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Journal of Emergency Medicine (JEMS), February 1983
Call Screening in Dallas:Triage with Care
Dr. Clawson calls the nurse screening approach the "Cadillac" of selective dispatch philosophies. We asked Leilani Starks, RN, coordinator of the Dallas Fire Departmentās call screening program, to describe the system there and the special challenges it presents.
Dallas, like other big cities, is face with one of the mose serious obstacles to effective emergency medical services: abuse and misuse of the system by callers demanding services in nonemergent situations. Segments of the public believe that the city not only owes them ambulance service to routine medical appointments, but also house calls to change dressings and make evaluations as to whether they need to see a physician. Abuse had reached such a state in Dallas that it was not unusual for callers to say, "I'd like to order a paramedic," The idea that they were asking for a $57,000 piece of equipment to give Band-Aids and first aid never occurred to some.
In addition to the obvious cost of manpower and equipment, there is the heart attack victim or choking child who is deprived of precious minutes of advanced life support because the first-up and second-up mobile intensive care units (MICUs) are out on non-emergency calls.
To initially combat this problem, the Dallas Fire Department spared no expense to educate the public. Their first effort had an adverse effect-there was a nine percent increase in non-emergency calls! Another more intense advertising campaign was tried and more successful, but only while the media blitz was active. As soon as it stopped, the abuse resumes.
Gail Walraven, an EMS consultant, was contracted to analyze the problem and help develop ways of solving it. She pointed out contributing factors, such as the way dispatchers taking emergency calls unknowingly contributed to unnecessary dispatches prompting alarmist responses from callers. She then suggested ways call screening might be possible while still ensuring that emergency patients receive prompt care. When Ms. Debra Cason, RN, paramedic training coordinator for Dallas, researched cal screening as part of her graduate studies, she showed the feasibility of such a program.
The Dallas System
The general emergency number in Dallas is 744-4444. The call is answered by an emergency operator who connects the caller to either fire or police dispatch or both depending on the emergency. If the citizen is requesting an ambulance, the call is transferred to the Dallas Fire Department.
The Dallas Fire Department dispatchers are uniformed firefighters who dispatch ambulance and fire equipment. There is not formal medical training required for their job. However, it is not unusual to find an EMT or paramedic on some shifts.
In April, 1981, the Dallas Fire Department began its Nurse Call Screening Program. Ideally, all medical emergencies that are not immediately life threatening are given to a specially trained nurse. Examples include minor trauma, accidental poisonings, obstetrical and gynecological problems and all pediatric emergencies. Those calls that are immediately life threatening are dispatched an MICU and are turned over to the nurse for medical self-help while the ambulance in en route. The premise of the program is, "We care, we help."
Having studied the alternatives of how to staff the screening program, the Dallas Fire Department opted to use registered nurses for two major reasons: 1) The higher level of training of a nurse gave obvious advantages in risk reduction of over-triaging which could be a problem with a screener of less training; 2) There is significant reassurance to the caller who knows that he/she is talking to a recognized medical professional.
Foremost, the caller is never told by the nurse that the situation is not an emergency. No one is ever shunted aside or made to feel they are a bother or that no one cares. Many of the callers are elderly, lonely, or depressed, and sometimes just need to hear a caring voice÷sometimes the only voice they may hear all week. The caller receives medical self-help in emergency situations, and if needed, an MICU. Part of the job of the nurse is to recognize people can hurt in many different ways and what may not be an emergency to her-whether it is a mother whose child has a bean in his ear or a jilted lover in the depths of depression-may be to someone else.
On every call that an MICU is not dispatched, the nurse makes a follow-up call (ranging from a few minutes later to the next day, depending on circumstances) to ascertain the caller's status. Many times the callers are referred to other agencies-but they always receive some form of help from the nurse.
When the program is fully implemented, it is estimated the city will yearly save $250,000-the cost to equip and staff an MICU for a year. In addition, it provides an added service for the public. Thus far, citizen response has been very positive.
The Nurse's Challenge
One of the most challenging aspects of the nurse's job is to gain control of a situation where the caller is hysterical, gather facts, and make a decision in minutes, often seconds, about a potentially life-threatening situation. During the eight months the program has been in effect, there have been no deaths directly related to call screening or any lawsuits from the program.
In addition to screening out non-emergency calls, the nurse gives medical self-help to callers in emergent and non-emergent situations. The two most important qualities are the ability to remain cool under pressure and make sound nursing judgments. One must often wade through a barrage of verbal abuse in order to discover the true situation of the caller.
Many of the calls given to the nurse dispatcher are from mothers, home alone with sick children. It is surprising the number of people who do not know what to do for a child with a fever, or when to see a doctor. Many of the non-English speaking people of various nationalities are unaware of the severity of their complaints or what to do about them. Medical self-help can and has ranged from calming a mother and telling her to cover and put pressure on a wound to control bleeding, to telling a mother how to breath for her child who was a near-drowning victim.
One call was received from a hysterical Spanish-speaking grandmother, whose grandchild was cyanotic and non-breathing after having a seizure. She was taught via the telephone to open the child's airway and maintain it until help arrived. (The child experienced no residual effects from the hypoxia and is currently on anticonvulsant therapy).
There is a large volume of calls from the despondent who feel it's just not worth the effort to go on living. Because of the length and depth of counseling needed, they are referred to suicide prevention counselors who have the time and training to deal with them.
Many accidental OD's or injestions involving children are given immediate poison first aid via the phone (using a poison control chart). To date, the most rewarding experience has been aiding in the delivery of a six-pound baby boy via telephone-and then meeting the proud parents and holding "my" baby.
Because of the volume of calls and the enthusiastic acceptance of the program, a second nurse has been hired. Although the program is in its infancy, it is already having far-reaching effects.
Call Screening Statistics, Dallas Fire Department EMS, Fiscal Year 1981-82:
Number of Calls handled by Nurse 10,059
Number of Calls screened out by Nurse 6,579
Percent of calls screened out 65%
Number of calls Nurse dispatched MICU 3,480
Number of Nurse dispatched calls that were
transported by MICU 2,817
Percent of calls dispatched by Nurse that
resulted in transport 81%
Number of medical self-help calls by Nurse 2,415