Poor Quality Improvement 101: The Slippery Slope

Recently I read a story from Alameda County, California describing the issues that they are having there particularly with responses to stabbings and shootings.  According to the article, the dispatch center in ALCO has abandoned their previous “send anyone to anything as soon as it comes in” system for a more nationally accepted system utilizing Priority Medical Dispatch.

Priority Medical Dispatch, or PMD, is supposed to prioritize calls and tailor responses to those calls by classifying them utilizing a limited amount of medical information.  Calls are classified from the lower “ALPHA” level response to the most serious calls classified as “ECHO” level calls.  ECHO runs are mostly reserved for cardiac and respiratory arrests.  The purpose of the system is to get the most serious calls taken care of first.  It is a means of phone triaging.  Using a series of questions, call takers do their own little “choose your own adventure” flow chart and end up with a call’s classification.

The claim made by paramedics and EMTs in ALCO states that on occasions since the change over from AMR to Paramedics Plus, runs that turned out to be fatal or serious shootings and stabbings were classified at the less serious “BRAVO” level.  Field providers are now demanding that prioritization changes be made to give these calls a quicker response.  I, for one, cannot help but feel like they are barking up the wrong tree.

I feel like I have seen both the “very good” and the “just okay” of Emergency Medical Dispatch and PMD throughout my career.  I have seen it work well, and I have seen it misused.  Any system that gets used is going to be less than perfect, and utilizing Priority Medical Dispatch is no exception to that rule.  I believe it was Justin Schorr who once described Priority Medical Dispatch’s greatest flaw as the “least informed person (the caller) is talking to the least trained person (the dispatcher)” any anytime we discuss dispatch, or the prioritization of any calls, that needs to be kept in mind.

The real issue in Alameda County, as is in most systems that have I seen struggle with the problems they are having, is a lack of training and QA/QI.  If they are using the same system that other areas around the country are, and presumably they are, then there should be little difference in the quality of prioritization.  Sure, there is always human error that we need to think about, but PMD seems pretty universal, it is just a matter of the techniques that one uses to reach their end point.

The County’s stated response, however, is to reevaluate their triage system to make “absolutely sure” that these calls are made a priority.  My fear here is over triage.  Again, we have a system taking the presumably easy (read: lazy) solution to a current problem and making a blanket policy due to some incidents that could probably be just as easily handled by better, more efficient review of the calls being taken.  Again, we are deciding to placate the upset public, or in this case providers, instead of trying to improve our service.

Imagine if we applied these same principals to the field.  Oh wait, we already do.  Just look at how often we C-Spine patients.  But that’s another story entirely.

I feel that the true issue lies in another statement made by some of the paramedics interviewed.  They see themselves getting diverted for what they feel are lower priority calls.  That says to me that the entire system is most likely falling short, and not just their ability to evaluate and prioritize shootings and stabbings.  The problem here is not prioritization.  The problem is the system and the way that they are choosing to deal with their problems.  This is a slippery slope they are heading down.  Once chest pain patients start getting longer response times, then they will be lumped in with the stabbings and the shootings.  Then, eventually, any pediatric call will be moved to the top of the list.  Before you know it, you’re back to the system previously used.

Priority Medical Dispatch is far from perfect, and it is only as good as the people who answer the phone, and the people who are making the call.  The people answering the phone are only as good as the training and feedback that they receive.  Instead of changing the system at the ground level, let’s take a look at the quality improvement system the county is using.  That is where the issue appears to really be.