Quality Assurance And Dispatch Stress

Jonny McMullan


When we think of QA data our first thought is often performance. With competing pressures and targets it is understandable we use the information available as a metric to improve or monitor performance at an individual or agency level; however, what if there was a more holistic interpretation of the data that could both improve performance and take care of our emergency dispatchers and patients?

We are all familiar with the suite of reports available through AQUA®: Incident Performance Reports, ACE Standards, Compliance Reports, Reviewer Comparison, etc. Within our agencies we are also aware which reports are utilized, published, and form the basis of our performance management processes. Agency-wide trends and patterns are monitored, and individual performance is reviewed, but how often do we ask the question of why certain trends occur and perhaps more importantly what may be the underlying cause? Is the answer always a lack of knowledge or can QA data identify an individual or team lacking support?

Dispatch stress

The growing body of literature on dispatch stress over the past decade has focused on the potential impact on an emergency dispatcher’s health and well-being. The short-, medium-, and long-term symptoms attributed to dispatch stress, (e.g., headaches, stomach problems, irritability, lethargy), are often cited as reasons for staff absence or potential burnout and turnover. Less frequently do we consider the impact of an individual feeling this way relative to their performance. While those Non-Compliant cases with Critical deviations can often be our focus, the Minor and Moderate deviations building over time may provide an indication of staff at risk. When we examine specific areas within a call, minor or moderate trends, while less serious in nature, may provide an insight into an EMD on the cusp of a dispatch stress crisis rather than struggling with protocol knowledge.

Case Entry

Case Entry Question 3 is often a trigger for an EMD who is struggling with dispatch stress. The “Okay, tell me exactly what happened” question can illicit vague answers from a caller or a focus on information the EMD does not deem necessary or relevant. In normal circumstances an EMD will politely refocus the caller by repeating the question or clarifying appropriately. EMDs at risk of a dispatch stress crisis, however, may be heard interrupting the caller abruptly or simply moving on without all the information, leading to inappropriate clarification deviations later in the assessment.

Case Entry Question 5 can be another indicator of stress in terms of how the EMD handles the “awake” question. Responses like “in and out,” “sort of,” and “her eyes are open” are very common from a caller struggling to assess exactly what is happening with the patient on scene. We expect an EMD to provide reassurance and interpret the information to record the most appropriate answer selection in ProQA®, but how often do we hear EMDs overclarify or force the caller to answer the question in a simple binary “yes or no” fashion? Is this a failure to understand the protocol or a demonstration of exasperation and compassion fatigue?

Chief Complaint selection

There are several ways an EMD may display signs of dispatch stress when selecting a protocol. Word-matching has become an increasingly common occurrence: We hear a word or phrase within a caller’s response and select a protocol that matches without assessing the overall picture. For example, “She felt weak all down one side and fell to the floor.” The stressed and fatigued EMD doesn’t apply any interpretation to the statement but hears the word “fell” and automatically selects Protocol 17: Falls, ignoring the symptoms of a stroke.

Alternatively, whenever a caller provides a long list of symptoms, we expect an EMD to listen carefully and assess the full detail when applying Chief Complaint Selection Rules. Where an EMD is under increased stress, it is common the caller is interrupted prematurely and the first thing mentioned, regardless of relevance, forms the basis of the Chief Complaint selection. Information overload becomes too much and the EMD lacks the normal degree of patience required to clarify, listen, and interpret appropriately.

Key Questions

QA data can prove highly effective in recognizing signs of dispatch stress during Key Questions. While there may be crossover with some of the issues mentioned in Case Entry and Chief Complaint selection, Key Questions can pose a unique challenge to EMDs. Having a specific set of answers visually presented on ProQA can add a level of exasperation to an already stressed EMD. In particular, those KQs that include a clarifier, or drive a specific code, often become stressors for EMDs that can be identified through answers being selected and then changed repeatedly OR with evidence of a lengthened period of time in sequences at a particular script.

The “serious bleeding” KQ is a good example of where an EMD’s customer service or ProQA accuracy and timing can be an indicator of dispatch stress. Repeated attempts to clarify to force a particular answer selection, constantly revisiting the question due to indecision, or inappropriately recording an answer as obvious within ProQA can pinpoint an EMD who is experiencing dispatch stress.


Nearing the end of the scripted protocol can present a different challenge to an EMD. One of the most common indicators of dispatch stress within DLS is related to frequency of penultimate/final panel use within ProQA. With increasing call volume and less opportunity for downtime between calls, the decision to link to Case Exit X2 or X3 may be a barometer of an EMD’s stress levels.

Changes in the DLS Link sequence or the length of time spent on a call can be signs that an EMD requires support beyond standard feedback. Linking to X2 and clearing the line inappropriately for an unstable patient may reflect that the pressure of the incident or delivering more complex PAIs is something they cannot face. Conversely, the opposite trend, where calls are lengthened unnecessarily and an EMD remains on the line on X3 inappropriately, can point to someone feeling anxious about answering the next call or burnt-out from the consistently high call volume and vicarious trauma.

Customer service

Finally, and arguably the most obvious area when identifying signs and symptoms of dispatch stress, are the customer service standards. While many deviations applied within the customer service section are Minor, the frequency of their application can be a metric used to uncover those EMDs feeling bereft of patience and compassion due to dispatch stress.

While any EMD can have a bad day or take a difficult call and fall afoul of desired customer service standards, this should be the exception and not the rule. If an EMD is consistently sounding disinterested, failing to provide reassurance, creating uncontrollable expectations to pacify a caller, or displaying prohibited behaviors then it is clear the issue is not the call or caller but the EMD themselves. Traditionally most complaints are related to customer service issues and feedback is understandably focused on the caller’s experience as a result. However, where there is a trend or ongoing issue with caller management, it may be that we need to focus on dispatch stress support for the EMD rather than the usual QA feedback processes.

How do we all improve and who can benefit?

QA data is crucial as a driver for performance management within our agencies. It is essential we work together at an individual, team, and agency level to discover any gaps in understanding or training and to protect our patients by making sure EMDs are the best they can be. However, we must also recognize that not all compliance issues are the result of a lack of knowledge on the part of the EMD. The QA data available to us can point to EMDs requiring support during a dispatch stress crisis and allow us to help our patients by helping our EMDs first.