Editor’s Note: Brett received this question from an Instructor Recertification Workshop regarding ProQA® changes released as ProQA v.5.1.1.48 in November 2023:
We are particularly interested in changes to the cursor priority and options for the Not alert patient in Case Exit. The current resulting “mandate” to Stay on Line has been problematic in our busy ECC. Can you explain what has changed and why?
Great question! Your concern about staying on the line when it may not be clinically necessary and potentially delaying incoming emergency calls is not uncommon. Additionally, there are QA concerns associated with not choosing a link highlighted by ProQA logic when that link does not seem appropriate in a particular case. These concerns supported related PFCs that have prompted these changes. Let me explain.
First of all, let’s talk about cursor priority. As we know, protocols are based on probabilities, and the various Priority Dispatch Protocols™ are no different. For instance, if a patient in cardiac age range presents with a dull pain in her/his chest, the probability of a heart attack cause is much greater than the same presentation in patient under the cardiac age range. And, conversely, if our first patient is also clammy and gray, the odds of heart attack etiology is increased. So, based on our answers to various Key Questions, ProQA illuminates the cursor priority to the code of most concern, based on our predetermined probability assessment.
However, it’s important to remember that the selection of a highlighted cursor was never meant to be mandatory. If this were the case, why require a selection at all? Why not simply auto-select and be done with it? The answer is the fact that all situations are different, and sometimes we need the human factor to consider important variables that may be as simple as how busy the EMD is or as complex as what is happening at a disaster scene.
Regarding the question today, we have a slightly different issue. The Not Alert cursor at Case Exit is highlighted not simply based on probability, but on a ProQA set fact—Not Alert was specifically selected at Key Questioning. Therefore, if the EMD does not select the highlighted option, the EMD is simply not in compliance with protocol. And there lies the legitimate concern that prompted this change.
The real issue here is the fact that simply because a patient was reported to be Not Alert during Key Questioning does not always mean the patient is clinically unstable and in need of constant EMD monitoring. We know the Not Alert question throws a big net and inherently over-triages, but this is purposeful and errs on the side of caution. So, how can we better differentiate the patient in need of constant EMD monitoring versus the “functionally alert” patient who will likely remain stable until responder arrival if monitored by a responsible and capable bystander at the scene?
The first thing we needed to consider is: Which patients do we ALWAYS want to stay on the line with? Answer: 1st party callers who are not responding normally as well as patients who are obviously unstable or who do not have a responsible person with them who can carefully monitor them until responder arrival. Fortunately, this was relatively easy to accommodate in ProQA.
The change effectively groups 1st party and 1st party alone patients into a conservative collective that ensures the EMD remains on the line when reported as not responding normally. Only in Urgent Disconnect situations should these patients ever be left unmonitored—and even so, usually not.
However, 2nd party callers are obviously with the patient. If they are competent, cooperative, and willing, and the patient appears to be stable, such a caller should be able to carry out simple monitoring instructions and call back if the patient’s condition worsens. The protocol now facilitates this with a new link. If Not Alert is selected in Case Exit for a 2nd party caller, a new option will present: Stable & Being Monitored – Routine Disconnect.
This new option effectively allows the EMD to compliantly disconnect when the apparently stable patient is being responsibly monitored by a 2nd party caller who can call back if the situation changes. Our hope is that this enhancement will lessen the burden on our busy EMDs while making the work lives of our ED-Qs a bit easier as well.
Brett A. Patterson
Academics & Standards Associate
Chair, Medical Council of Standards
International Academies of Emergency Dispatch®
Jayme Tidwell adds:
The introduction of the Stable & Being Monitored link as an alternative option to X-3 is anticipated to significantly improve DLS scoring positively. The well-known highlighted option feature should now be seen as a recommendation guided by protocol question responses. This new feature provides Emergency Dispatchers with a greater sense of comfort when opting for an alternative course of action tailored to the specific needs of their patient.
This change aims to empower Emergency Dispatchers to make decisions that are optimal for the patient and caller, while reducing Emergency Dispatcher apprehension about compliance repercussions. It emphasizes that the highlighted option is not obligatory, but choosing Not Alert when the patient is indeed functionally “not alert” remains the correct practice.
Jayme Tidwell
Director, Quality Performance Review (QPR)
Priority Dispatch Corp.™
Dr. Clawson adds:
An issue that this explanation of cursor priority and call termination helps to solve is clearly influenced by the difference between functional and non-functional not alertness. In essence, functionally not alert patients, while not discounting the underlying issue/conditions causing it, are in control of their own airway and can be closely observed with that in mind. Those patients who are not functionally alert pose a riskier situation when the call is terminated for any reason. When in doubt, stay on the line …
Jeff Clawson, M.D.
