Dying on hold: How new software is creating a logjam at Portland’s 911

When Candace Iron Hawk got home from her daughter’s softball game on April 7, her husband was face down on their bedroom floor unconscious. She and her daughter Morgan called 911 multiple times. They were placed on hold, hung up, tried again. As the minutes passed without an answer, Iron Hawk grew increasingly frantic not knowing what to do about her husband who was already turning blue.

“First it just rang and rang and rang and rang,” Iron Hawk told OPB. “And then an automated system came on and said, ‘Please hold, we’ll get to you as soon as we can, please don’t hang up,’ or something to that effect.”

Iron Hawk said while they waited on hold, the line would start ringing as if someone was about to answer, then they’d go back to being on hold. They hung up multiple times and called back hoping to get through.

“We went through that at least five times,” Iron Hawk said. “We went at that for about 15 minutes.”

The Portland Bureau of Emergency Communication, the city agency in charge of emergency and non-emergency dispatch in Portland and several smaller suburban cities that contract with the agency, disputes Iron Hawk’s characterization of how long she waited to talk to someone. The agency provided a record stating Iron Hawk spent a total of four minutes and 47 seconds on hold across the calls.

Once she was through to a dispatcher, they asked if Iron Hawk’s husband was breathing.

“I can’t tell. I don’t think so, he looks pretty blue,” Iron Hawk responded.

After asking a few more questions to assess Iron Hawk’s unconscious husband, firefighters and paramedics were sent to her home. Then the dispatcher guided Iron Hawk through administering CPR.

“It was horrifying,” Iron Hawk said. “Sometimes it’s crucial, you only have a minute or two and you need help. If they’re not there to help you…that’s all damage if not death.”

In a heart attack, blood is blocked from reaching part of the heart. With every passing minute, more cells die. Restoring blood flow is of paramount importance, hence the saying in emergency medicine that time is muscle.

And in recent months, time has been wreaking havoc at the Bureau of Emergency Communications.

On May 18, 2021, while still managing the fallout from the pandemic, staffing shortages and call volume that had recently started climbing rapidly, the Bureau of Emergency Communications transitioned to new, standardized scripts to dispatch fire and medical calls, known as ProQA. Immediately following the transition, hold times surged.

The city says the $2.3 million software will reduce Portland’s liability for emergency calls and increase efficiency by making sure the right responders are being sent to emergencies. But an OPB investigation reveals ProQA was pushed through over loud objections from dispatchers, who say the software has gummed up the 911 system, causing longer hold times and putting lives in danger.

“Admin will say [the increased wait times are] because an increase in calls,” one dispatcher wrote to Commissioner Mingus Mapps, the city commissioner who oversees BOEC, ahead of a January town hall Mapps held with dispatchers. “This is incorrect. They are covering up the fact that all medical/fire calls now take significantly longer to triage.”

OPB has reviewed nearly 9,000 pages of documents and emails about the implementation of ProQA and conducted interviews with 16 people familiar with the software, including six current and former dispatchers whose names aren’t being used to protect them from repercussions at work.

What that investigation shows is the month after ProQA launched in Portland, the number of people who waited five minutes or more for a 911 dispatcher to answer their call shot up almost 500% compared to the month before the program started. Nine months after implementation, it was up more than 800%. Dispatchers repeatedly told leadership at BOEC that their work was being hampered.

In response, employees have faced pressure to strictly follow the ProQA protocols, and some say their stress on the job has risen. Others have left BOEC.

Despite internally acknowledging the new software would impact performance, managers and city leaders have been publicly silent about the transition and its role in the agency’s skyrocketing hold times.

Priority dispatching

The Utah-based company that owns ProQA, Priority Dispatch, was founded by Dr. Jeffrey Clawson, an emergency medical technician and 911 dispatcher turned doctor who, in the 1970s, created a set of cards alphabetized by medical complaint, each containing a series of pertinent questions. Those cards would go on to become a system that would form the backbone of ProQA.

Today, Priority Dispatch says its software is used by 3,700 agencies across the world, and that Clawson’s standardized questions ensure the right people with the right equipment are responding during emergencies.

By sticking to the questions and scripts, advocates say dispatchers can work their way through even the most complicated calls to efficiently determine the appropriate response. The questions function like a choose your own adventure story, where the answer to each question determines the next step in the process. Used properly, advocates say emergency services are streamlined so first responders aren’t being over dispatched to calls where they aren’t needed.

Whereas in the past, a fire engine and ambulance with two paramedics may have responded with lights and sirens to something as potentially benign as a bloody nose, ProQA should help dispatchers determine if they can leave the fire engine off the call and send an ambulance with the flow of traffic instead.

“Before ProQA, they would just be responding with lights and sirens on everything,” BOEC director Bob Cozzie said. “What ProQA does is helps us define exactly what type of response needs to go to a particular call type. And when it’s a low priority call, they don’t need to have lights and sirens.”

Some of those changes have taken effect under ProQA, according to Portland Fire & Rescue records. In October, the fire bureau stopped responding to some sick person calls, leaving them in most cases to American Medical Response, a private ambulance company. And the following month, Multnomah County stopped responding to some fall-related calls that were older than six hours and were not presenting critical symptoms.

But according to the Portland Firefighters Association, the new software may actually be increasing their workload.

“It would seem like this program has generated a lot more call volume for us,” said Isaac McLennan, the union president. “What it feels like, from a very non-scientific way, is that we’re going on a lot of calls that don’t require a four-person fire engine…where a two-person ambulance would be sufficient to solve the problem.”

Cozzie said ProQA should also help cut down on so-called “wake effect” accidents, where the disruption of an emergency vehicle responding with lights and sirens causes car accidents. He did not know if ProQA had, in fact, reduced those accidents.

When seconds count: Emergency police call times

Source: Portland Bureau of Emergency Communications

Before using ProQA, dispatchers used a triage guide that was less rigid but got first responders on the road much faster, according to dispatchers and data provided by BOEC. It gave dispatchers more flexibility to make critical decisions in emergencies where seconds and minutes matter.

After Mapps received critical feedback from dispatchers, BOEC’s quality assurance manager, Ryan DesJardins, assured him the agency was seeing improvements in the time it takes to get calls dispatched.

“The amount of time it takes from when a dispatcher answers the call to when it is sent to dispatch decreased in 2021 compared to the four previous years,” he wrote in a note to Mapps’ chief of staff.

That appears to contradict data BOEC provided to OPB showing those times actually increased by as much as 20% in 2021, the longest it has taken since at least 2018. As a comparison, police dispatch in Portland does not use the ProQA system, and the time it takes to dispatch those calls only increased by 4.2% in the same time period.

When seconds count: Emergency medical call times

Source: Portland Bureau of Emergency Communications

Dispatchers told OPB the reason for the downward trend for medical and fire call times is ProQA’s rigid scripts, a feature critics say not only forces dispatchers to ask numerous irrelevant questions before sending fire or medical care to someone in a moment of crisis, but it also makes every call last longer.

“Many of us are concerned you’re being presented an inaccurate depiction of ProQA’s ‘success’ at BOEC,” another dispatcher wrote to Mapps in January. “It now takes us longer to set up calls and requires we stay on the line longer.”

Asked if Mapps still had confidence in BOEC leadership, Mapps said the past two years have been incredibly challenging at the agency.

“We asked dispatchers to implement new software during an unforeseen pandemic, so I get the frustration,” Mapps told OPB. “I have faith that BOEC leadership is giving me accurate information about these challenges.”

On an unusually slow mid-April day at Portland’s 911 call center, Kristina Gore took a call from a woman in respiratory distress. It took her about 40 seconds to listen to the caller’s initial description of what was happening, get her address and basic demographics before the ProQA screen popped up prompting additional questions.

“Is your breathing normal for you?” she asked. “Can you explain why it’s not normal? Are you clammy or having cold sweats?”

Gore made her way through more questions, asking about the woman’s medical history and any medications she had taken in the previous 24 hours.

When seconds count: Emergency fire call times

Source: Portland Bureau of Emergency Communications

One minute and 45 seconds elapsed before an ambulance was sent to the woman’s house. Gore then spent another minute and a half on the phone with the caller telling her to unlock her door, put any animals in a different room then asked additional questions like her full name, phone number and if she had COVID symptoms.

“That was a super typical, run-of-the-mill ProQA call,” Gore explained after hanging up.

Prior to the new protocols, she explained, “from the time that we heard someone’s initial complaint or whatever their symptoms were, to entering a code and sending it in the computer was much faster.”

Gore, who has been a dispatcher for 19 years and is being promoted to supervisor, said while it felt like a long time to dispatch that call, ProQA worked in this case. She said she was able to ask regimented questions to learn exactly what she and the medics needed to know in an acceptable time frame.

“I don’t find it particularly stubborn but this was a textbook call,” she said. “Sometimes when it’s a more difficult caller, I think that’s where the situation with ProQA feels a little more cumbersome.”

But the additional time Gore spent with this caller can have ripple effects. If every call takes longer, even if it’s just a minute or two, dispatchers aren’t answering incoming calls and a backlog builds.

Skyrocketing hold times

Fairview Mayor Brian Cooper sometimes personally responds to 911 and non-emergency calls. He said he’s driven to disputes between neighbors, calls about drug deals happening in the open and suspicious people lurking in neighborhoods at night.

Cooper, who has been in Fairview city government for a decade, said answering 911 calls is a recent, unofficial addition to his job description. When hold times creep high enough — lately, that can be well above 30 minutes on the non-emergency line — constituents will call Cooper’s cellphone and ask for help directly.

“I would be standing out there in the middle of the street, trying to get a hold of somebody,” Cooper said. “I now have the cellphone numbers of all duty officers that operate within Fairview. So I am personally bypassing the BOEC system.”

In September 2021, Cooper, along with the mayors of Gresham, Maywood Park, Wood Village and Troutdale, as well as Multnomah County Sheriff Mike Reese and two Multnomah County commissioners sent a letter to Portland leadership decrying extensive 911 call wait times.

Waiting for 911

Source: Portland Bureau of Emergency Communications

Unincorporated Multnomah County and the cities in east county depend on the Bureau of Emergency Communications and the City of Portland to dispatch first responders. The letter expressed alarm that the average time it took to get through to the emergency line had increased from 13 seconds in June 2019, to 56 seconds in June 2021.

“It was particularly troubling to hear in a presentation to Portland City Council on September 16, that this past summer, during peak call times, the wait time for emergency calls stretched to 4-5 minutes,” the letter stated.” Wait times for non-emergency calls increased from one minute thirty seconds to over ten minutes, despite the fact that BOEC received fewer non-emergency calls than in any of the previous three years.”

Two months later, Cozzie gave a presentation to the Fairview City Council where he acknowledged a learning curve associated with ProQA is one of a number of factors leading to longer hold times.

Cozzie told the council his expectation is that calls are answered immediately. He pointed to a national standard that 95% of 911 calls should be answered within 20 seconds or about six rings.

BOEC nearly met the national standard in March 2020 when dispatchers picked up 87% of 911 calls within 20 seconds. The agency has moved further away from meeting those goals in the year since implementing ProQA. In March 2022, the last month for which there is data, only 40% of 911 calls were answered within 20 seconds.

An ultimatum

According to multiple city officials and records obtained by OPB, the decision to adopt ProQA came after Multnomah County Medical Services, the agency which regulates emergency medical response in the county, forced Portland’s hand.

“Multnomah County Emergency Medical Services gave the City and BOEC an ultimatum to implement ProQA for medical services,” city attorneys wrote in response to questions submitted by the Portland police and firefighter unions in May 2020.

City attorneys explained that the county had threatened to remove medical dispatching from BOEC and contract with American Medical Response if they did not adopt ProQA, a move the city warned would have negative impacts.

Lisa St. Helen, BOEC’s operations manager, also said the transition came after Multnomah County threatened to pull medical dispatching from the agency.

Multnomah County officials disagree. County spokesperson Julie Sullivan-Springhetti told OPB that no one was given an ultimatum. Rather, she said, 911 medical triage was identified five years ago as a key area of improvement during a review of the county’s ambulance service.

County officials defended ProQA for many of the same reasons as BOEC leadership, but also praised the software’s strong audit trail. Sullivan-Springhetti said data so far shows Portland dispatchers are performing as well or better than dispatchers at other agencies using the same software. The statement did, however, acknowledge that the software is not without its challenges.

“As in other systems, less urgent calls can and do take more time to process and dispatch,” Sullivan-Springhetti said.

Whatever the county’s role in pushing ProQA, adoption has been led and supported by BOEC management and commissioners Jo Ann Hardesty — who formerly oversaw BOEC — and Mingus Mapps, the current commissioner overseeing the bureau.

Mapps, who took over BOEC earlier that year, told dispatchers this January that he is aware of the challenges facing the bureau.

“If there is one lesson here, it’s that, be very cautious about reorganizing your systems and your software in the midst of a surge on demand for your services,” Mapps told the group gathered on Zoom. “I know some are still skeptical about the software, skeptical of the value-added here. I think I’m convinced that this is a direction we need to go in.”

This week, Mapps again stood by ProQA, pointing out fire and medical calls make up 20% of 911 call volume. So far, in 2022, fire and medical calls make up 24.4% of 911 calls.

“The new ProQA system demonstrates positive results for cardiac arrest calls, enables call-takers to offer more standardized patient care, and ensures that BOEC only dispatches lights and sirens when absolutely necessary,” Mapps told OPB in an email.

The protocols may slow 911 call times, but for city officials concerned about legal risk, they have one massive benefit: liability protection.

According to its website, the International Academy of Emergency Dispatch, the industry organization that sets national dispatch standards and accredits dispatch agencies, requires agencies to adopt ProQA to become accredited. If that happens, the academy will provide “assistance with litigation and liability management.” Clawson, the Priority Dispatch founder and CEO, is also the founder and CEO of the IAED. The two organizations are headquartered in the same Salt Lake City building.

Priority Dispatch president Brain Dale said the conflict of interest issue has been raised in the past.

“The academy is overseen by the board of trustees. Dr. Clawson is certainly involved,” Dale said. “I don’t know how that would be settled, but I think that the Academy and Priority Dispatch both have done a lot of good in the communities that we work in.”

Dispatchers say that liability protection is coming at too high a cost for the agency and the Multnomah County residents who rely on it.

“The part about ‘helping people’ seems to have been set aside for corporate litigation fears,” one dispatcher wrote to Mapps in January.

In closing one liability gap, the city may be creating a new one. Iron Hawk, who waited on hold unsure what to do about her unconscious husband, said if she had witnessed his heart attack and thought the hold time had cost his life, she’d sue the city.

“That right there would have killed him, the fact that I couldn’t get through to emergency services,” she said.

Silent leadership

On April 21, 2021, Cozzie sent an all-staff email delaying the transition to ProQA by two weeks to allow for more training after dispatchers warned their bosses that they were not ready. The email said some dispatchers had asked to push it until after the summer when emergency calls typically spike.

“We repeatedly stated, summer is not the time to do this,” one of the dispatcher emails to Mapps said. “And yet we got it in the summer. Call hold times went up *significantly*.”

Dispatchers were not telling BOEC management anything they did not know. Internally, Cozzie was briefing city officials that performance would decline for some time after the transition.

Dale, the Priority Dispatch president, told OPB a small slow down during the initial adjustment period is to be expected.

“It takes them a while to trust it,” said Dale, who used to be a fire chief. “I know when we switched a long time ago…our call processing times went up a little bit throughout the first 30 or 60 days, then it started to level back out.”

Two months after ProQA was activated, Cozzie sent another all-staff email saying the combined effect of surging call volume, a blistering heat wave and ongoing COVID restrictions had made 2021 his most difficult summer in his 26 years working in emergency dispatch. He also said ProQA was playing a role.

“Add to this our recent ProQA implementation, and I completely understand the fear, anxiety, and extreme burnout that many are feeling,” he wrote.

In the email, Cozzie said management had considered multiple options to deal with the agency’s issues, including getting rid of ProQA until after the summer, getting rid of the medical portion until after the summer or allowing employees to use the old system “in a pinch.” Ultimately, they chose a fourth option, requesting assistance from Priority Dispatch for additional trainers and to help call takers.

The transition to ProQA was an enormous operation that took years of planning. For days after the transition, BOEC established a 24-hour command center staffed with Priority Dispatch representatives and dispatchers from Lake Oswego, Clackamas and Deschutes counties, agencies already using ProQA.

Cozzie and other city leaders at the time did not acknowledge the massive shift taking place at BOEC, or the effects ProQA was having on-call responses. Between May 18, 2021, when ProQA was activated and the end of the year, there were at least seven stories in local Portland media about 911 hold times increasing.

All of the stories included interviews or quotes from BOEC leadership. None mentioned ProQA.

Dispatchers took note of how the agency was being portrayed to the public.

“What is really happening is not shown or spoken of,” one dispatcher wrote in an email to Mapps. “Instead, some skewed numbers about staffing and call times are thrown out and all of us here actually working the floor gasp every time at how false this presentation is.”

An agency at a tipping point

ProQA is likely not the only factor dragging down performance, however.

Since 2019, more than 35 dispatchers have left BOEC out of a staff of about 100 call takers in recent years. Some months, call volume has increased by as much as 30% since 2019. That can mean up to 14,000 additional calls, some of them from callers around the country ranting about politics in the city.

“For us to have been able to meet that challenge, we would’ve had to see that call volume coming about two years earlier because of how long it takes our trainees to get through the process,” Cozzie told OPB. “Not only that, I would’ve needed to hire, above our funded staffing, probably at least an additional 30 dispatchers.”

Cozzie has repeatedly said call takers have become a bottleneck for a growing number of emergency, as well as non-emergency and other administrative calls, routed to 911 dispatchers. He told the Fairview City Council the agency has reached a tipping point and is unable to handle its current workload. He said he hopes a public awareness campaign will see about 91,000 non-emergency calls a year shifted to the county’s 311 line by this summer. Portland Mayor Ted Wheeler, who recently proposed more money to expand 311, doubled that estimate and told Willamette Week he expects it to divert 180,000 calls per year.

That line is currently staffed on weekdays between 8 a.m. and 5 p.m. If the mayor’s requested funding is approved, a long-planned expansion will increase operating hours to between 7 a.m. and 8 p.m., seven days a week. The city hopes its planned awareness campaign will educate the public as to which times and under which circumstances they should call 311.

Dispatchers say the fallout from ProQA has made a stressful job nearly unbearable, driving some to quit and increasing the number of people taking leaves of absence, exacerbating the very staffing shortage management claims is responsible for the 911 delays plaguing the agency.

Sitting in front of six large monitors at the 911 call center, a dispatcher who’s been at BOEC for more than 10 years told OPB that since the agency adopted ProQA and hold times increased, they’ve had to up their dosage of anti-anxiety medications. On one of their small screens blinked a box showing how many calls are on hold, a constant reminder that people are trying unsuccessfully to get through to 911. When the number gets high enough, the box starts flashing yellow. If it keeps going up, the light flashes red.

To help with the added stress, this dispatcher put a sticky note over the box.

“If I watch that, then I want to rush to help more people but you really have to focus on the one call and take one call at a time,” the dispatcher said. “I think we’re taking more time with ProQA…It’s not like we didn’t get the information we needed before.

A technological monster

Portland dispatchers aren’t alone in their outrage at ProQA. In fact, their complaints — rigid scripts, unnecessary questions, increased dispatch times — are so common, Priority Dispatch devoted an entire page of its website to busting what the company calls “myths.”

Agencies in Pueblo, Colorado, Salt Lake City, Utah, and Minneapolis, Minnesota, have all faced similar issues.

The Pueblo Fire Department saw its response times increase in 2020, in part, Fire Chief Barbara Huber said, because the city adopted ProQA. Huber said the rigid system hinged on whether or not callers were able to answer questions adequately, which can cause time delays.

Priority Dispatch was sued in 2019 after someone attacked two sisters in their Salt Lake City home and dispatchers never sent the police, despite four calls to 911. The lawsuit alleges the police were never dispatched because call takers were unable to make their way through the required questions. It said Priority Dispatch has created a “technological monster.”

The company pushed back against the allegations, saying their software never came into play because the dispatcher was unable to hear the home address.

After two years of using the protocols, Minneapolis abandoned them in 2019, citing many of the same issues surfacing in Portland such as veteran staff leaving and complaints of excessive-performance reviews.

“When I started with the city of Minneapolis, I was surprised this software was still being used considering the complaints from the community, first responders and staff,” said Kathy Hughes, who ran the Minneapolis Emergency Communications Center for two years and made the decision to stop using ProQA. “The irrelevant questions that were part of the script delayed calls and delayed response times for first responders.”

Hughes said she couldn’t speak for what was happening in other cities, only that ProQA didn’t work for Minneapolis.

Part of ProQA’s implementation is an increased number of performance reviews to ensure call takers are adhering to the scripts. Dispatchers say they get dinged for transgressions such as referring to a caller’s baby as “your baby” instead of “the patient.” One dispatcher told OPB they had more than 35 performance reviews last year. Prior to ProQA, the most they had had was 12.

“When we fight ProQA or don’t read it as scripted or we cry for help and voice our valid concerns, then we become problem people and they want to fix or reprimand us instead of focusing on the issue itself,” a dispatcher told OPB.

Second thoughts

The city had planned to expand ProQA in April 2023 to also triage police calls.

One Portland police officer, speaking on condition of anonymity because they weren’t authorized to speak to the media, said they’ve seen what it’s done to medical dispatching.

“I live in fear of when they roll it out to the law enforcement side,” the officer said.

A dispatcher warned Mapps that multiple people plan to quit if the city implements police ProQA. Another said it would be devastating.

“We are already barely hanging on, to also bring in Police (ProQA) would be a complete disaster,” they wrote in an email to Mapps.

The warnings of a disaster may have some merit. For months, Portland Police Bureau leadership has said the agency is woefully understaffed and unable to respond in a timely fashion to all the calls for service that come in.

“Most shifts, we are under our minimum staffing to just take the patrol calls,” Portland Police Chief Chuck Lovell said in a press conference on Tuesday. “A lot of times, particularly on weekends, we end up on priority 1s and 2s, which are life safety calls only, and the other calls end up holding.”

For now, the city may be listening to its 911 dispatchers and rethinking their past enthusiasm for ProQA.

BOEC confirmed to OPB on Monday the ProQA expansion for police is on hold indefinitely.