February 13, 2012
By Journal Staff
Nothing spells validation more accurately than scientific research: diligent, systematic, and unbiased. And nothing says more about the conviction of a scientist than the pursuit of independent investigations of the product he or she has placed on the market. But that’s precisely the story pushing the progression of the priority dispatch protocols (particularly the Medical Priority Dispatch System, or MPDS). As we’ve chronicled in the past three issues of The Journal, the emergency communications protocol used in thousands of centers worldwide grew from its beginnings at the Salt Lake City Fire Department thanks to the people and agencies supporting the need for standardized and dependable dispatch.
More than word-of-mouth, however, is the serious research Jeff Clawson, M.D., continues to conduct and oversee on behalf of his vision to bring emergency medical dispatch into the emergency medical services fold. He is a medical doctor and scientist by training who would now never dream of introducing anything into the market without data collection and testing to guarantee its soundness and reliability.
“When you start hearing ‘based on the data,’ listen, because that means someone has gone further than just the opinion stage,” Dr. Clawson said during an interview with Linda and Fred Hurtado subsequently published in Paramedic magazine (1984). “Any system survives or fails based on whether or not it’s doing the job, and the only way to determine that is to have a monitoring device.” Alas, good science can make or break the vision.
Study focusFrom its start, the priority dispatch system has had three essential components to emergency dispatching: interrogation questions, known as Key Questions; telephone help, known as Pre-Arrival Instructions; and response determinants for setting the level of response and the use of warning lights-and-siren.
Research has always focused on these components, although the emphasis of the research has necessarily shifted according to the tools available. “That’s an important point to bring out,” said Brett Patterson, National Academies of Emergency Dispatch (NAED) Academics and Standards associate.
“Experts helped to evolve the system but it wasn’t u n t i l the past five years that we’ve had the tools available to collect data for outcome research.”
Descriptive phase of researchEarly articles published in magazines serving the EMS community emphasized expert opinion; the observations of those in the field familiar with protocols and supporting the evolution and advancement of the medical dispatch science.
Validation in its more subjective form came through newspaper articles, mainly human-interest features written by reporters who knew little about protocol but a lot about the type of news articles that might grab their readers’ attention. Not uncommon were the subjects still making headline news today: parents caught off guard when baby decided it was time for delivery or a family member giving life-saving cardiopulmonary resuscitation (CPR) to a child found face down in the backyard pool.
These articles caught the interest of their intended audiences. But it wasn’t until physicians and national safety organizations started looking Dr. Clawson’s way and asking questions that he knew protocol was making inroads into a world beyond advocacy and intrigue. He was no longer preaching to his choir.
“Someone out there aside from Dr. Clawson and the organization was saying we need this,” Patterson said. “Others were getting involved.”
Outside noticeThe others included the National Association of Emergency Medical Services (EMS) Physicians (NAEMSP) and the American Society of Testing and Materials (ASTM), which both took positions in 1988 on the need for training and emergency medical dispatchers in standardized interrogations, pre-arrival instructions, and pre-determined unit responses. The NAEMSP Consensus Document on Emergency Medical Dispatch (EMD) states pre-arrival instructions are a mandatory function of the EMD because of the “first” first responder position in emergency services. Not only did the immediate action effectively eliminate the time gap between the call and arrival but, also, according to the NAEMSP statement:
Standard telephone instructions by trained EMDs are safe to give and in many instances a moral necessity. The statement represented the first official “standard of care” document from exactly the people who should have a position—the medical directors of North America. “It demonstrated that trained EMDs who use medically appropriate pre-determined protocols can prioritize EMS calls,” Dr. Clawson said. “Finally, dispatchers were receiving national recognition as a key element of the EMS system.”
Formalizing researchDuring that same year—1988—Dr. Clawson organized the National Academy of Emergency Medical Dispatch (the NAEMD, now known as the National/International Academies of Emergency Dispatch , or NAED/IAED) as the certifying and standard development organization for both emergency medical dispatch protocols and its associated curriculum and quality assurance processes.
To address the scientific issues related to emergency dispatch, the NAEMD in turn established the College of Fellows. Its express purpose: To conduct an on-going review of the current standards of care and practice in EMD and evaluate the tools and mechanisms used to meet or exceed these standards. The College of Fellows has since divided its members into seven boards and councils complementing individual expertise such as the Council of Research and Board of Accreditation.
Robert Martin was the NAEMD executive director at the time the College of Fellows came to be. He described the work of the internationally recognized experts in EMS, EMD, and public safety communications as a window into every other dispatch center in the world. The Fellows reviewed the findings collected from the affiliated communications centers, modified protocol based on the data collected and their professional consensus, and distributed the updates to all licensed users.
The process to control standards for protocols and all aspects of Dispatch Life Support was no different from that of the American Heart Association and its oversight of CPR, basic life support, and advanced life support. “In this way, the protocol remains unified and standard and not subject to arbitrary, anecdotal modifications that are not medically nor legally supportable,” said Martin, past executive director of the National Emergency Number Association (NENA) and now vice president of business development for the Washington, D.C., based e-Copernicus consulting firm.
“Since protocol is designed to help people in their moment of crisis, there is no other medically correct, morally-responsible way to do it.”
Quality assuranceQuality assurance (QA) became the watchword for EMD in the early 1990s. The QA goals highlighted compliance, particularly the application of retraining and procedural modification arising from noncompliance problems. QA took research and review on the part of communications centers. For example, findings from a MPDS compliance data study conducted at the Los Angeles City Fire Department proved the direct correlation between Case Entry and Key Question interrogations in relation to the accuracy of correct determinant level selections.
A study Patterson conducted at his communications center in Pinellas County, Fla., during the same period took the compliance question one step further. He filtered out the noncompliant calls and used only the protocol compliant calls to compare the EMD’s response code selection to paramedic findings on the scene in realtime QA. His findings showed 95 percent agreement.
“It was a first step,” Patterson said. “There was a lot of controversy over interrogating the untrained caller. The study supported our hypothesis that the caller reported what actually happened when asked the right questions.”
The Academy was collecting the objective data to enforce its own rule: strict compliance with Entry Level and Key Question interrogation was absolutely vital to the success of a comprehensive MPDS process and the EMS system it appropriately deploys.
Measuring the EMDThe first quantitative article assessing protocol’s effectiveness was published in the February 1983 issue of the Journal of Emergency Medical Services (JEMS). The article, which ran exactly two years after an article in JEMS had introduced the EMS world to Dr. Clawson’s dispatch system, highlighted ALS and BLS response percentage trends based on Salt Lake City Fire Department communications center dispatch data. The study concluded that the use of selective dispatch screening via the Medical Dispatch Priority concept was safe, effective, and economically appropriate; the results of the study reinforced the fact that medical dispatching should be one of the prime areas of national EMS attention and improvement in the 1980s.
Research published during the next decade assessed the effectiveness of EMDs providing pre-arrival instructions, both in terms of cost savings and saving lives. Dispatcher CPR continues to receive exceptional scrutiny in relation to its effects on out-of-hospital cardiac arrest.
The most profound study in terms of showing a direct correlation between MPDS and the identification of patients in cardiac arrest resulted in an article published in the Journal of Emergency Medicine (2004;21:115-118). The research team—Andy Heward, Michael Damiani, and Chris Hartley-Sharpe—conducted a two-stage study using data collected from the London Ambulance NHS Trust. The first stage compared cases coded by the ambulance team as cardiac arrest before MPDS (referred to as AMPDS in the U.K.) and cases triaged as cardiac arrest and found to be in cardiac arrest three years after MPDS was implemented.
The second stage looked at MPDS compliance in relation to the percentage of cardiac arrest calls found to be cardiac arrest upon the ambulance arrival. According to their findings, the MPDS resulted in a 200 percent rise in the number of patients accurately identified as suffering from cardiac arrest. In addition to increased accuracy of cardiac arrest, the study suggested compliance with protocol was an important factor in the accurate recognition of patient conditions.
Dedicated research committeeIn 2003, the NAED announced the formation of an important committee linking emergency dispatch with homeland security efforts. The CBRN committee (which stands for Chemical, Biological, Radiological, and Nuclear) brought together experts in public health, bioterrorism, epidemiology, and emergency communications to address these particular kinds of public safety threats from an emergency dispatch center perspective.
NAED Special Operations Division Director Greg Scott is the CBRN committee chairman.
During the year prior to the formal announcement, the NAED had been working closely with several local and regional efforts to use information from 9-1-1 calls as part of bioterrorism surveillance. The CBRN committee was a natural outgrowth of that work.
Among the tools in the CBRN’s study arsenal are integrated software systems, such as FirstWatch. The surveillance and data monitoring system can take information generated by the NAED dispatch protocols and in realtime compare Chief Complaints and related symptoms given to emergency dispatchers with those identified with bioterrorism or chemical agents or naturally occurring contagious diseases.
These are compared to historical records to see if any significant anomalies occur, and to trigger an alert when they do. The swine flu (H1N1) pandemic is a recent example of the CBRN in action. Earlier last year, anticipating a potential avian flu outbreak in the coming fall, the NAED had begun work on several items for both ProQA and cardset users. When the swine flu hit, the CBRN Committee conferenced on April 27 and formally requested an immediate release of all materials relevant to the situation with modifications specific to swine flu. It was out in all versions and languages in 48 hours.
Dedicated research staffDuring the past year, the Academy realized a long-held dream by creating a full-time position for research. Chris Olola, who received his Ph.D. in biomedical informatics in May 2009 from the University of Utah, will focus his attention on patient outcomes in relation to protocol and interoperability of data collection from the primary sources (EMD, paramedic, and the hospital receiving the patient).
The interoperability part—the exchange of data among the entities involved in emergency response—is a three-way stream of information. Interoperability is the icing on the research cake. The data exchange far exceeds the empirical approach to proving protocol’s impact, Dr. Olola explained.
“To prove something scientifically takes a statistical correlation between what you do and what happens down the road to the patient,” Dr. Olola said. “There’s an aggregate of data validating your studies’ hypotheses and findings.”
Connecting the linksThe first link is the communications center, specifically those using the protocols correctly (at very high compliance) and willing to share the data; the second is the field response unit associated with the specific centers; and the third is the hospital receiving the patient.
Connecting the three is the next phase in the evolution of research, according to Scott, who has long participated in data collection for the NAED. The barriers between links one and two have just about cleared, while the third has stalled over issues of data management services and privacy and confidentiality concerns raised by the administrative simplification provisions of the 1996 Health Insurance and Portability and Accountability Act (HIPAA). That link, however, to hospital data should improve, Scott believes, through the introduction of electronic medical records and the ability to mask confidential patient information through filtering processes.
Peer reviewIn the meantime the primary members of the NAED Council on Research—Dr. Clawson, Dr. Olola, Patterson, Scott, Heward, and Tracey Barron of the IAED U.K. office—pride themselves on the six studies so far published in prestigious peer-reviewed journals such as Resuscitation, Emergency Medicine Journal, Prehospital Emergency Care, and Prehospital and Disaster Medicine. The studies quantify, or measure, the accuracy of the EMD disease identification compared to patient outcome based on strict compliance to MPDS protocols. Several other studies are making their way through the proposal, writing, research, and review phases.
Dr. Olola calls peer-reviewed journals the gold standard of scientific study. Panels of experts in the specific field of study critique papers prior to acceptance for publication through a rigorous procedure that scrutinizes adherence to the six major steps of the scientific method. “We know the protocols are effective but it takes good data to prove this to others,” Dr. Olola said. “That’s the overall goal, to validate and prove protocols through scientific evidence-based processes that approve or disapprove predefined hypotheses.”
Outside reviewThe research team, however, does not go forward with any research project without the approval of an Institutional Review Board (IRB). The International Academy of Emergency Dispatch organized the IRB in 2008 and it comprises both experts (EMS/EMD, medical, and communications) and laypersons. Since the NAED research involves human subjects, the IRB provides protection for the rights and welfare of the subjects through initial and ongoing reviews. Jerry Overton, past president of the American Ambulance Association and now president and chief executive officer of West Coast-based Road Safety International Inc., heads the review board.
The research team stresses MPDS Protocol compliance in the data centers willing to share data and conduct research, and the team will not proceed with any research until verifying compliance to the system. Unfortunately, the same hasn’t always been followed by others conducting independent research correlating Determinant Codes to patient outcomes.
When that happens, the findings produce an inaccurate account of protocol’s and method’s validity and a letter to the journal of publication to point out the significant omissions and commissions in the study’s methods/design, findings, and conclusions.
“Compliance to protocols is key,” Scott said. “Without that, everything is skewed.”