Jeff Clawson, M.D., and Brett Patterson
I had an agency ask me if the Academy has a recommended process for transferring callers from one dispatch center to another, and if so, is there a minimum set of questions the answering point should ask prior to transferring the caller? Is this sort of thing safe?
They are looking for any articles or briefs that might have been published in the past.
Priority Dispatch Corp.
The Academy has not published a specific process for call transfers other than the basic guidelines for ensuring a complete transfer, i.e., hot transfer rather than callback and address confirmation. These guidelines are recommended with consideration to calls coming into the wrong PSAP or other error rather than calls being routinely transferred for Pre-Arrival Instructions, i.e., Dispatcher-Directed (DD)-CPR.
The Academy does not endorse nor recommend the exclusive transfer of calls for DD-CPR for a number of reasons. If the primary PSAP receiving the call is untrained and/or uncertified in the use of a Pre-Arrival Protocol, all callers and patients are at risk, not just those calling for cardiac arrest cases. It’s a bit like sending an ambulance to cardiac arrest calls only; everyone else is simply ignored from a pre-arrival standpoint. Additionally, history has shown us that once the primary PSAP calltakers begin to realize pre-arrival help is just a transfer away, they start transferring other callers in need, and this taxes the resources of the secondary PSAP that, rightly so, it’s hoped, does not turn these calls down.
Second, the transfer process itself is time-consuming, risky, and frustrating to the caller. In the cardiac arrest scenario where time is of the essence, the primary PSAP must be formally trained to appropriately interrogate the caller and recognize cardiac arrest, which takes at least a little time. When transferred to the certified EMD who has no knowledge of the call at all, more time is spent ruling out safety issues and confirming cardiac arrest before Pre-Arrival Instructions can begin. And the very nature of call transferring is risky because information must be transferred as well, and this process is subject to error. Transferring calls falls into the same category as “shift change” in medicine—a term that often strikes fear into the hearts of hospital personnel—because of the significant increase in patient care errors and lawsuits it historically creates. Additionally, the process is frustrating to the caller because it’s redundant; the caller is expecting just one person and one interrogation. Please see Principles of EMD, 6th Ed., pgs. 4.5-6 for further information concerning call transfers for Pre-Arrival Instructions.
But back to the point of specific processes for transfer. This is problematic because in many of the systems being prompted to do this by pending DD-CPR legislation, the secondary PSAPs are dealing with multiple rural agencies and the process varies so much between them it’s difficult to know what to expect, and this fact has proven to exacerbate the previously mentioned complications.
With all of this said, call transfers for DD-CPR are a current reality due to well-intended but incomplete legislation, and our emergency dispatch community must adjust. Here are a few recommendations that may help to mitigate the complications mentioned above:
Cardiac Arrest Recognition: At a minimum, calltakers accepting the initial call must be trained with regard to cardiac arrest recognition so these cases can be identified and transferred expeditiously. While it’s been proposed this process is easily mitigated with a “No No Go” protocol, one must realize this protocol has a nearly 50% false positive rate, and this results in many more transfers than the secondary PSAP may be ready for. Additionally, cardiac arrest is sometimes accompanied by scene safety concerns, and abbreviated protocols that consider only two possibilities (unresponsive and abnormal breathing or not) not only ignore sick but not dead patients, they miss interrogation specific to scene safety. Note: The Academy is developing a short online course to help agencies with cardiac arrest recognition training. It is protocol generic and is currently in its final draft stage.
Information Transfer: All primary PSAPs and receiving secondary PSAPs must agree on what information should be obtained before the transfer and what information should be transferred, verbally and electronically. Variance among operators and PSAPs causes information gaps, information loss, or even information overload, all of which can lead to errors.
Call Transfer Types: As mentioned, it’s common for primary PSAP calltakers to “evolve” and start transferring calls other than cardiac arrest simply because it’s obviously the right thing to do. Why help just one Chief Complaint when you know the resource you are transferring to is capable of helping others in need? Call centers need to be prepared for this inevitability and strategies should be in place for dealing with it. Specifically, funding for additional FTEs needs to be explored proactively.
Prepare for the Future: While DD-CPR legislation has “motivated” systems to consider limited Pre-Arrival Instructions, the current, international standard of care goes much further. Agencies need to consider the value and even the moral responsibility of providing Pre-Arrival Instructions to all callers in need, and the clear advantages of providing this service in-house, as opposed to the risks and inequities of limited call transfers. In reality, the standard of care regarding who should deliver Pre-Arrival Instructions is not a new one:
“There must be continuity in the delivery of EMD care. To provide correct medical care safely and effectively, the EMD that is medically directing, evaluating, and coding must maintain direct access to the calling party and must use a medically approved emergency medical dispatch priority reference system. The person giving the medical instruction to the caller must be the same person that asks the systematic interrogation questions.”1
This standard is an unequivocal statement created for known and tragic reasons.
I am happy to assist more specifically any way I can and would point out that no agency or system is alone in this endeavor. Therefore, networking with systems dealing with the same issues can be most helpful.
Brett A. Patterson
Academics & Standards Associate
Chair, Medical Council of Standards
International Academies of Emergency Dispatch
1 “Standard Practice for Emergency Medical Dispatch. ASTM F1258 – 95. 4.1.2.” ASTM International. 2014.https://ipfs.io/ipfs/bafykbzacedpku3duvucdb3nfbfrlirxqjeas4sld4phi2qti6tfrwxadnr4fa/standards/ASTM%20Standards/F/F%201258%20-%2095%20%282014%29.pdf
Jeff Clawson, MD, is the Chair of the Rules Group of the Medical Council of Standards of the IAED and Medical Director of the IAED Research, Standards, and Academics Division. He co-founded the IAED in 1988. As the inventor of the Medical Priority Dispatch System (MPDS), widely recognized as the international standard of medical dispatch care and practice, Dr. Clawson is often referred to as the “Father of EMD”. The Journal regularly publishes his “Ask Doc” column and the “Blast from the Past.”
Brett Patterson is Academics & Standards Associate and Chair of the Medical Council of Standards for the IAED. His role involves protocol standards and evolution, research, training, curriculum, and quality improvement. Prior to working with the IAED, he spent 10 years working in the Pinellas County EMS System, Florida. He answers members’ protocol questions in the Journal FAQ column.