Public Expectations of Receiving
Telephone Pre-Arrival Instructions from
Emergency Medical Dispatchers at 3 Decades
Post Origination at First Scripted Site
Amelia Clawson1, Pamela Stewart1, Christopher Olola PhD1, Scott Freitag2, Jeff Clawson MD1
International Academies of Emergency Dispatch, Salt Lake City, Utah, USA
9-1-1 Communication Center, Salt Lake City Fire Department, Salt Lake City, Utah, USA
1
2
Abstract
Introduction: Dispatcher-provided telephone pre-arrival instructions (PAIs) date
back over 3 decades in the United States of
America. In 1979, the Salt Lake City Fire
Department began providing Medical Priority Dispatch System™ (MPDS®) protocoldriven PAIs for every MPDS chief complaint
– including airway management, cardiopulmonary resuscitation (CPR), Heimlich
maneuver, and childbirth situations. Therefore, with 3 decades of experience with
scripted PAIs, Salt Lake City is a prime site
for studying public expectations of receiving
PAIs when calling 9-1-1. The authors hypothesized that the North American public has
strong expectations of receiving telephone
CPR and Heimlich maneuver PAIs and are
likely to accept transfer to phone-advice professionals when dispatchers determine that
their medical problem is non-emergent.
Objective: To assess public expectations
of receiving telephone PAIs from 9-1-1
Emergency Medical Dispatchers (EMDs), 3
decades after introduction.
Methods: The survey involved a random selection of Salt Lake City residents
in September 2007. The questionnaires
and response cards (in English language)
were mailed to a convenience sample of
2,000 respondents to complete. The survey
responses were presented and the expectations of receiving PAIs assessed. Evaluation
of the association between demographics and
PAI expectations was performed, adjusting
for PAI type. The difference between CPR
and Heimlich maneuver PAI expectations
was also assessed, along with willingness of
caller transfer to a phone-advice professional
when a medical problem is non-emergent.
Results: Two hundred and seventy
(270) survey questionnaires were completed and returned (10.4%) showing
ove ra l l , t h a t 8 8 . 7 % ( 9 5 % C I : 8 3 . 3 % ,
34
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92.8%) of citizen respondents expect
PAIs from EMDs. The expectation of
receiving PAIs was significantly associated with female callers (OR (95%CI):
3.05 (1.21, 7.65), p = 0.022). Citizens
age 15 to 45 years were significantly less
likely to accept transfer to a phone-advice
nurse than other age groups combined
(p = 0.033). Though not statistically significant, citizens age 60 to 75 years were
4 times more likely to expect to receive
CPR PAIs from EMDs, twice more likely
to expect to receive Heimlich maneuver
PAIs or accept transfer to a phone advice
nurse. Household income was not significantly associated with PAI expectations or
transfer to a phone-advice nurse.
Conclusions: The public has high expectations of receiving life-saving PAIs from
EMDs. Females have higher expectations of
receiving CPR or Heimlich maneuver advice.
In the future, with well constructed, scripted
telephone instructions in EMD protocols,
we expect similar public acceptance of a
wider range of enhanced telephone-directed
patient evaluations, advice, and care.
Keywords: Pre-Arrival Instructions
Expectation, Emergency Medical Dispatch
Protocol, Medical Priority Dispatch System,
Emergency Medical Service, Emergency
Medical Dispatcher, Cardiopulmonary
Resuscitation, Heimlich Maneuver, Nurse
Advice Transfer, Telephone Advice.
Introduction
The history of dispatcher-provided telephone pre-arrival instruction (PAIs) dates
back over 3 decades in the United States.
The first known recorded resuscitation-type
phone instructions occurred in Phoenix,
where an injured paramedic, assigned to the
dispatch center, began providing occasional
ad lib instructions for 9-1-1 calls in 1974.1
In 1979, the Salt Lake City Fire/Emergency
Medical Services Alarm Office began providing Medical Priority Dispatch System
(MPDS) protocol-driven instructions for
every one of the MPDS chief complaints –
including airway management, CPR, Heimlich maneuver, and childbirth situations.2
Cardiac ar rest (CA) is one of the
leading causes of mor tality in Nor th
America and the overall survival rate
for out-of-hospital CA falls below 5%. 3
Increased survival has been associated
with bystander cardiopulmonary resuscitation (CPR). 4 Several community training methods have been used in the past
to improve bystander CPR. 5-25 Lately, lack
of community interest and motivation
pose a great challenge, although dispatchassisted CPR PAIs have been shown to
enhance bystander CPR rates.26 For many
years, Emergency medical dispatchers
(EMDs) have also assisted 9-1-1 callers
through telephone PAIs to effectively perform the Heimlich maneuver procedure.
This procedure, which involves abdominal thrusts was introduced in 1974 to save
lives of choking victims. 27
Public awareness and expectation of
receiving telephone-directed help, virtually
non-existent in the 1970s, began to grow in
the 1980s, and got sporadic regional awareness whenever a dramatic “emergency dispatcher saves a life” story was covered in the
news, radio, or television media.
In 1989, the Columbia Broadcasting
System (CBS) primetime television show
“RESCUE 911”28 was broadcast to millions
of Americans and Canadians, as well as to
citizens of 45 other countries, highlighting
the importance of the dispatch role of 9-1-1
service in every case portrayed in the 7-year
series. It remained in re-runs until 2005.
By 1990, it is estimated that hundreds
of centers in North America had some type
of protocol and/or training to provide such
telephone help. Whether they actually did or
not, and to what extent, remains unknown.
The extent of the public’s expectations of
receiving PAIs has only been the subject of
one study to date, in the Rochester, New York
area in 2000. Billittier et al.29 reported in
their study that knowing how to “dial 9-1-1
or 9-11” numbers significantly predicted the
lay public’s expectation of receiving PAIs
and that the public expected to receive PAIs
when they make such calls. They recorded an
average expectation rate of receiving advice
of 76% (95% CI: 73%, 80%) for all of the four
following medical conditions: 88% (95% CI:
85%, 90%) for choking, 87% (95% CI: 84%,
90%) for not breathing, 89% (95% CI: 86%,
91%) for bleeding, and 88% (95% CI: 86%,
91%) for childbirth.
In several states in Australia, countrywide in the UK, and in a few Emergency
Medical Systems (EMS) in North America,
EMDs utilize special protocols to transfer the
caller to EMS-approved healthcare entities,
once it has been determined that a patient’s
medical problem is not urgent and non-life
threatening. This transfer is based on medically approved pre-set, low acuity codes. The
call may be transferred to a phone-advice
nurse or other professional non-emergency
care source, such as Rape Crisis Centers or
Mental Health Help Lines for further evaluation and care or, in some cases, return to
the 9-1-1/EMS system for a mobile response.
This method significantly optimizes the utilization of dispatch resources.30-32
The authors hypothesized that the North
American public today has strong expectations of
receiving telephone CPR and Heimlich maneuver
pre-arrival instructions when they call 9-1-1 and
are also likely to accept transfer to phone-advice
professionals when EMDs determine that their
problem is not a medical emergency.
Methods
Salt Lake City, the birthplace of scripted
PAIs, is a prime example for studying public expectations of receiving PAIs. The study
was based on a mail-in survey conducted in
September 2007. In collaboration with the
Salt Lake City Fire Department, a citizen
survey questionnaire, instruction sheet, and
a postage-paid return response card (Figure
1) were constructed and printed in English.
Using the 2007 Salt Lake City phone book,
a participant selection was accomplished
by selecting every 5th name on each 5th page
of the book. These addresses were vetted
against a zip code map from the phone
book while comparing each with a digital
internet source33 to identify actual resident
areas within the city limits. All non-Salt
Lake City addresses were excluded from
the study sample. Survey questionnaires
were then sent out via first class US mail in
September 2007, to a convenience sample of
2,000 residents in Salt Lake City. There was
no formal consenting process, but consent
was assumed with the return of a completed
survey response card. The respondents were
requested to anonymously complete and
mail back their responses in the pre-paid
survey response envelopes.
Figure 1: National Academy of Emergency Dispatch/Salt Lake City Fire Department 9-1-1 questionnaire and answer card – 2007.
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Data Analysis
A web interface with a report generation component was created for data
entry. Initial descriptive (frequencies and
averages) statistics were generated upon
the completion of data entry. Intercooled
STATA for Windows® software (STATA
Statistical Software: Release 9 ©2007,
StataCorp, College Station, TX, USA) was
used for detailed data analysis.
Odds ratio (OR) with 95% confidence
intervals (CIs) and p-values were used to
assess associations between study groups,
at 0.05 significance level. The study
responses were analyzed, while categorizing by the citizen’s gender, age, and type
of PAI. The next analyses evaluated association between the citizen’s expectations
of receiving PAIs and their age, and gender. The association between gender, age,
household income, and PAIs expectation
was also evaluated, while adjusting for the
type of PAI. Finally, the difference between
the level of the public’s PAIs expectation
to receive CPR and Heimlich maneuver
instructions was assessed, as well as the
level of acceptance of transfer to a nurse
when their problem was non-emergent.
Results
Two-hundred and seven (10.4%) citizens participated in the survey. Based on
this sample, Salt Lake City citizens expect
to receive PAIs from EMDs to help them in
the life-threatening emergencies of cardiac
Measure
Age (years)
Gender
n
Continuous
Pre-Arrival Instructions (PAIs)
Yes: n (%)
22 (56.6±18.3)
15- 45
56
50 (89.3)
6 (10.7)
45- 60
55
47 (85.5)
8 (14.5)
60- 75
43
41 (95.3)
2 (4.7)
>75
38
32 (84.2)
6 (15.8)
108
101 (93.5)
7 (6.5)
86
71 (82.6)
15 (17.4)
Female
‡
0.901
0.335
§
0.022
*Two-sided Fisher’s Exact test p-value, unless otherwise stated. †n(mean ± standard deviation). ‡Twosided Student t-test p-value for testing the difference in the mean age (with unequal variance) between the
two levels of the citizen’s expectation to receive PAIs from EMDs. The PAIs exclude transfers to advice
nurse for non-emergent cases. §Trend analysis p-value (Fisher’s Exact). Female citizens were three times
more likely to expect to receive PAIs from EMDs than males (OR (95%CI): 3.05 (1.21, 7.65), p = 0.022).
Table 2: Association between public expectation of receiving PAIs from EMDs by age and gender.
arrest and choking (Table 1), confirmed by
an average expectation rate of 88.7% (95%CI:
83.3%, 92.8%). They were also willing to
accept transfer to phone-advice professionals
when EMDs determined that their medical
problem was non-emergent (88.5% (95%CI:
82.8%, 92.8%)).
The level of public expectation of receiving
PAIs from EMDs was significantly associated
with female callers (Table 2). However, age was
not significantly associated with the likelihood
of expecting to receive PAIs from EMDs.
Citizens age 15 to 45 years were the
only group that was significantly less
likely than all the other age groups combined to accept to be transferred to a
Responses
Gender
Male
Female
Age (years)
n (%)
91 (44.2)
115 (5 5.8)
15- 45
59 (28.9)
45- 60
56 (27.4)
60- 75
45 (22.1)
>75
44 (21.6)
If someone you know collapsed in front of you and their heart
had stopped, would you expect the 9-1-1 dispatcher to tell you
how to do CPR to help them?
Yes
If someone you know was choking to death in front of you,
would you expect the 9-1-1 dispatcher to tell you how to do
the Heimlich maneuver to help them?
Yes
175 (86.2)
No
17 (8.4)
Don’t know
11 (5.4)
If the 9-1-1 dispatcher determined that your medical
problem was not an emergency, and recommended transferring you to a phone advice nurse for further evaluation and
care, would that be okay with you?
Yes
154 (75.5)
No
20 (9.8)
CPR = Cardiopulmonary resuscitation
Table 1: Profile of citizen responses categorized by gender, age, and type of PAI.
| emergencydispatch.org
†
170 (57.1±18.2)
Measure
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†
192
Male
Survey Questions
36
p*
No: n (%)
No
Don’t know
Don’t know
166 (81.4 )
16 (7.8)
22 (10.8)
30 (14.7)
phone-advice professional (p = 0.033)
(Table 3). Though not statistically significant, citizens age 60 to 75 years were four
times more likely to expect to receive PAIs
from EMDs to help them perform CPR,
and twice as likely to expect to receive
PAIs from EMDs to either help them do
the Heimlich maneuver or to accept transfer to phone-advice professionals for nonemergent situations. In addition, female
citizens were three times more likely
than males to expect to receive PAIs from
EMDs to help them do CPR or the Heimlich maneuver, but were less likely (odds
reduced by about 46%) to accept transfer
to phone-advice professionals. All the differences found, however, were not statistically significant.
There was no significant difference in
PAI expectation for CPR between citizens
living in households with incomes higher
than the overall median income ($41,864)
than for those who earned less. However,
citizens who had higher incomes than the
overall median income had slightly higher
odds of expecting PAIs for CPR. A similar
pattern was observed in the citizens who
accepted transfers to phone-advice professionals. On the other hand, although not
a statistically significant difference, those
living in households with income less than
the overall income had a high expectation of
receiving PAIs from EMDs to help them do
the Heimlich maneuver.
There was no significant difference in the
expectation of receiving CPR and Heimlich
maneuver PAIs (91.2% each) (Table 4).
Table 4: Comparison of public expectations of receiving CPR or Heimlich Maneuver PAIs from EMDs.
Cardiopulmonary Resuscitation (CPR)
Measure
n*
Male
Age (years)
Income#
PAIs:
n (%)
Heimlich Maneuver
†
OR (95%CI)
p
‡
n*
Phone Advice Nurse
PAIs:
n (%)
†
OR (95%CI)
p
‡
n*
Transfer:
n (%)
†
OR (95%CI)
p
‡
80
69(86.3)
85
74 (87.1)
74
68 (91.9)
Female
102
97 (95.1)
3.09 (1.07, 8.91)
0.062
107
101 (94.4)
2.50 (0.91, 6.82)
0.123
100
86 (86.0)
0.54 (0.20, 1.44)
0.336
15-45
45-60
60-75
>75
56
54
38
33
52 (92.9
48 (88.9)
37 (97.4)
28 (84.9)
1.38 (0.45, 4.25)
0.68 (0.24, 1.91)
4.34 (0.70, § )
0.45 (0.15, 1.34)
0.779
0.568
0.199
0.176
55
55
43
37
50 (90.9)
48 (87.3)
41 (95.4)
34 (91.9)
0.98 (0.34, 2.79)
0.55 (0.20, 1.48)
2.33 (0.57, §)
1.14 (0.33, 3.90)
1.000
0.268
0.369
1.000
49
50
38
36
39 (79.6)
46 (92.0)
35 (92.1)
33 (91.7)
0.34 (0.14, 0.86)
1.72 (0.57, 5.15)
1.68 (0.49, 5.66)
1.56 (0.46, 5.25)
0.033
0.439
0.571
0.770
1.04 (0.30, 3.60)
1.000
37
33 (89.2)
0.76 (0.24, 2.35)
0.747
35
32 (91.4)
1.50 (0.44, 5.06)
0.768
154
141 (91.6)
138
121 (87.7)
High
35
32 (91.4)
Low
146
133 (91.1)
PAIs = Pre-Arrival Instructions from EMDs. *Excludes all the “I don’t know/not sure” responses (CPR: n=22, Heimlich maneuver: n=11, Phone advice
nurse: n=30). †Odds ratio and 95% confidence interval. ‡Two-sided Fisher’s Exact test p-value. §The upper limit of 95%CI was undeterminable. #Median
household income (median; minimum-maximum: $41,864; $31,868 – $73,322); Low: household income is less than or equal to the overall median, High:
household income is greater than the overall median). Source: 2005-2007 USA Census Bureau (http://factfinder.census.gov/home/saff/main.html?_lang=en).
Table 3: Association between public expectation of receiving PAIs from EMDs for gender, age, and household income.
Discussion
After 3 decades of PAI availability locally
and exposure nationally, over 91% of Salt
Lake City citizens responding to this survey
expect to receive this elevated level of telephone help. A significant public expectation
obviously exists, therefore a public safety
standard of care and practice is no longer
disputable here.
This study has further examined several variations within the social parameters
affecting a citizens’ degree of expectation
of receiving PAIs from EMDs. Such expectations differ significantly by gender, and
slightly by age and median household
income. Females had a significantly higher
expectation of receiving CPR or Heimlich
maneuver PAIs from EMDs, than their male
counterparts. However, males with problems
not deemed by the EMD to be an emergency
were more likely to accept non-emergency
transfer to phone-advice professionals than
females. The responding citizens under 45
years of age and those over 60 had the highest
expectation of receiving PAIs.
Nearly 90% of all citizens reported that,
if their problem was determined not to be
urgent, they were “okay” with being transferred to phone-advice professionals for further advice. Within this group, citizens age
15 to 45 years were significantly less likely
(odds reduced by 66%) to accept a transfer
to phone-advice professionals when the 9-1-1
EMD determined that their medical problem was not an emergency. Although not
Citizen’s medical problem
Cardiopulmonary resuscitation(CPR)
Heimlich maneuver
statistically significant, citizens age 60 to 75
years were four times more likely to expect to
receive CPR instructions and twice as likely
to expect Heimlich maneuver choking relief
instructions. Similarly, they were nearly
twice as likely to accept transfer to phoneadvice professionals.
Households with an income higher
than Salt Lake City’s median level had high
expectations of receiving CPR instructions
and were likely to accept transfer to phoneadvice professionals. On the other hand, the
higher income households were less likely
to expect Heimlich maneuver instructions
(odds reduced by 24%). The differences in
both these instances, however, were not statistically significant, but certainly of interest.
Overall, there was no significant difference
between the expectation of receiving CPR
and Heimlich maneuver instructions,
although both were quite high (91.2%).
The clinical effects of these levels of
public expectation regarding PAIs are several and potentially wide reaching. A new
standard of public safety telephone care and
practice now clearly exists where it did not
(and could not) 3 decades ago. These public
expectations now likely include other aspects
of 9-1-1 intervention in areas related to
advice and direction by EMDs. Such aspects
include the acceptance of improved interrogation (questioning); the addition of more
intricate instructions, such as the recent
advent of phone instructions for high-risk
childbirth situations (including breech birth,
n*
PAIs: n (%)
OR (95%CI)†
p‡
182
192
166 (91.21)
175 (91.15)
1.01 (0.50, 2.04)
1.000
PAIs = Pre-Arrival Instructions from EMDs. *Excludes all the “I don’t know/not sure” responses (CPR:
n = 22 and Heimlich maneuver: n = 11). †Odds ratio and 95% confidence interval. ‡Two-sided Fisher’s
Exact test p-value.
Table 4: Profile of citizen responses categorized by gender, age, and type of PAI.
shoulder dystocia, and cord presentation);
as well as new phone procedures for stroke
identification and agonal breathing detection.34, 35 We believe that public acceptance
of new and more complicated instructions
can now be reasonably predicted.
In our opinion, the most unexpected
result of the study was the high acceptance
of being transferred to phone-advice professionals when the problem was determined
by the EMD as not being an emergency. That
this expectation was reported by about 90%
of respondents was most surprising, however,
in today’s healthcare climate, it is not totally
unexpected.
These findings support and build upon
the earlier findings of Billittier et al., 29
reported 10 years ago, in a geographic area
with significantly less history of receiving
9-1-1 telephone instructions.
Other concerns that could potentially
affect public expectations (for better or
for worse) include publicized governmental requirements, dispatcher liability, and
PAI-related lawsuits. However, the public
is likely not aware of the existence of statutes or EMS/EMD rules and regulations
that establish a governmental standard of
care for EMD training and protocol use,
including PAI provision, in their area.
The first process of this kind, started
in Utah in 1982, resulted in State EMS
regulations that required 9-1-1 centers to
have an EMD protocol in place, including
private ambulance companies or any service receiving emergency calls from the
public. The mandating of an EMD process, as opposed to EMS and paramedic
laws, rules, and regulations, has only very
slowly spread within the US. According to the International Academies of
Emergency Dispatch ® (IAED TM ) statistics, only 21 states have any statewide
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37
mandated EMD requirements. 36 Even
this does not insure that PAIs are “always
given when possible and appropriate” or
given correctly. 37 The fact that the public has such a high expectation of receiving PAIs, establishes, in-and-of-itself, a
clear standard of care. We also know that
about 3,100 centers in the U.S. have, at
one point, adopted these PAIs using some
version of the MPDS. 38 Model EMD Legislation and Model EMD Regulations and
Standards documents 36 have been published by the IAED, and have been used
in several states and jurisdictions to set
governmentally required standards of
EMD care and practice.
Contrary to what is often assumed,
there has never, to our knowledge, been
an issue of legal liability in any interaction with the public during a 9-1-1 call
in terms of the public’s acceptance of following dispatcher-given PAIs. Historically,
this assumption often came from within
the reluctant-to-change public safety
community itself, at times supported
by ill-informed city or county attorneys.
Rather it is the failure to provide PAIs,
and not the public’s willingness to follow
dispatcher-given PAIs that becomes a legal
liability. Generally, when the lay public or
elected officials are told that their community is not providing PAIs, they comment, amazed, “You mean we are not
doing this already?” Frequently, the public
is exposed to cases of failure to provide
PAIs – for which the unofficial legal term
is “dispatcher abandonment.” Public outrage can be significant in communities
bearing the brunt of high profile cases
where failure to provide PAIs seems so
blatant. 39 Indeed, one mother started an
organization called Parents Against Negligent Dispatch Agencies (P.A.N.D.A.),
after losing a twin daughter in a backyard
drowning incident (the dispatch center
provided no PAIs having been told by
local authorities not to give telephone
instructions for fear of liability). 40 The
issue of receiving PAIs becomes little
more than common sense once the public is exposed to the idea. To date, there
has never been a successful lawsuit that
we are aware of, regarding the worldwide
provision of medically approved PAIs. On
the contrary, each legal case in this arena
is related to the failure to advise. Such
absence of any reported, publicly known
error or legal case regarding the provision
of telephone instructions by EMDs could
38
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| emergencydispatch.org
be assumed to be a contributing factor to
the public’s acceptance and the public
safety community’s support and expansion of telephone-provided care. Future
investigation should concentrate on other
areas of scripted telephone-provided care
and advice, as well as how to best provide
these verbal services in the proper format,
context, and linguistic presentation. As
a recent chief of the Salt Lake City Fire
Department stated in a written order,
“Failure to provide pre-arrival instructions is not an option at City Fire.”
Study limitations
Although this survey was conducted in
Salt Lake City, which has used MPDS for
over 3 decades, there is no guarantee that
the same results could be applied to other
communities. In addition, the sample size
may have been too small to make valid conclusions. However, Salt Lake City should provide results consistent with other cities that
have had PAIs consistently given by EMDs
for a period of time significant enough to
create similar expectations. Future studies in
other locations are recommended to validate
these findings. Lastly, a small but important
number of citizens were still unsure of their
expectations of receiving PAIs from 9-1-1
EMDs (CPR: 10.8%; Heimlich maneuver:
5.4%; and transfer to phone-advice professionals: 14.7%). While we believe citizens’
expectations of receiving PAIs from EMDs
reflect widespread current reality, interpretations of these results should be done with
some caution.
Conclusion
The public in Salt Lake City clearly
expects to receive PAIs from EMDs when
they call 9-1-1 and the level of expectations
is significantly associated with female gender, but not with age. Females have higher
expectation than males of receiving CPR
or Heimlich instructions. Males are slightly
more likely to accept transfer to phone-advice
professionals when EMDs determined their
medical problem to be “not an emergency”.
Citizens in households with higher median
income have a moderate level (i.e., odds
ratio slightly more than 1.0) of expectation
of receiving CPR PAIs, along with accepting transfer to phone-advice professionals
for non-emergent medical conditions. In
the future, with well constructed, scripted
telephone instructions in EMD protocols,
we can expect public acceptance of wider
ranging and more comprehensive forms
of telephone-directed patient evaluations,
advice, and care.
Acknowledgments
We would like to acknowledge the determination and help of Lindsay Palmer, Natalie
Baird, Jillian Cowley, and Joel Hales at the Client Services Division and Internal Software
Applications Development Department of
Priority Dispatch Corp. (PDC), for addressing, mailing, receiving, sorting, and performing data entry of all the survey responses. We
thank Holly Mills at the Research & Standards
Division of PDC for her input on the graphics
for the figures presented in this manuscript.
We also gratefully acknowledge the Salt Lake
City Fire Department EMS Division and its
dually (Medical and Fire) Accredited Center of
Excellence Communications Center for their
30 years of support and effective dispatching,
relevant advice, and help with this study.
Source of support: No specific funding was
provided outside of the employment relationships noted in the competing interests
section below.
Contributors: AC, PS, JC and SF conceived the study design. All the authors substantially participated in the implementation
of the study and the acquisition of the data.
CO validated the data and performed data
analysis and interpretation. All the authors
drafted and critically revised the article for
important intellectual content, and finally
approved of this version of the manuscript
for submission to The Journal.
Conflict of Interest: JC is CEO and Medical
Director of the Research and Standards Division of Priority Dispatch Corp. and member
of the Council of Standards, and Board of
Trustees of the International Academies of
Emergency Dispatch. He is the inventor of
the Medical Priority Dispatch Protocol and
Quality Assurance System studied herein.
Ethical approval: The study was approved
by the International Academy of Emergency
Dispatch (IAED)’s Institutional Review
Board (United State Department of Health
and Human Services registration number:
IRB00006450). g
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