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.

  • Jason Murphy

    Being a paramedic supervisor in Oakland Ca (Alameda county), I can tell you prior to the changes, I was the fortunate recipient of complaints, for and against MPDS, from both the field and upper mgmt. You are right, EMT’s and Medic’s do not like to be diverted from what is perceived as a “critical” shooting call (for us, 27Bravo04) for higher level calls – chest pain w/cardiac hx, difficulty breathing, OD’s, etc. The ability of the caller to manipulate the response to them by answering questions disingenuously that are meant to triage the call appropriately is always possible but I doubt that happens all the time. There will always be those folks calling who fall through the cracks, and end up being a higher level call for their chronic lower back pain. MPDS does state in it’s field guide that it is up to the end user to make sure the determinants and priorities are appropriate for their system and that those decisions should fall to the medical directors and local EMS control/agency.

    So, Alameda county EMSA has now modified the priorty of the 27 card, making all shooting/stabbing trauma calls priority two, essentially making the call a delta level call, still coding at the bravo level. Only calls now that the rig can be diverted for are echo level calls.

    I ask myself, what’s next? Do we start to change the priority of the charlie level OD? Just because 80% of the time the charlie level OD is a ETOH subject that requires nothing more than a set of eyes and a bed at the ED (These folks usually AMA or just AWOL from the ED anyway, most times while the crew is still finishing up the pcr).

    I agree, there is a lot of QA/QI to do but the application of that needs to involve everyone, – field staff, supervisors, contractor mgmt, dispatch and county. Making decisions based upon some flawed news reporting and a couple of medics with agendas of their own will just bring us back to running lights and siren to everything.

    I, for one, would be on board to help/contribute to a quality assurance/improvement committee and I would like to see the county be more open to realistic input from the field/dispatch/ambulance mgmt.

    But then again, we are still measuring our system based cost per transport and on response time…so probably won’t happen, will have to wait for another NBC bay area investigative report.

  • Bob Sullivan

    A few years ago all “Bravo” shootings and stabbings to “Delta,” after similar outcry. It is easier to get away with a long response time to someone having chest pain in their house than for someone lying in the street in the middle of a large crowd.

    First, how realistic is it to figure out where someone is shot, or how sick they are, in a two minute phone call? Second, Oakland could do what Philadelphia does and just have the cops drive them to the hospital. Those patients seem to do better anyway.