Criteria based on what?

You all know I am not a fan of little boxes.

I dislike the little boxes we have to cram our patients into to treat them based on chief complaint.

Also on my list is the little boxes we take them to the hospital in.  Bolting a box onto a van isn’t enough.  More on that another time.

On the top of this list in big red letters are the little boxes our call takers are required to fit their callers into.

They must meet criteria in order to be coded, qualified, weighted, and then sent out to the trauma hungry troops on standby all over the City.

Problem is, it doesn’t work.

I do not know Dr Clawson, but I do know his system and that, if a system can correctly act on the information gathered and coded, it works most of the time.

What really gets me going these days is the purposeful miscategorization or non categorization used to move calls out of the call center faster than they need to be.  I am not alone in this experience, getting messages, tweets and emails from folks all over the USA asking me what they can do to improve dispatch.

You can’t improve dispatch.  Not until you improve the callers themselves.

One of my readers described it as GIGO (Garbage In, Garbage Out) meaning, in the most respectful of terms, that dispatch should not be changing anything the caller says and that if the caller is wrong, then I do hope my dispatcher is wrong as well.  If a person calls and tells the dispatcher that the space shuttle has crashed on main street and thousands are dead, maybe it did.  But the problem lies in sending that call out before it is coded.

The two most inexperienced people in the system are the ones guiding the system.  The caller and the call taker.

I have never been to a call that was reported, coded and turned out to be the same thing, mainly for the same reason my patients’ chief complaints never seem to jive with my treatment per protocol:

They don’t fit into your pre-determined boxes.

Many systems run a BLS tier, or perhaps a single paramedic resource to handle Omega, Alpha or even Bravo calls.  Here in mine, there seems to be no rhyme or reason to the assigning of resources on some calls.

A call coded by the system, based on information provided by the caller, to the call taker has been declared a 26A1, a sick call.  Yet in the call classification next to the code is the term BLEED-SEVERE.  And now the call becomes a code 3 and 6 or more lives are at risk.

“Better safe than sorry, right?”  Good thought.  Who is in more danger?  The person who bit their lip and called 911 or the 6 responders using red lights and sirens to respond to the call now thought to be more than it is.

“Then what’s the answer, smart guy?”

Ditch the codes.  Stop the tiny box requirement.

If they call and say “I bit my lip,” Dispatch it as such.  Let the responders apply calculated risk to the situation without being blinded by administrative tricks used to ring the bells faster, improving your call center stats.

If you can send a call out in 30 seconds without gathering all the information, that is not a success.

I am not blaming dispatchers.  That voices that tell me where the sick people are are not the ones in control of the dispatch system, but the ones required to work within it, not unlike me not liking aspects of my treatment protocols.

GIGO.

They relay what they are told and code the call.

It is the trick of changing the code or description that I don’t like.  That is how the cut fingers, bit lips and sleeping people send out a full ALS response and drain the system of resources at a time when we are getting stretched thin.

By changing from a criteria based system to a “plain text” system, two distinct things will happen.

Firstly, crews can use their judgment, ETA and experience to determine their response priority based on what the caller actually said, not what the system thinks they might be saying.

“My back hurts again” is not coded as “Non-Traumatic Pain-Code 3″ so the crews can apply their expert training to audit the dispatches in real time.  I worked in a system like this and it worked.

Secondly, it will become very complicated and difficult to classify and track types of calls for analysis after the fact.

“We don’t know how many CPR calls went out last quarter because we have to go back through each call instead of just pulling the codes.”

A recent study by UCSF and SFFD Medical Director Karl Sporer celebrates the finding that 1 out of 7 reports of a rescusitation in San Francisco turned out to be just that.  You can’t find stats like that celebrated outside of baseball.  1 in 7 was a success.  I see the 6/7 mis-reported or mis-coded calls as room for improvement indeed.

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28 thoughts on “Criteria based on what?”

  1. We use the same codes (AMPDS) here in Austria and they suck too.

    The best ist the 6D1 (sever Difficult Breathing), thats almost every time a Patient with COPD, but his Problem is not COPD related, something like He has COPD AND cut his Finger.

  2. We use the same codes (AMPDS) here in Austria and they suck too.

    The best ist the 6D1 (sever Difficult Breathing), thats almost every time a Patient with COPD, but his Problem is not COPD related, something like He has COPD AND cut his Finger.

  3. I’m in favor of the plain text dispatching, most places are going to plain text radio communications, so why not do the same with dispatches? I agree that most 911 centers will argue that they will no longer be able to provide accurate statistics, but what if the medics were given the coding responsibility as part of their paperwork? 9 times out of 10 the code from 911 is wrong anyway, so why not allow the person who actually treated the patient to code the call?

    Sadly, I don’t foresee this changing anytime soon, but it sure sounds like a nice goal to work towards. Maybe suggest a pilot program in your area Happy? You west-coasters seem slightly more open to testing changes than those of us over on the east coast.

  4. I’m in favor of the plain text dispatching, most places are going to plain text radio communications, so why not do the same with dispatches? I agree that most 911 centers will argue that they will no longer be able to provide accurate statistics, but what if the medics were given the coding responsibility as part of their paperwork? 9 times out of 10 the code from 911 is wrong anyway, so why not allow the person who actually treated the patient to code the call?

    Sadly, I don’t foresee this changing anytime soon, but it sure sounds like a nice goal to work towards. Maybe suggest a pilot program in your area Happy? You west-coasters seem slightly more open to testing changes than those of us over on the east coast.

  5. It’s a mix of poorly trained dispatchers and slightly informed lay-persons. Those who actually need the ambulance say all the right words, “My kids’ not breathing.” “My Uncle cut his arm off…” “Grandpa fell off the roof.” They say it like it is. Those who know how to work the system know that, if they call for a stubbed toe, they get two people who just take blood pressures and pulses, but if they say “broken foot”, they get someone who gives them pain meds.

    With the dispatchers, you have some that have previous medical training where, if someone calls in complaining of severe trouble breathing, yet they are chewing gum and talking in full sentances while lighting a cigarette, then the call will get coded appropriately. You have someone who lacks the basic understanding that, people who are having problems breathing shouldn’t be able to converse in full sentances.

    Better training and better systems is what is needed all around. I am hoping that, in the future, things will change. Until then, I will happily respond to calls like a 22 y/o male, 50 weeks pregnant, bleeding from the nose…

  6. It’s a mix of poorly trained dispatchers and slightly informed lay-persons. Those who actually need the ambulance say all the right words, “My kids’ not breathing.” “My Uncle cut his arm off…” “Grandpa fell off the roof.” They say it like it is. Those who know how to work the system know that, if they call for a stubbed toe, they get two people who just take blood pressures and pulses, but if they say “broken foot”, they get someone who gives them pain meds.

    With the dispatchers, you have some that have previous medical training where, if someone calls in complaining of severe trouble breathing, yet they are chewing gum and talking in full sentances while lighting a cigarette, then the call will get coded appropriately. You have someone who lacks the basic understanding that, people who are having problems breathing shouldn’t be able to converse in full sentances.

    Better training and better systems is what is needed all around. I am hoping that, in the future, things will change. Until then, I will happily respond to calls like a 22 y/o male, 50 weeks pregnant, bleeding from the nose…

  7. Why isn’t dispatch catching these? Why aren’t the responders complaining that their calls are coded wrong, causing an inquiry, and causing the people on the phones to do a better job? Dispatch can be changed but it won’t happen if there is a passive aggressive response to the problem: complaining.

    I’m not intending to attack this article. I am part of dispatch. I wholeheartedly agree with your issues. When someone sends an ALS call to me with text that says “lang barrier RP. Uncon PT” I want to know if anyone has tried to wake the pt? Pt may be sleeping but because some people don’t want to take an extra 15 seconds to ask them if they attempted to wake up the PT in a way that the RP could understand they code it ALS. EMD fail.

    Another solution would be giving the responders the ability to decide if they’re going to proceed yellow or go red based on the short report. Do you have that ability? I honestly don’t even know if my agencies have that ability. Often my hands are tied. At my agency, for example, FULL control of the call is with the person talking to the rp. I may dispatch and give a short report but if the situation changes I am restricted from sending additional apparatus unless the person taking the phone call tells me to or the field units tell me to.

    How much do you know about your EMD program? How can you work with it to change it? Maybe the administration is resistant to the idea because we know how people hate change but the people actually taking calls and working radios would be entirely on your side.

    It’s something to think about.

  8. Why isn’t dispatch catching these? Why aren’t the responders complaining that their calls are coded wrong, causing an inquiry, and causing the people on the phones to do a better job? Dispatch can be changed but it won’t happen if there is a passive aggressive response to the problem: complaining.

    I’m not intending to attack this article. I am part of dispatch. I wholeheartedly agree with your issues. When someone sends an ALS call to me with text that says “lang barrier RP. Uncon PT” I want to know if anyone has tried to wake the pt? Pt may be sleeping but because some people don’t want to take an extra 15 seconds to ask them if they attempted to wake up the PT in a way that the RP could understand they code it ALS. EMD fail.

    Another solution would be giving the responders the ability to decide if they’re going to proceed yellow or go red based on the short report. Do you have that ability? I honestly don’t even know if my agencies have that ability. Often my hands are tied. At my agency, for example, FULL control of the call is with the person talking to the rp. I may dispatch and give a short report but if the situation changes I am restricted from sending additional apparatus unless the person taking the phone call tells me to or the field units tell me to.

    How much do you know about your EMD program? How can you work with it to change it? Maybe the administration is resistant to the idea because we know how people hate change but the people actually taking calls and working radios would be entirely on your side.

    It’s something to think about.

  9. I have had this same complaint for a long time. I don’t like our “cookie cutter” approach to emergency medical dispatching. If EMT’s in the field can have discretion over what resources they need, why can’t an EMT working in dispatch do the same?

    I agree that it’s a system problem and not a dispatch problem. Good post.

  10. I have had this same complaint for a long time. I don’t like our “cookie cutter” approach to emergency medical dispatching. If EMT’s in the field can have discretion over what resources they need, why can’t an EMT working in dispatch do the same?

    I agree that it’s a system problem and not a dispatch problem. Good post.

  11. Any EMS system is unfortunately always going to require to ‘code’ complaints. Not just for daft bonus/target reasons but for genuine public health reasons, e.g. to help identify resource requirements, common presentations and to identify any stats that will change how you deliver health care to best suit local needs.

    However I completely agree with the lunacy of the dispatcher coding the information and a response being based on this.

    I believe the best solutions would be for a plain text solution to enable basic call logging and for a suitable response to be provided. Then AFTER the patient has presented the paramedic could update control with a suitable update from a preset list of codes which then enables the call to be closed. By changing the source of the information the data quality should markably improve and timing it after the initial response means that coding is not getting in the way of the reason d’etere – emergency health care!

    I shudder to think of some of the decisions made on current call data, bad information can be worse than no information!

  12. Any EMS system is unfortunately always going to require to ‘code’ complaints. Not just for daft bonus/target reasons but for genuine public health reasons, e.g. to help identify resource requirements, common presentations and to identify any stats that will change how you deliver health care to best suit local needs.

    However I completely agree with the lunacy of the dispatcher coding the information and a response being based on this.

    I believe the best solutions would be for a plain text solution to enable basic call logging and for a suitable response to be provided. Then AFTER the patient has presented the paramedic could update control with a suitable update from a preset list of codes which then enables the call to be closed. By changing the source of the information the data quality should markably improve and timing it after the initial response means that coding is not getting in the way of the reason d’etere – emergency health care!

    I shudder to think of some of the decisions made on current call data, bad information can be worse than no information!

  13. Great article on some of the issues with the 911 system, I’m glad my system does not code calls, they use plain language. I.E (Pre-Alert, Medical Aid. Trouble Breathing at 123 Any Street in Any Town)

    ~Brad
    @EMTGoose

  14. Great article on some of the issues with the 911 system, I’m glad my system does not code calls, they use plain language. I.E (Pre-Alert, Medical Aid. Trouble Breathing at 123 Any Street in Any Town)

    ~Brad
    @EMTGoose

  15. My system switched from MPDS to APCO for our triage cards this year, for several reasons, but most notably that our local medical director and QI committee could change response priorities without having to go through the MPDS bureaucracy. We get to tweak the cards based on what works in our system.

  16. My system switched from MPDS to APCO for our triage cards this year, for several reasons, but most notably that our local medical director and QI committee could change response priorities without having to go through the MPDS bureaucracy. We get to tweak the cards based on what works in our system.

  17. I agree that the MPDS system has its issues, general public, nursing homes and Dr. offices that have figured out how to work the system. It has its good points detailed cpr , Heimlich, bleeding instructions to name a few. The only thing that really sticks in my craw is “the most inexperienced persons” ” the caller and the call taker” we are in the top 10 largest services in the country. CAAS and ACE accredited system. (CAAS with a perfect score) my shift alone has over 100 years of experience in EMS both in the field and in dispatch. I alone have been a field medic for 26 years and still do both jobs. there are some issues with priority dispatch in general and don’t even get me started on SSM. But to unfairly lump all dispatchers as “the most inexperienced” is just wrong. Lets hope your dispatchers don’t read your blog or it could prove to be a very long shift.

  18. I agree that the MPDS system has its issues, general public, nursing homes and Dr. offices that have figured out how to work the system. It has its good points detailed cpr , Heimlich, bleeding instructions to name a few. The only thing that really sticks in my craw is “the most inexperienced persons” ” the caller and the call taker” we are in the top 10 largest services in the country. CAAS and ACE accredited system. (CAAS with a perfect score) my shift alone has over 100 years of experience in EMS both in the field and in dispatch. I alone have been a field medic for 26 years and still do both jobs. there are some issues with priority dispatch in general and don’t even get me started on SSM. But to unfairly lump all dispatchers as “the most inexperienced” is just wrong. Lets hope your dispatchers don’t read your blog or it could prove to be a very long shift.

  19. I also went and looked at the study and to the http://www.emergencydispatch.org/index.php website and if the study is correct your dispatch operation needs to be fired from the chief on down to the line dispatcher including your training department. we strive for less than a 3% over or under triage level. our medical director reviews 100% of all cardiac arrests reported from the field for appropriate treatment on their end and correct coding and pre arrival instructions on our end. we review 5% of all calls and have to maintan a 95% or greater accruacy in all the different areas of calltaking. If your guys only hitting the mark one out of 7 calls then i would hate to see what they are doing on the fire side.

  20. I also went and looked at the study and to the http://www.emergencydispatch.org/index.php website and if the study is correct your dispatch operation needs to be fired from the chief on down to the line dispatcher including your training department. we strive for less than a 3% over or under triage level. our medical director reviews 100% of all cardiac arrests reported from the field for appropriate treatment on their end and correct coding and pre arrival instructions on our end. we review 5% of all calls and have to maintan a 95% or greater accruacy in all the different areas of calltaking. If your guys only hitting the mark one out of 7 calls then i would hate to see what they are doing on the fire side.

    1. The study only looked at the final disposition of Cardiac Arrest, since that is the one and only metric we can show with certainty ALS makes a difference in.
      I would love to fire all of the Cheifs and take over, alas I am woefully underprepared for such a task, so I’m happy being a voice for positive change within the system.
      Auditing calls here may be a tougher task than most, we average 110,000 calls for service annually, including EMS, fire, transfers, street alarm boxes, and a number of other community services. It is difficult to gather so much data, especially since we only recently went to the ePCRs.
      Had I the free time I would donate it to help decode the mess that is call coding and comparing it to paramedic impression. Perhaps when I make Chief we’ll be able to hire someone into that position to make sense of all the data.
      Thanks for reading and even more for commenting,
      HM

  21. The study only looked at the final disposition of Cardiac Arrest, since that is the one and only metric we can show with certainty ALS makes a difference in.
    I would love to fire all of the Cheifs and take over, alas I am woefully underprepared for such a task, so I’m happy being a voice for positive change within the system.
    Auditing calls here may be a tougher task than most, we average 110,000 calls for service annually, including EMS, fire, transfers, street alarm boxes, and a number of other community services. It is difficult to gather so much data, especially since we only recently went to the ePCRs.
    Had I the free time I would donate it to help decode the mess that is call coding and comparing it to paramedic impression. Perhaps when I make Chief we’ll be able to hire someone into that position to make sense of all the data.
    Thanks for reading and even more for commenting,
    HM

  22. Whether it’s MPDS or any of the other “card” systems you have to realize that they are not intended to match resources to need. They are intended to be reproducible and defensible in court. They are risk management tools, not medical triage tools. Until the people that run EMS decide that the risk of litigation is outweighed by the benefit of getting care to people who need it quickly, and getting it to those who don’t less quickly, it won’t change. We used to use a plain language triage system which relied on the medical knowledge of our EMT/dispatchers, but it was replaced several years ago. Since then we go to more minor incidents as ALS calls and still miss a lot of critical calls because the callers can’t give answers that fit into neat categories. Thus the “Unknown” call about a man on the front porch of a single family home turns out to be a cardiac arrest, while the 23 y/o man lying in front of night club twenty minutes after closing time goes out as a “Cardiac Arrest”. Everyone, including the dispatcher knows that it’s not a cardiac arrest, but they have to “follow the rules”.

    Like so much in EMS, dispatch is broken in the real world, but works fine for managers who don’t actually have to respond to calls.

  23. Whether it’s MPDS or any of the other “card” systems you have to realize that they are not intended to match resources to need. They are intended to be reproducible and defensible in court. They are risk management tools, not medical triage tools. Until the people that run EMS decide that the risk of litigation is outweighed by the benefit of getting care to people who need it quickly, and getting it to those who don’t less quickly, it won’t change. We used to use a plain language triage system which relied on the medical knowledge of our EMT/dispatchers, but it was replaced several years ago. Since then we go to more minor incidents as ALS calls and still miss a lot of critical calls because the callers can’t give answers that fit into neat categories. Thus the “Unknown” call about a man on the front porch of a single family home turns out to be a cardiac arrest, while the 23 y/o man lying in front of night club twenty minutes after closing time goes out as a “Cardiac Arrest”. Everyone, including the dispatcher knows that it’s not a cardiac arrest, but they have to “follow the rules”.

    Like so much in EMS, dispatch is broken in the real world, but works fine for managers who don’t actually have to respond to calls.

    1. It doesn’t work for managers either, especially in a ‘high-performance’ system where the private ambulance provider is contractually obligated to meet 90% compliance for emergency response times. I think over-triaging calls is also a risky activity, especially when the rig going code 3 for back pain hits a school bus.

  24. It doesn’t work for managers either, especially in a ‘high-performance’ system where the private ambulance provider is contractually obligated to meet 90% compliance for emergency response times.

    I think over-triaging calls is also a risky activity, especially when the rig going code 3 for back pain hits a school bus.

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