It’s More Than Protocol
December 3, 2018
Mass exodus from Syria into neighboring Lebanon during the past seven years of civil war represents a 25 percent increase to Lebanon’s existing population of 4.4 million. There are no official refugee camps, and the 1.5 million Syrians seeking shelter live in tent cities or huts, unless taken in by friends or family.
The Plurinational State (Bolivia) is one of the most impoverished countries in South America and, because of its unstable economy, lacks the funding for infrastructure, education and training, and adequate health care. In 2015, approximately 13 percent of Bolivians were living on less than $3.20 (U.S.) per day.
Acute illness and injury—and lack of an emergency care system—contribute to Africa’s disproportionately high rates of morbidity and mortality that, according to the Disease Control Priorities Project, could be reduced significantly with a well-integrated and culturally relevant telecommunication infrastructure in consort with the EMS systems developing across many parts of the country.1
Economic disadvantage, large numbers of refugees due to multiple factors including political unrest and climate change, incongruent cultural mixes, and the inability to sustain infrastructure minimalizes standards of living for millions of people globally. While international aid organizations struggle to provide funding for basic necessities, adults and children often go without proper and sufficient health care. While emergency medical services (EMS) is on the list of priorities, seldom is there a way beyond the will.
The “way” is where the International Academies of Emergency Dispatch® (IAED™) and its affiliate Priority Dispatch Corp.™ (PDC™) have ventured during the past several years. As long as there is a stated commitment by leadership from the country and the “will” to develop an environment of change, the non-profit and profit sides of protocol are there to help.
“More and more countries are realizing that emergency dispatch is the entry point for EMS,” said IAED President Jerry Overton. “Countries see the difference we make, contact us for assistance, and we assess where they’re at in their development. Once you know, you can understand what they need and how the MPDS becomes part of their solution.”
Lebanese EMS actually pre-dates MPDS when, in 1964, the Lebanese Red Cross (LRC) established first-aid teams to respond to calls and, soon after, was designated the country’s out-of-hospital provider (LRC-EMS). The three-digit “1-4-0” summons response and during the past decade, it’s become evident that demand will increasingly outpace service capacity with no slowdown in the foreseeable future.
Realizing EMS was reaching the boiling point, LRC-EMS arranged its service priorities in eight categories to include fleet, training, human resources, and IT and communications. Each category in an initial plan (2007-2012) required a roadmap to develop the performance-based system envisioned. Progress hinged on mediating obstacles including the universal issues involving insufficient resources, limited funds (donations account for 40 percent of the LRC-EMS budget), fragmented administration across six centers, and the lack of quality assurance (data collection to support service delivery).
Five years into the project, LRC-EMS drilled down further to integrate the categories. A team attended Middle East NAVIGATOR 2013. After all, better field deployment requires optimal emergency dispatch. Overton, a world expert in EMS resource allocation, followed up on their request for assistance and spent two weeks in Lebanon “observing and listening.”
“I wasn’t there pushing a product or selling them a cardset,” Overton said. “I wanted to know where they were and where they wanted to go and if ours was the help they needed. I was amazed. In a country torn by war, they were committed to making a difference in the lives they could save.”
The level of commitment met the IAED criteria. Not only did the LRC-EMS desire to evolve the existing system, but they had come so far on the power of volunteerism. LRC-EMS depends on volunteers to fill all positions—answer and dispatch calls, respond to calls, provide medical assistance, manage stations, train, and everything else EMS demands. One paid administrator oversees the entire operation. At the time, there were 2,700 volunteers.
It became a matter of how the IAED and PDC could help.
Overton didn’t have to look hard. Emergency dispatch needed major work. The four primary and two secondary dispatch centers were not in sync. According to Overton’s initial assessment, there was no uniformity, little training, resource (ambulance) allocation was non-existent, information gathering was inadequate, public complaints went unanswered, and turnover was high. The LRC-EMS perspective had to move from simply answering calls and sending response to emergency dispatch as the clinical hub. The emphasis required strategies the IAED has always advocated: structured calltaking, constant oversight, policies that applied across the board, coordination among centers, data collection, and medical direction.
Overton called in a support team, starting with Ivan Whitaker, Program Administrator-Medical, PDC, whose background includes communication center director prior to joining PDC, expertise in organizational management, and a successful track record in effecting system consolidations. They went on a site visit. Whitaker requested data to chart call volume peaks and lows. He sat down to do the math.
The result is above and beyond an MPDS implementation date. Whitaker developed an organizational structure (complete with individual job descriptions), staffing complementing the ebbs and flow of call volume, and the resources they would need to create a sustainable and well-integrated emergency dispatch process. He and Overton reviewed the floor plan of the proposed consolidated communication center, recommending everything from the CAD system to the swivel seats and adjustable screens.
It’s like going through a cookbook of emergency dispatch.
“We look at all the ingredients necessary,” said Whitaker, who is in the thesis stage of a Ph.D. in organizational management. “We don’t want to start a process that down the road is negatively impacted by deficits.”
LRC-EMS has since made significant progress in the area of emergency dispatch. Phase I included consolidating three of the six centers. A single emergency dispatch center is under construction. Overton estimates it will be another 18 months [from July 2018] until they’re ready to implement MPDS and another year after that to achieve an Accredited Center of Excellence (ACE). Whitaker’s organizational chart is bible, and the LRC is hiring staff exhibiting a long-term commitment to the profession.
“This is incredibly gratifying,” Overton said. “It’s been Dr. Clawson’s vision from the start. Everyone working together can truly make a difference in saving lives.”
Mountainous terrain and winding, narrow cliff side roads—such as Camino de las Yungas, the “world’s most dangerous road”—combine to make Bolivia a lovely albeit dangerous place. People injured in traffic collisions, or any type of accident, cannot access ambulance or trauma services due to financial constraints and, in general, the lack of prehospital and hospital care. According to the World Health Organization (WHO), Bolivia ranks 126th out of 190 countries all over the world when it comes to the quality of healthcare.2 Hospitals and medical centers are clustered in the major cities like La Paz and Santa Cruz.
Emergency Network 118, established in 1997, summons an ambulance but not for everyone. In 2005, Emergency Network 118 had six ambulances, in addition to those of the hospital, and two personnel transport cars and the ambulances were used not only in cases of emergency, but also to transport the sick so that they can vote in their constituencies within the city.3
The international ranking, however, is moving up the scale in many areas, including medical care, social security, water, and sanitation. According to a more recent WHO report, Bolivia has seen a 20 percent improvement in health services; the government has built more than 1,004 health facilities in the last 11 years with another 49 hospitals in planning stages.4
The future is even more promising for the people with the country’s 2016-2020 social-economic development plan. The pillars, as they are called, in the plan are seen as foundations to build universal access for all Bolivians. Healthcare and telecommunications are priorities.
That’s where PDC’s expertise and the IAED’s philosophy entered the picture.
Emergency medicine is recognized as a specialty in Bolivia, but there are few people trained in this area. Emergency medicine education in Bolivia is scattered among independent agencies, without coordination of either training programs or certifications.5 There are no emergency medicine residency programs. In 2009, an ambulance was purchased through donations and stationed at a village along the Yungas roadway, which claims 200 to 300 lives in traffic accidents each year.
By 2017, the Bolivian Ministry of Health had multiplied the number of ambulances from 558 to 2,072 units in 11 years of management, which were distributed to 309 municipalities throughout the country.6 Five air ambulances provide transportation to low-income patients in remote areas requiring an operation or emergency surgery. Availability of a land or an air ambulance, however, does not guarantee that help—at least competent help—is on the way.
“They have the ambulances but people didn’t know where to call,” said PDC President Ron McDaniel. “Bolivia reached out to the UN and that’s basically how we got involved.”
McDaniel visited Minister of Health representatives in 2016 and toured several of the country’s hospitals and medical clinics to discuss the next steps in establishing an EMS/EMD system benefitting the entire country.
“I like to stand and watch in a hospital ER,” he said. “I ask questions. We don’t go in with answers. We learn.”
The trip resulted in outlining a plan that could take four to five years before the country is ready for MPDS.
“This is what I always saw as the direction for PDC,” McDaniel said. “It’s about building a process that goes beyond implementing protocol although protocol is the direction they’re going in a sustainable EMS system.”
The final pillar in Bolivia’s plan, Enjoyment and Happiness, builds on multicultural respect and the context in which it is expressed.7
“Cultural sensitivity is imperative,” Overton said. “You don’t go into a country and push American values and culture. We don’t change the protocol because our protocol is universal. But we do take the time to learn the culture, and assess the culture to understand how best we can meet their needs. It’s about people helping people and we’re fortunate to be in a position to do so.”
Going into Africa wasn’t on a whim.
The environment was right, taking into account the population’s mobile phone coverage (60 percent in sub-Saharan Africa), public access emergency numbers, and the potential of cloud-based services to advance EMD across regions.
The only part missing was a team to pull it all together, and that changed four years ago (November 2014) when PDC sponsored a meeting with the African Federation for Emergency Medicine (AFEM) to map the development of EMD systems suitable and sustainable for African settings. In addition to staff from PDC (McDaniel) and IAED (Overton), the working group represented 10 countries: Botswana, Cameroon, Ethiopia, Ghana, Kenya, Malawi, South Africa, Tanzania, Uganda, and Zambia. Among the group’s recommendations: a communication center in each country using a formal call processing and dispatching system developed around “high-volume, high morbidity and mortality events, acute conditions, and complaints.”8
The working group concluded that a “Well-conceived and developed EMD systems, appropriately tailored to African populations, may prove to be an effective, efficient intervention to help decrease the impact of the burden of acute disease.”9
Botswana was the first to implement MPDS in 2016, while Uganda is progressing similarly to Lebanon in establishing a comprehensive EMS system.
A telehealth hotline was a practical solution in the sparsely populated country of Botswana situated in the heart of the Kalahari Desert, with many areas accessible only by light aircraft and 4×4 terrain vehicles. Two nurses and one EMD using ProQA® handle emergency calls to the 992 line during 12-hour shifts at the MRI Botswana Call Centre in the capital city of Gaborone, the largest city in the country with a population of 231,626 in 2011. The nurses respond to the 130–250 medical calls coming in each month on the medical emergency line using Priority Solutions’™ clinical triage software Lowcode™.
Based on the nature and urgency of the call, the call center activates a rapid response from one of four MRI bases in the country—Gaborone, Palapye, Francistown, and Maun. Emergency first aid at the scene is followed by ambulance transport to the hospital. Typical calls include motor vehicle accidents (MVAs), secondary requests for inter-hospital transfer from smaller rural villages to specialist facilities—sometimes across the border to South Africa—and medical incidents such as chest pain and childbirth.
Divide and implement
McDaniel, Overton, and Whitaker are just part of an IAED/PDC team traveling the world to implement change. Ken Hotaling and Ross Rutschman are behind implementations in China, which boasts the highest percent of accredited centers in the world (almost 50 percent of all MPDS centers in China are ACE). Dr. Conrad Fivaz, clinical director of Priority Solutions, travels globally in support of secondary triage. Eric Parry, Director, PSAP Implementations at Next Generation Advanced 911 Inc. and PDC consultant, literally wrote the book about emergency dispatch administration ("Managing the 911 Center, A Book For Public Safety Communications Managers"). Amelia Clawson is director of IAED International Relations and there are IAED and PDC personnel in international offices around the world.
Wherever they go, establishing rapport is paramount and that takes understanding the political and social norms.
“As Dr. Clawson likes to say, ‘Make it stick’,” Whitaker said. “We don’t sell a country protocol and then walk away. We want to make it work for them long-term. We’re building a legacy.”
1Mould-Millman N, de Vries S, Stein C, Kafwamfwa M, Dixon J, Yancey A, Laba b, Overton J, McDaniel R, Wallis L. “Developing emergency medical dispatch systems in Africa – Recommendations of the African Federation for Emergency Medicine/International Academies of Emergency Dispatch Working Group.” African Journal of Emergency Medicine. 2015; Sept. https://www.sciencedirect.com/science/article/pii/S2211419X15000701 (accessed July 6, 2018).
2“Bolivia: Statistical data depicting the country’s surgical and anesthesia infrastructure.” Global Surgical Consortium. Not dated. http://globalsurgicalconsortium.org/files/Bolivia_2(1).pdf (accessed July 9, 2018).
3“Aid to cover any eventuality.” Bolivia.com. 2005; Dec. 18. https://www.bolivia.com/noticias/autonoticias/DetalleNoticia30440.asp (accessed June 27, 2018).
4“WHO Exalts Bolivia’s Advances in Healthcare.” Telesurtv.net. 2017; Oct. 24. https://www.telesurtv.net/english/news/WHO-Exalts-Bolivias-Advances-in-Healthcare-20171024-0026.html (accessed June 27, 2018).
5Berger E, Forsgren E, Forsgren S, Steinberg T. “Applying a collaborative model for emergency medical education development in Bolivia and Venezuela.” Annals of Global Health. 2014; June. https://www.researchgate.net/publication/266148143_Applying_a_collaborative_model_for_emergency_medical_education_development_in_Bolivia_and_Venezuela/fulltext/55e0dfcd08ae6abe6e8a41f6/266148143_Applying_a_collaborative_model_for_emergency_medical_education_development_in_Bolivia_and_Venezuela.pdf (accessed June 27, 2018).
6“Ministry of Health delivered 2.072 ambulances to Bolivians.” La Paz Communication Unit. 2017; Dec. 26. https://www.minsalud.gob.bo/2975-ministerio-de-salud-entrego-2-072-ambulancias-a-bolivia (accessed June 27, 2018).
7“Plurinational State of Bolivia: Economic and Social Development Plan (2016-2020) Within the Framework of Integrated Development for Living Well.” Ministerio de Planificación del Desarrollo. http://www.planificacion.gob.bo/uploads/PDES_INGLES.pdf (accessed June 27, 2018).
8See note 1.
9See note 1.
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