Sentinel Failures

Whenever a new client is interested in Telemedicine911, we ask them why.  We get the generic answers of “higher quality” and “better care,” but we also may learn of a bad patient case which prompted them to search for a better solution.  Please find  below common failures and examples of poor outcomes.  Hopefully this section will also prompt creation of better protocols before bad patient cases happen to you.

Failure Type 1: List of EMS and 9-1-1 Administrative Phone Numbers and Fax

A large tele-primary care program created a database of emergency phone numbers covering all the addresses of their patients. Some were 9-1-1 administrative 10-digit numbers and some were direct ambulance company numbers Providers and managers were given the excel sheet and directed to ask the patient their current address and cal the corresponding number to the city or county. Here are some things that happened.

  1. When the doctor called the 9-1-1 admen number, the doctor’s address showed up on the screens. Some dispatches sent first responders to the address they receive as per 9-1-1 policy.
  2. At times they caled these numbers and were placed on on-hold while dispatchers handled real 9-1-1 dialed emergencies
  3. At times they called the 9-1-1 dispatch and they no longer cover the area. 0-2% change, close, or open every 90 days.
  4. At times the ambulance company was called and states a 1 hour ‘transport time.’ Local ambulances are not always stationed with an average 8-12 min response time to all locations. 9-1-1 shuffles vendors to ensure coverage
  5. At times an ambulance number is called for a suicidal agitated patient. and police do not arrive with EMTs.
  6. NJ 911 The current NENA PSAP Directory contains information that was not provided by our office. Many New Jersey PSAPiurisdictions and contact numbers are not correct. None of the network transfer numbers appear in the directory as they can be dialed from anywhere and will not provide ANI/ALI information.’

 

Failure Type 2: Call the doctor’s local 9-1-1 and request transfer

For emergencies a large national telehealth company had their doctors call 9-1-1 from their local phone and request the call be transferred to the 9-1-1 dispatch servicing the address where the patient was located. Here are some things that happened.

  1. When the patient address was in a different state. the dispatcher did not have the technology to transfer.
  2. They had a patient in LA county when the doctor was located in Ventura county (2 hour drive). The doctor’s call was first transferred to the wrong dispatch center, then transferred again and again, but did finally reach the location. The process to 25 minutes.
  3. The doctor was rushing the emergency handoff. The doctor’s address (not the patient’s address) shows up on the 911 screens. The dispatcher did not understand the request. said they could handle the case, and sent a unit to the doctor’s address on the screen.
  4. A doctor called 9-1-1 and said she was calling on behalf of a patient in another area. She needed to be transferred. The police officer handling dispatch asked ‘Are you the person who is having an emergency?’ ‘Where are you located now?” The officer stated it is not their policy to transfer or send units to people who did not call 9-1-1 themselves. The officer instructed the doctor to have the patient call 9-1-1 themselves.

United States Transfer Testing and Data

Methods: ……

Data Table: ……

Hazard Analysis: ……

Discussion: ……

 

Failure Type 3: Intermediate Helper Staff

This method employees central staff to help providers coordinate telemedicine emergencies. Providers are given a phone number to call when there is an emergency for a staff member to help them. Staff members range from administrators with knowledge of emergency services to outsourced call centers who aid in all telehealth operations. Some of the reported failures include;

  1. Doctors have reported wait times over 15 minutes for staff to pick up and help them. Even if a call center is used as a backup. doctors should test pickup times for when they call.
  2. Handoff content changes 10-20% with each additional intermediate. This is similar to playing the Broken Telephone Game. When the doctor hands off the case to the administrator staff, who hands off the case to 911 dispatchers and EMS, information is left out or changed.

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