Critical Decision Points

Greg Scott

Greg Scott


Emergency dispatchers sometimes view case reviewers as too punitive in their approach, often because they are perceived, correctly or not, as putting significant effort into noting rote errors—mostly minor deviations such as simple scripting errors or small gaps in the caller-calltaker dialog.

These rote scripting errors can certainly be important, as can long gaps in the interrogation—so such errors cannot be overlooked by the case reviewer. Yet these types of errors are less serious in having an adverse effect on case outcome than other errors, such as skipping Key Questions or Dispatch Life Support (DLS) Instructions, and, most important of all, not selecting the protocol “best path.” Let us consider this last type of error.

Years ago, I wrote a piece in this journal about critical decision point protocol errors and how emergency dispatchers’ performance on any given case is reflected in how they manage each of the protocol critical decision points.1 By focusing on reducing critical decision point errors, case reviewers can help emergency dispatchers improve their performance dramatically, while also demonstrating to the calltakers they are reviewing that they really are focused on the big-ticket issues, as opposed to more nuanced performance measures that may not be as important.


Critical Decision Points


When using the Priority Dispatch Protocols, most cases have three critical decision points: Chief Complaint selection, Final Coding, and Dispatch Life Support (DLS) Link selection. Think of a critical decision point as a place where the protocol branches into several paths—each path containing a set of actions that must be completed by the emergency dispatcher to achieve the most favorable case outcome. Therefore, each protocol branch represents a choice made by the emergency dispatcher—a critical decision. These choices will make the difference between sending the proper response or not, giving the correct instructions to the caller or not, and passing on correct essential information to field responders or not.

Indeed, these critical decision points demonstrate why scripted questions and instructions are such an essential part of the emergency dispatch process. When followed as designed, they give emergency dispatchers the necessary information to make the right call when it really counts—and when their training and judgment are most in-demand—at protocol critical decision points.

By focusing on these critical decision points, and working to reduce errors for each of them, case reviewers can help emergency dispatchers make the right choice consistently and with more confidence. So what’s the best way to accomplish such an improvement? Let us examine the critical decision points in detail.


Chief Complaint selection


Selecting the correct Chief Complaint is typically the most difficult—and most important—decision the emergency dispatcher must make on a regular basis. To get it right, the first and foremost action is to correctly ask and understand the answer to the Chief Complaint query, “Tell me exactly what happened.” Since there are an infinite number of responses to this query, the emergency dispatcher is challenged to determine the correct Chief Complaint from information provided in the caller’s answer.

Case reviewers can provide valuable feedback on the emergency dispatcher’s performance here by reinforcing the written Chief Complaint Selection Rules and encouraging the emergency dispatcher to clarify the query whenever possible. For example, when using the MPDS®, the caller answers the initial Chief Complaint query as “I think he’s having a heart attack.” The EMD must clarify this response by saying “Describe exactly what he’s doing now,” “Describe his symptoms to me,” or something similar.


Final Coding


Final Coding, the next critical decision point in the typical case, is greatly simplified by using ProQA® software because this program contains protocol logic that will recommend a final Determinant Code selection when emergency dispatchers correctly enter answers to each of the questions presented to them. However, the recommended final Determinant Code selection is nothing more than that—a software-generated recommendation that must be confirmed by a well-trained, situationally aware emergency dispatcher. It is important that case reviewers make this well understood to all emergency dispatchers—you as the trained calltaker must make the final decision on Final Coding.


Dispatch Life Support Link selection


The DLS Link selected is the third, and last, critical decision point for most cases. Once again, while some links are recommended by the software, it is up to the sound judgment of the emergency dispatcher to make the definitive choice. Understanding when to select the DLS Links for the seriously at-risk patients and callers, as well as those that could be at risk, is a fundamental skill that all emergency dispatchers must learn and continue to refine over time. Understanding when to stay on the line is an area where the case reviewer can provide guidance and coaching in their comments and case narrative since this can be a judgment call for the emergency dispatcher.


Next steps


By focusing on the emergency dispatcher’s critical decision point choices and providing proper coaching, case reviewers can make substantial progress in improving emergency dispatcher performance over a short period of time. While the ProQA software logic can make recommendations and help in making critical decisions, there is still no substitute for the good judgment of an experienced, well-trained emergency dispatcher who is paying close attention to the information received while working to understand the complete situation.




1. Scott G. “Critical Decision Point Errors: When 90% Compliance Isn’t Good Enough.” The Journal of Emergency Dispatch. Winter 2002–2003.