Quality Considerations

*To take the corresponding CDE quiz, visit the College of Emergency Dispatch.*

In September 2024, the International Academies of Emergency Dispatch® (IAED™) introduced a new platform on our Facebook page “True 2 Q” where an IAED subject matter expert answers quality assurance questions, covering many topics. We hope our active users have found this resource to be helpful in our quest to provide consistent, Academy-approved answers to more than 400 questions asked during this short period of time.

As we move forward, we have recognized that Facebook’s logistical limitations may hinder our vision for future enhancements. So stay tuned as we implement further positive changes to assist your daily life as an ED-Q. In this article, I’d like to highlight a few of our users’ questions that have stood out, either because they share a common theme or because it could be beneficial for ED-Qs to review them with greater detail.

Chief Complaint Selection 
Many of our ED-Qs question the emphasis placed on the importance of selecting the correct Chief Complaint Protocol, often asking whether we are making this step in caller interrogation (and evaluation) more difficult than necessary.

We must remember that Emergency Dispatchers are not diagnosticians, investigating symptoms and drawing conclusions. Instead, they are required to take the caller’s description, apply the Chief Complaint Selection Rules, and follow the most appropriate path for the interrogation.

Of course, anyone who has worn the headset for more than a day knows that callers are not always straightforward in their responses to the Case Entry Question “Okay, tell me exactly what happened.” Though the caller’s description may be unclear or difficult to categorize, the Emergency Dispatcher’s selection can significantly impact the remainder of the call and the response sent.

As ED-Qs, we must use our experience and enhanced knowledge of the protocols to help guide our Emergency Dispatchers at the console. To gain confidence through compliance, they must become familiar with the Chief Complaint Selection Rules and learn the nuances of closely related protocols to make sound decisions on Chief Complaint Protocol selection.

Of course, this principle is far easier to apply when reviewing a call than when taking the call, which is why understanding the Emergency Dispatcher’s perspective is so important during call evaluation. In the Performance Standards, Chief Complaint Selection Standard 5 (Multiple Chief Complaints) is underutilized in the sense that an Emergency Dispatcher is making a real-time decision when the caller gives the “laundry list.”

Are we giving our Emergency Dispatchers a little wiggle room? We should consider whether the Emergency Dispatcher’s Chief Complaint Protocol selection (if technically incorrect) still results in an equal Determinant Code (response) level and leads to the same Dispatch Life Support (DLS) Instructions.

A great example of this is a caller reporting several heart problem complaints. In the middle of a long, convoluted explanation, the caller throws in “chest discomfort.” The Emergency Dispatcher selects Protocol 19: Heart Problems/A.I.C.D.

Is this correct? According to the Chief Complaint Selection Rules, no. However, we must consider why the Emergency Dispatcher did not select Protocol 10: Chest Pain/Chest Discomfort (Non-Traumatic). Did they not hear the caller mention the priority symptom of chest discomfort, or did they ignore it, having already decided Protocol 19 was the correct choice?

As an ED-Q, we know that there is an intentional redundancy designed within the Priority Dispatch System^™ and the individual Chief Complaint Protocols. Medical Priority Dispatch System^™ Protocols 10 and 19 are a great example of this overlap. When you place them side by side, the DELTA-level Determinants 1–4 are identical. DELTA-level Determinant 5 is the only DELTA-level Code that differs between the two protocols, with 10-D-5 being “Heart attack or angina history” (which accounts for 14% of all calls on Protocol 10) and 19-D-5 being “Just resuscitated and/or defibrillated (external).” With this overlap safety net, the two protocols catch a collective 86% of DELTA-level patients.

Now, giving our Emergency Dispatchers some allowance for achieving the same result does not mean we don’t do our due diligence and address this issue with them, providing guidance on what they must do when they next encounter this type of incident. However, it’s fair to question whether it’s entirely reasonable for this type of error to merit a CRITICAL deviation, especially when the response and instruction pathway remain the same.

Again, consider Chief Complaint Selection Standard 5 (Multiple Chief Complaints). When you review a case, you may find that the caller provides multiple complaints that are equal or nearly equal in severity. Emergency Dispatchers must use the Chief Complaint Selection Rules as a guide to determine the correct protocol, using individual protocol Rules and Axioms to support the decision.

One of the worst approaches for making dispatch decisions is using instinctual evidence of “I think” or “I feel.” Ultimately, as both ED-Qs and Emergency Dispatchers, we must follow the First Law of Medical Dispatch: “First, do no harm.”

At some point, all ED-Qs will face a case where there is no Rule or Axiom to back up the protocol selection. This is where we must decide if the protocol selected provides the appropriate response and correct DLS, followed by a good discussion with the Emergency Dispatcher. You could also address this issue with your Dispatch Review Committee (DRC) or Dispatch Steering Committee (DSC).

Further Q&A—trauma and shunts 
Trauma selection 
Now switching gears to handling cases of trauma, many ED-Qs have had questions about selecting the patient’s affected body area. Most commonly, ED-Qs have concerns about why the “head,” “chest,” and “neck” options are listed individually.

ProQA^® software is designed so that these three body areas will generate a follow-up question to determine whether the patient is experiencing difficulty breathing, intentionally precluding these areas from the other body area lists to capture this information.

Shunt documentation 
Another question raised by our ED-Qs is how to document an Emergency Dispatcher incorrectly initiating a shunt or not shunting when appropriately directed.

Let's first look at documenting an incorrect Emergency Dispatcher-initiated shunt (Universal Standard 20). The best way to record this in AQUA^® is under the section “Key Questions/Calltaker Initiated Shunt.” For the question “(If Appropriate) Shunted correctly,” select “No.” Always provide feedback here for follow-up.

It’s important to recognize that some Key Questions trigger automatic shunts based on entering certain answer choices. For example, a very common Key Question appears on Protocol 26: Sick Person (Specific Diagnosis): “Does s/he have any pain?” If the caller answers that the patient is having chest pain, but the Emergency Dispatcher does not select chest pain, the ED-Q must take the following steps (Universal Standard 28, Cascade event).

First, the ED-Q must deselect the “recorded correctly” checkbox. Second, the ED-Q must leave the Final Coding Level and Descriptor blank. There is no way of knowing the actual final code if the Key Question had been answered correctly, so the ED-Q should provide sufficient documentation for feedback here as well.

Dx tools documentation 
Understandably, there may be some confusion on where and how to document any Dx tools used correctly or incorrectly. In the top right section of Key Questions and DLS Instructions is a box titled “Diagnostics/DEs Form.”

This is where the use of the Dx tool is evaluated. Even though there is one line in the Key Questions and/or DLS section, this does not represent the intent of evaluating the correct use of any Dx tool.

Please note that you must click “save” to ensure the Dx tool evaluation selections and comments remain in place.

Conclusion 
As ED-Qs, we must remain objective and consistent as we mentor our Emergency Dispatchers to correctly use the protocols, provide lifesaving DLS Instructions, and exemplify great customer service. Understanding the intentional design of the protocol is helpful for making dispatch decisions and providing call evaluations. Use the tools (the Performance Standards and ProQA) to assist you in feedback and education.