witnessed arrest • •
Patient reported “breathing” Agonal breathing not recognized
Performance Standards for Dispatcher-Assisted CPR 80% 75 sec 62% ~3 min
Lewis M et al. Circulation. 2013;128:1522-1530
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Does EMD Work? • Can we safely allow for decreased response configurations? – BLS instead of ALS – “Cold” response
• What is an acceptable under triage rate? • Are there consequences of over triage? • Do Pre-Arrival Instructions work?
RESEARCH IN EMD!
Medical Direction and EMS Dispatch • Highly variable based on system / state • Areas of Potential Medical Direction – EMD Protocol Approval – EMD Quality Improvement • Retrospective tape review – Dispatcher CPR (AHA IIA) – PSAP Oversight – Complaint Investigation • EMD / PSAP – Multi-Agency Response Protocols • Minimizing delayed responses
Communications and CQI • EMS communications systems provides excellent means to monitor system performance in real time and retrospectively • Dispatch and Field Operations – Monitor response times / overall system function – Provides source for on-scene, concurrent CQI
• MEDCOM – Monitor clinical performance – Provides source for case reviews
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Recording Communications • Multi-channel digital recorder – Allows for electronic file transfers – Remote access
• Confidentiality of communications – May be subject to FOIA – MEDCOM should be considered confidential
• Use in CQI – Random selection – Sentinel events – Selected cases
Radios and the Medical Director • Should Medical Directors have radios? • Why? – Monitor system operations – Field response • Allows for “cherry picking”
– MCI response
• What type of radio(s)? – Portable vs. mobile vs. scanner – May need permission from agency / state
• How do you acquire the equipment?
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Final Thoughts • EMS Medical Directors should… – Advocate for high-quality EMS dispatch – Visit their PSAPs and EMD centers – Include dispatchers in positive feedback
Questions / Comments
[email protected]
911 References • Federal Communications Commission 911 – E-911: http://www.fcc.gov/911/ – VoIP: http://www.fcc.gov/pshs/services/911services/voip/Welcome.html
• National Emergency Number Association – http://www.nena.org/
• Assoc. of Public Safety Comm. Officials – http://www.apcointl.org/
• Find Me 911 Coalition – http://findme911.org/
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EMD References • NHTSA EMD Program – http://www.nhtsa.dot.gov/people/injury/ems/Reorder%2 0files%20for%20CDRom1.htm
• International Academies of Emergency Dispatch – http://www.emergencydispatch.org/
• APCO Institute – http://www.apcointl.com/institute/
• PowerPhone – http://www.powerphone.com
• New Jersey EMD Guidecards – http://www.911dispatch.com/info/emd/nj_emd_guideca rds_jan2012.pdf
Disaster and Radio References • Government Emergency Telecommunications System (GETS) – http://gets.ncs.gov/
• CDC – Health Alert Network – http://www2a.cdc.gov/HAN/Index.asp
• Radio Amateur Civil Emergency Services – http://www.qsl.net/races/
• Free radio frequency / system information – http://www.radioreference.com/
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