By Kory L. Sandoz and Greg Scott

There really isn’t any question of whether or not we will have another pandemic. The only questions are when it will occur and how severe it will be.

A pandemic is a disease that occurs over a wide geographic area and affects a high proportion of the population because they have little or no natural immunity. Influenza (the flu) is a contagious respiratory infection and an example of a pandemic infection. The flu can be serious and sometimes even fatal for certain groups (e.g., people with asthma, diabetes, compromised immune systems).

History shows at least 10 flu pandemics in the last 300 years. The largest outbreak was the Spanish flu pandemic in 1918–1919. The worldwide death toll is thought to be in the millions—an estimated 675,000 people died in the U.S. More recently, the swine flu, or H1N1 virus, caused a small scale pandemic in 2009. H1N1 was thought to have made 61 million people ill worldwide, but only 274,000 of those required hospitalization. It is estimated that 18,300 died from H1N1.1

Currently, in an average year the seasonal flu will hospitalize 114,000 people and cause about 36,000 fatalities in the U.S.2

Pandemic planning 

Planning is essential, and must be done well in advance. Sit down with a few key people and play out a scenario, such as an avian flu epidemic. What challenges will your organization face? How will you maintain staffing? What must be done at the center to accommodate staff? The best advice I can offer is planning to do more with less.


Since public transportation might be shut down—or endanger your staff’s health through exposure—consider creating solutions like using a shuttle bus or unused SWAT van to transport staff to work.


It is estimated that during a serious pandemic, 30 percent of your staff will be too ill to report for work and at its peak, absenteeism rates could be closer to 40 percent. Other local fire and medical agencies might request transfer of dispatch staff with EMT, paramedic, and LPN licenses to assist with hands-on patient care.

Consider the best use of your resources. While you may not want someone from accounting or warrants answering your 9-1-1 lines, they may be able to answer and redirect administration or business office phone calls.

A social distancing (limiting exposure) aspect helps keep people healthy, so you might want to ask in advance which of your staff members would accept longer shifts or other alternatives. For example, your comm. center might normally have two dispatchers on duty per shift. Under the contingency 24-hour plan, the two dispatchers take turns resting while both are available if things get too busy. If you have three dispatchers on duty, rotate one out for a rest period every six or eight hours.

Keeping your dispatch staff on-site 24/7 requires some logistical considerations. Staff in close quarters should wear a mask and gloves for protection. Food preparation and storage areas need to be available, and food should be stocked in advance. Gloves and disinfecting wipes should be on hand to decontaminate desk surfaces, radio microphones, telephones, keyboards, doorknobs, and any other commonly used surfaces.


As the pandemic subsides and daily life slowly returns to normal, several other issues will emerge, such as additional staffing, overtime costs, and expenses related to food, transportation, and other logistics. To help control costs, your comm. center might consider purchasing non-perishable and non-time sensitive supplies ahead of time.

 Post-traumatic stress

A 24-hour employee assistance line and access to some kind of peer and professional counseling is important. Your staff may have been touched by the death of patients, friends, and family members during a pandemic crisis.

Protocol 36

The IAED™ initially released Protocol 36: Pandemic/Epidemic/Outbreak (Surveillance or Triage) in 2009 in the event of an official pandemic flu outbreak; it was updated in 2010 in MPDS® v12.1 to reflect the expanded use of this protocol in earlier non-triage situations.

Since Protocol 36 is not used during normal (non-outbreak) operations, it requires advanced planning and setup, with “just-in-time” training and orientation for EMDs, as well as EMS administrators and responders. Most importantly, surveillance activity is done in advance of an officially announced outbreak and prior to an officially declared pandemic; emergency comm. centers may be engaged in public health authority requested or required surveillance activities to identify patterns, trends, and geographical clusters of symptoms.  

Surveillance (done prior to Protocol 36 implementation)

ProQA contains a flu surveillance tool: the Severe Respiratory Infection (Swine Flu) Symptoms screen. Click on the “Severe Respiratory Infection (Swine Flu) Symptoms” (V) button on the ProQA toolbar to access it. 

The screen—designed and activated by the IAED CBRN (Chemical, Biological, Radiological, Nuclear) Committee—provides a set of flu symptoms that the EMD can record for patients suspected of having the flu. Since specific symptoms may change as a particular outbreak spreads and more information is known about the disease, the EMD may rapidly update this screen incorporating data from public health organizations.

Surveillance is done in advance of an officially announced outbreak and does not call for the use of Protocol 36 at this point. Protocol 36 is activated only when the proper public health and governmental authorities announce a pandemic or an epidemic outbreak. This includes Level 0 (surveillance only), which can be implemented only when local concern of flu arrives. Level 0 allows for assessment of the extent of flu case penetration in real time and lets the EMDs become familiar with the protocol’s usage before patient triage is actually implemented.

Furthermore, each agency must develop a pre-approved response for every Protocol 36 Determinant Code, including all suffixes, based on the current pandemic level.

Implementing Protocol 36 for a declared pandemic/epidemic

Protocol 36 will identify potentially selected patients and assign a Determinant Code that accounts for both the patient condition and the degree of system depletion during an escalating crisis. ALPHA codes may be used to define non-EMS response and referrals only in Levels 1, 2, and 3 and only upon authorization of local medical control.

Level 1 (low triage) should be considered for ALPHA cases only; this maintains clinical response integrity while keeping triage risk low because patients with priority symptoms or conditions are not affected. The priority symptoms as defined in the protocol are:

Abnormal breathing

Chest pain/discomfort (any)

Decreased level of consciousness

SERIOUS hemorrhage

Level 2 (moderate triage) should be considered reduced response for CHARLIE cases and used to further lower or eliminate EMS responses for cases where priority symptoms or HIGH RISK conditions are identified.

Level 3 (high triage) should be considered referral of some CHARLIE cases and reduced response for DELTA cases and used to further lower or eliminate EMS responses for cases that contain priority symptoms (CHARLIE level) and reduce response in the DELTA level where normally the highest acuity patients occur.

Selection of Protocol 36

Rule 1 means: During an outbreak, Protocol 36 will sort out suspected flu patients from those who have other non-flu related conditions, such as asthma. Therefore, after a pandemic/epidemic is officially announced, the EMD must always select Protocol 36 when any of the complaints listed in Rule 1 are present. Cases not exhibiting any flu symptoms will be shunted to the correct Chief Complaint through the MPDS interrogation process and assigned a Determinant

Code consistent with the patient’s condition.

Rule 2 means: A patient with the flu will almost always have at least one of the flu symptoms defined on this protocol. During a declared outbreak, one flu symptom present is an indicator the patient is a true flu case. With two flu symptoms present, the EMD may reasonably conclude that the patient has the flu; hence, there is no need to continue the remainder of the specific flu questions. The EMD will move directly to Key Question 11 once two flu symptoms have been identified.

Rule 3 means: Some patients with a Chief Complaint that is a potential flu symptom (due to their description of the complaint) will not have the flu. Instead, they may have other serious underlying conditions, such as asthma. When no additional flu symptoms are identified in the Key Questions, the EMD must shunt to the correct Chief Complaint Protocol using the original complaint description given so that these conditions can be properly prioritized and treated.

Rule 4 means: Sometimes patients will take anti-inflammatory drugs such as aspirin to reduce flu symptoms. If the patient reports a recent fever that was relieved by such a drug, it is still important to record the existence of the fever (at the time the drug was taken). Always answer the fever question “yes” when the caller reports a recent fever relieved by medication.

Rule 5 means: If the complaint is Chest Pain (> 35), and additional symptoms of  sweats, vomiting, or a history of heart attack or angina are later identified, go to Protocol 10 and complete the call. While sweats and vomiting are symptoms of flu, they may also be present in heart attacks.

Rule 6 directs the EMD NOT to use Protocol 36 for any patient 65 years old or older. It has been shown that this age group is not likely to get significantly sick from H1N1.

Determinant Levels

The OMEGA codes were removed in the MPDS v12.1 update. The remaining MPDS Determinant Levels in Protocol 36 (ALPHA, BRAVO, CHARLIE, DELTA) have been adjusted to provide for more aggressive triage of patients with conditions associated with the flu. For example, all Chest Pain patients 35 years and older and all Breathing Problems patients without additional complicating symptoms are assigned the CHARLIE level.

A specific Determinant Code (36-C-5) is used for the HIGH RISK category with patient conditions known to have shown significantly poorer outcomes—diabetes, sickle cell disease, neurological diseases (affecting swallowing or breathing), pregnancy, or age 12 or younger.

The vertical ordering of Determinant Codes within any specific Determinant Level does not necessarily represent ascending or descending patient acuity; they are arranged to make it easier for EMDs to visualize and select the specific patient descriptions in Protocol 36, especially in the CHARLIE level.

Suffix codes

Suffix codes reflect the degree of outbreak severity (and subsequent resource depletion) your system is experiencing at any given time.

There are three suffixes used for determinant coding: A, B, and C.

The suffixes correspond with the announced numeric severity level of the pandemic outbreak in your system and region. The assigned severity level will depend on several factors, including the lethality of the flu virus, the increase in EMS calls, and the degree of EMS responder workforce depletion.

ProQA will automatically assign the correct suffix (severity level) to the case once the EMD enters the current severity level during the Key Questions. The Key Question that prompts the locally designated flu level will be displayed as a blue operator question in ProQA.  

The current severity level suffix is always attached to a Determinant Code so that a unique response can be assigned for each severity level within that code. For example, the coding of 36-C-1C could receive a different (and even more reduced) response than a code of 36-C-1B to reflect the current, increasing degree of system depletion and, therefore, diminishing the actual level of response.


Protocol 36 can only work effectively with precise and complete information; 100 percent compliance to Case Entry and Key Questions is imperative in arriving at the correct Determinant Code and response. Cutting corners to save time actually makes the process less effective and may place certain patients at increased risk.


1 Pandemic Flu History. http://www.flu.gov/pandemic/history/ (accessed June 18, 2014).

2 About Influenza. Amanda Kanowitz Foundation. http://www.amandakfoundation.org/aboutInfluenza.php (accessed June 18, 2014).

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