ORIC Triage By Emergency Medical Dispatchers Samuel J. Stratton, MD, FACEP Abstract Purpose: This study isan evaluation ofthe ability of moical trained and controled emergency medical ‘dispatchers tose llephone triage techniques to direct the appropriate prehospital unit to an emergency scene. Methods: Emergency dispatchers, cated ina formal emergency medical dispatch program, sre assigned one of four triage pias to incoming 9-1-1 ell, The actual field management delve for ‘each patent was compared withthe dispatcher’ triage to determine the appropriateness of triage. Resals: A total of 1,045 consecutive cals were reviewed with 74.4% sorted as needing advanced life support (ALS) units on scene; 65.3% (95% Cl, 61.9 t0 68.6%) of these calls quired ALS intervention, A total of 3.4% ofthe runs sorted to the nonALS response gop were identified to have repuired ALS interention. Comparing the need for ALS intervention, a significant difference was found between the triage groups. Conclusion: Emergency medica dispatchers, using a formal system for lephane tage, are able adic appropriate prehospital resoures othe emergency scene Introduction Emergency medical services (EMS) systems throughout the industrialized world have adopt- ‘ed methors of predispatch screening of emergency aid call in order that highly wained per- sonnel on advanced life support (ALS) units are used for true emergencies and remain avail able for Further advanced medical emergency calls." Tiered emergency medical dispatch is ‘stem of rapid telephone assessment by trained and medically controlled emergency die patchers who use their assessment to direct the appropriate EMS response units to the emer- ‘gency situation." In urban areas of the United States, it has been estimated that up to 30% of requests for ‘emergency medical ambulance aid are for non-emergency conditions" Generalized “lights- andsirens” responses by EMS units to all medical aid call places both the public and respor dents at risk a8 the units speed through crowded streets“? Furthermore, use of advanced ‘emergency services for val problems overtaxes emergency prehospital response teams and demoralizes members of response units that ate Wained to manage true medical emergencies? ‘There are a number of reasons for public misuse of EMS resources, including lack of acces sible primary care, need for transportation, and lack of knowledge of what constitutes a true medical emengeney." Emergency medical dispatchers are responsible for management of telephone calls coming to the EMS system trom the public. Clawson and Dernocoeus have separated the dispatcher's task of acting on incoming medical aid calls into distinct segments which include: intial tele phone input wiage; radio dispatch; logistics coordination; resource networking; and lesa ing by administration of telephone instructions." The ability of emergeney dispatchers to give medical instructions (including for cardiopulmonary resuscitation) by telephone has been describec.*' In 1985, Slovis etal showed that dispatchers using a newly implemented priority dispatch system could shorten average response times from 14.2 minutes to 10-4 min- ‘utes for 30% of patients deemed most urgent. In the same study, it was noted that, because of dispatch error, 0.8% of ealls were dispatched as least severe but subsequently were found to be of the most urgent medical nature Recently, published abstracts seem to support the ‘observation that emergency dispatchers can sort ALS all with “acceptable” accuracy! This study attempts to answer the question of the accuracy of predispatch triage of EMS te- sources by medically wained and controlled emergency dispatchers working in an urban EMS Emergency Department, Sant Mary Medical Center, ‘System. Long Beach, Cal fence: Samuel. Siraton, MD, PAGER, Los Angeles County EMS Agency, Paramedic Institue, PO'Box 268, Torrance, CA’ 90507-0268 USA cd Long Beach Emergency Medical Services July-September 1992 263Methods: ‘The setting for this study was Long Beach, California, a multiethnic, densely popula ‘ed area of urban Los Angeles County with a population of 429,433, The Long Beach EMS System, at the time of this investiga- tion, was a twortier system with all EMS dis: patches resulting in a full ALS response and calls considered non-emergency (approx imately 8%) referred to non-EMS resources. Prehospital medical care in Long Beach ‘is delivered by the Long Beach Fire Depart- ‘ment, which atthe time of this study (June, 1987) employed fifteen civilian dispatchers with a computerbased 9-1-1 emergency cal system. The dispatchers were responsible only to the fte department dispatch center: An average of 97 daily medical aid calls were handled by the Long Beach Fire Alarm Office. The basic life support (BLS) dlispatch-toscene time was 3.41.5 minutes and average ALS dlispatclito-scene time was 4141.8 minutes. During the study, seven Long Beach Fire Department ALS par medic units responded to all EMS 9-1 «alls. One base-hospital provided medical ‘control and was contacted by radi for field orders except in those situations requiring urgent endotracheal intubation or defibr lation, Prior to and during this study, dispatch cers were allowed to arrange alternate trans- portation, without a formal EMS respon ‘when a call was determined to be a non: emergency. Before the study, the determi- nation process for non-emergency calls was not welldefined. During the study, the for- imal dispatch triage criteria were used to make determination of a non. response, To educate dispatchers in emergency medical dispatch techniques, the Long Beach EMS Medical Director, Base Hospital Medical Director, and Prehospital Care Co- ‘ordinator (paramedic liaison nurse) were trained as emergency medical dispatch instructors through the Emergency Medical vergency ‘Triage By Emergency Medical Dispatchers Dispatch Training Program developed by lawson. This training program for dix patchers consisted of 25 hours of in- struction in the use of 32 symptom-based protocols designed to elicit telephone in- formation rapidly to make a decision on dispatch priority. The Emergency Medical Dispatcher Program (EMDP) includes pre- arrival instructions by the dispatcher to the caller. This instruction was included for die patchers, but the study focused on the suc- cess of dispatching appropriate units to the emergency scene, Using the EMDP, callers are entered into a specific protocol after answering standard questions that establish location and call back information as well as determination of chief complaint, age, level of conscious ness, and breathing of the victim. In any sit vietim is not breathing fo the state-of consciousness and breathing. uation in which not verified, a maximum EMS response is dlispatched. Using the Clawson Medical Priority Dispatch System, a fourtier plan was select ed for this study (Table 1).®* A conservative approach wo dispatcher triage was stressed {0 minimize undertriage. IFdoubt existed as to level of priority, the dispatcher was in- structed to go to the higher level of re- sponse. After all dispatchers were trained by the formal Emergency Medical Dispatcher Program, they used a fipard file protocol sgsiem for each incoming eal to help make 1h one of the four a determination of wh dispatch categories would be most appro: priawe for the EMS response. Bach incom: ing call received a dispatch priority by the dispatcher, and this priority was recorded fon a standard form which was kept with run documentation. As @ backup, each call ‘was audiotaped for review by medical eon: trol. During the study, actual field patient management was provided by the single ALS response system. Since patient field Medical Priority Dispatch Category ALPHA BRAVO CHARLIE DELTA Table EMS Response for Study ALS Immediate/BLS-Immediate Nearest BLS-Rapid Next Available BLS In Aroa Non-emergency (routine ambulance) |—Triage Categories Used: Immediate indicates a Full ‘Lights-and-Sivens” Response, ‘and Rapid indicates Moving Directly to Scene without Lights and Siren. Prehospital and Disaster Medicine Volt, NosStratton care vas unchanged, the study did not re- quite review by a committee on human ex- Perimentation Using consecutive calls, EMS response records were matched tothe dispatch priori ty assigned during the run and were r sewed for appropriateness of the dispatch priority assigned by the dispatcher to the run (Table 1). For example, sf run was ae signed level “Alpha” (ull ALS response) and ALS intervention was required in the actal field setting, i was determined tha the level ‘of dispatch was “appropriate.” Determination of the level of EMS inter: semtion required in the field was based on predefined criteria. In Los Angeles County, prehospital runs requieing ALS evaluation ‘were identified in local EMS polices and procedures (Table 2) Further, in Califor: nia, procedures for paramedics and BLS personnel were defined under the State Health and Safety Cade. These eriteria ‘were used to define an ALS run for puspos sof this study. The BLS level dispatches ‘were separated into ovo categories, The BLS “Baw eategory included runs that posibly ‘would require ALS upgrade after arsial ofa BLS unit atthe seene and evaluation of the patient, and BLS “Charlie” category runs "were those with a low probability for need of ALS upgrade, “Non-emergency” runs did not require direct EMS intervention by cither ALS or BLS personnel Dispatch priorities were runs and appropriateness of triage deter= ‘mined by considering the level of care aet- ally requived. Patient hospital records were reviewed when question existed as to level of ‘care required in the field and by patient condition. Audio tapes of calls were reviewed on all runs that were dispatched for less than the level of care actually requited in the field setting. Outcome infor= ation for runs rated as non-emergency and not receiving an EMS response was ‘obtained by telephone callback and inter view of the patient or a family member, Individual dispatchers were assigned com fidential identification numbers for coding data during the study, and the physician reviewing dispatches and runs was blinded a to the dispatcher making the triage deci sion. When an audio tape review was required, the identity of the dispatcher became apparent. This did not affect the objectivity or blinding of the smdy because at the time of audio tape review; the appro- priateness of the dispatch decision already natched to all Cardiopulmonary Arrest Hemonthage: ‘Signs of Shock ‘abnormal vaginal Significant Trauma: gastrointestinal by mechanism Pediatric Patients: ‘abnormal vital signs critically ‘Acute Shortness of Breath critically injured ‘Altered Level of Consciousness. abuse/neglect Primary Chest Pain age <3 years ‘Symptomatic Hypertension Extensive Bums ‘Asymptomatic Hypertension: Electrical Bums systolic pressure >200 mmiHig ‘Burns of Face/Neck diastolic pressure >120 mnvlg Near Drowning ‘Abdominal Pain: ‘Active Labor ‘with abnormal vital signs Miscarriage in pregnant patient Poisonous Contact acute onset Allergic Reactions Exposure to Hazardous Materials Multipte Casualty Extremity Wounds/Fractures: Suicidal Patients with neurologic compromise Hallucinations with vascular compromise Dangerous Behavior ‘Suspected Fractures of Femur, Hip, Pelvis, Spine, or Skull ‘Table 2—Prehospital Situations Recognized as Requiting ALS Evaluation in Los Angoles July-September 1992 265 Prehospital and Disaster Medicine