Using AQUA Like A Pro
April 19, 2023
As the IAED™ Associate Director of Accreditation and a member of the ED-Q Curriculum Board, I spend a lot of time working in AQUA® and seeing how ED-Qs use AQUA. In this article, I will go over common errors and provide tips for getting the most out of AQUA. This first article will cover AQUA Documents, Protocol Links vs. DLS Links, and minimum Standards of Practice.
The Documents section of AQUA has all the latest supporting information including explanations detailing the latest changes to AQUA. If you haven’t read these documents, now is an excellent time to start. It is good practice to review this section every time AQUA is updated to see if there are new or updated documents.
Contained in the Documents section are three user guide PDFs: “AQUA User Guide,” “AQUA Reports,” and “Help/FAQs.” These documents are a wealth of information on how AQUA works, what each report does, and common issues/questions. They are well worth a detailed read.
There are two statements to check out. “ED-Q Performance Standards Updates” provides a summary of all the updates since the last version of the Performance Standards was released. This is a must-read to make sure you are aware of all the changes. “Performance Threshold” explains the math behind the calculations in the Performance Threshold reports. You only need to read this if you want to know the exact formulas; AQUA does these calculations for you. This one isn’t for the faint of heart—there are stats involved.
“ED-Q Universal Deviation Reference” is the one reference document included. This document provides the general behind-the-scenes deviation weighting (MINOR, MODERATE, MAJOR, CRITICAL) of each performance/behavior. This is a helpful reference for understanding what the IAED has determined to be the most serious errors (for instance, not asking a scene safety question versus not asking a regular question). I recommend you read this one when you have a compliance level that doesn’t make sense to you.
There is one Official Position Statement, “Case Exit Disconnect Pathway,” which will be discussed below.
New Case Exit Disconnect Pathway
I would like to draw your attention to a new document in AQUA 18.104.22.168 called “New Case Exit Disconnect Pathway.” This document replaces “Protocol Link Error Statement.” It is an explanation of how to use a newly added deviation in the DLS section. This disconnect pathway will allow for the application of a MINOR deviation when an Emergency Dispatcher provides correct PDIs from memory without selecting the appropriate panel. When this occurs, the PDIs do not appear in the Post-Dispatch Instructions area of AQUA.
We want to encourage the habit of correctly progressing through ProQA® PDIs so Emergency Dispatchers don’t miss any instructions, as well as get them into the habit of not closing ProQA early to ensure they can respond to any new or updated situations while still on the phone with the caller.
Past practice of measuring this error as an “Incorrect Protocol Link” gave a MAJOR deviation, which is now considered too severe for this behavior. It is recommended that this practice be discontinued, and the new “Selected correct Case Exit disconnect pathway in ProQA” deviation found in the Questions/Instructions area of DLS Instructions be used instead.
This new MINOR deviation supports the philosophy of reasonableness. Please refer to the “New Case Exit Disconnect Pathway” statement in AQUA for complete details.
Protocol Link error versus DLS Link error
There can be confusion over when to measure something as a true Protocol Link error or a DLS Link error. This will clear things up for you.
Protocol Links connect parts of the protocol and assist the Emergency Dispatcher to stay in agreement with protocol structure and function. Examples of Protocol Link errors are shown in the graphic below.
In ProQA, Protocol Links are commonly found in PDIs as “Go to KQs” and in both PDIs and PAIs as “Return to KQs,” “Go to PDIs,” or “Last instruction — Close case.”
Yes, in PDIs “Go to KQs” is listed under the DLS Links, but it fits the definition of a Protocol Link error. This one is there to keep ED-Qs on their toes!
Make sure to apply the Protocol Link error when relevant as it is a lesser deviation than a DLS Link error. There are fewer Protocol Links compared to DLS Links. A deviation is applied when the Emergency Dispatcher does not select the correct Protocol Link.
DLS Links are panel directors. They are found in the red pop-up box in Case Entry and to the right of Chief Complaint PDIs and in the lower right-hand corner of individual PAI and Case Exit Protocols.
A deviation is applied when the Emergency Dispatcher selects the incorrect DLS Link and therefore goes to the incorrect instructions.
When to use minimum Standards of Practice
In AQUA there may be more than one way to apply a deviation for the same behavior. It is vital that your Quality Improvement Unit (QIU) agree on which way to measure such things. Minimum Standards of Practice is one such area. DLS Instruction Standard 1 (Possible and Appropriate) explains that failure to read certain DLS Instructions constitutes a failure to meet minimum Standards of Practice and generates a CRITICAL deviation. If an available deviation in AQUA provides a CRITICAL deviation for the error, one must not assign a DLS Link deviation and minimum Standards of Practice because that will make two CRITICAL deviations for the same error. For example, in medical if there is uncontrollable bleeding and the EMD selects X1 instead of X5, this may be scored as a DLS Link error (CRITICAL deviation) OR minimum Standards of Practice but not both. Your QIU must decide how this is to be scored so it can be applied consistently.
Now, if the Emergency Dispatcher does not stop a caller from doing something that is clearly a risk to the safety of the caller, victim, patient, or responder and there is no specific deviation in AQUA to address this, it is measured as failure to meet minimum Standards of Practice. For example, if the EFD clearly hears the caller state they are going to pour water on a grease fire on their stove, we expect the EFD to immediately tell the caller not to do that as it would be unsafe. If the EFD fails to do that, they are not meeting the minimum Standards of Practice. It can only be captured in AQUA by giving this deviation.
The correct way to score PDIs in AQUA has already been covered in a previous article in the Journal of Emergency Dispatch. You can read it here: https://www.iaedjournal.org/pdis-in-aqua.
I hope this helps clear up some common areas of confusion when using AQUA. The next article will address Key Questions, Post-Dispatch Instructions versus Diagnostic Tools, Key Questions selection errors versus New and Updated Information, Sub-Chief Complaints, ECCS versus Customer Service, and Test Cases.
Have AQUA questions or suggestions for this series about pro tips? Email Kim.Rigden@emergencydispatch.org.
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