Dispatcher Prioritization of 9-1-1 Medical Calls in the City of San Bernardino CA: The Impact on Patient Care.

The system used by San Bernardino City CA. Fire Department (SBFD) dispatchers to prioritize 9-1-1 medical calls for service had not been formally evaluated to determine its impact on patient care and overall service delivery. The purpose of this research was to analyze specific elements of SBFD’s response prioritization system to determine its ability to effectively allocate resources based on patient needs, and to examine its potential effect on patient care. Evaluative methods were used to analyze dispatching records and patient care data from emergency medical service (EMS) calls processed through SBFD’s 9-1-1 communications center. The research answered the questions of how much impact the use of this system had on EMS resource availability and response times, how proficient SBFD dispatchers are in following system protocols, and how often the system’s use results in insufficient resources being sent to a medical call for service. The research found that the system’s use increased EMS resource availability by 10.2% on average, and decreased response times to specific higher priority medical calls by up to 32.5%. The research also found that SBFD dispatchers were proficient in following established system protocol, with average protocol compliance scores of greater than 95%. Finally, research found that in 6.5% of the EMS calls categorized by dispatchers as lower priority, the patient could have benefited by a higher priority response. However, the research concluded that the system’s use resulted in a greater number of patients being affected by the positive benefits of a shorter response times than were affected by a lower priority response. Recommendations were made on where changes in the system could be made to improve its efficiency, and how it could be expanded to improve EMS delivery in the City of San Bernardino. Dispatcher Prioritization 3 TABLE OF CONTENTS Abstract . 2 Introduction.4 Background and Significance . 6 Literature Review.14 Procedures.27 Results . 39 Discussion.44 Recommendations.51 Reference List . 56 Table of Figures Figure 1: SBFD Fire and EMS Calls for Service from 1998 through 2006 . 9 List of Tables Table 1: Overview of Response Criteria Used by SBFD based on MPDS Protocols.11 Appendicies Appendix A: SBFD Patient Contact Report (PCR) Sample . 63 Appendix B: Quality Assurance Report for SBFD Dispatch Center for October 1, 2007 through December 31, 2007 . 64 Dispatcher Prioritization 4 Dispatcher Prioritization of 9-1-1 Medical Calls in the City of San Bernardino CA: The Impact on Patient Care. Introduction Over the past decade, the number of emergency medical service (EMS) calls that the San Bernardino City Fire CA. Department (SBFD) has responded to has increased at an average rate of 7% per year. This increased demand on fire department resources has resulted in a decrease in service level due to response times that are longer than the standards established by the SBFD. In response to this trend, the SBFD implemented an Emergency Medical Dispatching (EMD) program in their emergency communications center that included a system of prioritizing EMS calls for service. This call prioritization system uses SBFD dispatchers to allocate resources to each medical call for service based on the medical urgency of the patient’s chief complaint and their reported symptoms. The chief complaint and symptoms are determined through the caller’s responses to a series of medically based questions asked by trained SBFD dispatchers. There is evidence that the system’s use increases SBFD’s advanced life support (ALS) resource availability and decreases their response times. Each of these outcomes helps ensure that these resources can respond in a timely fashion when they are critically needed. However, there is also evidence that occasionally, the system recommends sending basic life support (BLS) resources to calls for service when it is later determined that the patient’s condition warranted ALS intervention. This usually occurs because of incomplete or errant information provided by the caller, sudden changes in the patient’s condition, or dispatcher error. Dispatcher Prioritization 5 The evidence from each of these scenarios represents potential clinical benefits and risks to the patient. The problem, however, is that insufficient research has been done to determine the frequency in which each scenario occurs, or the potential impact that each scenario could have on patient care. The purpose of this research was to measure the systems impact on emergency medical service (EMS) resource availability and response times, its ability to effectively allocate resources based on the patient’s medical condition, and to determine dispatcher proficiency in following the system’s protocols. Evaluative methods will be used in conducting this research. By collecting and analyzing SBFD’s computer aided dispatch (CAD) records, the research will first answer the question of how much impact the dispatch prioritization system used by SBFD has on ALS resource availability in the SBFD. Using the same records, the research will answer the second question of how much impact the dispatch prioritization system used by SBFD has on ALS response times for 9-1-1 callers with higher priority medical symptoms in the City of San Bernardino. The third question that this research will answer is how often the system’s use results in BLS resources responding to medical calls where it is later determined that ALS intervention was indicated either by protocol or by clinical presentation. This question will be answered through a review of medical records from patients who received a BLS response due to the use of SBFD’s call prioritization system. Finally, the research will answer the question of how proficient SBFD dispatchers are in following the EMS call prioritization protocols used to determine the appropriate level of response for each patient. Based on the findings of this research, recommendations will be made Dispatcher Prioritization 6 on how the SBFD could effectively use its emergency dispatching resources to increase their effectiveness in pre-hospital EMS delivery. Background and Significance As the public’s expectation of fire and emergency service agencies continues to expand, fire department leaders are faced with the challenge of meeting increasing service demands with limited resources. One notable example of this type of service expansion is the delivery of pre-hospital EMS by fire service agencies. Once considered a secondary duty in many fire service organizations, EMS delivery has now come to the forefront of operations in most fire departments across the United States. Recent statistics indicate that nationally, over 55% of all fire department calls for service are EMS related, while actual fire runs have fallen to about 8% (United States Fire, 2007). The evolution of emergency services provided by the SBFD is similar, if not more pronounced than the national trends. Established in 1878, the SBFD has a long and proud heritage of service to the community. Like most fire departments, the SBFD’s roots trace back to its original exclusive mission of suppressing fires. Over time, however, the citizen’s of San Bernardino City voiced a clear desire to expand the department’s role to include the delivery of pre-hospital medical care. In response, the SBFD instituted the City’s first fire department based paramedic program in 1976. The program began with 23 paramedics responding from 3 of the City’s 10 fire stations. All other emergency operations personnel were trained to a minimum level of Emergency Medical Technician-1 (EMT-1) (Shaw, 2003). At that time, the city’s population was approximately 80,000 people, and although the public favored the paramedic program, no additional funding was secured to sustain it. Dispatcher Prioritization 7 Currently, the SBFD employs 159 emergency operations personnel delivering fire protection and EMS to nearly 200,000 citizens. Since the fire based paramedic program was initiated in 1976, the department has opened two additional fire stations, placed paramedics on every SBFD engine company, added a two-person paramedic squad, and nearly doubled the number of paramedic trained fire personnel employed by the fire department. Although the SBFD is the primary ALS provider in the City of San Bernardino, they do not provide medical transportation. This service is provided through a contract with a private medical transportation company. The majority of this expansion in the SBFD has been accomplished through the City’s general fund monies. No dedicated tax revenue source has been established to sustain the EMS program. This frequently places Fire Department needs in competition with other vital City needs, with funding that is often insuff