Twenty years ago, experts began recognizing the need to develop emergency prehospital care to meet the varying clinical needs of emergency. It was offered as a solution to rising demand, difficulties in meeting response time targets for patients with life threatening conditions, and a mismatch between the service provided and the needs of 911 and 999 callers with non-urgent conditions.1
In most U.K. and USA services, the only circumstance in which patients could be left at scene was in the case of refusal to travel. According to a 2004 study, few services in either country had written protocols that allowed crews to refuse transportation to hospital, and even fewer had alternative means of transportation in place such as taxi or minivan transportation.2
However, despite recognition of need, the inappropriateness—and inefficiency—of current models of alternative care lacked clear evidence concerning how to safely develop the service. The authors concluded that further research in this area was required as a matter of urgency.3
Jump ahead 10 years to increasing recognition that EMS could play a role in mitigating cost without compromising care by redirecting patients identified as low acuity in an 911/999 call. A nurse triage service could change the way EMS responds to patients’ calls for help.
The Emergency Communication Nurse System™ (ECNS™), secondary medical telephone triage, was developed as a logical, feasible, and economical approach to EMS resource allocation. Using the ECNS, a nurse can make a reasonable final determination as to the type and place of care the patient receives, and thus identify the most appropriate healthcare resource and destination when used in conjunction with a locally defined Directory of Services (DOS).4
The system reduces patient and EMS costs, employs resources more efficiently, and maintains high levels of patient satisfaction—although its actual application and an agency’s reasoning for implementation may vary.
ECNS is the logical extension of Medical Priority Dispatch System™ (MPDS®), said Dr. Conrad Fivaz, clinical director of Priority Solutions Inc. ™ (PSI™).
Fivaz said that ECNS “builds and grows on an identifiable body of knowledge supplied through meaningful research, explicitly assembled and available, and used in practice.”
The research exacts a defensible basis for practice. The body of knowledge the research provides is what uniquely sets the MPDS and ECNS apart from other systems. Their consistency provides a standard for evaluating performance and lends to the design of training and education.
Las Vegas Fire and Rescue, Nevada, USA
The first full-time registered nurse was hired on Feb. 7, 2022, at the Las Vegas Fire and Rescue (LVFR) emergency communication center, four years into their ECNS operations. The RN/ECN works alongside the EMDs and, in addition to answering ENCS calls, she is the Q and administrative lead over the part-time nurses.
Center ECN staffing has relied on seven part-time RNs since implementing the program in July 2017. Nurses work 8-, 10- or 12-hour shifts between the hours of 7 a.m. and 9 p.m. Holding full-time positions elsewhere, the nurses signed up for shifts a month in advance.
The nurses are ECN certified and to qualify for the position, they must have emergency room experience, said LVFR Assistant Chief Ashanti Gray, who oversees Support Services which includes Communications. “The fast-paced environment translates to doing that over the phone.” The transition from floor to phone was not instant, Gray said. "Protocol in combination with relying on their ears, and not their eyes, took some adjustment.”
Hiring a full-time RN was a bow to the program’s success and aligned with LVFR alternative care goals.
Satisfaction comes from offering a different level of care that the public genuinely appreciates. “Once callers are introduced to ECNS, it’s not unusual for them to call and ask for the nurse,” Gray said.
LVFR communications is a secondary PSAP serving Las Vegas. A 911 call is answered by police and transferred for medical or fire triage and dispatch. An EMD code built into MPDS for suspected low acuity conditions flags the ECN. The patient is then referred to the ECN. However, “They’re not locked in,” Gray said. The patient can elect to have an ambulance sent instead of speaking with the ECN.
ECNS has been a resource saver for EMS and a security line for people who are unsure of where to call. ECNS is part of a larger plan for alternative care and joins existing programs such as the community paramedics. They feed into one another. For example, in the future the community paramedic may be able to contact the ECN—with patient consent—for low acuity conditions. If all sides are in agreement, the paramedic would then be free to respond to the next call.
A line dedicated to ECNS is next on the LVFR communications docket.
Urgences-Santé, Montreal, Quebec (Canada)
In 2013, Diane Verreault introduced secondary telephone triage for non-emergency calls at Urgences-Santé, the statutory public emergency medical service for the islands of Montreal and Laval, Quebec, Canada. The process directed non-urgent 911 calls to the existing Info-Santé (811) team.
Telephone triage was one way of reducing unnecessary ambulance runs, said Verreault, then the clinical director. Results of the telephone triage provided evidence of the program’s success.
Program success convinced Verreault to go one step further. She developed a proposal to bring telephone triage into the communication health centers. The registered nurses and EMDs would work in proximity, rather than in disparate facilities. It made sense. “I wanted operational fluidity,” Verreault said. The communication health center would be the hub for emergency and non-emergency care. The EMDs and nurses could support one another, particularly if similar software was employed. The Province of Quebec is a long-time user of the Medical Priority Dispatch System™ (MPDS®) and most centers are an Accredited Center of Excellence (ACE).
Verreault, a former hospital emergency care nurse clinician and paramedic, understood a nursing professional’s desired environment—autonomy and the freedom to provide independent clinical judgment. “The evaluation of a patient has to be determined by the nurse, not a computer software,” Verreault said. She investigated telephone triage products. ECNS offered the desired clinical security and autonomous benefits. “A nurse could skip a question when obvious and redirect instructions based on clinical judgment without leaving anything out of the assessment,” she said. “I had always feared missing something.”
ECNS didn’t let that happen, Verreault said.
ECNS “is not a software; it’s a system. It comes with training, certification, continuous medical education, and quality performance standards,” Verreault said. During COVID-19 registered nurses were added directly to the communication health center to provide and enhance the amount of secondary triage required in the event of high call volume.
Compatibility issues relating to the French language and culture preceded implementation. Working closely with PSI, Verreault verified and corrected more than existing 2,500 ECNS Key Questions, 1,500 self-help instructions, and protocol titles. She certified as an Emergency Communication Nurse (ECN) and ECN-Q and ECN-Q Instructor. She was involved in recruiting registered nurses and was central in policy creation and training.
“It was a challenging year,” Verreault admitted.
Verreault, who retired her position after 36 years at Urgences-Santé, acts as a nurse triage consultant. Groupe Alerte Santé, Longueuil, Quebec, Canada, is the second highest call volume health communication center in Quebec and covers the south shore of Montreal and a part of the eastern township. It’s Verreault’s second ECNS implementation.
Groupe Alerte Santé, Longueuil, Quebec (Canada)
Claude Marie Hébert works in an agency where compliance—and motivation—are high. In 2020, the clinical operational director at CCS Groupe Alerte-Santé reviewed 2,050 calls as part of the center’s ACE requirements and in a package of responsibilities that include MPDS oversight and taking the lead in choosing ECNS.
“I wanted guidelines for the nurses to follow and consistency among the nurses.” Hébert’s familiarity with MPDS made ECNS the prime candidate. “We knew what we were getting into,” she said.
Alternative care starting in emergency communications was a priority. Hébert had studied the subject to meet requirements of a time management course project for training purposes. “We could not continue sending every patient to emergency rooms.” Two years later, “COVID happened and ECNS followed faster than anticipated.”
With the assistance of Verreault, Hébert implemented the nurse telephone triage system in July 2021. Since Hébert is not a nurse and Verreault is, she relied heavily on Verreault’s clinical assessment. “I was in charge of operations,” Hébert said. “I made sure the trajectories were working.”
Once Verreault arrived, similar to Urgences-Santé, Case Exit questions were added in LowCode™ to create a databank of resources and referrals. A list of reasons for maintaining paramedic response (such as no clinic appointment available, home care nurse not available, or mobility problems) was also built into the system.
The process now includes transmitting patient case files to local health officials for follow-up and quality assurance. The ECN makes a follow-up call, and a questionnaire sent to the patient helps confirm compliance with instructions, level of satisfaction, and health status (is the patient feeling better?).
Verreault praised the teamwork. “It was a professional reawakening. We were all interested in doing this the proper way.”
Reducing unnecessary ambulance trips, however, went beyond the standard ECNS process at Urgences-Santé. In line with the concept of getting the patient the right help at the right place, a co-evaluation project was established by combining the expertise of EMDs, ECNs, and paramedics.
An EMD answering 911 calls can redirect a patient with a low acuity condition to an ECN given patient consent to do so. If an ambulance is dispatched for emergency reasons, paramedics responding onsite automatically transport a medically unstable patient. If the patient is medically stable, paramedics contact an ECN to conduct a co-evaluation.
The paramedic provides the visuals absent in telephone triage (such as monitoring vital signs, glycemia, EKG result, coloration), Verreault said. The nurse “sees” the patient’s condition through the onsite paramedics and the test data entered via LowCode and transmitted to the ECN. The ECN’s initial assessment, co-evaluation with paramedics, and data determine the most favorable course of patient care. Upon patient consent, the paramedics do not transport and respond to the next assignment. Since July 2021, 50% of the patients co-assessed by ECN and paramedics accepted home care instructions. All non-transported patients are scheduled for follow-up during the next 24 hours.
“Two years ago, this was an idea,” Hébert said. “We worked hard, and it all came together. We are pioneers in alternative care [in emergency communications]. We’re embracing the technology.”
Now that’s teamwork
The process at Groupe Alerte Santé proves an important point, Verreault said. An ECN and EMD working together build a relationship of trust by drawing on each other's expertise. For example, the EMD knows the status of all the resources based on time frame, availability, start shift, and end shift of resources. When the ECN calls, the EMD team leader or emergency dispatcher helps in prioritization, according to resource availability and opportunity. Add paramedic co-evaluation and the team combines their knowledge and experience for optimal patient care while also reducing EMS off-load delay and increasing the paramedic availability for life-threatening emergencies.
This is the way of doing things right, Verreault said. Her hope is continued momentum throughout the province. Not only is it good for the patient and EMS, “I’m having the time of my life,” Verreault said.
Regional Emergency Medical Services Authority (REMSA), Reno, Nevada (USA)
The Regional Emergency Medical Services Authority (REMSA) was the first ECNS ACE accredited agency in the world. The date was April 15, 2015, and a $9.1 million innovation grant from the Centers for Medicare and Medicaid Services (CMS), U.S. Department of Health and Human Services, accelerated the momentum of REMSA’s alternative care programs into the future.
ECNS (accessible through a 7-digit Nurse Health Line or transfer from 911, with patient consent) was only part of the plan. The grant, funded in 2012, launched a system of community health programs to improve access to the appropriate level of healthcare throughout Washoe County, Nevada (USA). Nurse triage, alternative destination transports, and community paramedicine were introduced in the same package.
“EMS has to capitalize on our ability to be nimble and agile to ensure that we are optimizing care for our patients,” said Adam Heinz, REMSA Integrated Healthcare Executive Director.
REMSA was also among the first to implement the OMEGA Determinant Descriptor. This group of codes within the MPD provides an evidence-based guideline for determining the most appropriate type of care for 911 callers who do not have an acute complaint or life-threatening medical emergency. The OMEGA codes allow low acuity 911 calls to be transferred out of the EMS system to the Nurse Health Line—which is a more appropriate level of care. In addition, it frees up resources for serious emergencies.
The Nurse Health Line—similar to the other facets of alternative care—had its challenges in taking the lead in telephone triage and gaining public favor. Being the first, they leaned on PSI and the IAED to define nurse qualifications and to streamline the process. When initially launching the program, they met with all the stakeholders—medical directors, local elected officials, co-response partners and hospital administrators—to identify potential implementation barriers and gain stakeholder input and support.
Identifying and recruiting registered nurses with the proper state credentialing, required adjusting the hiring process. Patient description, hypervigilant listening, and over-the-phone questioning replaced visual assessments. State licensing requirement complicated hiring (REMSA draws from licensed nurses in both Nevada and California). Since an average ECN call takes 15- to 20-minutes, quality and compliance review also takes longer. The expectation that many people still have is that when they call 911, the response will include a police car, a fire truck, and an ambulance—all with lights and sirens. Telephone triage remains a relatively new concept—and relies on a response that does not involve emergency apparatus.
“We have to change the mindset,” Heinz said. “We need people to get comfortable with the idea that these Nurse Health Line protocols are safe and that by using them, they are actually helping us save lives by freeing-up emergency resources for critical calls.”
REMSA stayed the course convinced telephone triage was part of a changing EMS ecosystem, Heinz said. The solution to many of the challenges in EMS including recruitment, retention, cost-management, and patient satisfaction is through navigating callers to the right level of care. “We are able to keep the patient [with non-acute symptoms] home.” Appropriate care also reduced the potential of an ER visit (and, down the road, exposure to COVID-19) and saved resources for patients displaying higher acuity conditions.
A continuing public relations campaign highlights the benefits of alternative care, and the REMSA website outlines when it is appropriate to call 911 or the Nurse Health Line. The ECNS script was adjusted over time to a more conversational tone. “We better acclimate the patient [to telephone triage] through conversation,” said Heinz. “We make sure they feel safe, comfortable.”
For all its negative effects, COVID-19 pushed the envelope of public acceptance. “COVID-19 highlighted the pressure on the healthcare system,” said Heinz. “The pandemic was a catalyst. It provided exposure to a lot of alternatives for receiving quality care. ECNS played a critical role.”
Performance indicators show the public’s growing confidence in the Nurse Health Line. Heinz said, “There will always be people who struggle with the concept. But we are seeing a difference.”
Each year, the REMSA communications team responds to more than 80,000 calls for assistance among the 600,000 residents it serves in Washoe County. The Nurse Health Line averages 2,100 calls a month; the nurses—there are eight on staff—complete an ECNS protocol on about half of these callers.
Northwell Health Services, New Hyde Park, New York (USA)
In 2013—the year in which Northwell adopted ECNS—numerous studies were assessing the feasibility of alternative modes of transport and alternative destinations from a patient’s perspective. Would the non-critically ill patient, for example, be willing to consider either transportation to an urgent care center or the primary care physician's office rather than an ambulance to the emergency department?
One such study found that over two-thirds of the 1,058 people surveyed were willing to consider transport via either taxi or medical transport van and willing to consider either transportation to an urgent care center or their primary care physician's office.5
While the feasibility debate played out, Northwell Health became an early adopter of population health through innovation and technology (collecting, staging and analyzing data sets to gain insights and make decisions), through becoming a recipient of a five-year state grant with the overarching goal to reduce avoidable hospital admissions by 25 percent statewide. The Institute for Healthcare Improvement grant, which is in its last year at Northwell Health, provided a three-dimensional approach to optimizing health system performance. The Advanced Illness Management (AIM) program, or “Triple Aim,” as it is called, is exactly what Northwell has achieved:
- Improved patient experience of care
- Improved the health of populations
- Reduced per capita cost of health care
The grant promoted Northwell’s commitment to optimal patient engagement in the home. Programs benefitting include Northwell’s secondary nurse telephone triage, the Sports Therapy and Rehabilitation (STARS) program, which offers direct and virtual for patients requiring physical therapy, and the patient portal “FollowMyHeart.” The portal gives patients more control over managing their healthcare through online access to medical records from Northwell and other medical providers.
How does ECNS fit into the picture? ECNS bridges the home to the expert care necessary. ECNS fills the gap between hospital discharge and continuum of patient care away from the hospital. The 20 full-time ECNS dedicated registered nurses provide a link to the most appropriate care, said Edward Jablonski, RN, Nursing Manager at Northwell Health. “The functionality [of ECNS] is managing health at home and by making sure patients are being seen in the most appropriate place.”
Northwell’s innovations help make ECNS a primary point of contact rather than simply a way to de-escalate the level care in non-acute medical situations. For example, patients calling a clinic after hours are transferred to the secondary nurse triage. The assistance between the time of the call and open clinical hours has resulted in an 80% decrease in off hour calling. Patients find the service valuable, Jablonski said. “They have a qualified person to talk to” without waiting overnight for a callback.
An early plan of attack—fleeting as it turned out—was to temporarily suspend telephonic nurse triage using ECNS due to the incredible influx of calls and the limited ECNS staff available at the Northwell Health CCC. That thinking changed quickly. Rather than suspending operations, it was decided that ECNS could provide the most benefit to patient care and, ultimately, assist in managing patients calling with potential symptoms and triaging them according to severity level. They put together a strategy to prepare for increased call volume.
The result being patients’ growing reliance and confidence in secondary nurse triage.
“Overall, Northwell flipped ECNS on its head,” said Jablonski. ECNS has become part of the Northwell fabric of healthcare.
Northwell’s clinical call center is a 24/7 operation, with generally at least four RNs available to take calls. In 2021, nearly 58,000 calls were answered, although not all patients are triaged.
At Northwell, a fourth domain to AIM performance standards—healthcare team well-being—was a given. As an example, the toll of COVID-19 led to the creation of an interdisciplinary team to support “team members’ emotional, spiritual, physical, social, and financial well-being and provide resilience coaching.”6
“We’d be left in the dust without it [support structures for frontline providers],” said Jablonski.
Northwell Health is New York's largest healthcare provider, serving NYC, Long Island, and Westchester and is accredited as the world's second ECNS ACE. ECNS complements Northwell’s overall care management system, which includes home-based services to an average of 1,200 people in Queens and Long Island, New York (USA), through its AIM program. The program favors options outside of emergency department visits for low-acuity symptoms based on the reported Chief Complaint.
Sources
1 Snooks HA, Dale J, Hartley-Sharpe C, Halter M. “On-scene alternatives for emergency ambulance crews attending patients who do not need to travel to the accident and emergency department: a review of the literature.” Emergency Medical Journal. 2005; Feb. 25. https://emj.bmj.com/content/21/2/212 (accessed March 4, 2022).
2 See note 1.
3 See note 2.
4 Fivaz C, Marshall G. “Necessary Components of a Secondary Telephonic Medical Triage System at 911.” International Academies of Emergency Dispatch. 2015; August 12. https://cdn.emergencydispatch.org/iaed/pdf/WhitePaperSecondaryMedicalTriageComponentsFINAL8272015.pdf (accessed March 4, 2022).
5 Jones C, Wasserman E, Li T, Shah M. “Acceptability of Alternatives to Traditional Emergency Care: Patient Characteristics, Alternate Transport Modes, and Alternate Destinations.” Prehospital Emergency Care. 2015; May 22. https://pubmed.ncbi.nlm.nih.gov/25998167/ (accessed March 4, 2022).
6 Miranda E. “Meaningful Changes Leaders Can Make to Promote the Long-Term Well-Being of the Health Care Workforce.” Institute for Healthcare Improvement. 2021; July 7. http://www.ihi.org/communities/blogs/meaningful-changes-leaders-can-make-to-promote-the-long-term-well-being-of-the-health-care-workforce (accessed March 4, 2022).
