Rising to COVID-19 Challenge

Courtesy of WebMD at https://www.webmd.com/lung/coronavirus

Audrey Fraizer

Managing the unpredictability of COVID-19 in emergency communications comes down to several factors and chief among them is irrepressibility.

Irrepressibility is the ability to understand the challenge and, in understanding it, create a new shape to operations diverging from the norm. The very nature of irrepressible actions and organizations allows forward thinking in difficult situations.

At least, that’s the message of public safety leaders at Northwell Health Clinical Call Center (CCC), New York (USA); Prince George’s County Fire & EMS Department, Maryland (USA); and Prince George’s County Public Safety Communications (PSC), Maryland. To explore methods in emergency management of the pandemic, their organizations are prime examples of how innovation has kept their agencies from buckling under the strain.

They had the capacity to act decisively and act outside of routine.

Northwell Health Clinical Call Center

The first case of the COVID-19 pandemic in New York City was confirmed in March 2020, and the city was an epicenter of the COVID-19 outbreak in the United States during spring 2020. During March–May 2020, approximately 203,000 laboratory-confirmed COVID-19 cases were reported to the NYC Department of Health and Mental Hygiene (DOHMH).1 The New York City Fire Department’s (FDNY) 911 system was overwhelmed by calls for medical distress apparently related to the virus, and the volume of calls nearly doubled from about 4,000 911 calls a day to nearly 7,000 calls per day.2

Northwell Health CCC leaders knew they had to act, and it had to be fast.

“Nobody saw this coming, the way it escalated,” said Edward Jablonski, RN, Nursing Manager at Northwell Health. “We had contingencies in mind, particularly as they were related to the potential of any outbreak, but this really pushed forward in our planning.”

An early plan of attack—fleeting as it turned out—was to temporarily suspend telephonic nurse triage using the Emergency Communication Nurse System (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.

“We created a way to de-escalate,” said Debra Tomassetti, RN, Assistant Vice President, Clinical Call Center and Complex Care Management, Northwell Health. “We knew that we would not be able to use our triage software for every call because the average time to triage is about 16 minutes.”

The first order of business was the immediate increase of nurses capable of assisting in caller triage. The time involved in the Academy’s ECNS certification course, which also requires Medical Priority Dispatch System (MPDS®) certification, however, did not meet the urgency of their crisis. They wanted to scale down requirements, pull RNs from the floor, training them to use ECNS, and, when call volume dropped and their help was no longer needed, return them to manage care on the floor.

They contacted the International Academies of Emergency Dispatch® (IAED) and Priority Solutions, Inc. (PSI) and came up with a plan.

Gigi Marshall, RN, ECNS Program Administrator, and Conrad Fivaz, M.D., Priority Solutions, Inc., Medical Director, responded with a two-week turnaround, creating a specific certification for nurses who were not certified in ECNS. Jablonski, a certified ECNS instructor, attended the modified ECNS instructor course.

They redeployed RNs that were working in other departments to the clinical call center to assist with the influx of COVID-19 calls. The first modified ECNS course was held April 23, certifying six RNs as an ECN-p (pandemic) in three days. An ECN-p would assist only in managing pandemic-related calls. They do not assist with any other type of ECNS call and were required to pass an ECN-p certification exam.

“They all passed the exam and got to work,” said Tomassetti, who was also ECN-p certified.

Their addition to the CCC brought the total to 17 ECNs available to help patients during the center’s 24/7 operations. ECNs and ECN-p’s complete COVID-related calls from start to finish. Each patient encounter is defined by infection status and status assigned across the continuum of care. A declared emergency is the only time the call is handed off to central dispatch—FDNY or Northwell—for immediate response.

Behind the scenes, CCC Program Manager Daniel Lee worked “furiously” to set up a system that would normally take weeks to put in place. They partnered with Northwell Health Center for Emergency Medical Services (CEMS) and FDNY to answer calls in the community regardless of whether they were part of the Northwell Health system. They created workflows to add a recommended care level of “see a provider immediately” or “receive a telehealth visit from an M.D.” within 24 hours, resulting in fewer ambulance deployments and fewer emergency department visits.

Augmenting staff was only part of the plan. A pilot program allows five ECNs to work from home at remote stations. Additional ECNs will move operations home pending equipment availability. At the end of November, Northwell Health CCC implemented a program to deliver monoclonal and clonal antibodies for patients who tested positive for COVID-19 and with specific comorbidities that put them at risk for severe complications, hospitalization, and death.

 Jablonski said the situation was overwhelming during the early days. Patients were scared. There was little known about the virus—its transmission and symptoms and access to emergency care. The ECNs not only filled an increasing gap in care, but they also gave patients an empathetic bedside manner over the phone. They projected a calming voice, Jablonski said.

“The staff is very dedicated in bringing that voice to the phone,” he said. “The patients accept their recommendations with confidence and get a lot of satisfaction in staying home [based on their symptoms and required level of care].”

Tomassetti commends their dedication.

“They have been working day and night throughout this pandemic and have been kind, caring, and empathetic to all patients. They are the calming voice for panicked family members in fear for their loved one’s lives, and physicians are grateful for the resources we connect to their patients.”

And, of course, it’s not over, and no one can predict the “if” or “ever.”

“We’re early in the sixth inning, second half, and we’re at the point where we can manage without adding staff or stress,” Jablonski said. “There’s still something new every day. Keeps us fresh.”

The CCC is part of CEMS in Syosset, New York (USA), which coordinates care for patients served in the New York metropolitan area’s largest hospital-based ambulance service. The CCC is an MPDS and ECNS Accredited Center of Excellence (ACE). Operating 24 hours a day, seven days per week, the CCC supports over 10 Northwell Health businesses and clinical service lines, including off-hours clinical support to 23 medicine service line (MSL) practices. People outside the network can also access the CCC for assistance and referral.

 CCC call volume has increased 400% over the past 12 months.

ECNS is the nurse triage system implemented directly in EMS communication centers to provide alternative referral options to patients with non-life-threatening, non-emergency, and low-acuity Determinant Codes as assessed by ProQA® and the MPDS Protocol. The ECNS Pandemic protocol had been COVID-19 ready since March 5, 2020—six days prior to the World Health Organization’s (WHO) declaration of the pandemic.

Prince George’s County

Deputy Fire Chief Brian Frankel is Director of Emergency Operations Command for Prince George’s County Fire & EMS Department (Maryland, USA). As such, he is used to overseeing large quantities of supplies to outfit and protect his 1,000 career firefighters and 1,500-member volunteer firefighting force. Their proximity to numerous federal installations heightens the responsibility and reinforces the urgency to stay a step ahead of any real or pending crisis.

Preparedness for COVID-19 has roots in the 2014 Ebola epidemic.

The 2014 Ebola epidemic was the largest in history, affecting three countries in West Africa, particularly Sierra Leone, Guinea, and Liberia. In October 2014, the Centers for Disease Control and Prevention (CDC) implemented enhanced entry screening at five United States airports that receive over 94% of travelers from Guinea, Liberia, and Sierra Leone, including at Dulles International Airport (Virginia, USA). The District of Columbia Department of Health (DC Health) began actively monitoring travelers from these countries residing in or visiting the District of Columbia in October 2014.3

Considering the risk Ebola posed to his firefighters, Frankel’s predecessor secured an Urban Area Security Initiative Grant for the purchase of Personal Protective Equipment (PPE) through the Office of Homeland Security. Ebola never escalated to the level of potential threat, leaving the N95 respirators and related safety PPE in stock for later use. The funding also covered the cost of a biodecontamination system for disinfecting masks.

“We went through the stock supply during the first two months of COVID,” Frankel said. “But we were fortunate. We weren’t scrambling to get the right resources at the start.”

The “start”—as far as word of the virus raising red flags—occurred in January. “The thing” in China was beginning to jump borders, and in mid-February 2020, clusters of the virus appearing in Seattle, Washington (USA), convinced Frankel it was time to position themselves for response.

Data collection took on even greater importance and, since March 2020, data has been collected daily through FirstWatch, which gathers information through a secure ProQA connection. FirstWatch provides data surveillance and analytics for public health and other purposes by capturing, translating, and transmitting information about their 911 callers, patients, and systems. For example, at Prince George’s, the software scours dispatch information looking for certain call types in the notes of the CAD to indicate a potential COVID-19 patient and provides the number of persons under investigation (PUI) “in real-time.” They also track at-home sudden cardiac arrest to get a better estimate of the prevalence of COVID-19 within the community since many patients are reluctant to call for a condition that could land them in the hospital.

FirstWatch—in collaboration with Prince George’s County EMS—also developed a regional 911 medical care and transport dashboard to manage resource use and coordination.

Frankel defines success in their ability to reduce exposure to their responders and know the number of units they’re running to get the right resources to help the public. Data is the key, he said.

“Data tells the story,” Frankel said. “Getting the right information and putting it in EMS hands before they go on the call is a big part of the solution.”

Success also depends on collaboration, he said.

“It takes a team to do this most effectively.”

Collaboration

Prince George’s County Public Safety Communications (PSC) center is among the primary public service agencies collaborating to address patient care and responder safety during crisis. The center is an independent entity under the Office of Homeland Security and an IAED triple-ACE (medical, fire, and police). The agency is divided into three sections: calltaking, fire/EMS dispatch, and law enforcement dispatch. Emergency calltakers handle all 911 calls that come into the center, more than 2 million a year. Emergency dispatchers dispatch all calls and ensure vital airable information is passed to the responders for their safety and the safety of their citizens.

Like everyone else, Howard “Chip” Ewing had no idea regarding the severity of the coronavirus as 2019 wrapped up, although by the end of January 2020, they started devising actions they could take if the virus escalated as it eventually did.

“February into March, things weren’t looking good,” said Ewing, PSC Assistant Operations Manager, Fire/EMS Dispatch Section. “We knew way ahead that we were in for a fight. The pieces of what we needed to do were falling in place.”

Ewing plotted worst-case scenarios. What happens if they lose a shift due to the virus’ spread? What happens if the virus goes undetected inside the comm. center? Ewing, along with other PSC command staff, put together emergency staffing plans. They developed transfer plans between the primary and backup centers in case of infection. The centers were put in lockdown. Staff was scheduled to arrive 15 minutes before shift for temperature screenings and to answer the same questions posed to callers. Night shift was assigned to the odd numbered consoles and day shift to even numbers. Center design already positioned consoles six feet apart.

The emergency dispatchers answer each call (medical, fire, and police)—prior to Case Entry—starting with three questions correlated to the coronavirus symptoms:

  • Do you have shortness of breath?
  • Do you have a fever?
  • Do you have a cough?

Two out of three “yes” answers merit an alert to response and a highlight in the CAD and on the unit’s mobile digital computer (MDC). Frankel said the dispatchers remind responders to look at the MDC as a matter of built-in redundancy. The alert signals PPE preparations.

Neither Frankel nor Ewing believe the country will be back to where it was pre-pandemic, despite the vaccine rollout. The same applies to public safety response.

“We will continue to do what we have done,” Ewing said. “We will not react to information but be ready for it. We will keep to the current routine for the benefit of staff, responders, their families and, ultimately, the public we serve.”

Frankel said we could live with this for the rest of our lives.

“Nobody knows. There are too many questions. I am also an optimist. I have faith in science.”

Editor’s Note: Frankel and Ewing will be presenting “Sharing is Caring: Managing the COVID-19 Pandemic Together!” at NAVIGATOR 2021. They will review and discuss how critical of a role clear and direct communications played between agencies, personnel, and the public during the COVID-19 pandemic.

Sources

1 “COVID-19 Outbreak — New York City, February 29 – June 1, 2020.” Centers for Disease Control and Prevention. 2020; Nov. 20. https://www.cdc.gov/mmwr/volumes/69/wr/mm6946a2.htm (accessed Feb. 10, 2021).
2 Watkins A. “N.Y.C.’s 911 System Is Overwhelmed. ‘I’m Terrified,’ a Paramedic Says.” New York Times. 2020; March 31. https://www.nytimes.com/2020/03/28/nyregion/nyc-coronavirus-ems.html (accessed Feb. 10, 2021).

3 “Ebola Outbreak.” DC Health. 2014; Nov. 20. https://dchealth.dc.gov/page/ebola-information (accessed Feb. 9, 2021).

Keys to managing the crisis

Collaboration

Share information. As said by Howard “Chip” Ewing, PSC Assistant Operations Manager, Fire/EMS Dispatch Section, Prince George’s Public Safety Communications, “Information is power.”

At Northwell, the ECN nurses helped train other nurses and put in many extra hours to accommodate for the extraordinary increase in call volume, Tomassetti said.

Data collection

Use and apply tools at your fingertips. “It is foolish not to use the tools as part of the decision-making,” Ewing said.

Preparation

Throughout the year, as calls increased steadily, Northwell Health CCC added trainings and new processes as appropriate.

No second guessing about patient status

Response can only be as good as the information received from the caller. Until proven otherwise, consider every caller a possible patient under investigation (PUI).

Credit staff

Prince George’s County Fire & EMS Department

“As operations chief, I reinforce what they do and support them,” said Deputy Fire Chief Brian Frankel is Director of Emergency Operations Command for Prince George’s County Fire & EMS Department. “None of us has ever done this before, to this extent. We have to be sure we take care of each other.”

Northwell Health Clinical Call Center

“Amazing how fast they were able to jump on call. They’ve worked hard, and if we didn’t have the team, none of this would be possible,” said Debra Tomassetti, RN, Assistant Vice President, Clinical Call Center and Complex Care Management, Northwell Health.

Audrey Fraizer is managing editor of the Journal of Emergency Dispatch.

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