Medical Call Review for 5161 Chaplain Way 2/6/2010Ron Roth, MD

Final 2/15/10

Medical Director, City of Pittsburgh, Department of Public SafetyMedical Director, Allegheny County Emergency Operations CenterInformation generated for this document was obtained from review of recorded call taking, dispatching and callback audio files from the AlleghenyCounty Emergency Operations Center (EOC), review of patient care records(PCR) generated by City of Pittsburgh Paramedics, discussion withadministration from the EOC and City of Pittsburgh Bureau of EMS andpersonal knowledge of the event. This review focuses specifically on themedical aspects of this call, recognizing that there were certainly otherfactors including road conditions that contributed to this tragic event.During the evening of 2/5/2010 and continuing throughout the early morningof 2/6/2010 the region was blanketed with nearly 2 feet of snow in shortperiod of time. The poor road conditions resulted in challenges to emergencyvehicles responding to calls. In addition, the number of requests for EMSservices more than doubled the average number of calls for a similar timeperiod. As a result, EMS call prioritization was initiated along with callholding and callbacks.During the time period from 2/6/2010 2:09 through 2/7/2010 7:56 there were4 individual events generated at the EOC for 5161 Chaplain Way.As an overview, each of the calls from 2/6/2010 was initially processed asmedium priority abdominal pain calls. The third call (P000183) was upgradedafter additional information was obtained. With respect to the emergencymedical dispatch (EMD) process, the calls were appropriately screened bythe call takers and entered into the CAD computer using our EMD softwareProQA. The call takers and software appropriately identified the patient at

This is a confidential document generated as part of the ContinuousQuality Improvement program for the City of Pittsburgh Department of Public Safety and the Allegheny County Emergency Operations Center

5161 Chaplain Way had abdominal pain without priority symptoms (alteredmental status, shortness of breath, fainting or suspected aortic aneurysm.) The calls were coded as ABD2 (with scale ranging from 0–highest to 3-lowestpriority)Because of the high call volume and long turnaround time for ambulancesdue to the weather, calls were being held in a pending queue and prioritizedfor dispatch. This is a standard procedure for EMS dispatch. When callvolume exceeds resources, calls with higher priorities (more likely to havetime sensitive medical conditions) such as heart attacks, shortness of breath,falls outside with the potential for hypothermia, are dispatched prior to callscoded with lower priorities. In general, this system works well to mitigateshort term time periods when demand exceeds available resources. Thesystem does work for longer term events but has limitations as identified bythis specific case.Call backs by paramedics/physicians enhance this process and serve as asafety net for the short term (several hours.) However, during the declaredweather emergency, the system was required to perform the callscreening/holding function for over 24 hours. Since this was a unique eventfor all parties involved, there was no previous knowledge on how to handlethis type of event. As a result, the existing procedures for managing pendingand repeat calls, call backs and unit dispatching were less effective.EMS units were dispatched for every request for assistance from 5161Chaplain Way. Unfortunately, there were time delays between the requestand response of the EMS providers. For calls P0033 and P0073 the delayswere less than 2 hours. While not desirable, the delays were appropriatebased on the number of calls in the pending queue, many with higherseverities. The third call, call P00183 shows a greater than 9 hour delayfrom request to dispatch. This occurred during the peak of requests for EMSresponses. During this time, the pending queue always had higher priority(E0 and E1s) calls awaiting responses. Numerous call backs occurred(patient to EOC and EOC to patient) during this time period. Each time thecall was correctly identified as patient with chronic abdominal pain withoutpriority symptoms.Unfortunately, what appeared to be underappreciated by some parties is thefact that this was the third request for service by the same person for thesame complaint. In addition, most if not all, were unaware of the details of the previous call. This may have occurred for several reasons. The CAD

screen does identify previous calls to the same address but requires anoperator to drill down to additional an additional screen to pull up the details.While call takers and dispatchers may be proficient in this process, theparamedics/physicians doing call backs are probably less likely to use thisfunction.Each call was seen as an individual request for assistance. Knowledge gainedon previous calls was not communicated at the time of the next request. As aresult we made the same request over and over (can you walk to theambulance?) It was clear from the first call that the patient would not walk tothe ambulance and identified by the second call that he could not walk to theambulance.Limitations with respect to the call back function for the EOC paramedics5061/5062 contributed to the communications problems. The current systemof documenting call backs on paper works well when the system is notoverwhelmed. However, during the first day of the winter emergency, thesystem required rapid processing of a large number of calls and formal paperdocumentation was for the most part abandoned. With multiple peoplemaking call backs over multiple shifts, information obtained on one call backwas not communicated to other personnel making call backs over theextended time period. While paramedics/physicians can document in CAD,this function is rarely used due to lack of training. In addition, the function of using the M[space]period(event#)comma to enter information appears to beless desirable then entering information directly from the event entry screen.(This is as per TCOs working the room that day.) There apparently is no alertfunction when M[space]period(event#)comma is used. Therefore, importantcall back information may not be seen by the TCOs in a timely manner. The call back areas can accommodate two personnel, each with a phone, citycomputer and CAD. They are in close proximity to the EMS and Firedispatchers which is a great advantage. Adding personnel to the area(physicians/district chiefs) without adding phones and computers mayactually reduce efficiency. The physicians had no access to CAD except viaparamedic 5061. In addition, the same phones used to make call backs, wereused to recruit additional personnel for the field, take call offs and otheradministrative duties. Often phones and personnel were not available for callbacks.During the event, it was difficult for the call screeners to track calls oncethey left the pending queue. Once a call was dispatched, the call screeners