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Emergency Medical Services, Volume 13, Number 4; July/August 1984
Jeff Clawson, MD
Regulations and Standards for Emergency Medical Dispatchers: A Model for State of Region
Over the last 15 years, the overwhelming majority of states have enacted some form of EMS legislation or rules/standards regulating EMT and paramedic training and practice. The weak link has remained the EMS dispatcher, who, prior to 1979, had on the average not a single hour of medical training (1). Since that time, the concept of medical priority dispatch training has spread from Salt Lake City throughout Utah and now North America (2,3). It is estimated that as many as 400 communities have adapted the program for their own use.
However, a major gap still exists in EMS-one that will be very difficult to fill. To date, only one state (Utah) has enacted any form of regulatory standards for medical dispatchers; however, it is a great accomplishment in terms of creating the first organized governmental approach to medical dispatch competency as a public duty. The process in Utah was not simple, but can be reconstructed to serve as an early model.
Historically, the process began with the development of the medical dispatch priority card system at the Salt Lake City Fire Department, followed by the state-level emergency medical dispatcher training course, which taught a number of innovative concepts concerning the protocol card system. This training course, which carried state certification, was first taught in Salt Lake City and included 25 dispatchers from several different agencies (1). The process was repeated and refined a number of times. Over the next three years, the training manual was revised four times and the card system six times. While the courses became quite popular at the individual dispatcher level, required training for all dispatchers was adopted initially by only the Salt Lake City Fire Department, Davis County Sheriffās Office and Gold Cross Ambulance.
Early resistance was offered by high-level fire administrators, but was overcome as time progressed. The Utah Paramedic Association became involved quite early in the process. In 1981, we approached the association with a rough plan for statewide standards. With the initial blessing and expertise of the director of the Utah State EMS Bureau, a draft of EMD regulations was prepared.
In an early Paramedic Advisory Committee meeting, it was decided that not just ALS agency dispatchers should be required to have EMD training, but that the standards should include all medical dispatchers in Utah-ALS and BLS. As it turned out, this was to be a fateful decision. This draft was sent to all entities suspected of providing medical dispatch services throughout the state.
We were certainly not prepared, however, for the response that followed. While modest resistance came from some municipal departments providing ALS, many rural law enforcement agencies were incensed. The need was questioned, the economics decried and the safety of pre-arrival instructions doubted. Almost all police medical dispatch services, while providing initial call receipt, do not respond themselves. Usually, they dispatch local-often volunteer÷EMT ambulance squads.
The State Bureau of EMS held two public hearings, the second of which lasted five hours, and more than 50 separate opinions were expressed! After a number of administrative delays and political meetings, in which the proposed regulations were clarified and redefined, a compromise version was reached. Mandatory training, which was strongly supported by physicians, nurses, paramedics, hospitals, and trained dispatchers, was dropped. The regulations then read, "Dispatchers serving medical providers are not required to be certified as EMDs, but are encouraged to voluntarily seek training and certification through a department-approved course."
A number of medical control people and the Utah Paramedic Association vowed that they would press hard in the future for required training after the program and regulations gained greater acceptance. The State EMS Regulatory Committee, after the historical regulations and standards, effective July 1,1983. The EMS Regulatory Committee also established an Emergency Medical Dispatch Advisory Board to make recommendations concerning dispatch protocols, training, curriculum, instructor programs, as well as to review all new selective dispatch protocols now required by the regulations.
The process was one of the mose taxing and political struggles that has occurred in Utah EMS. Throughout this difficult and drawn-out process, the follow-through and hard work of the staff at the Utah State EMS Bureau were certainly important factors. The steadfastness of the Utah Paramedic Association as unbiased defenders of patient care is a monument to the organizational effectiveness of nonphysician medical control.
From evaluating the problems encountered in effecting implementation of these administrative rules, we can suggest a three-part process. The regulations and standards actually entail three separate concepts that are interdependent, but which can stand alone. First is the establishment of training, certification, and recertification standards. This defines the baseline quality of any dispatcher who has passed a state-approved EMD course. As one can see, participation in the training process, while it is defined, is voluntary at this stage. This is the simplest part to effect.
Second is the adoption of a generic dispatch protocol system on a regional or statewide basis. In Utah, this is simply defined in the standards as, "All agencies who routinely accept calls for EMS assistance from the public and dispatch emergency medical personnel shall have in effect a selective medical dispatch system." This system is defined generically as "a department approved reference system used by a local dispatch agency to dispatch aid to medical emergencies, which includes: (a) systemized caller interrogation questions, (b) systemized pre-arrival instructions and ( c) protocols matching the dispatcher's evaluation of injury or illness severity with vehicle response mode and configuration." The Utah State Health Department, through the EMS Bureau, will "assist local dispatch agencies in implementing a selective medical dispatch system by providing technical assistance and making available standard selective medical dispatch system caller interrogation questions, pre-arrival instructions and vehicle response mode protocols. The state standard questions, instructions and protocols may be used intact or modified by dispatch agencies with approval by the local medical authority and the department."
Since the use of a protocol system is not a taxation or funding issue, the resistance to implementing this stage was only mild. It is logically arguable that, in the absence of required EMD training, the need for a protocol reference system to maintain quality control and avoid error is even more clearly necessary. Medicolegal expert James E. George, editor of the EMT Legal Bulletin, has stated:
An "upfront" clearly articulated written policy in support of telephone screening of emergency calls, coupled with sound guidelines and protocols for use by dispatchers, would provide a ray of legal light in an otherwise murky area of heavy potential liability. A reasonable system of call screening can provide a good legal defense for both the EMS dispatcher and his employer, should a charge of negligent handling of emergency calls be raised by a plaintiff. Where reasonable guidelines are in effect, the EMS dispatcherās conduct will be less vulnerable to charges of careless or reckless judgment. Similarly, EMS employers can point to such guidelines a system of risk management in an area where human error and its dire consequences are clearly foreseeable (4).
Stage three, mandatory training, is the obvious last step. By far, this will be the most difficult to effect. Letās step back to get some perspective on the issue.
Today, no one would think of allowing ambulance technicians to function without EMS certification or allow paramedics to do likewise. But remember that medical dispatching is 10-15 years behind the mainstream of EMS evolution; hence, the dilemma.
It is wise to pursue the implementation of required training cautiously. You can reasonably expect rural and law enforcement groups to lag in enthusiasm in regard to anything that appears "mandatory." The word "mandatory" itself is disliked by many.
The widespread training and certification of EMDs on a voluntary basis for a few years allows for a mellowing process, due to a firsthand knowledge of the benefits of such training and expertise in dispatch. As one might suspect, the push for improvement often comes from the bottom up-the dispatchers themselves. As happened in Utah, the paramedic and/or EMT associations can play a very important role in the process. Certainly, medical control groups, such as state chapters of the American College of Emergency Physicians and the Emergency Department of Nurses Association, will support the concepts of medical priority dispatching and the associated training programs.
The necessity for government to establish regulatory standards can be inferred from what are proving to be prophetic statements by medicolegal experts. As James E. George said in 1981:
EMS dispatchers must always avoid the appearance of responding to or categorizing emergency calls in a haphazard or arbitrary manner. A unified procedure will provide an excellent method of safeguarding against arbitrary decisions making. Without a unified system, one dispatcher may decide that a critical situation exists primarily on the level of emotion he detects on his own "gut" reaction, without being able to articulate a clear reason for his decision (4)."
The evolutionary lag of medical dispatch behind other more popular areas of EMS suggests that some "radical surgery" needs to be performed on outdated, traditional concepts of EMS dispatching (2,5). The public now has the right to expect such leadership to come from an appropriate government level in assuring the quality and effectiveness of the critically important communications and treatment link between the caller and responder.
The Utah EMD Regulations and Standards (see Table III), while a compromise remain an EMS milestone. The process has been an excellent learning experience from which many potential problems can be avoided and many valuable positive directions identified. A three-component model has been derived as a base for EMS progressives and governmental entities to attempt standardization, medical control and quality assurance in the key area of medical dispatching throughout the 1980s (6).
Table I: Sample dispatch priority card for stabbing/gunshot wound.
Key questions Pre-arrival Instructions
Table II: Dispatch priority card system Index.
Table III: Emergency medical dispatcher regulations of the Utah Emergency Medical Services Systems Act, Title 26, Chapter 8.
Section 1. Purpose
1. To provide for the establishment of minimum standards to be met by those providing medical dispatch services in the State of Utah so as to promote the health and safety of the people of this state.
2. To establish training and certification standards for dispatchers who voluntarily request certification as emergency medical dispatchers.
Section 2. Definitions
As used in these rules and regulations:
completed a department-approved emergency medical
medical leadership for the provision of basic and/or
advanced life support services in the dispatch agencies'
4. Person Any individual, firm, partnership, association, corporation,
company, group of individuals acting together for a common
purpose, agency or organization of any kind.
5. Selective medical dispatch system A department-approved reference system
used by a local dispatch agency to dispatch aid to medical
emergencies, which includes: (a) systemized caller
interrogation questions, (b) systemized pre-arrival
instructions and ( c) protocols matching the dispatcher's
evaluation of injury or illness severity with vehicle
response mode and configuration.
Section 3. Requisites for providing medical dispatch service
Section 4. Personnel
Dispatchers serving medical providers are not required to be certified as emergency medical dispatchers, but are encouraged to voluntarily seek training and certification through a department-approved course.
Section 5. Certification
The department shall develop an emergency medical dispatch training and certification program. Curriculum standards shall be established by the department with certification standards as follows:
To be certified as an emergency medical dispatcher (EMD), an individual must:
Recertification is required every three years to maintain state certification. This period may be modified by the department.
These rules and regulations shall not preclude any physically handicapped individual from certifying or recertifying who takes the required CPR course and can then demonstrate proficiency in verbally describing these methods to a caller.
Those individuals who permit their certification to lapse may be recertified by completion of the recertification requirements and person interview with a department-designated interviewer.
The department may, in its own determination, for good cause, deny, suspend or revoke for a specified period of time, the certification of any emergency medical dispatcher where the facts submitted to it justify such action.