Altered Standard of Care Training for Administrative Personnel

Welcome to the S-SV EMS AgencyAltered Standard of CareAdministrative Module 2

This is the second of three modules of the Altered Standard of Care Training. This section focuses on:

• The addition and use of a Scheduled Transport Center,• Creating a Public Access Number, and • Changes in the medical dispatch protocol

This module will take approximately 1 hour to complete. At the end of this module there will be a 10 question quiz. You must complete the quiz with an 80% success rate to pass. The questions will be based on the information learned during the training module.

NOTE: Completion of the quiz is required to receive CE credit.

This training provides an example of how the current 911 system may be altered during a major disaster or pandemic outbreak. The scenario and changes shown in this module are hypothetical only and should not be taken as actual changes to the system. System changes may follow the model that is shown in this training, but could vary based on the severity and type of incident.

The purpose of the Altered Standard of Care Training is to provide information regarding the alteration of the EMS system in response to an increased demand for medical-aid services, beyond the capacity of the current system providers.

After completing this training, you should be able to:

• Describe the use of a Scheduled Transport Center• Explain the use of a Public Access Number including the use of 2-1-1• Identify changes made to dispatch protocols using the altered standard of care.• Understand the use of a Scheduled Transport Center.

A pandemic outbreak has affected a large portion of the population. It is a severe variation of the annual flu virus. The EMS system has increasingly become overwhelmed, and there is no estimated time when this impact will end.

We simply do not have the resources and personnel to handle the demand for more ambulances.

Ahead we will discover what changes can be made to the system to handle this type of overload

Due to this pandemic outbreak, many people have been calling 911 for various reasons. To address the impact, the public access system must be altered in

order to meet the increased demand.

In Module 1 we looked at how the normal dispatch priority system works, now let’s look at how the process might be changed, beginning with the

Scheduled Transport Center and Public Access Number.

The MHOAC has decided to implement two additional resources reduce the impact on the local EMS system. These resources include:

The is designed to coordinate all medical transportation requests from all system access points including:

• hospitals, • health facilities,• Public Access Number, • 911, and • the field.

By establishing a Scheduled Transport Center the stress on the 911 system will be significantly decreased, and will allow dispatchers to manage a higher call volume and improve call turn-around times.

Activating this separate center will allow the Transport Center staff to explore all the alternatives for the transportation needs of the calling party.

All calls coming into the Scheduled Transport Center will have already been triaged.

• Immediate/Emergent patients will have been referred to 911.

• Minor/Worried-Well patients will have been referred to the Public Access Number.

Therefore, all incoming calls to the Scheduled Transport Center are assumed to be “DELAYED.”

Upon receiving a call, the Scheduled Transport Center staff will obtain the following information from the calling party;

• Patient’s name, age, and chief complaint

• Location and call-back number

After obtaining the location and patient information, the call taker will assess the patient’s ability to walk unassisted.

Ambulatory patients will be directed to be transported to their private doctors office, clinic, urgent care, or emergency department.

If the patient does not have transportation available to them, the Transport Center may provide public transportation vouchers, send a shuttle bus, or schedule BLS transport.

Alternative Transport Options – Benchmarking the Phoenix Fire Department

Phoenix Fire Rescue has a system of paramedic-engine non-emergency alternative transport referrals. Results of the authors research visit, interviews and field observations in Phoenix demonstrated a well functioning system of alternative transport for non-emergency patients once they had been thoroughly assessed on the scene.

Alternative Transport Options – Benchmarking the Phoenix Fire Department (con’t)

If the patient is mobile without need of assistance and meets the criteria of a non-emergency case, the PFD paramedics, in concert with their station officers have the discretion to refer the patient to self-transport or public taxi service. PFD provides patients with a taxi voucher if they lack their own transportation.

- http://www.usfa.fema.gov/pdf/efop/efo35927.pdf

Non-ambulatory patients will fall into two categories:

Wheelchair transport

OR

BLS/Gurney transport

For any patient requiring transport to the emergency department, the Scheduled Transport Center will coordinate destinations with the Control Facility.

YES

NO

Obtain Patient information and chief

complaint.

Call to Scheduled Transport

Center

Is patient able to stand and walk unassisted?

Ambulatory Non-Ambulatory

Direct the patient to use this

transportation resource to seek

medical attention

YES

Does the patient have access to public

transportation?

NODoes the patient

have friends/family that can transport

them?

NO

Does the patient have their own

vehicle?

Ambulatory

YES

YES

NO

Schedule transport service (taxi, bus, or BLS transport)

Schedule wheelchair transport

Schedule BLS transport

NO

Is patient able to sit in a wheelchair

Non-Ambulatory

YES

The Scheduled Transport Center will ideally have coordination with the 911 dispatch center and Public Access Number via 2-way radio communication in the event of an emergency requiring BLS transport.

Emergency calls will always take precedence over scheduled BLS transport calls. Therefore, BLS ambulances may be rerouted and patients rescheduled due to accommodate more urgent calls.

The Scheduled Transport Center is designed to coordinate all medical transportation requests from:

A. Hospitals and health facilitiesB. Public Access Number C. 911 and the fieldD. All of the above

We have reviewed how a Scheduled Transport Center might be established

and operated during a disaster.

In the next section, we will review principles for establishing a Public Access Number and a website for

providing public information.

Creating a Public Access Number would greatly relieve the stress on the 911 system by referring the public to the appropriate resources without

having to call 911 and utilize emergency responders unnecessarily.

In July 2000, the Federal Communications Commission (FCC) reserved the 211 dialing code for community information and referral services.

The FCC intended the 211 code as an easy-to-remember and universally recognizable number that would enable a critical connection between individuals and families in need and the appropriate community-based organizations and government agencies.

211 works a bit like 911.

Calls to 211 are routed by the local calling center.

The 211 center’s referral specialists:• question callers, • access databases of resources available from

private and public health and human service agencies,

• match the callers’ needs to available resources, and

• link or refer them directly to an agency or organization that can help.

211 played a critical role during the San Diego wildfires of 2007 by providing information and support to more than 130,000 residents in 5 days.

“The 211 service was an invaluable resource during the firestorm in that it freed up calls from 911. We could give information on repopulated neighborhoods to the 211 operators. We saw 911 calls diminish over time because of that.” -- San Diego Sheriff Bill Gore

As of October 2011, 2-1-1 serves over 260 million Americans (86.6% of the entire population)

covering all 50 states (including 37 states with 90%+ coverage) plus Washington DC and Puerto Rico.

Blue- >80% Green- 100%

As of April 2011, 27 Counties in California have adopted the use of 211.

According to California Alliance of Information and Referral services (CAIRS), there are currently three of the ten counties within the S-SV EMS Agency system (Shasta, Nevada, and Yolo) that have an active 211 system, with other counties scheduled to roll-out the 211 system in the near future.

www.211shasta.com

www.dial211.com

During a disaster or emergency activation, call-takers for the Public Access Number should be trained to triage calls in a similar fashion as 911 call-takers.

Consideration should be given to staffing the call center with Registered Nurses.

One King County, Washington study (Smith, W.R., 2001) that was presenting in the pre-hospital Research Forum in Orlando, concluded that transferring non-urgent 911 calls to a nurse on the front end resulted in a decrease in BLS responses in the Seattle area over a four month period with no reported adverse patient outcomes and the maintenance of high levels of patient satisfaction.

-www.usfa.fema.gov/pdf/efop/efo35927.pdf

As mentioned before, the Public Access Number, Scheduled Transport Center, and the 911 call center will ideally have coordination with each other via 2-way radio communication.

If a call comes in to the Public Access Number that is a medical emergency, the call taker will:

•contact the Transport Center to request a BLS ambulance and QRV response* to the patient’s location.

•Stay on the line with the calling party to provide medical care instructions until field responders arrive.

*The Transportation Center will communicate with the 911 dispatcher to request a QRV and first responders to respond as needed.

Obtain:•Incident Location•Call back number•Patient age•Level of Consciousness•Status of breathing•Chief Complaint

Call Taker

211 or Other Public Access Number

Provide Pre-Arrival Care Instructions

Medical Emergency?YES

Call-taker will contact the Transport Center to

request field response. NO

At home care Higher level of care

No medical need

Assess the level of medical need

If it is determined that the caller has only minor medical care needs, they may be:

• Given self care or family care instructions

• Directed to sources of health information on the internet

Examples of medical web support include:

•WebMD.com•CDC.Gov (Centers for Disease Control)•Bepreparedcalifornia.ca.gov (CDPH), and •Local Public Health Department websites

If it is determined that the caller needs to be seen by a medical practitioner they should be assessed for their ability to obtain necessary transportation.

If the patient is unable to transport themselves or have family transport them to their personal physician, they should be transferred to the Scheduled Call Center.

If it is determined that the caller has no medical need, they may be:

• Transferred to other social or public service call center,

• Referred to other public information websites,

• Referred to appropriate agency or county services.

A Public Access Number is the number people will use in emergency situations where a paramedic is needed.

www.disasterdoug.com

www.disasterdoug.com

The establishment of a Public Access Number and Scheduled

Transport Center should decrease the public demand for resources.

www.disasterdoug.com

In order to respond to those with the greatest needs in the community, the standard protocols used by the emergency medical dispatch centers will need to be altered.

The Altered Standard Order Form lists these nine areas to be considered for implementation.

Items to be altered will be initialed by the MHOAC, EMS Agency Medical Director, or designee.

In this scenario, the MHOAC and EMS Agency have elected to discontinue:

• Discontinue Use of Emergency Medical Dispatching (EMD) Procedures & Implement Altered Triage Algorithm

• Discontinue Use of Pre-Arrival Instructions (PAI)

Now we will look at an altered triage process that ranks patients based upon the severity of need. This triage system will use the following categories:

requires immediate medical intervention

needs medical attention, however, the response can be somewhat delayed.

May be assisted with self-care or system resources other than 911 medical resources.

Needs non-medical community services.

www.disasterdoug.com

IMMEDIATE DELAYED MINOR DECEASED

Now lets look at the Altered Standard for a medical-aid request.

End Call Center YESIs it a Medical Emergency?

911 Call Center

Reporting PartyCalls 911

During an emergency, the 911 call taker will determine whether or not a medical need exists, and transfer the

call to the appropriate “End Call Center.”

SOBAcute ALOC

Severe Bleeding

End Call Center YESIs it a Medical Emergency?

The Emergency Medical Dispatcher will determine the severity of the emergency based upon the patient symptoms, including:

•Shortness of Breath (SOB),•Acute or sudden Altered Level of Consciousness, or•Severe or uncontrolled bleeding.

Paramedic(QRV)

YES

SOBAcute ALOC

Severe Bleeding

End Call Center YESIs it a Medical Emergency?

If the patient exhibits one of these three problems (SOB, Acute ALOC, or severe bleeding), dispatch will send a paramedic in a QRV to the scene to provide care to the patient.

(if there are any delays in ALS response a BLS unit will be dispatched to the call.)

1. “Can pt. talk”

2. “Can pt. walk”

unassisted

ON

SOBAcute ALOC

Severe Bleeding

If none of these problems are present, the dispatcher will then determine if the patient can:

End Call Center

211 or (7 digit) Public Access

CenterNurse Support

Line

YES

1. “Can pt. talk”

2. “Can pt. walk”

unassisted

If the patient is able to talk and walk without assistance, direct the patient to the Public Access Number or nurse support line for further assistance.

Transport Center

Check availability of:

Family/FriendPublic TransportDial-a-RideTaxiFlu Bus

NO

1. “Can pt. talk”

2. “Can pt. walk”

unassisted

If the patient is unable to talk or walk unassisted, the dispatcher will transfer the call to the Scheduled

Transport Center.

www.disasterdoug.com

Schedule BLS Transport

(pt call-back-confirm)

NO

Transport CenterCheck availability of:

Family/FriendPublic TransportDial-a-RideTaxiFlu Bus?

If the Transport Center is unable to identify available transportation for the patient, a BLS unit would be

scheduled to transport the patient.

211 or (7 digit) Public Access

CenterNurse Support

Line

Schedule BLS Transport

(pt call-back-confirm)

NO

Transport Center

Check availability of:

Family/FriendPublic TransportDial-a-RideTaxiFlu Bus?

NO

YES

Paramedic(QRV)

YES

1. “Can pt. talk”

2. “Can pt. walk”

unassistedON

SOBAcute ALOC

Severe Bleeding

Medical Dispatch YES

Is it a Medical Emergency?

911 Call Center

Reporting PartyCalls 911

(if any delay in ALS response, a BLS unit is dispatched.)

www.disasterdoug.com

If a patient calls 911 and it is determined that the patient can, 1)Walk unassisted and 2)Talk unassisted, the caller would:

If you answered,

you are…

This resource is available for patients that do not need an ambulance even though they have called 911. They will be given instruction on what to do for their signs and symptoms. www.disasterdoug.com

In this module, we have reviewed changes that could be made to the standard Emergency Medical Dispatch System, including:

•Establishment of a Public Access Number/Nurse Support line•Establishment of a Scheduled Transport Center•Discontinuation of Pre-Arrival Instructions•Implementation of a Modified Dispatch Triage Algorithm

You will now be quizzed on what you have learned in this module. Thank you for your participation in this training module.