By Art Braunschweiger
In ProQA, the Send screen appears when enough Key Questions have been answered to identify the appropriate Determinant Code. That code is highlighted in green. Selecting a code highlighted in yellow, if available, allows the calltaker to override to a higher Determinant Level. When not on the Send screen, an override code is available anytime the up/down arrows on the Reconfigure Response button appear in yellow. This button will bring the calltaker back to the Send screen where an override can be selected.
In ProQA training classes for Priority Dispatch, I typically ask the dispatchers attending whether their agency policy permits them to do this. The answer is invariably “no,” often accompanied by a look that suggests I’ve proposed something heretical.
Many agencies aren’t comfortable giving their dispatchers the ability to override and require the calltaker to send the code that ProQA presents. Common rationale is that taking the subjectivity out of the decision is one of the reasons that they’ve adopted ProQA in the first place. But there’s an important point that needs to be clarified. As International Academies of Emergency Dispatch (IAED) then-Board of Accreditation Chair Brian Dale noted in a session at NAVIGATOR 2014 in Orlando, Fla., “ProQA does not recommend anything. ProQA presents the most likely Determinant Code based on the Key Question answers that have been selected.”
That may seem like mere semantics, but it’s not. ProQA can’t recommend who or what should respond to your call, because it can’t possibly know your local resources and their capabilities. For that reason, the override feature in ProQA is only intended to be used when the calltaker does not believe the resources dispatched will be adequate to assess or care for the patient. Such a decision might be based on the patient’s condition or the circumstances surrounding the call. This capability ensures that the needs of the patient will be met, even if a determining factor exists that ProQA doesn’t capture. An example might be a patient with a mild headache who reports he has a condition that causes him to quickly lose consciousness when this happens. A mild headache codes at the ALPHA level, whereas the condition reported would require a CHARLIE-level response.
Given ProQA’s proven accuracy in coding, overrides should be far and few between.1 They can be further limited by an agency and its medical director taking steps to ensure the appropriate resources are matched to each Determinant Code. Authority to override the ProQA code highlighted in green must be approved and defined by agency policy and medical control. To have override authority, calltakers should have in-depth knowledge of local resources and their capabilities.
Calltakers should be required to document the reason for overriding, and overridden calls should be reviewed by the Quality Improvement Unit and, if necessary, the medical director. (The Determinant Code resulting from an override can be readily identified by a zero as the final number, as in 10-C-0.)
Protocols are based only on probabilities, and nothing can replace the human brain. Unusual circumstances do occur from time to time when an override might be appropriate. Therefore, overrides shouldn’t be automatically consigned to the “forbidden zone” but rather given due consideration for approval within very specific guidelines. You never know, it just might save a life.
Clawson J, Olola CHO, Heward, A, Scott G, Patterson B. “Accuracy of emergency medical dispatchers’ subjective ability to identify when higher dispatch levels are warranted over a Medical Priority Dispatch System automated protocol’s recommended coding based on paramedic outcome data.” Emergency Medical Journal. 2007; 24: 560-563.