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TIERED MEDICAL DISPATCH FOR THE ORANGE COUNTY FIRE AUTHORITY
EXECUTIVE LEADERSHIP
BY: Matt Vadala Orange County Fire Authority Orange County, California
An applied research project submitted to the National Fire Academy as part of the Executive Fire Officer Program
November 2003
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ABSTRACT
The problem was that the Orange County Fire Authority (OCFA) was
experiencing a significant increase in unit responses, particularly to medical calls, which
were increasing risks, operating costs, and liability.
The purpose of this applied research project was to evaluate medical priority
dispatch methods and programs for reducing the number of unit responses to EMS calls
within OCFA’s response area.
The evaluative research method was used to answer the following questions.
1. What alternative dispatching programs exist that enable tiered responses to
medical calls?
2. How do alternative dispatching programs compare to OCFA’s existing emergency
medical dispatching (EMD) program?
3. What are the risks and benefits associated with implementing a tiered medical
dispatch program?
4. What are the costs required to successfully implementing a tiered medical
dispatch program?
The research procedures included literature searches at the National Emergency
Training Center’s (NETC) Learning Resource Center (LRC), Huntington Beach Library,
and Internet. The literature review included information from textbooks, periodicals,
professional journals, reports, and copies of dispatch protocols from public and private
organizations. Personal interviews were conducted with OCFA staff and other agencies
nationally using tiered medical dispatch. In addition, surveys were distributed to EFO
graduates seeking their input on the research questions.
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The results of the research indicated that both the public and private sectors
realize the importance of limiting responses to the most appropriate resources, and that
alternative dispatching programs exist that would permit OCFA to implement tiered
responses to medical calls. The results also suggested, that despite the costs and potential
risks, there were benefits to OCFA implementing tiered medical dispatch.
The recommendation was for OCFA to implement a tiered medical dispatch
program as a method of reducing the number of units responding to medical calls,
improving response times and coverage, and reducing risk, liability, and operating costs.
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TABLE OF CONTENTS
ABSTRACT 2
TABLE OF CONTENTS 4
INTRODUCTION 5
BACKGROUND AND SIGNIFICANCE 6
LITERATURE REVIEW 11
PROCEDURES 28
RESULTS 32
DISCUSSION 42
RECOMMENDATIONS 58
REFERENCES 65
APPENDIX A (Survey & Interview Questionnaire) 68
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INTRODUCTION
The problem is that the Orange County Fire Authority (OCFA) is experiencing
significant increases in unit responses, especially to medical calls. The additional number
of Code 3 unit responses, coupled with increased traffic congestion, is elevating potential
risks to both firefighters and to the public. Increased unit responses are also causing
areas of the county to be left unprotected during periods of peek activity. Increased unit
activity over the past 5 years is causing an increased number vehicle accidents resulting
in increased liability claims and insurance costs. This trend is expected to continue into
the foreseeable future. The volume of responses is also adding stress on apparatus in the
form of operating and maintenance costs, and some believe increasing stress on
responders as well.
The purpose of this applied research project is to evaluate medical priority
dispatch methods and programs for reducing the number of unit responses to EMS calls
within OCFA’s response area.
The evaluative research method was used to answer the following questions.
1. What alternative dispatching programs exist that enable tiered responses to
medical calls?
2. How do alternative dispatching programs compare to OCFA’s existing emergency
medical dispatching (EMD) program?
3. What are the risks and benefits associated with implementing a tiered medical
dispatch program?
4. What are the costs required to successfully implementing a tiered medical
dispatch program?
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BACKGROUND AND SIGNIFICANCE
Orange County is located in the heart of Southern California, with Los Angeles to
the north and San Diego to the south. Orange County covers 798 square miles, including
42 miles of scenic coastline. There are currently 34 cities within the county.
Orange County’s population remains the second largest county in California,
trailing only Los Angles County, and is the fifth largest county in the nation. In fact,
Orange County has a population greater than twenty-one of the country's states.
Orange County remains one of the fastest growing areas in the nation. It is
currently ranked the fifth fastest growing county in the country. In 2002 Orange County's
total population was estimated to be 2,890,444, which equates to an average annual
increase in the last decade of approximately 44,500 new residents a year. The county’s
steady population growth is expected to continue, with population projections in Orange
County exceeding three million residents by 2005 and over 3.6 million 2010.
Orange County is one of the most densely populated areas in the United States. It
is second only to San Francisco for the most densely populated county in California, with
a population density estimated in January 2002 in excess of 3,665 persons per square
mile, it is 2.5 times as dense as Los Angeles County.
The preceding statistical information was taken directly from the Orange County
2003 Community Indicators Report, published annually by the Orange County Business
Council and the County of Orange.
The Orange County Fire Authority (OCFA), a joint-powers agency, was formed
March 1, 1995. It is comprised of 22 contract cities plus the unincorporated communities
and areas of Orange County, California. Previously known as the Orange County Fire
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Department from 1980 to 1995, the OCFA is one of the largest regional fire service
agencies in California. The OCFA serves a population of over 2.1 million residents
within 568 square miles, in addition to over 180,000 acres of wildland and urban
interface areas.
The Fire Authority is a diversified public safety agency providing contract fire
protection, technical rescue, emergency medical services (EMS), hazardous materials
response, wildland defense, and fire prevention services. The OCFA operates from 63
fire stations located throughout Orange County. The Authority currently has five
additional fire stations under construction and several more in the planning stage. The
OCFA is a combination department comprised of approximately 780 career and 500
reserve firefighters supported by nearly 250 staff (non-sworn) personnel.
OCFA calls for service and unit responses have steadily increased at a rate of 10%
annually over the past five years. According to Bob Leysack, OCFA Information System
Section, from July 1, 2002, through June 30, 2003, OCFA personnel responded to
approximately 77,500 emergency calls, resulting in nearly 170,000 emergency unit
responses. It is projected that both calls for service and unit responses will continue to
rise at the same rate, for the foreseeable future. Medical calls, basic life support (BLS)
and advanced life support (ALS), also continue to steadily increase. During this same
period, OCFA responded to nearly 55,000 medical emergencies, accounting for nearly
70% of the OCFA’s total emergency incidents.
Data from the California Highway Patrol (CHP), July 2003, reveals that the
highest concentrations of vehicles, and the most traffic-congested areas in the state, are in
Southern California. The state data also shows the number of registered vehicles in
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Southern California has steadily increased over the past five years. In addition, state
statistics proclaim that Southern California has the highest number of traffic accidents in
the state.
The United States Fire Administration (USFA) released a comprehensive study in
2001, which examines the causes of deaths for “on-duty” firefighters. The USFA
Firefighter Fatality Retrospective Study: 1990-2000 is an in-depth analysis of the causes
for more than 1,000 on-duty deaths which have occurred in the United States during the
last decade of the 20th century. Each year in the United States, approximately 100
firefighters are killed while on duty and tens of thousands are injured. Although the
number of firefighter fatalities has steadily decreased over the past 20 years, the
incidence of firefighter fatalities per 100,000 incidents has actually risen over the last 5
years. Since 1984, motor vehicle collisions have accounted for between 20 and 25
percent of all firefighter fatalities, annually.
Fire departments across the nation have been grappling with how to reduce
vehicle accidents. According to federal statistics, motor vehicle collisions are the second
leading cause of firefighter deaths. As a result, some fire departments are experimenting
with “on the quiet” (without red lights and sirens) response policies when responding to
emergencies.
With California’s increasing population, traffic congestion, and annual miles
driven, accidents and fatalities involving ambulance and fire vehicles will continue to
increase. Emergency vehicle related collisions per 1,000,000 miles driver are seven
times higher in California than the national average, and emergency vehicle collisions are
thirteen times the collision rate for civilian vehicles (Saunders, 1994).
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A recent newspaper article in the Los Angeles Times, August 18, 2003, by Li
Fellers, outlined a plan by the Los Angeles Fire Department aimed at reducing collisions
with drivers who fail to yield to emergency responders. Under the new department rules,
fire trucks trapped in traffic must shut down their sirens and wait with the other motorists
for the traffic to clear. Fire officials drafted the rules after an internal review showed that
their fire vehicles had been involved in 824 accidents from 1999 through 2001.
During the past five years OCFA vehicle accidents have also increased
dramatically according to Fausto Reyes, Manager of the OCFA Risk Management
Section. The greatest number of accidents occurred while on emergency calls, according
to Reyes. There has also been a marked increase in the number of injuries caused by
OCFA units. The OCFA has paid out large sums of money in claims to accident victims
over the past 5 years, and as a result, the OCFA’s insurance premiums have increased
significantly as stated by Reyes.
“As OCFA unit responses have increased, there has been a corresponding increase
in the number of vehicle accidents. The increased number of vehicle accidents has
caused OCFA insurance premiums to nearly double over the past five years”, per Reyes.
The Orange County Fire Authority (OCFA) is experiencing a significant number
of unit responses, especially to EMS calls. Medical calls that some believe could be
handled with one BLS unit responding Code 2, currently receive an ALS unit, BLS unit,
and transport unit all code 3. An example is a car accident with minor injuries.
These current response protocols place emergency responders and the public at
risk daily. In addition to response risks, during periods of high activity, units are often
out of position or unavailable to respond to more serious medical emergencies in their
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first-in area. Unavailability of first-in resources requires units to respond from
surrounding districts further enlarging the uncovered area and increasing response times.
This practice results in a reduced level of service, and increased cost, vulnerability, and
risk.
There is also a public perception that the OCFA is not operating efficiently and is
an example of big government wasting money. For example, it is not uncommon to read
in OCFA Customer Satisfaction Surveys, or for citizens to inquire, why two fire engines
and an ambulance responded with red lights flashing, and sirens and air horns blasting,
when their need could have been handled more quietly with only an ambulance.
The Orange County Fire Authority currently uses the OCFA Emergency Medical
Dispatch (EMD) System. Dispatchers in the OCFA Emergency Communications Center
(ECC) identify the type medical problem and dispatch a pre-programmed response.
However, with the exception of minor injuries “below the knee or below the elbow”, the
typical response is minimally three units, an ALS engine or van, closest BLS engine or
PAU (paramedic assessment unit), and an ambulance.
The OCFA EMD reference system is used primarily after the dispatch. It is
designed to provide self-help instruction to callers until first responders arrive. The EMD
booklet is not used to categorize medical responses (life threatening/ALS, or
routine/BLS), to identify call prioritization (Code 2 or Code 3), or to dispatch the most
appropriate number and type of units (unit allocation).
This applied research project has been completed in accordance with the National
Fire Academy’s (NFA) Executive Fire Officer (EFO) Program. This research paper
relates specifically to the course content of the Executive Leadership (EL) 2003, R-125
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Course, Module 2, Transformational Leadership; Module 3, Decision Making Skills;
Module 5, Being in Transition - Understanding Change; Module 8, Introduction to
Influencing; and Module 10, Networking.
The main concepts of the five modules that directly apply to the problem in this
research paper include, the executive fire officer’s role and responsibility to analyze
current and future trends, forecast probable issues and situations, recognize being in
transition and understand change, conduct and implement decision making skills, and
lead required changes and solutions by influencing and networking.
This research project dealing with the problem of increased unit responses to
medical calls, and the implementation of tiered medical dispatch in the OCFA as a
possible solution, is also linked to the National Fire Academy’s 5-Year Operational
Objectives. Specifically, Objective 3 which states, “To appropriately respond in a timely
manner to emergent issues.”
The research and analysis obtained as a result of this applied research project
form the foundation to begin solving the issue of increased unit responses, and ensure
continued operationally efficient, cost effective, and safe responses to medical
emergencies within the OCFA’s protection area.
LITERATURE REVIEW
A literature review of current materials was performed to address the research
problem and to answer questions posed in the applied research project. Extensive
literature searches gathered information that was useful in addressing the problem and
questions. The literature was helpful in arriving at objective results, and ultimately
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recommendations on reducing the number of unit responses and using tiered medical
dispatch.
Literature searches were conducted at the National Emergency Training Center’s
(NETC) Learning Resource Center (LRC), Huntington Beach Library Information
Services System, Internet, and the OCFA Information Systems Section. The literature
review included information from textbooks, periodicals, professional journals, reports,
and copies of actual dispatch plans and procedures from both the private and public
sectors. In addition, searches were conducted online through Internet search engines to
identify relevant documents and further sources of information.
Current literature was used to compare the broad findings of others experienced
with using tiered medical dispatch, to surveys and interviews with OCFA staff and other
agency experts. Thorough research of current literature, combined with the interviews
and surveys, provided the basis for comprehensive procedures that adequately addressed
the research problem.
The literature review covered a wide range of information on resource
deployment. A broad scope of written materials was valuable in gaining insight into
evaluating the problem and answering the research questions. Specifically, published
materials were valuable in clarifying the concept of medical priority dispatch, or tiered
medical dispatch. The review was also important in documenting and accurately
evaluating why resource allocation and management is important in reducing unit
responses to medical aids.
In addition to defining priority dispatch, the literature findings were beneficial in
identifying alternative dispatching programs and how they compare to OCFA’s.
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Literature was also useful in evaluating what are the risks verses benefits, and what costs
are associated with implementing tiered medical dispatch.
What alternative dispatching programs exist that enable tiered responses to medical
aid calls?
A number of alternative dispatch programs exist that support tiered responses to
medical calls. The most commonly used tiered medical dispatch program is the Clawson
priority dispatch system. The Clawson system has been used by public and private sectors
in both the United States and Canada for over two decades.
The Clawson medical dispatch system is now used in over twenty other counties
in 16 different languages. There are 2,500 agencies worldwide that use it, 2,400 of them
in the United States (Wilson, 2003).
Dr. Jeffrey Clawson’s emergency system tries to minimize the use of lights and
sirens as a critical step in reducing risks to responders and the public, by improving skills
at the dispatcher level where emergency calls are received. Clawson’s goal is to curb the
use of red lights and sirens, which he contends, fails to save lives or significantly reduce
response times (Wilson, 2003).
Industry experts have estimated that there are 12,000 ambulance-related crashes
annually in the United States, causing 120 deaths. A recent industry survey found that
only a third of the 200 largest ambulance services nation-wide still respond to all
emergencies with lights and sirens (Charalambous, 2002).
The Clawson system of “priority dispatch” is based on “call screening”.
Emergency medical dispatchers use call screening to determine what level of response is
required. This is accomplished by asking four basic questions, what Clawson calls the
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four commandments of medical dispatch: 1) chief complaint, 2) age (approximate), 3)
status of consciousness, and 4) status of breathing (Wilson, 2003).
Another tiered medical dispatch program that has been used for several decades
is the Dallas Fire Department Nurse Call-screener Program. Analysis of dispatch
procedures led the Dallas Fire Department to develop a quality assurance program using
registered nurse call-screeners. The nurse, located in the dispatch center, performs
quality assurance and call screening. “The nurse screens calls for medical service to
determine if they are emergency or non-emergency. In life-threatening medical
emergencies, the nurse provides medical self-help advice to callers until ALS units arrive.
In non-emergency situations where an ALS unit is not required, the nurse gives medical
self-help advice and provides follow-up information, including referrals to other services
and agencies (Starks, 1983, p. 30). The Dallas Fire Department gave several major
reasons for using registered nurses to screen calls. The risk of misjudging the seriousness
of the medical emergency is reduced and the caller is reassured by talking to a medical
professional.
Another tiered medical dispatch program uses a similar call screening process;
however, it uses “Emergency Medical Dispatchers” instead of nurses. Salt Lake City’s
development of medical priority dispatch, a form of the Clawson system, includes
training and certification of Emergency Medical Dispatchers (EMD). This system also
further defines the concept of call screening, allows for more formal control, and may
prove more economically feasible to the fire service. “In addition to basic dispatch
techniques, the EMD is trained in the use of a medical dispatch priority card system. The
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reference system is structured around the concept of key questions, pre-arrival
instructions, and priority dispatch” (Clawson, 1991, p. 33).
King County Washington’s EMS program includes a tiered medical response
system. The major components include call receipt and triage by dispatchers to ensure
that the most appropriate levels of emergency medical providers are sent to the scene, and
assistance to callers by dispatchers until arrival of the first responders (Cobb & Vickey,
2002).
The EMS Division of King County Washington system also has adopted the
Seattle Fire Department’s Medic One Program model. The model allows jurisdictions to
levy a property tax for providing emergency medical services. For the past thirty years,
the system has maintained the highest reported survival rates in the treatment of out-of-
hospital cardiac arrest patients across the nation. Medical control is seen as one of the
main components contributing to their success. The tiered medical response system is
based on a medical model that operates under legal authority of the Medical Program
Director (MPD). The PMD is responsible for setting training standards, medical control
supervision, and quality review of medical information by dispatchers and treatment by
responders in the field (Cobb & Vickey, 2002).
Another key component of the Medic One tiered response system is the utilization
of Criteria Based Dispatch Guidelines (CBDG). Dispatchers screen and triage calls for
the most appropriate resource within the system. Under this system, medically trained
dispatchers use a series of pre-defined medical criteria for triaging various types of
medical problems. If the call meets specific pre-determined low-risk guidelines not
needing ALS or rapid response, the call is transferred to a 24-hour telephone referral
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nurse line. If the call is determined to need immediate medical response, the nearest fire
department BLS unit is dispatched. If the dispatchers determine that the patient’s
symptoms meet specific dispatch guidelines identifying that the medical emergency is
potentially life threatening, the closest ALS unit with paramedics is also dispatched
(Cobb & Vickey, 2002).
“About one-third of all EMS responses in King County receive both BLS and an
ALS response. In 1999, 35% or 49,800 calls for emergency medical care received an
ALS response” (Cobb & Vickey, 2002, p. 2).
How do alternative dispatching programs compare to OCFA’s EMD Program?
The OCFA currently utilizes a traditional medical dispatch model and not tiered
medical dispatch. The program is based on rapid call assessment and dispatch, coupled
with the conservative philosophy of dispatching to the worse case scenario. The dispatch
goal is to ascertain the necessary medical information and process the call in 30 seconds
or less. As a result of the rapid conservative assessment, most EMS calls default to ALS
level responses. The philosophy is to get someone on scene quickly to make an
assessment - ALS, BLA, or transport, and let the first arriving officer cancel what isn’t
needed.
In the OCFA’s Emergency Medical Dispatch (EMD) Program, dispatchers in the
Emergency Communications Center (ECC) identify the type of medical problem and
dispatch pre-programmed responses. However, with the exception of minor injuries such
as those “below the knee or below the elbow”, the typical response is three units – an
ALS engine or van, closest BLS engine or PAU, and a transport ambulance. The OCFA
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EMD reference system is used primarily after the dispatch to provide the caller with pre-
arrival instructions.
The program is designed for dispatchers, using an EMD reference booklet, to
provide self-help instructions to callers until first responders arrive. The reference
booklet is not intended to perform “call screening” - categorizing responses into ALS
“emergency” verses BLA “non-emergency” calls. The program also is not used to
ascertain “call prioritization” – determining Code 2 or Code 3 response, or is it intended
to identify “unit allocation” – identifying the most appropriate resources (ALS, BLS, or
transport).
In this era of tight fiscal restraints it is imperative to make the most efficient use
of human and material resources by not continuing to apply this traditional model. The
existing EMD procedures, and consequent unit response, is not based on sound medical
evaluation prior to dispatch, but rather on the desire to protect the organization from
potential litigation due to call processing times. In addition, most response procedures
require the use of red lights and sirens en route to the scene, and many times also call for
the use of red lights and siren for transports (St John & Shephard, 1993).
The Ontario Canada Ministry of Health, states that, “The guiding principles of
any tiered response program are to deploy adequately trained and equipped public safety
personnel to the scene of life threatening medical emergencies as soon as possible, and to
ensure the availability of sufficient staff and resources to safely and efficiently access,
threat, extricate, and package the sick or critically injures persons.” (p. 3)
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In the private sector, the “Big Three” (Medtrans, AMR, Rural/Metro) are all
currently working on “Pathway Management” models. Most of these models integrate
pricing and service provisions, all forms of transport, and greater use of the
communications center to screen calls and respond the most appropriate resource.
”Pathway Management” can be defined as the process that seeks to ensure
patients receive the appropriate care, in the proper place, at the right time, based upon
their needs. The “gatekeeper” in the communications center can be defined as the initial
provider who makes decisions whether referrals and other healthcare services are
warranted for a given patient. “Pathway management will include using the proper
resource (i.e. ambulance, wheelchair van, convalescent van, transportation van, and even
taxis) to move patients to the proper health care facility (i.e. emergency room, urgent-care
facility, doctor’s office). Other forms of care may include paramedics, physician
assistants, nurses, and even doctors providing home health care instead of transporting”
(Ludwig, 1997, p. 60-61).
Also in the private sector, AMR has developed a centralized call-taking and
dispatch center that coordinates emergency and non-emergency transport in central
California. “This control point is called Private Call Answering Point (PCAP) and is
currently processing 35,000 phone calls each month. Special call takers that have 240
hours of training take calls to determine what level of service and transport mode is
required” (Ludwig, 1997, p. 60-61).
The use of call screening coupled with call prioritization makes for an even more
cost-effective operation. “It doesn’t make sense operationally to commit your ALS
resource to a call that, quite frankly, might have been handled by taxis” (Furey, 1997, p.
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50-51). Furey goes on in his article to suggest that “the system” may want to use the
public sector for ALS responses and route lesser BLS emergencies and transportation
events to private providers.
Unlike OCFA’s EMD system, the Clawson emergency medical priority dispatch
system tries to minimize the use of lights and sirens, as a critical step in reducing risks to
responders and the public, by improving skills at the dispatcher level where emergency
calls are received (Wilson, 2003).
The Clawson priority dispatch system focuses heavily on “priority dispatching”
using Emergency Medical Dispatchers (EMD). The system is structured around the
concept of key questions using a card system, pre-arrival instructions and dispatch
priorities. Strong medical control is built into the key questions. The key questions
emphasize the importance of obtaining symptoms (e.g., chest pain) rather than diagnosis
(heart attack), in addition to the patient’s age, state of consciousness, and breathing. The
key questions lead to the appropriate pre-arrival instructions and establish the correct
level of response -dispatch priority. The number of “maximal responses” (ALS level
response and units responding with red lights and sirens) is greatly reduced, and the
decision making for dispatchers simplified. (St John & Shephard, 1993).
Using EMDs to provide call screening is an advantage to fire service managers
because it eliminates the need to hire doctors or registered nurses, in addition to
dispatchers (Clawson, 2003). Clawson also suggests that using EMDs for call screening
may be more compatible and consistent with terminology and procedures followed by
firefighters and paramedics.
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Clawson goes on the say that in terms of time and money, the 25-hour EMD
course for dispatchers, adopted by the Department of Transportation as a national
standard, is certainly less expensive to provide than EMT training (minimum, 81 hours),
and is less useful to the dispatcher.
What are the risks and benefits associated with implementing a tiered medical
dispatch program?
One of the greatest risks associated with implementing tiered medical dispatch is
the potential for liability caused by increased call processing times (call screening)
adding to the overall response time to get medical resources on scene.
“Fear of liability has stopped many institutions from putting an emphasis on
delivering medical aid from the dispatch level because service operators don’t want to be
held liable for screening calls and giving medical instructions over the phone (Clawson,
2003).
Another potential risk with tiered medical dispatch is the potential for increased
error rates in assigning appropriate resources to medical emergencies (unit allocation).
What was originally thought to be a benefit may prove to be a risk. A department may
decide initially to provide ALS response to all incidents for purposes of legal protection.
However, it may be unable to defend delays, or unavailable response, of ALS units to
victims of chest pain or severe trauma if even one ALS unit is tied up responding to a
simple fractured arm or routine medical call (St. John & Shephard, 1993).
There are other risks associated with Tiered medical dispatch. As the incidence
and severity of fires continues to decrease in most areas, an increased EMS response
continues to mean the survivability of many fire departments. By dispatching for and
21
responding maximally to all requests, total unit responses increase. This is often seen as
desirable by both labor and management for several reasons.
Increased unit responses equates to increased activity and visibility for the agency
and theoretically good public relations. The additional unit responses increases
justification for additional personnel and vehicles, and everything that goes with them –
training, supplies, apparatus, facilities, and salaries. It can also be argued that the
increased unit activity translates into increased personnel productivity in the form of less
idle time (St. John & Shephard, 1993).
Even though the three components of tiered medical dispatch (“call screening”,
“call prioritization”, and “unit allocation”) pose potential risks, many believe that it is
these same components that also provide the greatest benefits to implementing tiered
medical dispatch. Some believe that the benefits out weigh the risk. Specifically, the
potential reductions in both total unit responses, by using “call screening” and “unit
allocation”, and reductions in the number of Code 3 responses, by utilizing “call
prioritization”.
A significant benefit to tiered medical dispatch is call screening. “Dallas, like
other big cities, is faced with one of the most serious obstacles to effective emergency
medical services: abuse and misuse of the system by callers demanding services in non-
emergency situations. Dallas initially attacked the problem by launching an expensive
public education program. This only served to make the public more aware of the service
available and, in consequence, the number of non-emergency calls increased
dramatically.” (Starks, 1983).
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Another major benefit is increased safety for responding crews and the public.
Fewer unit responses, translates directly into increased safety for firefighters and the
public because of the reduction in the number of vehicles responding to calls, especially
Code 3. It is no longer a sound safety practice to require emergency response (red lights
and siren) to all EMS incidents, exposing crews and the public to the additional hazards
of an emergency response, just to arrive one to two minutes earlier for non-emergency
patients (Clawson, 1991).
Research confirms emergency response vehicles, running Code 2 or Code 3,
produce “wake effect” accidents as drivers are startled by lights and sirens. In 1997, Salt
Lake City and Salt Lake County reported 377 “wake effect” accidents compared to 85
civilian/emergency responder collisions. In other words, “wake effect” accidents
produced by emergency vehicles responding with red lights and sirens are 4.4 times more
likely to occur than compared to no use of lights and sirens. Due to these statistics, many
emergency response vehicle operators have established a policy limiting the use of lights
and sirens hen responding to emergency situations (Fors, 1998).
Dispatchers put emergency responders, patients and the public in danger when
they fail to prioritize calls by degree of emergency (Wilson, 2003).
“It’s not ethical to run over a kid in a crosswalk because you were responding to a
call for a sprained ankle. Every call to 911 is not an escalating emergency.” (Dr. Jeffery
Clawson in the Detroit News, Monday, January 27, 2003).
“The loss of life that results from traffic accidents involving emergency response
vehicles, the cost of repairs and replacement, and ever increasing insurance pay-outs can
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be prevented or reduced by establishing a policy that limits the use of lights and sirens”
(Fors, 1997, p. 66).
“It is medically feasible to dispatch less than an ALS unit on many EMS incidents
and to drive without red lights and sirens not only during transport, but also during initial
response.” (St. John & Shephard, 1993, p. 31-35).
“In 1983, for example, the number of emergency medical vehicle accidents in Salt
Lake City dropped 78 percent after the city implemented the dispatch system
(Clawson’s). Salt lake City now goes on all routine traffic accidents “cold”, or without
lights and sirens” (Clawson, 2003, p. 1-3).
This reduction in unit activity not only has the potential to reduce the number of
accidents and injuries, thus reducing liability insurance and claims, but also has the
potential to reduce operating cost in the form of “wear and tear” on units and stress
claims from responders. “Ambulance operators who used the system (Clawson) have
seen dramatic improvements in expenses, accident rates, and burnout of paramedics”
(Wilson, 2003, p. 20-23).
Another benefit to implementing tiered medical dispatch is the potential for
additional apparatus to be available for simultaneous calls in the same general area. For
many departments increased call volume, coupled with fiscal restraints, is severely taxing
restricted resources. Not only are most agencies denied additional resources and new
positions, but also many are faced with actual reductions in force, either thorough
dismissal, or at best, attrition. Consequently, fire service managers must be able to justify
the positions he or she already has, and use these human resources as efficiently as
24
possible to meet ever increasing demands for service. One way to do this is by using
tiered medical dispatch (St. John & Shephard, 1993).
Along the same lines, another benefit of tiered medical dispatch is improved area
coverage, and reduced travel times to medical calls. One of the most notable benefits to
tiered medical dispatch is the contention that those in dire need will receive not only the
most basic help as quickly as possible, but also the most advanced help as quickly as
possible (St. John & Shephard, 1993).
Still another alleged benefit to tiered medical dispatch is the potential for reduced
medical costs to patients and increased ALS skills. It is time to question whether we are
serving to best interests of all our patients by providing large numbers of costly ALS unit
responses when 80% to 90% of EMS incidents nationally require only basic life support
(BLS) (Starks, 1983).
Over 70 million Americans are transported to hospital emergency rooms for care
each year (Hafen, 1998). Only 8.4 percent of patients transported by ambulance to an ER
actually needed definitive care rendered by an emergency room. Medicare patients
showed that 94.6 percent of all Medicare patients transported to an ER could have
received treatment at another more appropriate resource (Ludwig, 1997, p. 60-61).
There is another benefit, the potential for more skilled ALS providers. Using
fewer paramedics to serve ALS patients translates into greater efficiency and
effectiveness because ALS personnel have more opportunities to practice their skills.
This means decreased skills degradation and increased patient care. Benefits to the
department include decreased staffing and training costs (Starks, 1983).
25
What are the costs required to successfully implementing a tiered medical dispatch
program?
There will be costs incurred to modify the existing OCFA Emergency Medical
Dispatch procedures, or to implement a new EMD program that supports tiered medical
dispatch protocols. Both options will require the purchase, installation, and training of
new computer software required for dispatchers to process calls.
Both alternatives would also require training on priority dispatch, not only to
dispatchers, but also for Operations personnel. There will also be costs associated with
educating the public, the medical community, and political supporters.
Theoretically the use of call screening and call prioritization makes for a more
cost efficient operation. “Although this facet of dispatching is often associated with
private sector providers of EMS, there is benefit to the public sector as well by not
committing ALS resources unnecessarily. It doesn’t make sense to commit your ALS
resource to a call that, quite frankly, might have been handled by taxis” (Furey, 1997, p.
50-51).
Automation and the use of computers can become an issue associated with
implementing tiered medical dispatch. “Agencies will have to choose between using a
flip card system or purchasing a computerized means of EMD reference such as touch
screens interfaced with CAD. In any event, keep a copy of the cards around for those
times when your CAD is out of service” (Furey, 1997, p. 50-51).
Clawson states that $250 per dispatcher is the average cost of training dispatchers
to use his call-rating system in a three-day class (Wilson, 2003).
26
There are significant costs to developing and maintaining a continuous quality
improvement (CQI) program associated with call screening, call prioritization, and unit
allocation. Analysis of dispatch procedures led the Dallas Fire Department to develop a
quality assurance program using registered nurse call-screeners. “The nurse, located in
the dispatch center, performs quality assurance and call screening to determine whether
the call is an emergency or non-emergency. In life-threatening medical emergencies, the
nurse gives medical self-help advice to callers until ALS units arrive. In non-emergency
situations where an ALS unit is not required, the nurse gives medical self-help advice and
provides follow-up information, including referrals to other services and agencies”
(Starks, 1983, p. 30).
Once the decision is made to make a change in dispatch procedures, there is a cost
associated with conducting a thorough system evaluation. “An evaluation should be done
consisting of collecting and reviewing present and past data about the system that not
only clearly defines where the system is presently, but provides justification for the
change” (St John & Shephard, 1993).
Another cost is the design of the new dispatch/response procedures. “The
procedures should include input from all appropriate sources such as operations
managers, EMS, dispatchers, field providers, training personnel, and physician or
medical group. The input should outline time tables for training and start-up, including
clearly defined objectives, action plans for meeting objectives, and identification of
responsible persons” (Clawson, 1991, p. 33-34).
An equally important cost, but often forgotten, is the need to research not only the
legal authority to make such changes, but the potential political impacts to the
27
organization. Successful implementation of any plan should also include objectives
aimed at public education, including public service announcements, written press
releases, press conferences, and be prepared to address issues and concerns from the
medical community such as local doctors, private ambulance companies, and hospitals
(St John & Shephard, 1993).
Funding associated with implementing a priority medical dispatch program
should include collecting data and providing feedback, not only during a reasonable trial
period, but also on a continuous basis. Adequate data feedback is essential to support the
continued existence of the new program as well as suggest modifications for greater
effectiveness and increased patient care (Clawson, 1991).
The literature review influenced the research by identifying alternative dispatch
systems, both in the private and public sectors within and outside of the United States.
The literature review was important in assessing methods and programs for reducing the
number of unit responses to EMS calls. Literature findings revealed how tiered medical
dispatch programs compare to the OCFA’s existing EMD program. The assessment also
provided information from others on why tiered medical dispatch is so important for
agencies to implement.
In summary, the literature review provided findings from others that helped
address the problem OCFA is experiencing concerning significant increases in unit
responses, particularly to medical calls. The literature was also helpful in more
accurately defining the components that make up tiered medical dispatch, and in
answering the individual research questions. Specifically, the literature review more
28
clearly identified some of the risks, benefits, and costs, associated with implementing a
tiered medical dispatch program.
PROCEDURES
The following definitions are taken from the California Emergency Medical
Services Authority (EMSA), Emergency Medical Services Dispatch Program Guidelines,
published in March 2003.
Definition of Terms
Call Screening. The process emergency medical dispatchers use to categorize
medical emergencies into “potentially life threatening emergencies” requiring Advanced
Life Support (ALS), or “non-life threatening medical calls” requiring a Basic Life
Support (BLS) response, or no medical emergency.
Call Prioritization. The process emergency medical dispatchers use to determine
whether a medical emergency is time sensitive (life threatening) requiring units to
respond with red lights and sirens (Code 3), or (non-life threatening) without red lights
and sirens (Code 2).
Continuous Quality Improvement. A program to insuring safe, efficient, and
effective performance of emergency medical dispatchers regarding their use of the tiered
medical dispatch response system and delivery of patient care provided.
Emergency Medical Dispatcher. A person trained to provide emergency medical
dispatch services in accordance with approved guidelines.
Emergency Medical Dispatching. The reception, evaluation, processing and
provision of dispatch life support; management of requests for emergency medical
29
assistance; and participation in on-going evaluation and improvement of the emergency
medical dispatch process.
Post-Dispatch Instructions. Case-specific advice, warning, and treatments given
by emergency medical dispatchers through callers after dispatching field responders.
Pre-arrival Instructions. Medically approved scripted instructions given in time-
critical situations where correct evaluation, verification, and advice is given by
emergency medical dispatchers to callers that provide necessary assistance and control of
the situation prior to arrival of emergency personnel.
Tiered Medical Dispatch. A medical dispatch system that incorporates call
screening, call prioritization, unit allocation, and may include post-dispatch instructions
(PDI) and/or pre-arrival instructions (PAI).
Unit Allocation. The process emergency medical dispatchers use to identify the
most appropriate number and type of medical provider (ALS, BLS, or transport) required
to respond to medical emergencies.
Limitations
The only limitation identified during the research was the low number of
responses to the external survey. The external survey was intended to provide
comprehensive data on alternative tiered medical dispatch programs used in similar size
and type fire agencies across the nation. The lack of adequate data resulted in the
External Interview Survey being deleted from the research materials. Consequently, the
original research is limited to the Literature Review, EFO Class survey and follow-up
Interviews, and personal interviews with OCFA staff and material experts in other
agencies nation-wide.
30
Research Methodology
The evaluative research method was used to address the research problem. This
was accomplished by assessing methods and programs that could be used to reduce the
number of unit responses to EMS calls within OCFA’s response area. The procedures
used in the study, both literature review and original data from surveys and interviews,
address each of the research questions. Specifically, what alternative dispatching
programs exist that enable tiered medical responses, how do they compare with OCFA’s
existing EMD procedures, and what are the risks, benefits, and costs associated with
successfully implementing a tiered medical dispatch program for the OCFA.
The research procedures used to gather information, clarify issues, answer
questions, and ultimately arrive at objective results included a broad literature search.
The research was conducted at the National Fire Emergency Training Center’s (NETC)
Learning Resource Center (LRC), Huntington Beach Library Information Services
System, Internet, and data obtained from managers in OCFA’s EMS, Risk Management,
and Information Systems Sections.
The literature review included information from textbooks, periodicals,
professional journals, reports, and copies of actual tiered medical dispatch procedures
from both the private and public sectors within and outside the United States. In
addition, searches were conducted online through Internet search engines to identify
relevant documents and further sources of information.
Current literature was used to compare the broad findings of others from private
sector ambulance companies and other medical dispatch agencies within and outside the
31
United States, to the surveys and interviews with OCFA managers and staff, and with
material experts from other agencies using tiered medical dispatch.
Thorough research of current literature, combined with objective questionnaires
and interviews, provided comprehensive information that adequately addressed the
research problem and answered the research questions. The tired medical dispatch
questionnaire used to obtain input from EFO class members, and interviews with content
experts appear as Appendix A.
The survey questionnaire was provided to the twenty-three EFO classmates in the
May 2003, Executive Leadership course, on Thursday, May 28, 2003. The survey group
represented twenty-three different fire agencies across the United States. Classmates
were given three days to respond with their answers and comments to the survey
questionnaire. At the end of five days, sixteen surveys, 70% were completed and
returned in time for follow-up discussions. The purpose of the follow-up was to obtain
additional insight and input prior to the end of class. In the weeks the followed, many of
the participants were re-contacted via telephone interviews for more information.
Of the sixteen surveys received, eight, 50%, use tiered medical dispatch,
including call screening, priority dispatch, and unit allocation. The remaining eight
agencies do not differentiate between levels of response or between mode of response at
the time of dispatch.
Five of the eight agencies using tiered medical dispatch, over 60%, use the
Clawson Priority Dispatch System. The three remaining agencies use a tiered medical
dispatch system developed “in-house”. Seven of the eight agencies, using tiered medical
dispatch rated their programs successful to very successful.
32
In addition to the surveys, personal interviews were conducted with EMS
managers at several large metropolitan fire departments in Southern California currently
using tiered medical dispatch. The basis of the interviews was the survey questionnaire
that appears in Appendix A. Personal interviews proved to be the most beneficial source
of information. Interviews offered additional opportunities for dialog and follow-up
questions. This dialog provided depth, insight, and detailed answers to the questions in
the form of specific examples.
The purpose of the individual surveys and personal interviews was to address the
research problem and solicit input concerning the four research questions. Specifically,
to learn of related issues and considerations from those with experience involved in
implementing a priority medical dispatch program.
The questionnaire was designed to encourage individual comments in order to
provide additional clarification or offer more detailed answers. The intent of the surveys
was to obtain data from material experts, who had experience with tiered medical
dispatch. This data could then be combined with the literature findings to obtain more
complete and objective information.
In summary, these procedures (literature review, individual surveys, and personal
interviews) provide an objective process that permits easy and logical replication for
others interested in researching tiered medical dispatch as a solution to reducing unit
responses to EMS calls.
RESULTS
Results of procedures employing a comprehensive literature review of public and
private sources within and outside the United States, along with detailed surveys and
33
interviews combine to provide thorough answers to the individual research questions.
Detailed findings are provided in narrative form below for each of the survey questions.
What alternative dispatching programs exist that enable tiered responses to medical
calls?
Discovered were volumes of material on alternative programs that permit tiered
medical dispatch. Literature suggests, however, most tiered medical dispatch programs
appear to be related in some fashion to one basic program, the Clawson Priority Dispatch
System. The Clawson system has been used by public and private sectors in both the
United States and Canada for over two decades. The Clawson system is now used in
over twenty other counties in 16 different languages, by 2,500 agencies worldwide, 2,400
of them in the United States.
Survey results and interviews support this literary finding. Half of the agencies
interviewed in the EFO survey use some form of tiered medical dispatching, including
call screening, priority dispatch, and unit allocation. Survey data concludes that over
60% of those surveyed use the Clawson Priority Dispatch System. Those interviewed
also stated that Clawson’s concept of priority medical dispatch “can easily go hand in
hand with systems using tiered unit response”.
The results of findings indicate that the remaining agencies using tiered medical
dispatch developed their own “in-house” system. Data shows that 88% of all agencies
using tiered medical dispatch, Clawson or “in-house” system, rated the program
“successful” to “very successful.”
The results of literature review suggest that integrated priority dispatch and tiered
response is most frequently used in large systems where multiple levels of EMS response
34
are possible. Some example is the tiered response system used in Baltimore County,
Maryland; Dallas, Texas; Salt Lake City, Utah; King County, Washington; and Seattle,
Washington.
Research identified another tiered medical dispatch program that has been used
for several decades, the Dallas Fire Department Nurse Call-screener Program. Analysis
of dispatch procedures led the Dallas Fire Department to develop a program using
registered nurse call-screeners. The nurse, located in the dispatch center, performs
quality assurance and call screening. Talking to a medical professional reduces the risk
of misjudging the seriousness of the medical emergency is cited as the major reason for
using registered nurses to screen calls.
Research revealed another tiered medical dispatch program using a similar call
screening process. However, this system uses “Emergency Medical Dispatchers” instead
of nurses. Salt Lake City’s development of medical priority dispatch, a form of the
Clawson system, includes training and certification of Emergency Medical Dispatchers
(EMD). The program further defines the concept of call screening, allows for more
formal control, and may prove more economically feasible for the fire service.
Literature review uncovered another form of tiered medical dispatch. Like other
tiered medical dispatch programs, the King County Washington EMS program’s major
components include call receipt and triage, and pre-arrival instructions by dispatchers.
However, the program also has adopted the Seattle Fire Department’s Medic One
Program model. Seattle’s model allows jurisdictions to levy a property tax for providing
emergency medical services. For the past thirty years, the system has maintained the
highest reported survival rates in the treatment of out-of-hospital cardiac arrest patients
35
across the nation. Medical control is seen as one of the main components contributing to
their success. The tiered medical responses system is based on a medical model that
operates under legal authority of the Medical Program Director (MPD) who is
responsible for setting training standards, medical control supervision, and quality review
of medical information by dispatchers and treatment by responders in the field.
How do alternative dispatching programs compare to OCFA’s existing emergency
medical dispatching (EMD) program?
Alternative dispatch programs enabling tiered medical dispatch are very different
compared to OCFA’s existing EMD program.
To understand how alternative dispatching programs compare to OCFA’s EMD
program it is necessary to understand OCFA’s existing system. The OCFA currently
utilizes a traditional medical dispatch model, and not tiered medical dispatch. The
program is based on rapid call assessment and dispatch, coupled with the conservative
philosophy of dispatching to the worse case scenario. The dispatch goal is to ascertain
the necessary medical information and process the call in 30 seconds or less. As a result
of the rapid conservative assessment, most EMS calls default to ALS level responses.
The objective is to get the first-arriving officer on scene quickly to make an assessment
and cancel resources that aren’t needed.
In OCFA’s Emergency Medical Dispatch (EMD) Program, dispatchers in the
Emergency Communications Center (ECC) identify the type of medical problem and
CAD recommends pre-programmed unit responses. However, the typical response is
three units – an ALS engine or van, closest BLS engine, and a transport ambulance.
36
Although the existing OCFA dispatch system has all of the necessary components
for tiered medical dispatch, the program was not designed as a priority dispatch system.
For example, the OCFA EMD reference system is used after the dispatch. It is designed
to provide the caller with pre-arrival instructions. The EMD reference booklet is not
intended to perform “call screening” - categorizing responses into “emergency” verses
“non-emergency” calls. The current OCFA program also is not used to ascertain “call
prioritization” - Code 2 or Code 3 response, nor is it intended to identify “unit allocation”
in CAD - the most appropriate type of resource (ALS, BLS, or transport). However,
OCFA’s current system does have all of these required elements, including pre-arrival
instructions and CQI, that could be modified and integrated to perform tiered medical
dispatch.
The existing EMD procedures, and consequent unit response, is not based on
sound medical evaluation prior to dispatch, but rather on the desire to protect the
organization from potential litigation due to long response times. In addition, most
response procedures require the use of red lights and sirens en route to the scene, and
many times also for transports to hospitals.
By comparison, in the private sector, the “Big Three” (Medtrans, AMR,
Rural/Metro) are all currently working on “Pathway Management” models making
greater use of the communications center to screen calls and respond the most appropriate
resource.
Also unlike OCFA’s EMD program, the Clawson Priority Dispatch system, and
other similar tiered medical dispatch programs such as those used in Salt Lake, Dallas,
Seattle, King County, all take longer to perform call screening. However, as a result of
37
better call screening, often fewer units are dispatched to individual calls, leaving more
resources available for area coverage and response to simultaneous emergencies. In
addition, these systems frequently recommend that units respond Code 2, no red lights
and sirens. This feature of tiered medical dispatch reduces the potential for accidents,
wear and tear on apparatus, and stress to responders.
What are the risks and benefits associated with implementing a tiered medical
dispatch program?
Findings from surveys and interviews reveal that call screening used in tiered
dispatching could be viewed as a risk. Information provided by those surveyed and
interviewed indicates that call screening could take two to three times longer when using
a program such as Clawson’s. Several survey participants believe that tiered medical
dispatch increased overall response times, especially on non-emergency calls.
Implementing this type of tiered medical dispatch program could result in longer total
response times for OCFA.
Findings suggest that there may be a “tradeoff” for the additional time necessary
to perform call screening. Literature suggests that although call screening takes longer
and this could be seen as a risk, the screening process frequently recommended fewer
units initially respond especially ALS units. Having more ALS units available for area
coverage and simultaneous responses, according to some critics, may in fact reduce or
even offset the increased call screening time.
Another potential risk with tiered medical dispatch is the potential for increased
error rates in assigning call prioritization (Code 2/Code 3) appropriate resources (unit
allocation), and confusion with terminology at first between dispatch and the field.
38
Consequently, some departments choose to provide an ALS response to all incidents
initially for purposes of legal protection and to avoid citizen complaints.
There are other risks associated with tiered medical dispatch and fewer unit
responses. Literature suggests that by responding maximally to all requests, total unit
responses increase and this is often seen as desirable by both labor and management.
Increased unit responses equates to increased activity and visibility for the agency, and
theoretically good public relations.
Findings suggest that additional unit responses increases justification for
additional personnel, vehicles, training, supplies, apparatus, facilities, and salaries. Some
proponents argue that additional unit responses can also translate into increased
experience and personnel productivity in the form of less idle time.
In an interview with OCFA EMS staff another risk was identified. Given the
current labor environment, it was suggested that implementation of tiered medical
dispatch may be met with resistance from the local firefighter’s union, and that “buy-in”
may be difficult to obtain.
Unlike OCFA’s conservative, quick dispatch, rapid response procedures, and pre-
arrival instructions, literature asserts that tiered medical dispatch may offer more benefits
than risks. Surveys and interviews suggest that often fewer resources are dispatched to
EMS calls making more resources available for area coverage and response to
simultaneous emergencies.
Interviews with an EMS chief from a large county fire department commented
that Code 3 responses were reduced by 15%. Another chief from a large Midwestern city
39
using tiered medical dispatch observed that tiered medical dispatch reduced engine
responses to non-emergency EMS calls, especially at assisted living facilities.
Also unlike the OCFA EMD system, literature suggests that units more frequently
respond without lights and sirens making responses safer for responders and the public as
a result of call screening.
Findings suggest that one of the most notable benefits to tiered medical dispatch
is that those in dire need will receive, not only the most basic help as quickly as possible,
but also the most advanced help as quickly as possible. Literature also supports the
argument that tiered medical dispatch offers improved area coverage, and reduced travel
times to medical calls. Again, more resources may be available for area coverage and
response to simultaneous emergencies.
Literature, surveys, and interviews all agree that reductions in unit activity not
only have the possibility to reduce the number of accidents and injuries, thus reducing
liability insurance and claims, but also has the potential to reduce operating cost in the
form of “wear and tear” on units and stress claims from responders.
Still another alleged benefit according to literature is that tiered medical dispatch
reduces medical costs to patients and that using fewer paramedics to serve ALS patients
translates into greater efficiency, effectiveness, and increased ALS skills because ALS
personnel have more opportunities to practice their skills. The benefits to the department
include decreased staffing and training costs.
According to literature, another benefit to good call screening coupled with
accurate call prioritization is a more cost-effective system. Proponents argue that it
doesn’t make sense operationally to commit ALS resources to calls that might have been
40
handled by taxis. Findings also suggest that “the system” may want to use the public
sector for ALS responses and BLS emergencies, and route non-emergency medical calls
and transportation events to private providers.
Participants in the EFO study responded that one of the benefits of tiered medical
dispatch is better contractual conditions with the private ambulance companies and
tighter response time criteria for Code 2 and Code 3 responses.
What are the costs required to successfully implementing a tiered medical dispatch
program?
Interviews with OCFA staff argue that there will be costs incurred to modify
OCFA’s EMD procedures, or to implement a new EMD program that offers tiered
medical dispatch. OCFA staff content that either option will require the purchase,
installation, and training of new computer software required for call screening,
prioritization and unit allocation.
For example, literature reveals that for the Clawson system, the average cost of
training dispatchers just to use his “call-rating” system averages $250 per dispatcher for
the three-day class.
Interviews with OCFA staff suggest that both alternatives would also require
training for Operations personnel. OCFA staff also contend that initial costs associated
with educating the public, the medical community, and political supporters will require a
commitment of time and money. Staff believes that in addition to the “start-up” cost, the
ongoing cost of continuous quality improvement (CQI) associated with call screening,
call prioritization, unit allocation, and pre-arrival instructions must be considered in
implementing a tiered medical dispatch program. Participants in the EFO survey
41
responded that they needed better CQI for their dispatchers, supporting OCFA staff
assertions.
Literature and interviews with users contend that, although important, there is a
cost associated with conducting a system evaluation prior to implementing the dispatch
program. Findings recommend that an evaluation consisting of collecting and reviewing
present, past, and potential future response data is essential. It is not only necessary to
clearly define where the dispatch system is presently, but also to provide justification for
changes and projected future needs.
Literature and surveys agree that another substantial cost is the design of new
dispatch and unit response procedures. Both sources agree that procedures should
include collaborative input from both providers and users. Some examples included
Operations managers, EMS and training staff, dispatchers, ambulance companies,
hospital physicians or medical groups. The input should outline time tables for training
and start-up, including clearly defined objectives, action plans for meeting objectives, and
identification of responsible persons.
Literature and interviews reveal another equally important cost, but often
forgotten, the need to research not only the legal authority to make such changes, but also
the potential political impacts to the organization.
Many in the EFO survey also stated that their departments should have conducted
more PR (public relations) to advise citizens that they may experience longer response
times due to call screening and “quiet responses”. Literature and interviews also strongly
contend that successful implementation of any plan should prioritize objectives aimed at
public education, including public service announcements, written press releases, press
42
conferences, and be prepared to address issues and concerns from the medical community
such as local doctors, private ambulance companies, and hospitals.
Research shows that another cost associated with implementing a tiered medical
dispatch program should include the means to collect data and provide feedback. It is
recommended that feedback is essential, not only during a reasonable trial period, but
also on a continuous basis to support the continued existence of the new program as well
as suggest modifications for greater effectiveness and increased patient care.
In summary, detailed results of procedures, broad literary reviews from public and
private sectors, along with surveys and interviews of OCFA staff and outside agencies,
combine to provide thorough and objective answers to the research questions.
Specifically, literature proves that alternative dispatching programs exist that
would permit OCFA to implement tiered responses to medical calls, thus reducing overall
unit responses. In addition, findings show how these alternative programs compare with
OCFA’s current procedures, what the risks and benefits are, and what cost are required to
implement a tiered medical dispatch program. The results suggest that despite the cost
and potential risks, there are benefits to OCA implementing a priority medical dispatch
system.
DISCUSSION
The OCFA has several alternatives to implementing a priority medical dispatch
system. The OCFA can remain with their current EMD system. The Authority can
completely abandon their current medical dispatch program and adopt an existing tiered
medical dispatch program such as Clawson’s Priority Dispatch System. A third
alternative is to develop a priority medical dispatch program “in-house” to meet OCFA’s
43
unique system requirements. This could be accomplished by modifying OCFA’s existing
dispatch procedures. This includes enhancing call screening, call prioritization, and unit
allocation, while retaining their existing pre-arrival instructions and CQI Program.
Developing and implementing a system that revises OCFA’s call screening,
priority dispatch, and unit allocation “in-house” could require a significant commitment
of resources, according to OCFA EMS staff interviewed on September 17, 2003. Staff
believes that several major issues may be problematic in evaluating current and projected
system needs. Staff’s concern is the absence of a good records management system
(RMS). Two of the most significant RMS issues include the lack of uniformity in data
collection necessary to make good decisions, and the large number of inaccurate and
incomplete incidents reports completed by responders.
Staff also strongly believes that PAUs are currently under utilized. They assert
that PAUs are not being used effectively or efficiently in the overall EMD delivery
system. Staff contents that if the role of PAUs were increased, the number of unit
responses and skills degradation could be reduced.
Another concern is the current uncertainty in the health care system nationally and
locally that could impact OCFA service delivery capabilities (K. Miller, MD; J. Howlind,
Battalion Chief; and R. Grubb, RN; OCFA EMS, personal interview, September 17,
2003).
The OCFA EMS staff contends that relevant internal and external factors to
designing and implementing a tiered medical dispatch system must be identified. Staff
further suggests that pertinent policy questions must be answered before designing or
adopting a response system for OCFA. For example, what is the goal of OCFA’s priority
44
dispatch program? Is the goal to provide rapid response and high quality service, or is
the aim to reduce unit responses, and are the two goals in direct conflict?
Literature findings support the belief that it is important to first identify factors
driving the need for change. “The initial step to managing change is to identify what
factors inside and outside the organization may influence the change” (FEMA, 1996, p.
SM2-3).
OCFA EMS staff believes that the following questions are relevant and must be
addressed by any group evaluating tiered medical dispatch for OCFA:
1. What is the real goal OCFA is trying to achieve, and is it response time based?
2. What are the objectives for call screening and priority dispatch?
3. What is the legal authority and what is the approval process to make changes?
4. What legal requirements, and contractual obligations exist?
5. What data is needed to make “best decisions”, and where do we go to find the data?
6. What are the area demographics, and how does that influence decisions?
7. What are the actual EMS call types and response numbers for each call type?
8. What are the priority dispatch system components and how do they inter-relate?
9. Who are the stakeholders, and what are their issues/concerns?
10. What are the internal and external change agents, positive and negative?
11. What resources/support are needed, from whom, what are the impacts?
12. What systems currently exist, and which can be modified to meet OCFA needs?
An integrated regional medical delivery system is needed along with tiered
medical dispatch from the program to be successful (J. Howlind, EMS Chief, OCFA,
interview, September 17, 2003). Chief Howlind advocates a countywide systems-
45
approach that includes; not only paramedic receiving centers and base station hospitals
for ALS patients, but also the use of Urgent Care Facilities as alternatives for certain BLS
patients. The use of alternative facilities would help reduce hospital saturation and unit
diversions to receiving centers hospitals further away. The result is shorter response
times to hospitals, less time units are committed, and better area coverage.
In an Interview on Monday, October 6, 2003, with Tom Arnold, Operations Chief
for the Newport Beach Fire Department, regarding the Clawson dispatch system, he too
suggests that tiered medical dispatch is only one component of the overall EMS deliver
system that needs to be evaluated. He proposes a system-wide review of the EMS
delivery system as the best approach to assessing the best alternative dispatching
program. Chief Arnold further recommends, as part of the assessment, that OCFA
consider options for fire department transport as an integral component of any tiered
medical dispatch system. He further suggests that the OCFA consider more effective
ways to use their PAUs, especially in conjunction with a fire department transport
program.
To date, integrated priority dispatch and tiered response is most frequently used in
large systems where multiple levels of EMS response are possible, such as the tiered
response system used in Baltimore County, Maryland (St. John & Shephard, 1993).
Whether a large or small system, discussions concerning priority medical dispatch
center on response hazards and the need to reduce the number of Code 3 responses.
Clawson (1996) claims that response hazards to EMS crews and the public are greatly
reduced by using call screening and priority dispatch procedures.
46
According to a 1994 position paper by the National Association of Emergency
Medical Services Physicians and the National Association of State EMS Directors,
“while much talk has ensued regarding the public’s responsibility to watch out or get out
of the way, EMS should not blame the public for the problem of emergency motor
vehicle collisions.”
Pennsylvania attorney Douglas M. Wolfberg, a former EMT whose firm
represents mostly ambulance companies, said that he believes use of lights and sirens
causes more deaths and injuries than it saves lives.
Other literature findings agree with Wolfberg. Over 70 million Americans are
transported to hospital emergency rooms for care each year (Hafen, 1998). Only 8.4
percent of patients transported by ambulance to an ER actually needed definitive care
rendered by an emergency room. Medicare patients showed that 94.6 percent of all
Medicare patients transported to an ER could have received treatment at another more
appropriate resource (Ludwig, 1997, p. 60-61).
Research into emergency medical services liability over a five year study period
analyzed 76 incidents in the United States filed against both public and private EMS
agencies. Fifty percent of the accidents involved litigation due to a vehicle collision with
an ambulance. Eighty-five percent of those accidents occurred during emergency
operation (red lights and sirens) of an ambulance either enroute to the scene or hospital
(Morgan, Wainscott, & Knowles, 1994).
Literature suggests that there is more than liability from emergency vehicle
accidents than simply injuries. Industry experts have estimated that there are 12,000
ambulance-related crashes annually in the United States, causing 120 deaths. A recent
47
industry survey found that only a third of the 200 largest ambulance services nation-wide
still respond to all emergencies with lights and sirens (Charalambous, 2002).
“I witnessed instantaneous panic reactions among automobile drivers who, after
being approached by a fast-moving ambulance with siren yelping and lights blazing,
didn’t know whether to stop, swerve, pull over, or just keep going. Many such drivers
become hazards to themselves, to other vehicles, and to the EMS crew and patients,”
wrote Clawson in a 1996 article in the Journal of Emergency Medical Services” (Wilson,
2003, p. 20-23).
Research confirms emergency response vehicles, running Code 2 or Code 3,
produce “wake effect” accidents as drivers are startled by lights and sirens. “In 1997,
Salt Lake City and Salt Lake County reported 377 “wake effect” accidents compared to
85 civilian/emergency responder collisions. In other words, “wake effect” accidents
produced by emergency vehicles responding with red lights and sirens are 4.4 times more
likely to occur than compared to no use of lights and sirens. Due to these statistics, many
emergency response vehicle operators have established a policy limiting the use of lights
and sirens when responding to emergency situations” (Fors, 1998, p. 43-45).
A study last year in Pre-hospital Emergency Care that looked at 339 fatal
ambulance crashes found that 60 percent of them occurred during emergency use. The
study went on to identify that response times saved by using lights and sirens ranged
from 45 seconds per run in urban areas to 3.63 minutes in rural areas. The study
concluded that a 3.5 minute savings from quicker arrival did not translate into clinically
significant improvements for the patients (Wilson, 2003).
48
Clawson claims that his concept of priority dispatch (call screening and call
prioritization) can easily go hand in hand with any system using tiered unit response.
“Prioritization of responses, and call-taker training enables agencies to match resource
configurations to the seriousness of the incident and maximize available resources while
minimizing response time and the potential for emergency vehicle collisions” (Clawson,
2003, p.2).
However, not everyone using the Clawson system agrees that the Clawson
classifications match resource configurations to the seriousness of the incident. In a
personal interview with Denise Mitchell, EMS Director for the Anaheim California Fire
Department, on Wednesday, October 22, 2003, she advises that the Clawson
classifications didn’t match the Orange County EMS Agency Treatment Guidelines.
Some examples she noted were loss of consciousness (LOC), stabbings, shootings,
overdoses, and certain heart related calls. Under Clawson, these emergencies can be
initially classified as “Bravo” calls, non-ALS, or Code 2 responses. Under Orange
County Treatment Guidelines these same emergencies are all considered ALS calls and
would be “Charlie” or “Delta” (Code 3) responses.
As a result, EMS Director Mitchell advised that their department had to change
the Clawson response classifications to conform to Orange County treatment guidelines.
Chief Tom Arnold, Newport Beach Fire Department, stated that they too, along with
neighboring Fountain Valley Fire Department also had to modify the Clawson system.
According to Arnold, the Clawson call screening time was excessive and the call
prioritization did not fit response protocols. The biggest issue with the Clawson system
49
was the increased call screening time that made it impossible to and maintain reasonable
response times.
St. John and Shephard (1993) suggest that it’s time to review and even revise
policies calling for emergency responses (red lights and sirens) to all incidents. Clawson
(2003) agrees, and contends that the use of strong medical control in defining
dispatch/response procedures may ultimately determine that “in a sizeable number of
incidents the use of red lights and sirens is unnecessary.”
Hunt, Brown, Cabimum, et al. (1995) compared ambulance transport times from
the scene to the hospital for both routine and priority responses in an attempt to determine
if priority responses saved time or lives. Fifty emergency medical transport times were
compared in both routine and priority modes based on similar traffic conditions, response
routes, and times of the day. The conclusion was a 43.5-second mean time savings in
using priority over routine response. The study also stated that ALS capability of the
transporting unit frequently precludes the need for transport with red lights and sirens,
which results in only minimal timesavings.
In a similar study using another EMD system to determine the affects of the mode
of response and transport (red lights and sirens), the findings revealed that 92% of
patients transported using the routine mode, resulted in no adverse outcomes (Kupas,
Dula, & Pino, 1994).
The individual questionnaires to Executive Leadership classmates proved
insightful in addressing the research questions and helpful in obtaining candid
information about their experiences using tiered medical dispatch.
50
A survey questionnaire regarding tired medical dispatch (refer to Appendix A)
was provided to the twenty-three EFO students in the May 2003, Executive Leadership
Course, representing twenty-three different fire agencies across the United States. The
classmates were given three days to respond with answers and comments to the survey
questionnaire.
At the end of five days, sixteen surveys, 70% were completed and returned. Over
the next week and a half, individual meetings with each respondent were conducted. The
purpose was to follow-up on the questions and to obtain further information and details.
Half, of those surveyed use some form of tiered medical dispatching, including
call screening, priority dispatch, and unit allocation. The remaining eight agencies do not
differentiate between levels and mode of response at the time of dispatch.
Five of the eight agencies using tiered medical dispatch, over 60%, use the
Clawson Priority Dispatch system. The three remaining agencies using tiered medical
dispatch developed variations of the system “in-house”. Seven of the eight agencies,
using tiered medical dispatch rated their programs successful to very successful.
When asked in follow-up interviews about the benefits of tiered medical dispatch
one fire chief responded that, “We now have better contractual conditions with the
private ambulance companies. For example, tighter response time criteria and
requirements for Code 2 and Code 3 responses.”
Clawson also asserts that savings in the amount of fuel used, in vehicle wear and
tear, and in stress to personnel, will prove well worth the initial investment of time and
effort in developing these more realistic, reasonable, and clearly defined dispatch
51
procedures. None of the agencies surveyed or interviewed that are using priority medical
dispatch could substantiate this claim.
Battalion Chief Steve Maiero, EMS Chief for Contra Costa County Fire
Department commented that, “We’ve reduced Code 3 responses by 15%.“ Fire Chief
Timm Schabbel, South Bend, Indiana, observed that “The tiered system has really cut
down on the engine responses to non-emergency calls, especially at assisted living
facilities.”
Regarding how successful their programs were and what they would have done
differently, or would do to improve their program, one fire chief in the EFO study
responded that they needed “better CQI (continuous quality improvement) for their
dispatchers in order to rate their program a success.” Another fire chief stated that, “We
should have conducted more PR (public relations) to advise our citizens that they may not
get a response as quickly as in the in past.”
Concerning the risks and costs associated with implementing tiered medical
dispatch, one fire chief in the EFO survey observed that, “There are times when we
wished we still had an ALS unit responding automatically to certain calls.” During
follow-up interviews, another fire chief stated that, “Tiered medical dispatch has
increased response times, particularly to BLS and non-emergency calls.”
Regarding Clawson’s claim that his tiered medical dispatch system reduces
response times, in personal interviews with both Chief Arnold, Newport Beach Fire
Department, October 6, 2003, and Denise Mitchell, Anaheim Fire Department, October
22, 2003, both claimed that the Clawson system actually increased overall response
times. They both attributed the increase response times to the additional time required to
52
perform call screening. Chief Arnold stated that, “Clawson didn’t work well for us or
Fountain Valley. Call screening increased our response times too much. We had to
make every call a Charlie response (Code 3), ask the rest of the required questions after
dispatch and then forward the additional info to responding units.”
“As of August 1, 2003, our dispatch office switched to the Medical Priority
Dispatch, or Clawson System, as it is known. Since this time we have noticed a dramatic
increase with call processing times, which in turn is really screwing up our numbers for
our Standards of Coverage. Our dispatch times went from 50 seconds to 2-3 minutes”
(B. Kazmierzak, Training Captain, South Bend, IN., personal communications, August
26, 2003).
(R. Grubb, RN; OCFA EMS, personal interview, September 17, 2003), noted that
OCFA is not currently meeting our overall response time goals for the first unit to arrive
on scene to medical emergencies within five minutes 90% of the time. However, the
average annual call processing time goal for OCFA dispatchers (under one minute) is
being met, with many calls being processed in approximately 20 seconds. It was
suggested that additional call processing time would be required under tiered medical
dispatch resulting in even longer response times to medical emergencies.
Another potential risk to the OCFA in implementing tiered medical dispatch may
come from the local firefighter’s labor organization. In an interview with OCFA EMS
staff it was suggested that tiered medical dispatch may be met with resistance from the
local firefighter’s union, and that it may be difficult to obtain the necessary “buy-in” to
have the program accepted.
53
Anaheim Fire Department’s EMS Director, Denise Mitchell, voiced a similar
labor concern. Mitchell stated that, “Anaheim runs 20,000 medical calls per year with
50% of them being BLS. Under our system, truck companies handle the BLS calls. The
truckers had a big adjustment going to medical aids and because to the number of BLS
calls, were not always available to respond to structure fires. We experienced a long
learning curve, many complaints, and bad attitudes.”
One fire chief interviewed in the EFO study stated that his organization
experienced confusion with the new tiered medical dispatch terminology being used in
dispatch.
Interviews with OCFA staff and program experts from other agencies using tiered
medical dispatch also expressed views on potential risks and costs. OCFA staff agreed
that there will be costs incurred to modify the existing EMS procedures, or to implement
a new program that supports tiered medical dispatch protocols. Both options will require
the purchase, installation, and training of new computer software required to process calls
in the ECC. For example, Clawson said $250 per dispatcher is the average cost of
training dispatchers to use his call-rating system in a three-day class (Wilson, 2003).
Some would assert that training costs are not limited to dispatchers. Findings
from survey questions and interviews with other agencies reveal that no matter what
tiered medical dispatch alternative is selected, the new system would also require training
for Operations personnel. For example, literature, survey and interview findings
emphasis that there will be start-up costs in developing and maintaining a continuous
quality improvement program.
54
Findings suggest that start-up costs are not limited to internal audiences. There
will also be costs associated with educating the public, the medical community, and
political supporters. A fire chief from the EFO study in a follow-up interview stated that
he regretted that his department didn’t do more PR (public relations) and more
community out reach to advise citizens that they may not receive the same response as
quickly.
Some proponents believe that the use of call screening and call prioritization can
produce a more cost efficient operation. “Although this facet of dispatching is often
associated with private sector providers of EMS, there is benefit to the public sector as
well by not committing ALS resources unnecessarily. It doesn’t make sense to commit
your ALS resource to a call that, quite frankly, might have been handled by taxis” (Furey,
1997, p. 50-51).
In an interview with OCFA EMS staff, it was noted that OCFA Paramedic
Assessment Units (PAU), engines assigned a single paramedic, are considered BLS units.
As a result, an ALS unit (engine or paramedic van assigned two paramedics) is also
dispatched to most EMS calls. This contributes to skills degradation on PAUs and
inefficient use of valuable resources. Also, this dispatch configuration often commits two
engine companies on ALS calls leaving two stations uncovered. In addition, this practice
also increases the potential danger to responding crews and the public by placing two
units on the road responding with red lights and sirens. It was suggested that tiered
medical dispatch might recommend only PAUs for certain medical emergencies. This
would reduce the number of dual engine responses, improve coverage and paramedic
skills on PAUs, reduce citizen complaints of too many units on calls, reduce wear and
55
tear on apparatus, reduce operating costs, and potentially reduce stress on responders.
Another recommendation from staff is to respond PAUs Code 3 and ALS units Code 2 to
certain types of medical calls
Another staff recommendation is to consider the use of the new Reserve Program
squads and patrols to provide BLS coverage. It is suggested that Reserves be paged out
to cover squads and patrols whenever the Career unit at the station is dispatched. The
squad or patrol would respond to subsequent calls in the station’s first-in area. This
response model places a unit on scene quickly to assessment patients and to provide
initial intervention. Using squads and patrols in this manner also helps to maintain
interest in the Reserve program, and improves morale and EMS skills.
Automation and the use of computers can become an issue associated with
implementing tiered medical dispatch. “Agencies will have to choose between using a
flip card system or purchasing a computerized means of EMD reference such as touch
screens interfaced with CAD. In any event, keep a copy of the cards around for those
times when your CAD is out of service” (Furey, 1997, p. 50-51).
The ongoing cost of continuous quality assurance associated with call screening,
call prioritization, and unit allocation must be considered in order to implement any
successful tiered medical dispatch program. This analysis of dispatch procedures led the
Dallas Fire Department to develop a quality assurance program using registered nurse
call-screeners. “The nurse, located in the dispatch center, performs quality assurance and
call screening to determine whether the call is an emergency or non-emergency. In life-
threatening medical emergencies, the nurse gives medical self-help advice to callers until
ALS units arrive. In non-emergency situations where an ALS unit is not required, the
56
nurse gives medical self-help advice and provides follow-up information, including
referrals to other services and agencies” (Starks, 1983, p. 30).
Once the decision is made to make a change in dispatch procedures, there is a cost
associated with conducting a thorough system evaluation. “The evaluation should consist
of collecting and reviewing present and past data about the system and not only clearly
defines where the system is presently, but provides justification for the change” (St John
& Shephard, 1993).
Another cost is the design of the new dispatch/response procedures. “The
response procedures should include input from all appropriate sources such as operations
managers, EMS, dispatchers, field providers, training personnel, and physician or
medical group. The input should outline time tables for training and start-up, including
clearly defined objectives, action plans for meeting objectives, and identification of
responsible persons” (Clawson, 1991, p. 33-34).
Another equally important cost, but often forgotten, is the need to research not
only the legal authority to make such changes, but the potential political impacts to the
organization. “Successful implementation of any plan should include objectives aimed at
public education, including public service announcements, written press releases, press
conferences, and be prepared to address issues and concerns from the medical community
such as local doctors, private ambulance companies, and hospitals” (St John & Shephard,
1993, p. 31-35).
Cost associated with implementing a tiered medical dispatch program should
include the means to collect data and provide feedback, not only during a reasonable trial
period, but also on a continuous basis. “Adequate data feedback is essential to support
57
the continued existence of the new program as well as suggest modifications for greater
effectiveness and increased patient care” (Clawson, 1991, p. 33-34).
The relationship between the broad review of literature and specific findings from
questionnaires, surveys and interviews with OCFA staff and other agencies, combine to
provide an overall perspective on tiered medical dispatch with concise answers and clear
explanations to the research questions. Specifically, the findings clearly answer what
alternative dispatching programs exist that enable tiered medical dispatch, how these
alternatives compare to OCFA’s existing EMD system, and what are the risks, benefits
and cost associated with implementing a tiered medical dispatch system.
The combined findings reveal that implementing tiered medical dispatch,
although having many benefits, has implications that must be seriously considered in the
final recommendation. These implications center on the relative risks and cost verses
benefits. The implications of these research findings is significant to the OCFA because
they will directly impact service delivery “standards of coverage”, staff capacity, budget
constraints, and potential community relations and liability.
In summary, although literature, surveys, and interview results support the need
for organizations to consider implementing tiered medical dispatch, there are still risks
and costs associated with priority medical dispatch systems that must be considered on an
individual basis. After reviewing the findings, it is the author’s opinion, despite the
potential risks and costs, that if the OCFA does not adopt a tiered medical dispatch
system, their ability to continue providing high quality, cost effective service will be
severely hampered.
58
RECOMMENDATIONS
Detailed literature research from the public and private sectors within and outside
the United States, including interviews and surveys with program users, combine to
provide objective, logical, recommendations concerning the problem and research
questions. The results of the findings recommend that the OCFA implement a tiered
medical dispatch program as a method of reducing the number of unit responses to
medical calls. It is recommended that OCFA’s EMS dispatch program also be part of an
integrated response system intended to improve response times and area coverage. It is
further recommended that the priority dispatch program be cost effective and efficient for
the OCFA to s implement and sustain. Lastly, it is recommended that the program
provide flexibility to meet future demands.
The author believes that the best means to implement the recommendations is for
the OCFA to modify its’ current EMS dispatch system, rather than adopt a new program.
More specifically, it is recommended that the OCFA revise its’ existing EMS dispatch
and response policies and procedures to minimizes liability, risks, and operating costs,
and maximizes benefits associated with tiered medical dispatch.
Surveys and interviews support the author’s recommendations to update OCFA’s
existing practices to accommodate priority dispatch in lue of attempting to modify an “off
the self” or “canned” program such as Clawson. All of the essential elements of tiered
medical dispatch exist in OCFA’s current program – call screening, call prioritization,
unit allocation, pre-arrival instructions, and continuous quality improvement (CQI).
Refining OCFA’s existing EMS program will help ensure response classifications remain
consistent with Orange County EMSA treatment guidelines.
59
It is recommended that refinements be made to OCFA’s call taker questions to
satisfy enhanced call screening without increasing call processing times. The author also
recommends consolidation of existing “call types”. This recommendation will simplify
the call screening and prioritization process by reducing the number of dispatch choices
in CAD. To improve call prioritization and unit allocation, the author recommends that
OCFA obtain approvals to allow more effective and efficient use of PAUs, squads, and
transport units.
To accomplish these recommendations, the author further recommends, based on
the findings of others, that a diverse ad hoc advisory committee is assembled. The
purpose of the Tiered Medical Dispatch Advisory Committee is to serve as a steering
committee. The committee is to be comprised of stakeholders at various levels within
and outside the OCFA. The committee’s main objective is to provide project direction
and oversight. In addition, the committee is to advise and update political groups, gain
support for the Tiered Medical Dispatch Working Group, and obtain approvals from the
OCFA Board of Directors for implementation.
It is also recommended that an ad hoc focus group or working group be formed
comprised of members from appropriate OCFA departments and sections. The purpose
of the working group, is to compare existing OCFA EMS response procedures, evaluate
best options and practices, and recommend to the advisory committee the most suitable
EMS response system for the OCFA.
In addition, the focus group is to identify specific program implementation issues,
concerns, and needs. The intent of the working group is to also ascertain the best
implementation methods and strategies. The working group is to serve as the focal point
60
to receive input on developing program revisions. This group will also function as the
nucleus for the program’s transition team.
Literature findings and interviews recommend a review of current dispatch
operations and EMS delivery be conducted, prior to implementing a tiered medical
dispatch program. It is recommended that one of the first assignments for the working
group be to evaluate the existing OCFA EMS delivery system and recommend system-
wide changes. Assessment of the overall EMS delivery system should address the use of
PAUs, squads, and the transportation component. The evaluation should also include a
list of existing assets and procedures, that could continue to be used, coupled with the
identification of additional resources required to implement enhancements to the
program.
The focus group is to also assess staffing requirements. Specifically, the number
and type of personnel required to implement and maintain the new system. Staffing
requirements should also contain the estimated number of man-hours, including support
staff time required to sustain the enhancements.
Along with the amount and type of physical, appraisal should included start-up
costs such as software and reference documents. In addition, a projected annual
operating budget to support the system should be developed and presented to the advisory
committee.
Interviews with priority dispatch program users recommend developing a phased
implementation process with corresponding timelines. The author recommends that five
phases be used. These phases include: 1) planning/preparation, 2) testing/transition, 3)
start-up/implementation, 4) evaluation/modification, and 5) monitoring/ refinement.
61
Literature, survey, and interview findings all suggest that an issue often
overlooked in implementing a new response system is adequately preparing the public,
politicians, medical community, and in-house providers (dispatchers and first responders)
for the change. Findings recommend, and the author agrees, that successfully
implementing a tiered medical dispatch program requires effective community and
department education, coupled with a public outreach and awareness program.
The author recommends, based on the findings of others, that the working group
identify internal “organizational barriers” and external community obstacles that might
hamper transition to the enhanced system. The group is to also recommend the best
strategies to overcome each issue. This includes identifying political proponents and
opponents, developing compelling community relations’ strategies, and implementing a
persuasive public information plan. It is further recommended that strategies and
resources be provided to engage with each group separately.
Research also reveals that implementing tiered medical dispatch often imposes
workload impacts on dispatch centers frequently resulting in the need for additional staff.
The author recommends that the working group focus heavily on potential dispatch and
EMD issues. Two specific areas include identifying techniques to reduce call-screening
times and to provide pre-arrival instructions in a timely manner without increasing staff.
The dispatch study should also include an analysis of existing call processing,
dispatching, and EMD procedures. After identifying impacts, the group should
recommend system changes required to implement the enhancements. These findings
will be useful in determining resource requirements such as dispatch staffing and physical
assets i.e., phones, desks, and computers.
62
Interviews and surveys reveal that there are major adjustments for field personnel
transitioning to a tiered medical dispatch system. Specifically, the use of new
terminology and different response protocols. It is recommended that early in the
planning and preparation phase that change models be identified to ensure measures are
taken to prepare staff for the system changes. The author recommends that the working
group identify major transitional changes and recommend actions to minimize impacts.
Surveys and interviews suggest that changes in apparatus, equipment and supplies
should be considered. It is recommended that the focus group determine what, if any,
effects there may be on current apparatus configurations, and what types and amounts of
equipment and supplies are needed to support new response protocols.
It is recommended, based on interviews conducted with other fire departments
using tiered medical dispatch, that a review of operating policies and procedures affected
by the changes be identified, rewritten, and trained on prior to implementation. The
author recommends that new policies also consider potential impacts on existing service
contracts and inter-agency agreements. For example, Automatic and Mutual Aid with
cooperating fire departments and participating agencies.
Findings from literature, surveys, and interviews all agree that close system
monitoring, data analysis, and refinements are critical to the success of the program. The
author recommends that a CQI standing committee consisting of ECC and EMS
managers and staff be formed. The purpose of this focus group is to regularly review
dispatch and field response data, monitor performance levels, report system deficiencies,
and recommend enhancements. This group would be responsible to develop and oversee
63
a Continuous Quality Improvement (CQI) program intended to ensure performance
standards are maintained.
Interviews with OCFA EMS staff identify the need to include Orange County
EMSA, beginning in the initial stages of program development. Staff strongly suggests
working closely with the medical community to address issues such as call screening,
EMD practices, response protocols, and treatment guidelines. Staff contends that one of
the most important elements contributing to the success of OCFA’s priority dispatch
system will be obtaining “credit” or recognition for the use of PAUs. It is recommended
that PAUs respond without additional paramedic units (vans or engines) to certain
medical calls. This recommendation will improve effectiveness, efficiency, safety,
service, and PAU paramedic skills. At the same time, this enhancement will reduce the
number of unit responses, wear and tear on units, operating costs, and citizen complaints
of too many units on medical calls.
To ensure success, adequate funding to implement and sustain program
modifications is seen as a necessary element by those interviewed. One agency stated
that their decision to provide fire department transport and to charge for supplies
generated the needed funding to sustain their program. The author recommends that the
working group identify funding sources, long with fiscal practices and methods to
implement and sustain the program improvements.
In summary, the results of findings recommend that the OCFA implement a tiered
medical dispatch program as a method of reducing unit responses to medical calls,
improving response times and coverage, and reducing risk, liability, and operating costs.
64
The author recommends that OCFA modify its’ existing EMS dispatch and response
policies to accomplish implementation.
It is further recommended that an ad hoc working group be formed. The purpose
of tis focus group is to implementation issues from a total EMS delivery perspective. The
working group would be responsible to identify and recommend the best medical priority
dispatch practices to ensure high response standards, minimize risks, emphasize benefits,
and be cost effective and efficient for the OCFA to operate.
The author recommends that the working group report to an advisory committee
that serves to provide program oversight and direction. Lastly, the author recommends
that a CQI standing committee be established to ensure system enhancements continue to
meet future needs.
65
REFERENCES
California Emergency Medical Services Authority. (2003, March). Emergency
Medical Dispatch Program Guidelines, 1-10.
Charalambous, Nicholas. (2002, November). Anderson County, South Carolina
Independent. Sirens to be Limited to Emergencie,1-5.
Clawson, Jeffery. (1991, February). Dispatch Priority Training: Strengthening the
Weak Link. JEMS Magazine, 33-34.
Clawson, Jeffery. (2003, January). EMTs Risk Accidents for Non-emergency
Cases. National Academy of Emergency Dispatch, 1-3.
Clawson, Jeffery. (2003, June). Fire Protocols. National Academy of Emergency
Dispatch, 2.
Cobb, Leonard A, & Vickey, Gortdon. (2002, May). 1998-2003 EMS Strategic
Plan Update. EMS System and Operational Design, 1-8.
Drayer, Tom. (2003, July). California Department of Forestry. CDF Weekly
Safety Briefing- Fire Safety Tip, 1-5.
Federal Emergency Management Agency (FEMA), United States Fire
Administration. (1996). Strategic Management of Change, (Publication No. NFA-ED-
SM). Emmitsburg, MD: National Fire Academy.
Fellers, Li. (2003, August). L.A. Fire Trucks Face New Rules, Speed Limit, Los
Angeles Times Newspaper, 4.
Fors, Carl. (1997, March). Safety Radar Performance Comparison. BMW
Roundel, 66-88.
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Fors, Carl. (1998, July). Warn Them with Drone Radar Transmitters. Journal of
Emergency Medical Services, 43-45.
Furey, Barry. (1997, March/April). Emergency Medical Dispatch. 9-1-1
Magazine, 52-53.
Hafen, Brent Q. (1998). Prehospital Emergency Care and Crisis Intervention. (3rd
Ed.). Englewood, CO: Morton Publishing.
Hunt, R., Brown, L., Cabimum, E., Whitley, T., Prasad, N., Owen, D., Mayo, C.
(1995). Is Ambulance Transport Times with Lights and Sirens Faster than Without?
Annals of Emergency Medicine, 25, 507-511.
Kupas, D., Dula, D., Pimo, P. (1994, November). Patient Outcomes Using
Medical Protocols to Limit “Lights and Siren” Transport. Journal of Pre-hospital and
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Ludwig, Gary. (1997, April). Get Ready for Pathway Management. EMS Report,
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Morgan, D., Wainsscott, M., & Knowles, H. (1994, October). Emergency Medical
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Ontario Canada Ministry of Health. (1997, April). Guidelines for Tiered
Response, 1-6.
Saunders, C. C. (1994, September). Ambulance Collisions in an Urban
Environment, Pre-hospital and Disaster Medicine, 133-135.
Starks, Leilani. (1983, February). Call Screening in Dallas, JEMS Magazine, 30.
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St. John, Dorothea R. & Shephard, Reggie D. (1993, August) Emergency Medical
Services – EMS Dispatch and Response. Fire Chief Magazine, 31-35.
Wilson, Steve C. (2003, January). Ranking Dispatch Calls Could Save Lives,
Associated Press, 20-23.
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APPENDIX A
Orange County Fire Authority Tiered EMS Dispatch
Questionnaire
1. Does your department provide EMS? If the answer is yes, please continue. • BLS only _____ • ALS only _____ • Both BLS & ALS _____
2. Does your department use a tiered EMS response system – send different
types and amounts of EMS resources based on need? If the answer is yes, please continue.
3. What system or criteria does your department use to determine the level of
EMS responses? 4. How successful is your program in responding the appropriate number and
type of resources to a particular EMS incident? 5. What are the Risks associated with tiered medical dispatch? 6. What are the Benefits associated with tiered medical dispatch? 7. What are the costs required implementing tiered medical dispatch? 8. Is there anything that your department would do differently to improve your
tiered EMS dispatching protocols? 9. Other Input: Comments, suggestions, and “lessons learned”. May I contact you personally for additional information? Your name and title: Your Agency: Contact Information (address, telephone, and e-mail):
