Top Care Over The Phone

Audrey Fraizer

Audrey Fraizer

ACE Achievers

Audrey Fraizer

Janice Warshauer, Registered Nurse, was a longtime hospital and in-home care infusion nurse when circumstances dictated a change, although in retrospect the transition wasn’t so different from what she had been doing for the past 22 years.

It was more about shifting perspective.

“It’s a matter of listening closely to what the patient is saying,” said Warshauer, describing her move from a visual to virtual environment in the Northwell Health System complex of integrated services. “Sometimes it takes asking the question differently, but you learn the approaches that work best for helping the patient.”

Warshauer is among 10 certified Emergency Communication Nurses (ECNs) providing care selectively routed to them from callers—patients and caregivers—requesting assistance for symptoms related to acute or chronic medical conditions. Chief Complaints are triaged using algorithms built into the Emergency Communication Nurse System (ECNS), a protocol-based automated system developed by the International Academies of Emergency Dispatch® (IAED).

Several primary and secondary Public Safety Answering Points (PSAPs) incorporate ECNS to complement overall EMS goals, but only two have achieved status as an Accredited Center of Excellence (ACE). Northwell Health Clinical Call Center in Syosset, New York (USA), was the second, earning the distinction on Aug. 7, 2017.

Debra Tomassetti, Clinical Call Center Program Director, said it was a team approach.

“We’re dedicated to ECNS,” she said. “It works hand in hand with EMS and is part of an integrated approach for ultimate patient care. ACE shows we put the time and effort into what we do.”

Accredited Center of Excellence

ACE was a great fit for Northwell, said Jeffrey Pick, RN, Clinical Call Center Quality Assurance (QA) Manager. Northwell had looked at several measurement-based accrediting options but chose the ACE program because of its focus on call detail.

“ACE is the key to the lock of what we are doing,” Pick said. “Accreditation is tailored to listening to calls, and call quality makes for better patient outcomes. If we can make the call better, the whole process improves.”

Pick reviews 100 percent of ECNS calls. He monitors an ECN’s progress, evaluates performance, and recognizes through his review the areas needing further training and the incidence of low to urgent medical complaints. He also assesses the ECN’s customer service—patient/nurse rapport is established through voice only—including communication skills necessary to clarify or ask for detail and paraphrasing to check accuracy. He also checks their compliance in using the software tool as directed and following instructions.

“We needed the structure and stability the system provides,” Pick said. “LowCode® [the program’s software] has literally saved the day on many occasions. You can’t always remember all the questions. It’s important to have the script.”

From clinic to phone

Although Warshauer does not “see” the patient, clinical experience during her career—pattern recognition, skilled know-how, and common sense understanding—and LowCode help her to estimate patient symptom urgency. Software is based on pattern recognition, supporting a nurse’s intuitive ability to compare general descriptions to patient presentation in making triage decisions. After listening to the patient’s description and prompting more information when necessary, she assigns a symptom-based protocol. She verifies there are no priority symptoms (e.g., trouble breathing), performs further assessment, and recommends an appropriate level of care.

“We [ECNs] are able to recognize what’s going on with the patient and provide the best treatment option for the condition,” Warshauer said.

Warshauer has spent her entire career at Northwell, shifting to the clinical call center three years ago because of chronic back pain resulting from two decades of lifting patients. It was a relatively new program at the time and one that 25 years ago she never imagined doing. Advice nurses have been around since the early 1970s—started as a way for HMOs to cut costs by having nurses rather than physicians handle calls, minimize unnecessary office visits, and encourage self-care at home—but that was not what she had trained to do.

“I didn’t want to leave nursing,” she said. “ECNS was a major transition, but I also saw it as a good chance to use my skills in a very challenging way.”

The transition turned out easier than she had anticipated. She listens to what patients feel and finds each day as atypical as working on a hospital floor or making home visits. She has the opportunity to “know” longer-term care patients, such as those who are homebound, and the ability to get patients to a recommended setting in an appropriate amount of time. She also likes answering patient and caregiver questions.

“I love the program,” she said. “The calls are not always symptom-based. Caregivers want reinforcement and assurance. Are they are doing the right thing? Patients want to know they have someplace to go. They know they have care until it’s time to see the doctor.”

Complex operation

Telephone triage is a complex operation that requires accurate and timely referrals to avoid delays in patient care and, if indicated, to make sure the patient is seen before symptoms escalate. While there are no shortcuts, ECNs spend 16 minutes on average per call, depending on several factors, including Chief Complaint and recommended level of care. At the Northwell Health Clinical Call Center, an ECN can recommend self-care, dental care, or direct the PSAP to initiate a three-way conversation to include the ECN, primary care provider, and patient. Community paramedics (CP) trained to evaluate and treat acute illness can be sent to the patient’s home for symptoms requiring urgent in-person evaluation and possibly in-home treatment.

Candidates must have at least five years’ clinical nursing experience, excellent written and verbal communication, and basic knowledge of current pathology and pharmacology. They must be familiar with accessing electronic health records, patient triage, and confidentiality and privacy laws. They must also project a patient-centric personality and demonstrate the ability to multitask (listening while using the computer-based system).

Training involves Emergency Medical Dispatcher (EMD) certification, followed by the ECNS certification course. Upon earning both certifications, the ECN sits with a mentor and listens to calls. The ECN and mentor switch roles, with the mentor acting as a coach. After six weeks of alternating roles—answering calls and mentoring—the ECN acts independently.

Care management system

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, through its Advanced Illness Management (AIM) program. The program favors options outside of emergency department visits for low-acuity symptoms based on the reported Chief Complaint.

Staying out of the hospital is better for the patient, explained Karen Abrashkin, M.D., Medical Director, Northwell Health Clinical Call Center. Hospital visits can expose the already medically vulnerable patient to infection and further compromise weakened physical agility. Home is where they want to be.

“That’s where they’re comfortable, and there are many advantages for both the patient and family to treatment at home if the patient’s condition allows,” she said.

Ultimately, the decision rests with the patient. The nurse asks the patient, “Do you want to remain at home?” and offers scenarios describing the various care options.

“The patient trumps everything,” Tomassetti said. “Once you explain and give choices, the patient feels more comfortable. You’re building a level of trust.”