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January / February 2010
Volume 22, Number 1

When Kim Cunningham answers the phone, she’s well aware that the call could be a matter of life and death — and she’s prepared to help.

Cunningham is a dispatcher with Montgomery County Emergency Medical Services, but her duties go beyond sending an ambulance and telling callers what to do when preparing for help to arrive.

She is a first responder herself, having been certified by the National Academies of Emergency Dispatch to give pre-arrival medical instructions for callers whose loved ones are going through everything from imminent childbirth to shortness of breath to a seizure.

Most urban and suburban areas provide pre-arrival instruction services to residents experiencing an emergency, but no such service exists in most rural areas — where the service is perhaps most needed, due to longer ambulance response times.

But years after gaining Legislative funding and conducting a successful pilot and beta program in which Montgomery County allowed its emergency medical dispatchers to help residents in participating emergency service districts outside its own service region, the county’s EMS district is offering the service to rural counties and districts anywhere in the state.

The service is still being funded via legislative dollars until September 1, so counties who want to try out the program can do so for free until then. After that date, the service will be offered based on a multi-tiered subscription model, in which counties with lower call volumes pay a smaller amount, said Steve Shelton, the executive director of the East Texas Area Health Education Center, a U niversity of Texas Medical Branch community response program that focuses on underserved populations in the area.

UTMB and the East Texas AHEC worked with Rep. Jim McReynolds (D-Lufkin) and Sen. Bob Deuell (R-Greenville) back in the 79th legislative session to start the regional pilot program and prove that the emergency medical dispatch service could be offered from a central location efficiently and effectively. The only requirement for a 9-1-1 answering point to be eligible is that they be under the jurisdiction of the Commission on State Emergency Communication (CSEC), which is the agency that funded the legislative pilot program.

“The subscription model will allow for the local 911 entry points to use the 911 funds that they receive from the state to pay for the subscriptions,” Shelton said. “Each tier will allow a set number of calls within that tier and then calls over that set number of calls would be paid for on a call-per-call basis.”

The business plan will be finalized within the next couple months and rolled out April 1, though Shelton said counties may still have access to the free pilot program after that date. “(911 answering points) can enter the pilot at any time and at Sept. 1 all communities participating in the program will move to the subscription model,” he said, adding that already, sheriff’s offices in Bandera, Burleson, Blanco, Cooke and Grayson counties are participating in the beta program. Other participating entities using the program are in Kendall, Hill, Liberty, Wharton and Fannin counties.

Shelton said they chose to wait until Sept. 1 to charge a fee so that entities can plan for the service in their budgets, though he also said answering points can request funding dollars from CSEC to cover their subscription rate. “It’s actually state funds being passed through to the local jurisdiction that will enable them to subscribe to the service, it wouldn’t necessarily even be local funds required for the subscription, but they need the information for the subscription rate for the tiers so they can plan it in their request from the commission. … The program is designed for the smaller community and rural answering points, to support their needs.”

Communities that participate in the pilot must undergo training provided by the Montgomery County regional emergency dispatch center.

The service itself is top-notch and the first of its kind in the country; the Montgomery County center stays accredited by the National Academies of Emergency Dispatch (NAED). Accreditation by the academy takes time, energy and resources to achieve, but the center — which also provides dispatch for its local EMS district — cuts no corners.

“We are an accredited Center of Excellence as recognized by the National Academies of Emergency Dispatch, and we know through the national academy that there are no other regional accredited centers, that are centers that have proven that they are administering the protocol correctly and have the quality improvement processes in place to ensure that,” said Montgomery County Associate EMS Director-Communications Frank Marshall.

According to the academies Web site, there are less than 100 accredited emergency medical centers nationwide.

“There are some large metropolitan areas in the country that are using call centers, like nurse call centers for doing additional screening to determine in some cases whether or not to respond with an ambulance,” Marshall said. “This is not that type of service.” When a person first calls 9-1-1, the call is routed to the local answering station, which gets the person’s basic location and emergency information and sends the ambulance. If it’s a medical emergency, the local dispatch center then transfers the call to the regional center, which provides the pre-arrival medical care instructions. The transfers are quick and seamless, and in certain situations the regional dispatchers stay on the phone with the caller until help arrives.

“In rural parts of Texas, response times are typically 20 to 25 minutes or more, in some cases, and that’s uncommon if we’re only talking about an urban setting where response times are typically 10 minutes,” Marshall said. “So you can see where a critical patient is going to need pre-arrival instructions for a longer period of time, and that the caller can truly, truly make a difference in taking care of the patient and knowing what to do for the patient before the ambulance gets there when the ambulance is 20 and 25, 30 minutes away.”

But rural communities are often not equipped to provide prearrival instructions themselves. Equipment is not necessarily an issue; entities can order a cardset of pre-written questions to ask callers and patients for about $500, and pay about $30 a year to keep the book up-to-date, Marshall said. It’s an additional $300 to train a dispatcher on the protocol for using the cardset.

The Montgomery County dispatchers are trained using the cardset, but actually use highly sophisticated and intuitive computer software that leads them through medical emergencies with just the click of the button. The software can also do simple things like time a person’s breathing or contractions so that dispatchers can know exactly how much difficulty the person is having or how far into labor they are.

“The software I think is just more intuitive and makes use of the protocol easier,” Marshall said.

The bigger issue is making sure the protocol is being correctly followed, documenting that on a daily basis and then looking for the patterns within those reviews that could indicate weak areas that need to be addressed.

“It’s not to say that rural communities struggle with long response times. I think it’s just a fact that if you choose to live in rural Texas, one of the things you know about that is that typically emergency services are further away from you, just like Wal-Mart is,” Marshall said. “What they struggle with typically is a lower call volume that doesn’t support the need for this level of service. This level of service doesn’t come cheap. There’s an awful lot of training involved at the dispatcher level, there’s additional overhead in administering the licensed protocol, there’s additional overhead involved in the quality improvement aspect of it and ensuring that your call takers are delivering the protocol in a prescribed manner.”

The Montgomery County dispatch center has trained supervisors to go back and review calls based on the national academies’ standards. Dispatchers are graded on everything from case entry — whether the right questions were asked in the right order — to customer service — whether the dispatcher’s tone of voice was appropriate throughout the call, whether they were compassionate, whether there were any gaps between questions.

“If she (the dispatcher) starts stumbling through there like she’s trying to find something, that would be a gap and she would be counted off,” Marshall said. “(Dispatchers) have to be very reassuring up front that help is already on the way and that the questions that we are about to ask are questions that are going to allow us to provide additional help before the ambulance got there, and that it isn’t a mechanism in place to cause any delays in care.”

The purpose of the pilot program wasn’t to prove that pre-arrival instructions could help rural areas, but to prove that the service could be offered regionally or statewide.

“They are having an emergency, so they didn’t need to feel like their call was being transferred around the world. It needed to be as seamless as, ‘Stay on the line, I’m going to connect you with someone that can help you,” Marshall said, snapping his fingers. “And it happens that fast. Otherwise, you’re going to make the caller feel like the ambulance isn’t on the way or they’ve been placed on hold; 30 seconds to a person who is having an emergency seems like 30 minutes. … We need to be able to not drop calls.”

Overall, Marshall said providing the pre-arrival instructions helps not just callers and patients by providing life-saving information, but the entire emergency medical services system. Patients are in better condition than they would be had the instructions not been offered, and the system itself is stronger.

“One of the things dispatchers struggle with across the country is that they are not recognized as a part of the EMS system. We work really hard with our staff and our field staff to bring the two groups together, because they are not just dispatchers. Dispatchers send the repair guy to fix your washing machine, they send the plumber or the taxi cab,” he said. “These guys are a part of the EMS system. They are the first first-responder. They are delivering health care in a very unique way; they are just doing it by telephone. What they do is tremendously important in today’s health care model and the way we deliver emergency health care.”

To join the pilot, contact Shelton at (409) 772-7884 or email him at steve.shelton@utmb.edu.