Audrey Fraizer

Audrey Fraizer

Story Vault

By Audrey Fraizer

Regional Emergency Medical Services Authority (REMSA) nurses were the first line of defense for many patients reeling from the fever, body aches, and cough due to a flu strain made even more troublesome because of a vaccine that did not fully meet the target strain.

While they never met a single one of their patients face-to-face, they were ready and able to get them to the right level of care through an over-the-phone assessment and triage process that benefits everyone involved.

REMSA’s medical communications center is an Accredited Center of Excellence (ACE) and among the first centers in the U.S. to offer safe and effective pre-hospital care through the Academy’s Emergency Communications Nurse System (ECNS). REMSA is an emergency medical service based in Reno, Nev.

The comprehensive nurse triage system—comprising more than 200 symptom-based algorithms, taking into account gender, age, and previous medical history—has far surpassed expectations in combination with a 10-digit Nurse Health Line, said Elaine Messerli, registered nurse, Manager, Clinical Operations, REMSA.

“We are amazed at the call volume,” she said. “This was a needed resource in our community, particularly for people who don’t know how to maneuver the health care system.”

Nurse triage

A hand in navigating at REMSA begins with a call to the 24/7 non-emergency Nurse Health Line. The registered nurse—there are eight on staff—answering the call assesses the patient’s illness or injury.

The Nurse Health Line averages 2,100 calls a month; the nurses complete an ECNS protocol on about half of these callers.

The Emergency Communication Nurse (ECN) uses the ECNS LowCode software, which integrates with ProQA, to triage the caller/patient’s symptoms, provide further assessment, and determine the level of care appropriate for that patient. A patient with a critical, life-threatening condition surfacing at any time during the conversation is transferred to a REMSA EMD. In this case, an ambulance is sent immediately and the caller is directly and seamlessly transferred to the 9-1-1 Public Service Answering Point (PSAP) and certified emergency medical dispatchers (EMD).

The registered nurses do not offer advice for definitive treatment, Messerli said.

They rely on proven protocols when giving instructions to the patient; although, as with an EMD, the ECN offers recommendations for managing symptoms until a primary care provider sees the patient, and the patient is diagnosed and prescribed treatment.

“This is an evidence-based program,” Messerli said. “The nurses are depending on their experience and a results-driven program to provide health care benefits to our community.”

REMSA has also started to implement the OMEGA Determinant Descriptor, a group of codes within the Medical Priority Dispatch System (MPDS) that provide an evidence-based guideline for determining the most appropriate type of care for patients calling 9-1-1 with a request that is not an urgent medical emergency.

The Omega codes allow very low acuity 9-1-1 calls to be transferred out of the EMS system to an alternate, more appropriate level of care. This protocol does not result in a “non-response” but, rather, leads to an alternative avenue of care for the patient. A service directory of available health care resources generated for the community served provides addresses, phone numbers, and directions to the selected health care resource nearest the patient.

The advantages so far, Messerli said, have been huge in terms of patient care and cost savings.

According to the protocols, a patient referred to an alternative out-of-hospital setting, such as the primary care physician’s office or urgent care facility, is at far less risk of exposure to infections acquired in the hospital. EMS resources are reserved for the more critically ill patients, and the same applies to a hospital’s emergency department.

“When people don’t know what to do, they call 9-1-1,” Messerli said. “This gives them options and gets them to the right level of care.”

A similar program has been offered in the U.K. for the past 12 years, and several other centers in the U.S., Australia, and Africa have introduced nurse triage. But as the next example indicates, it’s not a one-size-fits-all process.

Louisville Metro EMS (LMEMS)

Finding alternatives to sending an ambulance and the subsequent ER visit for patient care was a priority for LMEMS. The decision to look at what was available was based on practical analysis. The patient population was growing and wasn’t going to stop, so it came down to either asking the city council for funding to buy more ambulances or taking a step back to evaluate what else they could do.

“We knew we had to look at options for managing the non-emergent patients,” said LMEMS Chief of Staff Kristen Miller. “We put a premium on identifying pieces of the pie, and ECNS had the clinical judgment we wanted. It’s a well-thought-out system.”

EMDs in the MetroSafe Communications Center are first in line to process LMEMS’ low-acuity calls. There isn’t a seven- or 10-digit number to call. A patient assigned an OMEGA code or a subset of selected ALPHA codes during EMD interrogation is transferred to the ECN for further assessment.

The thought of talking to a nurse when calling 9-1-1, however, was not an immediate success for most patients. People didn’t know what the EMD meant when asking, “would you like to speak to a nurse” after assigned an OMEGA or subset ALPHA code. They generally said “no,” preferring the ambulance response expected when calling 9-1-1.

“We were asking for permission,” Miller said. “The EMD now explains that the caller is being transferred to a nurse for further assessment.”

The strategy empowered callers; patients learned ways to self-manage care from a registered nurse who listened and engaged in actual conversation. The interaction also brought a new perspective regarding frequent callers or callers whose conditions were non-emergency.

“A lot of folks don’t know where to turn,” she said. “They are not intentionally misusing the system. They need help and don’t know their options so the safest way to get help is by calling 9-1-1.”

Satisfaction levels have since gone through the roof, Miller said, and ECNS has opened their eyes to a whole new world of alternative care.

“We looked at ECNS as a means to an end,” she said. “This was the solution. But instead it opened our eyes to many more alternative care ideas, programs, and projects we can offer to our community.”


ECNS is the fourth pillar of pre-hospital care offered by the Academy, alongside the Medical Priority Dispatch System (MPDS), Fire Priority Dispatch System (FPDS), and Police Priority Dispatch System (PPDS). Its objective, however, goes beyond providing instructions while callers await response by EMS, fire, or law enforcement personnel.

ECNS defies the idiom of putting the cart before the horse. The “you call we haul” tradition is rapidly changing.

ECNS was developed as a logical, feasible, and economical approach to EMS resource allocation. The higher the acuity, the further the patient is pulled along the continuum toward a more immediate response, such as ambulance transport if the patient’s condition deteriorates dramatically over the course of the conversation. ECNS is not a substitute for the MPDS—the closest allied protocol system. ECNS complements pre-hospital care that begins with the 9-1-1 caller seeking emergency medical assistance.

“ECNS is a single component of a comprehensive system,” said Mark Rector, Director—New Business, Priority Dispatch Corp. (PDC). “It adds an additional tier of resource allocation.”

He also mentioned that ECNS is an important element to an integrated Mobile Healthcare-Community Paramedic program.

A nurse in the comm. center

In addition to the upfront elements—such as the symptom-based algorithms—there’s a lot going on in the background. ECNS incorporates the skills and experience of registered nurses into EMS, and that brings an overlay of professional care relatively new to the system.

“My position at Priority Solutions offers the best of both worlds,” said Gigi Marshall, RN, ECNS Program Administrator. “It has allowed me to use my nursing care skills and my experience in education.”

Marshall was an emergency room nurse for more than 20 years, taught nursing students in the academic setting for the past decade, and then decided to take on a multi-faceted role that combines her professional background into pre-hospital nurse triage.

ECNS pairs her skill of “thinking like a nurse” to the multiple steps she met daily on the floor. She is a critical thinker. She is logical and systematic. She applies reasoning as her guide to clinical decision-making to ensure safe nursing practices and quality care.

“Nurses approach a problem with the idea of what we hope to accomplish on behalf of our patients,” Marshall said. “We develop the pattern of recognition and appropriate responses over the course of our work. We know what needs to be done for patients and direct their care.”

The skill set can be explained in stages of performance: information gathering, focusing, remembering, organizing, analyzing, generating, integrating, and evaluating. They are the same skills inherent in ECNS.

“When we input patient responses to the questions we ask while using ECNS, a determinant is made,” Marshall said. “The more urgent the patient’s presentation, the faster the determinant is identified. There is a built-in rationale. ECNS is a very versatile and useful tool.”

Similar to the other IAED pillars of care, ECNS is vibrant, evolving to meet the demands of EMS, 9-1-1 centers, and their callers, said Conrad Fivaz, M.D., Emergency Response Operations Director, Priority Solutions Inc. (PSI) and Chair, ECNS Council of Standards.

And, as he emphasized, ECNS relies on established well-defined metrics to draw the user through a predictable, repeatable, and verifiable process. A time stamp feature added to ECNS Version 4.5 complements the demonstrable element in secondary nurse triage by recording time in relation to an event’s particular starting point.

“The data is produced in a consistent, reliable manner,” he said. “We can measure outcomes against the system’s recommendations to improve performance.”

Results win awards

A research study focusing on the efficacy of the emergency center nurse triage system was selected as the recipient of the 2014 Sophus Falck Scientific Abstract Award for pre-hospital care at the European Society for Emergency Medicine’s 8th European Congress in September 2014.

The study, titled “Using EMS Telephone Triage Data to Assess the Amount of Ambulance Resources Saved through Telephone Triage,” found that out of more than 2.6 million emergency 9-9-9 calls in the U.K. that received a phone or face-to-face response between April 2011–April 2012, nearly 90,000 were resolved through “hear and treat” secondary triage response.

More telling, the study found that those secondary triage responses resulted in deployment savings of 22.5 million British pounds (or nearly $29 million) and saved the British ambulance services 134,935 total unit hours.

Fivaz credits the results—the evidence-based success potential of secondary triage response—as the reason the International Academies of Emergency Dispatch captured the international stage.

“Emergency medical services (EMS) all over the world are looking for ways to conserve resources without jeopardizing patient care,” he said. “The award recognizes telephone triage as a very viable alternative. It’s a system gaining international momentum.”

Another study, published in the March/April 2015 Annals of Emergency Dispatch and Response (AEDR), presented an analysis of cost savings based on centers using ECNS: LMEMS and the MetroSafe 911 Communications Center and Medstar EMS in Fort Worth, Texas. According to the results, patient records from a combined 3,976 cases analyzed saved nearly $1.2 million in payments by directing patients away from the emergency department to alternative points of care. The vast majority of patients—91.2 percent—ranked their experience with the service as “highly satisfied.”

Evidence = allies

Evidence-based EMS programs are also an ideal model for attracting participants and funders through innovative programs, grants, and partnering with hospital systems and care providers.

LMEMS applied for a grant through Passport Health Plan, which provides one-year $50,000 grants for innovative programs that improve the health and well-being of Medicaid patients in a 16-county service area.

The grant became the seed money for ECNS implementation at LMEMS. Based on the program’s success at the end of the first year’s operation—estimated 30 percent savings to patients in their medical transportation costs—LMEMS made the program permanent and in the next year received a Bloomberg Foundation grant to add a second nurse and management services for patients with chronic conditions who frequently call 9-1-1.

The sky is the limit it seems from talking to Miller.

LMEMS has already added a paramedicine outreach program and, for the future, is considering a stretcher van system to assist patients who have mobility concerns and need transportation to an appointment or urgent care clinic. They’re also considering a 7-digit nurse help line.

“ECNS is the most wonderful program in the world,” Miller said. “It made so much sense to us from the start, and it now has led us to planning the addition of other spokes we can add to the hub of our EMS system.”

The REMSA Nurse Health Line is part of REMSA’s Community Health Program which was launched in July 2012 as part of a $9.8 million Health Care Innovation Awards grant funded by the Center for Medicare & Medicaid Services (CMS), Department of Health and Human Services.

Messerli believes nurse triage is the wave of the future.

“This will become the norm,” she said. “Avoiding overuse of ambulance and ER, when appropriate, is key to decreasing health care costs while still providing the best level of care to the patient.”