July 30, 2014
By Audrey Fraizer
Norman Rivera shys away from questions focusing on his “contributions” to dispatch, although they must be signficant considering the 2014 Communicator of the Year Award he received for his efforts.
“I was hesitant when directed to do this,” said Rivera, EMD, Toronto Emergency Medical Services (TEMS), in Ontario, Canada. “I’d rather stay in the shadows.”
The peer-nominated award acknowledges Rivera’s confidence—and reserve—as it translates into the position of respect he holds in the comm. center and among field responders. He dispatches ambulances, trains new calltakers, and dispatchers on the floor.
“People look up to me in the center,” he said. “The medics on the road know my voice. When I’m on the radio, they know they’re in good hands.”
That's where he changes the conversation. He’d rather talk about why, after eight years, he still really likes his job.
“The staff is amazing,” he said. “There’s a sense of family. We help each other out. We know each other’s strengths and weaknesses, and pitch in. We’re a team.”
The same goes for his co-dispatcher, Rory Donahue. At TEMS for eight years, Donahue said staff support adds to the positive experience. He also credits the Medical Priority Dispatch System™ (MPDS), a part of TEMS’ chain of emergency response since 1992.
“MPDS is consistent and a system we can depend on to assess individual needs,” said Donahue, a Toronto parks and recreation employee prior to joining TEMS. “I’ve used it from the start, and to me, it’s great.”
TEMS is about team
TEMS Central Ambulance Communications Center (CACC) Cmdr. Leo Tsang said teamwork is essential to the organization.
“We truly believe that everyone needs to be integrated into the team,” Tsang said. “We couldn’t achieve what we have without the team approach.”
By any standards, the size of TEMS with respect to its personnel, coverage area, call volume, and response volume, complicates the team concept.
Toronto EMS is the largest municipal paramedic service in Canada, covering 641 square kilometers (247 square miles) and a daytime population of 3.5 million people (resident population is 2.8 million). TEMS processes 420,000 emergency calls per year, with requests for service resulting in transporting 200,337 patients per year or an average of 550 transports per day, according to 2013 figures. TEMS operates a fleet of 241 vehicles, which includes ambulances and bus-sized emergency support vehicles for transporting up to 20 patients at a time in case of a mass casualty incident.
The 172-member comm. center staff includes calltakers and dispatchers, a destination coordinator for paramedics, an out-of-town response coordinator, information technology, and supervisory personnel. The comm. center is supported by the Education and Quality Improvement Unit (EDQIU) that has six certified EMD-Qs.
Kim Rigden-Briscall compared TEMS to a gigantic machine, albeit a well-oiled one.
“TEMS is incredibly big and at the same time, incredibly dedicated,” said Rigden, commander, CACC Education and Quality Improvement Unit. “This is a very hardworking group of people. They really understand the Academy’s expectations.”
In 2000, TEMS mandated EMD certification for dispatchers and calltakers. In 2006, it became comm. center policy to train supervisors in IAED™ quality assurance standards. TEMS then launched into the Academy’s Twenty Points of Accreditation.
The process renewed the emphasis on strict MPDS compliance according to Academy standards. The EDQIU began auditing calls and providing one-on-one feedback to EMDs. By the end of December 2007, the ACE application was in the mail.
Donahue recalls how everyone pitched in from all levels within the organization.
“It required the effort of dispatchers and management,” he said. “We each had a responsibility. We all had to meet the same high standard.”
Carlynn Page, IAED associate director, delivered the eagerly anticipated news via a congratulatory phone call on April 8, 2008.
TEMS representatives were present at NAVIGATOR 2008, held in Baltimore, Md., to accept the ACE award. However, in keeping with the TEMS team spirit, IAED President Scott Freitag made a second presentation of the ACE award at the Toronto center for the benefit of the entire staff.
The scope of TEMS’ commitment to the use of MPDS is reflective in the agency’s desire to use methodology that links patient outcomes with MPDS Determinant Codes to establish local ambulance response plans.
The system links MPDS Determinant Codes with patient outcome data gathered from the paramedic’s electronic patient care record. This clinical data has allowed TEMS to create Determinant Level-specific responses. Instead of having the four levels of responses typically seen in many centers (ECHO/DELTA=ALS/HOT, CHARLIE=ALS/COLD, BRAVO=BLS/HOT, and ALPHA=BLS/COLD), TEMS gives each individual MPDS Determinant Code its own response plan based on the historical data that shows the likelihood of an intervention. For instance, a 2-D-1M requires a BLS response within 8 minutes and 59 seconds with firefighter first responder response while a 2-D-1I requires an ALS response within 8 minutes and 59 seconds with a firefighter first responder response.
Response plans are built on clinical evidence, which is generated from a database of over 500,000 patient records linked to 9-1-1 calls from a three-year period. The data is continuously reviewed and response plans can be adjusted based on medical evidence. Not only does it improve patient care at the point of response but it also determines the level of EMS resources dispatched according to high- and low-acuity patient types.
Building response plans based on Determinant Codes and patient outcome data are highly dependent on high compliance in the use of the protocol and MPDS Determinant Codes, Rigden said.
Optimal efficiency an ongoing objective
Tsang commends Chief Paul Raftis for his “good work” in synthesizing teams and setting them in a direction for the future.
“He makes sure our voices are heard and invites research,” Tsang said. “He keeps up with medical best practices.”
Tsang has a paramedic background and is a product of the TEMS leadership program and has taken on several front line leadership positions. He certified as an EMD soon after taking over comm. center operations, although he has never answered a call to 9-1-1 or dispatched response.
“I was a fish out of water and responsible for 120 people,” Tsang said. “But I settled into the groove. The EMD course helped me to acclimate and understand the role.”
Tsang was introduced to MPDS several years ago when he was a paramedic. He sat down with a comm. center supervisor for an explanation of the protocols when a call—from his paramedic perspective—was mishandled. He was skeptical of the protocol’s benefits to EMS and the role that calltakers and dispatchers play in response.
He came away impressed by the system behind protocol and an appreciation of the job that comm. center staff perform.
“The tape told no lies,” Tsang said. “It was an eye-opener. Response could only be as good as the information the caller provides.”
Donahue was in awe of dispatchers.
“I had an idea of what an EMD did but to sit down next to a dispatcher was something else altogether,” he said. “Being an EMD is a job you have to watch to understand. It’s complicated. It’s challenging. Not many people realize how closely we work hand in hand with paramedics and, yet, stay in the background. We’re spokes in the wheel.”
Rigden accepted her position a few months after Tsang arrived, determined to continue to meet the requirements for the center’s Accredited Center of Excellence (ACE), for a third time, and to optimize the center’s quality improvement program.
She was the ideal candidate with an extensive background in emergency response in the field and in comm. centers. Her reputation in all things Priority Dispatch System protocols and quality assurance precedes her, and she is careful not to tread too heavily on established grounds.
At TEMS, Rigden made some immediate observations: staff is driven, the center is always busy with little downtime, and there’s an expectation to deliver EMS in a high-performance service delivery model.
“People here feel strongly about what they do,” said Rigden, a certified EMD instructor, a master medical Q instructor, and a senior Q in the National Q program.
She asked questions and learned the history and culture of TEMS. If there was something she didn’t understand or if there was an issue concerning protocol, she asked more questions and looked for a solution.
Rigden chose her initial projects carefully. She invested time and resources into improving the EMD call review feedback procedure and streamlining the training and quality improvement processes, in general. She offered refresher courses in the Academy’s performance standards and ProQA. She followed with an upbeat “catch them doing it right” approach to maintaining compliance.
“Emergency dispatchers are the most highly scrutinized people in the world,” Rigden said. “I am very dedicated to doing things in ways that are positive but at the same time correct a problem when it exists.”
She emphasizes consistency.
“It might sound odd but it’s about putting predictability in an environment that is unpredictable,” she said.
The calming, reassuring voice of the calltaker provides a large dose of encouragement to callers and patients in the throes of unpredictable and urgent situations. It’s the ability to help that makes the job most satisfying, combined, in optimum call scenarios, with providing Pre-Arrival Instructions (PAIs) leading to a baby’s delivery or the resuscitation of a patient in suspected cardiac arrest.
Donahue’s assistance with an over-the-phone delivery during his third year on the job provides a memorable and job-satisfying event. He heard the baby give its first cry and received a stork pin.
“MPDS gave me a focal point,” he said. “The steps were a big help. The call was personally quite rewarding.”
Awards are welcome, but they’re not the incentive behind Donahue’s or Rivera’s reasons for doing a great job. Rivera said they’re not the types looking for attention.
“We tend to like our work to speak for itself,” he said.