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Heart Attack
(Myocardial Infarction)
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EMERGENCY MEDICAL DISPATCHING: Rapid Identification and Treatment of
Acute Myocardial Infarction
NATIONAL INSTITUTES OF HEALTH
National Heart, Lung, and Blood Institute
EMERGENCY MEDICAL DISPATCHING:
Rapid Identification and Treatment of Acute Myocardial
Infarction
National Heart Attack Alert Program (NHAAP)
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
National Institutes of Health
National Heart, Lung, and Blood Institute
NIH Publication No. 94-3287
July 1994
FOREWORD
Coronary heart disease (CHD) continues to be the leading
cause of death in the United States despite a remarkable
decline in CHD mortality over the last 30 years. The
National Heart, Lung, and Blood Institute estimates that as
many as 1.25 million people will experience an acute
myocardial infarction (AMI) in 1993, and nearly 500,000 will
die.
The importance of early treatment has been underscored in
the last decade with the results from clinical trials of
thrombolytic therapy demonstrating mortality reductions with
earlier treatment. Out-of-hospital sudden cardiac death is
an ever-present threat, further highlighting the importance
of early recognition and treatment.
However, a fundamental barrier to timely treatment is delay
--at the level of the patient, the emergency medical
services (EMS) system, and the emergency department. In
June 1991, the National Heart, Lung, and Blood Institute
launched the National Heart Attack Alert Program (NHAAP)
with the goal of reducing AMI morbidity and mortality,
including sudden cardiac death. The NHAAP Coordinating
Committee was formed to help develop, implement, and
evaluate the program. This committee is composed of
representatives of 39 national scientific, professional,
governmental, and voluntary organizations interested in
lowering AMI morbidity and mortality through professional,
patient, and public education.
The importance of the EMS system for cardiac care has been
highlighted in the American Heart Association's recent
guidelines for cardiopulmonary resuscitation and emergency
cardiac care where early access to EMS is identified as the
first link in the chain of survival for cardiac arrest. The
chain of survival concept has been expanded to include
patients with symptoms and signs of AMI.
Emergency medical dispatching has been recognized as a vital
part of the early access link in the chain of survival for
cardiac arrest. The potential important role for emergency
medical dispatchers (EMD's) in the prehospital care of
patients with symptoms and signs of an AMI, as well as
patients with cardiac arrest, is the underlying assumption
of this paper.
Thus, while emergency medical dispatching is a broader topic
than AMI and cardiac arrest, this paper represents a
consensus of its potential contribution to the seamless
prehospital identification and treatment of patients with
AMI, including cardiac arrest, as well as a consensus of the
critical issues and recommendations for medical dispatch
protocols, processes, training and certification, and
quality control and improvement.
Nevertheless, it should be noted that there is a paucity of
research related to outcomes associated with emergency
medical dispatching. Only through evaluation research can
the optimal EMD processes and protocols, associated with
specified outcomes, be elucidated.
Claude Lenfant, M.D.
Director
National Heart, Lung, and Blood Institute
-----------------------------------------------------------
MEMBERS OF THE WRITING GROUP
Lead Writer
Jeffrey J. Clawson, M.D.
President
National Academy of Emergency Medical Dispatch
Salt Lake City, Utah
Contributors
James M. Atkins, M.D.
Medical Director, Dallas Emergency Medical Services
Professor of Medicine
Department of Internal Medicine
University of Texas Southwestern Medical Center at Dallas
Dallas, Texas
Charles K. Francis, M.D.
Professor of Clinical Medicine
Columbia University College of Physicians and Surgeons
Director
Department of Medicine
Harlem Hospital Center
New York, New York
Charles Glass
Highway Safety Specialist
Office of Enforcement and Emergency Medical Services
National Highway Traffic Safety Administration
Department of Transportation
Washington, D.C.
Fred Hurtado, B.A., EMT-P
Member, College of Fellows
National Academy of Emergency Medical Dispatch
Salt Lake City, Utah
Susan Ryan, M.Sc.
Chief
Emergency Medical Services Division
National Highway Traffic Safety Administration
Department of Transportation
Washington, D.C.
Jane Scott, Sc.D., M.S.N.
Health Scientist Administrator
Center for Medical Effectiveness Research
Agency for Health Care Policy and Research
Rockville, Maryland
Staff
John C. Bradley, M.S.
National Heart Attack Alert Program Support Contract Manager
NHLBI Education Programs Support Contract
R.O.W. Sciences, Inc.
Rockville, Maryland
Mary McDonald Hand, M.S.P.H., R.N.
Coordinator
National Heart Attack Alert Program
Office of Prevention, Education, and Control
National Heart, Lung, and Blood Institute
National Institutes of Health
Bethesda, Maryland
Michael Horan, M.D., Sc.M.
Director
Division of Heart and Vascular Diseases
National Heart, Lung, and Blood Institute
National Institutes of Health
Bethesda, Maryland
Acknowledgments
Jeffrey Grunow, R.N., EMT-P
Assistant Professor of Emergency Medical Care Studies
Eastern Kentucky University
Richmond, Kentucky
Carl C. Van Cott
Assistant Chief, Engineering
Office of Emergency Medical Services
North Carolina Department of Human Resources
Raleigh, North Carolina
-----------------------------------------------------------
NATIONAL HEART ATTACK ALERT PROGRAM COORDINATING COMMITTEE
MEMBER ORGANIZATIONS
Agency for Health Care Policy and Research
American Academy of Family Physicians
American Academy of Insurance Medicine
American Association of Critical Care Nurses
American Association of Occupational Health Nurses
American College of Cardiology
American College of Chest Physicians
American College of Emergency Physicians
American College of Occupational and Environmental Medicine
American College of Physicians
American College of Preventive Medicine
American Heart Association
American Hospital Association
American Medical Association
American Nurses' Association, Inc.
American Pharmaceutical Association
American Public Health Association
American Red Cross
Association of Black Cardiologists
Centers for Disease Control and Prevention
Department of Defense, Health Affairs
Department of Veterans Affairs
Emergency Nurses Association
Federal Emergency Management Agency
Food and Drug Administration
Health Care Financing Administration
Health Resources and Services Administration
International Association of Fire Chiefs
National Association of Emergency Medical Technicians
National Association of EMS Physicians
National Association of State Emergency Medical Services
Directors
National Black Nurses' Association, Inc.
National Center for Health Statistics
National Heart, Lung, and Blood Institute
National Highway Traffic Safety Administration
National Medical Association
NHLBI Ad Hoc Committee on Minority Populations
Society for Academic Emergency Medicine
Society of General Internal Medicine
-----------------------------------------------------------
INTRODUCTION TO EMERGENCY MEDICAL DISPATCHING
The American Heart Association (AHA) has proposed the
concept of a "chain of survival" for victims of cardiac
arrest.(1) The chain of survival includes four links, each
of which must be robust to ensure maximal survival rates.(2)
The components of the chain are:
1. Early access to the emergency medical services (EMS)
system
2. Early cardiopulmonary resuscitation (CPR), either by
bystanders or first-responder rescuers
3. Early defibrillation by first responders, emergency
medical technicians, or paramedics
4. Early advanced life support.
Although the chain of survival was initially conceptualized
for cardiac arrest victims, patients with an acute
myocardial infarction (AMI) also benefit from the chain-of-
survival approach to emergency cardiac care in the
community.(3)
The first link of the chain of survival (early access)
encompasses several major actions that must occur rapidly.
Among these are recognition of the symptoms and signs of the
AMI by the patient and bystanders, notification of the EMS
system (often by use of the 9-1-1 emergency telephone
number), recognition of a cardiac emergency by the medical
dispatcher, and activation of available EMS responders.
Each action is a part of the early access link.(2)
During the past 15 years, the public has been educated to
use the 9-1-1 emergency telephone number to summon help for
a range of emergencies, from minor problems to life-
threatening conditions.(3,4) The value of the 9-1-1 system
is probably increased if there is a qualified professional
--the emergency medical dispatcher (EMD)--to process
emergency medical calls.(2,5)
An EMD is a trained public safety telecommunicator with the
additional training and specific emergency medical knowledge
essential for the efficient management of processing 9-1-1ø
calls and other emergency medical communications.(6) EMD's
can perform some important functions that may enhance the
efficiency and effectiveness of prehospital care for AMI
patients. They can elicit symptoms from callers to
determine if a heart attack is possibly occurring(7,8) and
activate appropriate EMS responders to deal with the AMI
patient.(9) Dispatchers can also provide 9-1-1 callers with
instructions for how to care for the possible AMI patient
until help arrives--including CPR, if necessary.(7,10-16)
Effective emergency medical dispatching has the goal of
sending the right EMS resources to the right person, at the
right time, in the right way, and providing the right
instructions for the care of the patient until help arrives.
This goal can be ideally accomplished through the trained
EMD's careful use of a protocol that contains the following
elements:(6,17,18)
1. Systematized caller-interrogation questions that are
chief-complaint specific
2. Systematized prearrival instructions
3. Protocols that determine vehicle response mode and
configuration based on the EMD's evaluation of injury or
illness severity
4. Referenced information for dispatcher use.
The impact of well-trained, medically managed EMD's on the
early care of potential heart attack victims is believed to
be potentially beneficial. Five elements seem to be key to
an effective emergency medical dispatch program:
* Use of medical dispatch protocols
* Provision of dispatch life support (see definition below)
* EMD training
* EMD certification
* Emergency medical dispatch quality control and
improvement processes.
This paper discusses each of these elements and makes some
recommendations for improving emergency medical dispatching
in the United States. Local, county, and State governments
have a responsibility to ensure that 9-1-1 and emergency
medical dispatch centers are staffed by qualified EMD's.
This involves including emergency medical dispatching as
part of a community's assessment of its EMS needs, and
designating resources that are indicated, to serve the
welfare of its citizens.
ø or a 7-digit emergency access telephone number in those
areas without 9-1-1 service.
-----------------------------------------------------------
ISSUES AND RECOMMENDATIONS FOR EMERGENCY MEDICAL DISPATCHING
Two documents on emergency medical dispatching that have
been developed by nationally authoritative agencies are:
* The ASTM's "Standard Practice for Emergency Medical
Dispatch"(6)
* The National Association of EMS Physicians' (NAEMSP)
position paper, "Emergency Medical Dispatching."(17)
The recommendations set forth in these documents are
believed to be appropriate, and all EMS systems are
encouraged to implement them as much as possible. Rather
than repeating or superseding the points made in those
documents, this paper addresses emergency medical
dispatching issues with an emphasis on care of the AMI
patient and reiterates the recommendations that are relevant
for an emergency medical dispatching system to effectively
handle the AMI patient.
The ASTM is also currently developing two additional
documents on emergency medical dispatching. It is
anticipated that these standards will parallel many of the
recommendations contained in this paper. These documents
are:
* The ASTM F-1552 "Standard Practice for Training,
Instructor Qualification and Certification Eligibility of
Emergency Medical Dispatchers"(19)
* The ASTM F-1560 "Standard Practice for Emergency Medical
Dispatch Management."(20)
It should be noted that few well-constructed, objective,
published studies exist that address the components or the
effectiveness of components of emergency medical
dispatching. This is in large part due to the difficulty in
defining, as well as determining, those patient outcomes or
improvements in patient conditions that are a result of
emergency medical dispatching. The patient's condition can
deteriorate during the time it takes a prehospital provider
to arrive at the scene. Outcome parameters based on the EMS
personnel's initial patient findings are not well defined
for most prehospital problems other than cardiac arrest and
critical trauma. To guarantee that outcomes actually result
from the use of a given protocol, a study must demonstrate
high compliance to that protocol by the dispatchers.
Studies must clearly identify the exact protocol or specific
part of the protocol that is undergoing evaluation. The
need for further studies regarding the training and
retraining, quality control and improvement of EMD's, and
the benefit and optimum configuration of prehospital EMD
protocols is a general recommendation of this paper.
Medical Dispatch Protocols
Effective EMD practice is based on the consistent use of
medically approved dispatch protocols. These protocols are
a written system of procedures for the evaluation of,
response to, and provision of care to emergency
patients.(13) A written dispatch protocol system directs
the EMD to complete a chief-complaint-specific, preplanned
interrogation of the 9-1-1 caller to accurately assess and
act on the medical emergency.(6) A dispatch protocol
requires the EMD to interrogate the caller to identify the
demographics, characteristics, and general medical problem
of the patient and to determine the status of consciousness
and breathing. This is followed, when appropriate, by a
more specific systematized interrogation related to the
reported general medical problem, selected by the EMD from
among protocol choices that cover all possible presenting
medical emergencies. Systematized interrogation is an
essential component of a comprehensive medical dispatch
protocol, even for those systems not prioritizing between
advanced life support (ALS) and basic life support (BLS)
calls.(5)
The dispatcher interrogation process has four important
purposes:
1. Provide the EMD with the information needed to make a
correct decision regarding initial unit response,
including type of EMS personnel required and use of
lights and siren
2. Enable the EMD to determine the presence of conditions
or situations requiring prearrival instructions
3. Enable the EMD to provide responders with prearrival
information for planning of, and preparation for,
on-scene patient care activities
4. Assist in ensuring the safety of the patient, the
responders, the caller, and other bystanders.
Use of a medical dispatch protocol helps the EMD to avoid
making a faulty "diagnosis" of the medical emergency and
incorrect dispatching decisions. When EMD's fail to use
medical dispatch protocols, they may be prone to make an
assessment of the situation based on inadequate information.
The EMD may fail to identify the patient's chief complaint
and, therefore, may provide inadequate response or advice.
EMS literature provides many examples of the adverse
outcomes and legal problems arising from such faulty
dispatch practices.(21,22)
The issue of patient and bystander denial of or inability to
recognize heart attack symptoms is commonly encountered at
dispatch.(13)
Medical dispatch protocols should include standardized
response classifications based on the EMD's structured
assessment of the medical urgency of the incident and
indicate the level of EMS response needed. These response
classifications should be based on recognized medical
symptoms and the type of incident.(9,23-25) In systems that
vary levels of response, dispatch protocols should specify
which situations require an ALS versus a BLS response. This
is important in those EMS systems that are "tiered" and
allow rapid response by a level of EMS personnel appropriate
for the seriousness of the emergency as determined by the
EMD (e.g., ALS personnel are dispatched for life-threatening
emergencies). Medical dispatch protocols may also specify
which situations require a lights-and-siren response to the
scene and which do not. With EMS vehicle-related accidents
in the United States reported to have been 2,400 for
ambulances in 1990,(26) it is medically unsound and
managerially unsafe to require lights-and-siren response on
all incidents.(27-29)
Response classifications will vary from one EMS system to
another based on the type of system resources, response
limitations, traffic patterns, and geography of their
service areas. Response configurations often become more
complex for larger or more sophisticated systems.(23-25) It
must be stressed that decisions regarding response
assignments are a responsibility of medical management and
should be subject to the approval of the medical director of
an EMS system.(6,11,12)
Ideally, standardized response classifications should be
based on a uniform coding system. This would assist in
consistency of use, statistical comparison, and scientific
research across EMS systems that use the same medical
dispatch protocols.(9)
The non-English-speaking caller poses an ever-increasing
challenge for many dispatch centers, especially those in
large urban centers. This issue has three basic solutions:
1) sufficient staffing of EMD's with multilingual capability
where a center's constituency has demonstrated frequent use
of a particular language or languages other than English; 2)
secure access to a language-interpreting service such as
that provided by one of the major long distance carriers;
and 3) provision of medical dispatch protocols in commonly
encountered languages. At the time of publication of this
paper, alternate language versions of protocols used in the
United States are available in Spanish, French, and German.
It is recommended that emergency medical dispatch protocols:
* Be medically approved
* Be uniform throughout each EMS jurisdiction
* Use standard response classification codes to facilitate
scientific comparison and study among systems using the
same protocols
* Be followed consistently and nonarbitrarily by all EMD's,
except when additional clarification is needed
* Delineate the types of cases requiring an ALS versus a
BLS response (especially in tiered systems) and the types
of cases requiring use of lights and siren from those
that do not.
Dispatch Life Support
Dispatch life support encompasses the knowledge, procedures,
and skills used by trained EMD's to provide care through
prearrival instructions to callers. It consists of those
BLS and ALS principles that are appropriate for application
by EMD's. Dispatch life support forms the basis for
establishing the content and application methodology for
prearrival instructions used by medical dispatchers.(30)
The NAEMSP(17) has also defined dispatch life support (see
the definitions that follow).
Prearrival instructions differ from the less well-specified
telephone aid, and the differences between them form the
basis of recommendations for standardization of EMD training
and practice (including dispatch life support):
Prearrival Instructions. Prearrival instructions are
medically approved, written instructions given by trained
EMD's to callers that help provide necessary assistance to
the victim and control of the situation prior to the arrival
of EMS personnel. Prearrival instructions are read word for
word by the EMD to the fullest extent possible.
The necessity to routinely provide prearrival instructions
has been addressed by the NAEMSP: "Pre-arrival instructions
are a mandatory function of each EMD in a medical dispatch
center. . . .Standard medically approved telephone
instructions by trained EMD's are safe to give and in many
instances are a moral necessity."(17) The failure to
provide prearrival instructions, when possible and
appropriate, is currently being litigated in the Nation's
courts as a form of dispatcher negligence. It is
interesting to note that one of the most significant
obstacles to the establishment of prearrival instructions,
and medical dispatch protocol systems in general, has been
the notion that agencies can be successfully sued for
engaging in such activities. It appears that there has
never been a dispatcher negligence lawsuit filed for the
provision of medically sound prearrival instructions. There
are a significant number of lawsuits recently completed or
in progress for which the omission of prearrival
instructions (or "dispatcher abandonment," as the legal
terminology describes it) has been alleged.
The nature of prearrival instructions is such that they must
be provided in a timely manner, over the telephone, and
without the benefit of practice or visual verifications.
Thus, it is important that EMD's carefully adhere to
protocols for the provision of telephone-instructed
treatment in a standard, nonarbitrary, and reproducible way.
-----------------------------------------------------------
Box 1.
Application of Emergency Medical Dispatching Principles to
the Patient With Suspected AMI and Cardiac Arrest
Emergency medical dispatching principles, as operationalized
in medical dispatch protocols and prearrival instructions,
can be readily applied to the potential AMI and cardiac
arrest patient. For all patients, key questions are asked
as to whether the patient is reported to be unconscious and
not breathing to ascertain if a cardiac arrest has occurred.
For example, the answer "I'm not sure" regarding breathing
status given by a second-party caller (someone who can see
or easily access the patient) is assumed to mean "no";
therefore, a maximal response, preferably ALS/paramedics,
would be sent immediately. The key questions, then, also
determine the most appropriate level of response. If a
cardiac arrest has been verified, first responders can be
given the chief complaint, approximate age, the status of
consciousness and breathing, and the dispatch response code,
facilitating preparation for possible use of an automated
external defibrillator. Prearrival instructions in the case
of a cardiac arrest would entail dispatcher-assisted CPR.
For a patient with chest pain, additional dispatcher
interactions with the caller are recommended to overcome
caller or patient denial or to validate that the caller's
descriptions of symptoms and signs may represent the
presentation of a heart attack. Specifically, the
dispatcher may ask the caller if the patient has severe
indigestion; tightness; heavy pressure; constricting band
and crushing discomfort in the chest with the spread of
these feelings to the arms, jaw, neck, or back; as well as
the presence of nausea or sweating. Verification of these
symptoms directs the dispatcher to advise the responders so
that their functions at the scene can be expedited.
Prearrival instructions in these cases would include correct
positioning of the patient, instructions for vomiting, and
instructions to monitor very closely and to call back if the
patient's condition worsens.
-----------------------------------------------------------
Telephone Aid. Telephone aid, as defined herein, consists
of "ad libbed" instructions provided by either trained or
untrained EMD's. Telephone aid differs from dispatch life
support in that the instructions provided to the caller are
based on the dispatcher's previous training in a procedure
or treatment but are provided without following a scripted
prearrival instruction protocol. This method exists because
either no protocols are used in the medical dispatch center
or protocol adherence is not required by policy and
procedure (e.g., the dispatcher is "trained" in CPR and thus
describes to the caller, to the best of his or her verbal
ability, how to do CPR).
As noted in the section (above) on prearrival instructions,
dispatchers must carefully adhere to written protocols.
Unfortunately, coupled with a growing interest and effort
within public safety agencies to provide some type of
telephone instructions to callers, many agencies are
"allowing" dispatchers to ad lib instructions. There
appears to be a significant difference between dispatch life
support-based prearrival instructions and telephone aid.
Telephone aid, as defined, may only ensure that the
dispatcher has attempted to provide some sort of care to the
patient through the caller but does not ensure that such
care is correct, standard, and medically effective or even
necessary in the first place.
Telephone aid often causes the following predictable errors:
1. Failure to correctly identify conditions requiring
telephone intervention and therefore prearrival
instructions in the first place (e.g., "saving" an
infant having a febrile seizure who was incorrectly
identified as needing CPR due to failure to follow
protocols that are medically designed to verify
need--verify breathing, pulse, etc., before
potentially dangerous dispatcher-invasive treatments
such as compressions are initiated).
2. Failure to accurately identify the presence of interim
symptoms and signs (or the lack of them) during the
in-progress provision of telephone intervention (e.g.,
dispatchers who ad lib CPR sequences often miss
important patient verifiers that cannot be seen by the
dispatcher, such as watching for the chest to rise).
3. Failure to perform (describe or teach) multistep
procedures, such as CPR care, in a consistent and
reproducible fashion regardless of which dispatcher in a
center provides such help (e.g., quality assurance
review of these types of cases often reveals that
dispatchers in the same center [or even the same
dispatcher] perform care differently each time if they
are not following scripted prearrival instruction
protocols closely).
Telephone aid, as defined, often provides only the illusion
of correct help via telephone without predictably ensuring
consistent and accurate instructions to all callers.
Telephone aid, therefore, is usually considered an
inappropriate and unreliable form of dispatcher-provided
medical care.
Medical dispatch practice must be safe, competent, and
effective. The systematic use of medically preapproved
protocols will help to ensure that the dispatcher
performance is structured and reproducible and can be
objectively measured.
In light of the important differences between prearrival
instructions and telephone aid, and to improve
standardization of EMD training and practice, it is
recommended that:
* Dispatch life support be adopted nationwide as an
essential concept of emergency medical dispatch
* Dispatch life support be standardized
* Prearrival instructions be provided from written protocol
scripts for all medical emergencies.
Medical Dispatcher Training
Formal EMD training contributes to the safe and effective
performance of the medical dispatcher's role in EMS.(11)
Guidelines for the core content of EMD courses are currently
being standardized by the ASTM.(19) These guidelines will
provide direction for the training (and certification) of
EMD's regarding appropriate decisions about EMS responses in
a safe, consistent, and nonarbitrary manner. Within the
context of this broad goal, current EMD training is
generally at least 24 hours in length (e.g., three 8-hour
days). A typical course consists of an overview of
dispatching objectives and basic dispatch techniques,
concentrating on known problem areas. The role of the EMD
is defined, and the concepts of medical dispatching are
discussed in detail. The medical dispatch protocol in use
by the sponsoring EMS agency is learned, with emphasis on
interrogation skills, protocol compliance, and the provision
of prearrival instructions. Common medical problems are
reviewed, with an emphasis on interrogation specifics for
each type of problem, and the relevance and relationship of
listed prearrival instructions. Throughout the training,
the importance of identifying the presence or absence of
symptoms (such as "chest pain") during interrogation is
emphasized, rather than making a judgmental diagnosis of
"heart attack." The medical significance of the various
levels of urgency for each chief complaint and its resultant
response is clarified to give the student the ability to
prioritize quickly the various types of incidents
confronting EMD's daily. Often, courses use mock case
drills to give the dispatcher a hands-on feel of protocol
performance.
A formal examination to test student understanding and
assimilation of the curriculum should be administered at the
completion of an EMD course. This enables formal
certification in jurisdictions requiring or allowing
it.(6,17,31)
It is recommended that EMD training:
* Be required of all medical dispatchers
* Be consistent in core curriculum content nationally
* Be based on the medical dispatch protocol selected and
approved by the sponsoring agency's physician medical
director, allowing for practice use of the protocol by
the EMD trainee.
Medical Dispatcher Certification
Given the very important role of the dispatcher in the chain
of survival, certification should become governmentally
mandated throughout the United States.(6,17,31)
Certification should include requirements for continuing
education and recertification. Continuing education
programs should incorporate formal written and practical
tests. Continuing education and recertification allow EMS
agencies to formally promote and ensure the ongoing quality
of EMD performance. Certification also establishes
processes for decertifying individuals who cannot meet
minimum standards. There have been no studies to determine
the optimal frequency or process of recertification;
therefore, expert panels have recommended that EMD's should
be recertified every 2 to 4 years.(6) At least 12 hours per
year of continuing education should be required for EMD
recertification.(20,31)
It is recommended that EMD certification:
* Be required of all EMD's through either State government
processes or professional medical dispatch standard-
setting organizations
* Require continuing education and recertification as
components of a continuing certification process.
Medical Dispatch Quality Control and Improvement
Each EMS system should have in place a comprehensive quality
improvement program. Four goals in the quality control and
improvement of medical dispatch activities are that:
1. Dispatchers understand medical dispatch policy,
protocol, and practice
2. Dispatchers comply with medical dispatch policy,
protocol, and practice
3. Deficiencies in understanding and compliance with
medical dispatch policy, protocol, and practice among
dispatchers be corrected
4. Medical dispatch policy, protocols, and practice be
updated on a continuous basis to ensure that they are
appropriate and effective.
A comprehensive quality control and improvement system for
emergency medical dispatching has several components. Among
these are selection of personnel; orientation; initial
training; certification and recertification; continuing
dispatch education; physician medical direction; data
generation; case review and performance evaluation;
correction of performance problems (risk management); and
decertification, suspension, or termination.(32) These
components of medical dispatcher quality improvement are
essential for maintaining the type of employment environment
necessary to ensure safe and effective patient evaluation
and care.
One of the most important areas of quality
control/improvement is that of case review and performance
evaluation.(32) Between 7 and 10 percent of each EMD's
cases should be randomly reviewed.(20) The review of random
cases ensures that each dispatcher's current practice
(especially compliance with protocol) is determined.(33) In
addition, the review of out-of-the-ordinary cases (both
excellent and problematic) is important. These cases are
often identified by sources external to the dispatch center.
The involvement of EMS field personnel in reporting
incidents that appear to represent dispatch-related problems
can be very helpful in strengthening the performance and
policy evaluation process.
These case reviews should serve as the basis for periodic
dispatcher performance evaluation. The cumulative level of
compliance to protocol of each medical dispatcher should be
evaluated and compared with preset levels of acceptable
practice. This provides an objective method of establishing
thresholds of performance for these essential members of the
EMS team. Corrective steps may include continuing education
or disciplinary action.
In the absence of adequate case review and performance
evaluation, it has been shown that dispatcher compliance to
protocol deteriorates and is generally under 50 percent.(34)
Medical direction is an essential element in the overall
assurance of quality performance of EMD's. Just as medical
direction is uniformly recommended for emergency medical
technicians and paramedics, the EMD requires careful
attention and guidance. According to the NAEMSP, "The
medical aspects of emergency medical dispatching and
communications are an integral part of the responsibilities
of the Medical Director of an EMS system. . . .Quality
Improvement, Risk Management, and Medical Control and
Direction are essential elements to the management of
medical dispatch operations within the EMS system."(17)
It is recommended that ongoing medical dispatch quality
control and improvement processes:
* Be in place for all medical dispatch centers
* Allow for random review of cases
* Require high-level compliance to protocol as a major
factor in dispatcher performance evaluation
* Be the basis of dispatcher reeducation, feedback,
discipline, and medical management
* Be carried out under the medical direction of a qualified
physician.
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SUMMARY
The EMD is a key member of the EMS team. EMD's may have a
profound effect on the early care of potential heart attack
victims. To ensure optimal emergency medical dispatching,
this paper has made a number of recommendations, which are
highlighted below:
* Each EMS system should utilize a set of written,
medically approved dispatching protocols for the
evaluation of, response to, and provision of care to the
AMI patient. These protocols should be followed
consistently and nonarbitrarily by all EMD's.
* Dispatch life support should be provided by each EMS
system. EMD's should be required to use medically
approved, written prearrival instructions to help callers
provide aid to the AMI patient and control the situation
prior to the arrival of EMS personnel.
* Every EMD should be formally trained, based on a
nationally consistent core curriculum, with an emphasis
on mastery of the dispatching protocol used by the
sponsoring EMS agency.
* Certification should be required of all EMD's, either
through State governments or professional medical
dispatch standard-setting organizations. This process
should also mandate continuing education and
recertification.
* Every EMS system should have in place a system of
continuous quality improvement for medical dispatching.
This should include a random review of each EMD's cases.
Periodic performance evaluations should be conducted with
each EMD, with emphasis on the EMD's adherence to
dispatching protocol.
* All aspects of emergency medical dispatching should be
the ultimate responsibility of the EMS physician who
provides medical direction for a given EMS system. That
is, an EMS physician should be in an authoritative
position to manage the medical care components of an EMD
program, including overseeing training, selecting and
approving dispatch protocols and prearrival instructions,
and evaluating the EMD system.
These recommendations, if implemented, may result in
improvement of emergency medical dispatching in general--
and potentially better identification and treatment of
patients with symptoms and signs of AMI, in particular.
-----------------------------------------------------------
REFERENCES
1. Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving
survival from sudden cardiac arrest: the "chain of
survival" concept. A statement for health professionals
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the Emergency Cardiac Care Committee, American Heart
Association. Circulation 1991;83(5):1832-47.
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19. American Society for Testing and Materials (ASTM).
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qualification and certification eligibility of emergency
medical dispatchers. September 1994.
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Vaughn WK. An analysis of ambulance accidents in
Tennessee. JAMA 1987;258:1487-90.
28. Clawson JJ. The red-light-and-siren response. J Emerg
Med Serv 1981;6(2):34-5.
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establishing standards that work. J Emerg Med Serv
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31. Clawson JJ. Regulations and standards for emergency
medical dispatchers: a model for state or region. Emerg
Med Serv 1984;13(4):25-9.
32. Clawson JJ. Quality assurance: a priority for medical
dispatch. Emerg Med Serv 1989;18(7):53-62.
33. Clawson JJ. Medical dispatch review: "run" review for
the EMD. J Emerg Med Serv 1986;11(10):40-2.
34. Clawson JJ. Six month status report with evaluations and
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Salt Lake City: Medical Priority Consultants, Inc;
December 27, 1990. 21 p.
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DISCRIMINATION PROHIBITED: Under provisions of applicable
public laws enacted by Congress since 1964, no person shall,
on the grounds of race, color, national origin, handicap, or
age, be excluded from participation in, be denied the
benefits of, or be subjected to discrimination under any
program or activity (or, on the basis of sex, with respect
to any educational program or activity) receiving Federal
financial assistance. In addition, Executive Order 11141
prohibits discrimination on the basis of age by contractors
and subcontractors in the performance of Federal contracts,
and Executive Order 11246 states that no federally funded
contractor may discriminate against any employee or
applicant for employment because of race, color, religion,
sex, or national origin. Programs of the National Heart,
Lung, and Blood Institute are operated in compliance with
these laws and Executive Orders.
-----------------------------------------------------------
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
National Institutes of Health
National Heart, Lung, and Blood Institute
NIH Publication No. 94-3287
July 1994
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