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QUALITY IMPROVEMENT

Going Beyond the 9-1-1 Call What


BC Emergency Health Services
isDoing to Improve Timely Access
toEmergency Care
Kerry Campbell, Jessica Jaiven, Kimberly Banfield, Corinne Begg, Janice Butler and Leanne Thain

Abstract
British Columbia Emergency Health Services (BCEHS) uses an Within the three DOCs, emergency medical call takers
internationally recognized Medical Priority Dispatch System (EMCTs) use the Medical Priority Dispatch System (MPDS)
to assign appropriate responses to 9-1-1 calls based on to assess incoming 9-1-1 calls and then assign an appropriate
patients clinical acuity. In 2015, 71% of Omega calls (classi- response based on the patients clinical acuity. Callers triaged
fied as calls involving low acuity injuries) were assigned an as not requiring emergency medical services (EMS) are
ambulance. To better meet patients needs, BCEHS collab- classified as Omega calls, where ambulance transport to the
orated with HealthLink BCs Nursing Services (HLBC NS) emergency department is not the most appropriate option.
to audit over 2,000 calls. Based on the results, three Plan, Instead, patients are offered access to alternative commu-
Do, Study, Act (PDSA) cycles were implemented, yielding a nity resources, thus avoiding unnecessary ambulance trips,
35% decrease in ambulances assigned and a 173% increase personal expenses and lengthy emergency department visits.
in referrals to HLBC NS to provide more suitable support. Currently at BCEHS, low acuity 9-1-1 calls that satisfy
Ultimately, the interventions allowed these ambulances specific criteria1 are transferred to the Ministry of Healths
tobe reallocated to more critical patients. HealthLink BCs Nursing Services (HLBC NS) for deeper
clinical assessment and in-the-moment telephone advice
Introduction/Background (HealthLink BC 2017).
British Columbia Emergency Health Services (BCEHS) is an In 2015, approximately 10,000 Omega calls were received
agency of Provincial Health Services Authority (PHSA) with across BCEHS DOCs. BCEHS internal data warehouse
a mandate to provide provincial ambulance and emergency identified that 71% of Omega calls were inappropriately
health services under the Emergency Health Services Act assigned an ambulance, and only 24% of low acuity calls were
(1996). BCEHS supports the provision of high quality and transferred to HLBC NS. While there are instances in which
timely patient care to the people of British Columbia who an ambulance response is required for particular types of
require emergency, prehospital services (BCEHS 2017). low-acuity calls (e.g., Omega calls that satisfy specific criteria),
BCEHS daily business includes three regional Dispatch it is important to note that 100% of Omega calls that do not
Operations Centres (DOCs) in Kamloops, Vancouver and satisfy this criteria are deemed appropriate to be transferred
Victoria, British Columbia. toHLBC NS.

72 Healthcare Quarterly Vol.20 No.3 2017


Kerry Campbell et al. Going Beyond the 9-1-1 Call What BC Emergency Health Services is Doing to Improve Timely Access to Emergency Care

To quantify the opportunity for improvement, baseline data engaged stakeholders from BCEHS and HLBC NS. The team
were collected and analyzed. This information highlighted the sought to understand the problem, establish objectives, gather data,
need to improve effectiveness in supporting the low acuity analyze trends and continuously communicate about the changes
patient population through other avenues, in turn, reallocating and interventions within BCEHS call centres and HLBC NS.
these ambulances to more life-threatening injuries. Preliminary The project team implemented three PDSA cycles that
findings demonstrated the following problems: included seven interventions:

1. Omega calls were being dispatched ambulances rather than 1. Revising the BCEHS Omega Call Management proce-
transferred to HLBC NS: dure: BCEHS Omega Call Management procedure has
84% of the time this was because of 9-1-1 EMCTs been revised including the criteria that must be satisfied
reluctance to transfer Omega calls to HLBC NS. tosend an ambulance to an Omega call.
11% were not transferred to HLBC NS because the 2. Conducting focused QI audits of low-acuity calls: Three audits
patient had no other means of transportation. were conducted including a comprehensive review of over
2. Dispatch staff perceived that most calls transferred to 2,000 Omega calls. The first phase included baseline data and
HLBC NS would be returned to the Dispatch Centres. the two subsequent phases informed PDSA cycles to determine
This negatively impacted the approach taken to manage the impact of the interventions put in place. A designated
Omega calls: Quality Improvement Coordinator (QIC) conducted the
Of the transferred calls, the data demonstrated that only audits to ensure there was minimal subjectivity. A customized
11% were returned to BCEHS from HLBC NS. audit template ensured the project team could measure:
3. BCEHS and HLBC NS had no mechanisms to track the the quantity of Omega calls that met the exclusion
volume and types of calls that are returned from HLBC criteria and appropriately had an ambulance assigned;
NS back to BCEHS. the volume of Omega calls that did not meet the
exclusion criteria yet were transported by ambulance;
In addition to Omega-specific data collected, a 2015 report the volume of Omega calls transferred to HLBC NS; and
on BCEHS Metro Operations highlighted that 28% of patient the volume and types of Omega calls returned from
calls responded to by an ambulance fall into the least acute HBLC NS to BCEHS.
category and that a 6% growth in demand per year is projected 3. Collaboration between BCEHS and HLBC NS, using
over the next five years2 (BCEHS Action Plan Transforming monthly meetings to:
Emergency Health Services 2015). improve transparency, by sharing data to understand
With this in mind, the evidence highlighted the need for opportunities for improvement,
system-wide improvements including: reviewing the process establish a process to analyze Omega calls returning
for responding to low-acuity calls; improving dispatch perfor- from HLBC NS and
mance to ensure appropriate call management and cultivating facilitate discussions to address gaps in communication
innovative, effective ways to deliver emergency health services. between BCEHS and HLBC NS.
4. Daily Dispatch Supervisor call reviews: Daily, the Supervisor
Interventions/Methodology at each Dispatch Operation Centre (DOC) reviewed all
To manage increasing demand for ambulance services, BCEHS Omega calls that were not transferred to HLBC NS. This
embarked on key initiatives to maximize the efficient use of provided Supervisors with the opportunity to follow up with
resources. Several members of the BCEHS Quality, Patient the EMCT to learn about why the call was not transferred,
Safety and Accreditation (QPSA) team, in collaboration with and reiterate the benefits of the revised Omega procedure.
leaders from the dispatch centres, initiated and led a quality 5. Tracking and resolving patient and family complaints: To
improvement (QI) project. By connecting patients with HLBC mitigate potential negative patient experiences, the project
NS, callers are able to obtain in-the-moment clinical advice leads collaborated with the Provincial Health Services
from a registered nurse to determine the next steps in managing Authority (PHSA) Patient Care Quality Office (PCQO)
their condition. Concurrently, HLBC NS plays a vital role to track and trend any patient or family complaints
in helping to free up emergency resources, which improves associated with Omega calls.
BCEHS ability to provide timely emergency care to patients 6. Tracking and resolving occurrence reports from HLBC NS
with serious orlifethreatening conditions. and BCEHS staff: BCEHS has an established infrastruc-
The project team used a combined QI and change management ture to receive and resolve concerns from BCEHS staff, in
approach, specifically, Plan, Do, Study, Act (PDSA) cycles. To the form of occurrence reports, which provide important
drive meaningful change and measurable improvement, the team insights from front-line staff.

Healthcare Quarterly Vol.20 No.3 2017 73


Going Beyond the 9-1-1 Call What BC Emergency Health Services is Doing to Improve Timely Access to Emergency Care Kerry Campbell et al.

7. Conducting a Culture Pulse Survey: As of June 2017, a 5. The efforts of all three DOCs resulted in three times
randomized subset of EMCT staff, with significant experi- as many calls (that did not meet the exclusion criteria)
ence handling Omega calls, were interviewed. The interview referred to HLBC NS.
was conducted using a template with nine Likert Scale and
six open-ended questions with the aim of understanding Figure 1 shows that a higher percentage of Omega calls
staffs perspectives on: were transferred to HLBC NS rather than transported by
transferring calls to HLBC NS; ambulance. This provides patients with more timely access
the types of calls that are challenging to send to HLBC to clinicians and allows ambulances to be allocated to higher
NS, yet do not meet the current exclusion criteria list; and acuity patients (e.g., stroke, cardiac arrest, short of breath, etc.).
the overall perceptions related to handling Omega calls Figure 2 illustrates from the start of this QI project
across the DOCs. (Fall2015) there has been a consistent and significant increase
in the number of Omega calls transferred to HLBC NS as a
Results result of the three PDSA cycles. The data show the implemen-
Monthly data were collected using operation reports from the tation of each PDSA cycle resulted in improvements in the
DOCs and Computer Aided Dispatch (CADs) in ambulances number of patients referred to HLBC NS.
to inform the projects indicators. A summary of improvements As of March 2016, a significant shift occurred to transfer
is listed below: Omega calls to HLBC NS, which was a reflection of the
implementation of the projects first formal PDSA cycle
Between March 2016 to June 2017: (Figures1and 2).
1. An average of 41% of Omega calls were referred to The QI audit results also identified ways in which BCEHS
HLBC NS. This represents a 173% increase in Omega can better serve our patients, through improved collaboration
calls referred to HLBC NS, compared to baseline data with external agencies and supports. For example, the organiza-
(Figures1 and 2). tion was able to ascertain the same four patient conditions that
2. An average of 37% of Omega calls were transported by most frequently had an ambulance inappropriately assigned
ambulance. This represents a 35% decrease in ambulances and were often the most challenging for EMCTs to confidently
assigned to these calls compared to baseline data (Figure1). refer to HLBC NS; they are:
3. An average of 8% of Omega calls were returned from
HLBC NS. This represents a 27% decrease in returns. falls;
4. Year to date, the projects interventions have translated to an psychiatric (non-suicidal)/suicidal ideation;
average of 183 patients per month using HLBC NS services, unidentifiable priority symptoms; and
subsequently freeing up critical ambulance resources. traumatic injuries.

FIGURE 1.
Percentage of 9-1-1 calls transferred to HLBC NS versus transported by ambulance

Percentage of Omega calls transported to destination Percentage of Omega calls transferred to HLBC NS
60
Percentage of total Omega calls

50

40

30

20

10

0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
2015 2016 2017
Month
HLBC NS = HealthLink BCs Nursing Services.

74 Healthcare Quarterly Vol.20 No.3 2017


Kerry Campbell et al. Going Beyond the 9-1-1 Call What BC Emergency Health Services is Doing to Improve Timely Access to Emergency Care

A review of the returned calls also highlighted that the were under the impression that the majority of calls they refer
main reasons for the return were for transportation (i.e., the to HLBC NS returned to BCEHS, which was inaccurate.
patient had no other way to get to the hospital), a higher level of Toclarify these misconceptions, updates about this project
response (i.e., HLBC NS was able to identify that the patients have been widely communicated across BCEHS using different
symptoms required EMS support) or for lift assists (i.e., patient tools and media such as infographics and articles published in
was unable to stand or get up). Figure3 outlines the volume the BCEHS Weekly Bulletin (with a readership of over 4,000
and types of calls returned to BCEHS from HLBC NS. staff), as well as face-to-face presentations within all three of
Lastly, the culture pulse results indicated low confidence the DOCs. In addition, the results to date have demonstrated
among BCEHS EMCTs when referring patients to HLBC key trends that will inform other care alternatives (i.e., Crisis
NS, and there appeared to be misconceptions associated with Line, home care supports, etc.) to increase the scope of support
using HLBC NS as a resource. For example, many EMCTs BCEHS can provide patients.

FIGURE 2.
Omega calls transferred to HLBC NS control chart

Percentage of Omega calls transferred to HLBC NS Upper control limit Mean Lower control limit
60
PDSA cycle 1 PDSA cycle 2 PDSA cycle 3
Percentage of total Omega calls

50

40
Mean = 45.7%
30
Mean = 14.9% Mean = 39.9%
20

10 Mean = 33.9%

0
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
2015 2016 2017
Month
HLBC NS = HealthLink BCs Nursing Services; PDSA = Plan, Do, Study, Act.

FIGURE 3.
Top reasons for returned calls from HLBC NS

Frequency Cumulative frequency


100 1.00
90 0.9
80 0.8
Cumulative frequency

70 0.7
Frequency

60 0.6
50 0.5
40 0.4
30 0.3
20 0.2
10 0.1
0 0
Transport only Higher level Lift assist/patient Psychiatric (non-suicidal)/ No reason provided Incomplete call
of care required unable to move suicidal ideation by HLBC NS assessment
Reason for returned call
HLBC NS = HealthLink BCs Nursing Services.

Healthcare Quarterly Vol.20 No.3 2017 75


Going Beyond the 9-1-1 Call What BC Emergency Health Services is Doing to Improve Timely Access to Emergency Care Kerry Campbell et al.

Change Process/Discussion Calls from a care facility, medical clinic, mental health
Throughout this initiative, the project team ensured this project clinic, nursing professional or physician;
yielded tangible, measurable results with a clear line of account- Unaccompanied incompetent adult or unaccompanied
ability and responsibility. Front-line staff and leaders have been minor;
consistently engaged throughout the project phases through Environmental conditions exist which may cause a
working groups, the culture pulse survey and assisting in detriment to the patient (e.g., exposed to the elements);
designing and implementing the interventions. Important status Caller was referred to BCEHS from HLBC NS;
updates were communicated to staff in a way that improved their Omega level lower distal injuries (e.g., injuries to the
awareness of the changes and the reasons behind the desired foot, femur, hip); and/or
change (e.g., improved response times and patient care). Dispatch Supervisor approves a higher level of response.
Going forward, the Dispatch Supervisors will play a crucial 2. BCEHS current 9-1-1 volume has increased 6.1% in the
role in sharing and receiving information from front-line last four quarters.
staff. Continuous call audits, feedback education sessions
and collaboration with HLBC NS will ensure that any new References
processes are adopted within each DOC. Our data collection BC Emergency Health Services. 2015. BCEHS Action Plan- Transforming
Emergency Health Services. Retrieved July 16, 2017. <http://www.bcehs.
(including measuring and analyzing trends) and reporting out ca/about-site/Documents/transforming-emergency-health-services-
(to staff and front line leaders) will mitigate the possibility of action-plan.pdf>.
any forward progress coming to a halt. As the change stabilizes, BC Emergency Health Services. 2017. Retrieved July 16, 2017.
and targets achieved, the project team will continue to explore <http://www.bcehs.ca/>.
alternative pathways with external agencies and partners (i.e., Emergency Health Services Act, 1996. Chapter 182. Retrieved
Crisis Line, home care supports, etc.). Further PDSA cycles July 16, 2017. <http://www.bclaws.ca/Recon/document/ID/
will be implemented to measure the impact that these pathways freeside/00_96182_01>.
have on improved support for patients. Healthlink BC. 2017. Nursing Services at HealthLink BC. Retrieved
July 22, 2017. <https://www.healthlinkbc.ca/nursing-services>.
Conclusion
For patients with less acute medical needs, the emergency About the Authors
department is not always the best option for care. To support Kerry Campbell, BSc, PMP, is a leader in Quality, Patient Safety
and Accreditation for BC Emergency Health Services. Kerry can
these patients, BCEHS is committed to exploring alternatives
be contacted by e-mail at kerry.campbell@bcehs.ca.
that connect patients with additional care pathways. BCEHS
has strategies in place to sustain this improvement and ensure Jessica Jaiven, MSc, MPH, is director of Quality, Patient Safety
and Accreditation for BC Emergency Health Services. Jessica can
resources are more readily available for high acuity patients
be contacted by e-mail at jessica.jaiven@bcehs.ca.
inneed of urgent hospital care.
Kimberly Banfield, BA, MA (Health Leadership), is a leader
in Quality, Patient Safety and Accreditation for BC Emergency
Acknowledgements
Health Services. Kimberly can be contacted by e-mail at kimberly.
The authors would like to acknowledge the cooperation of banfield@bcehs.ca.
colleagues at both HealthLink BC and BC Emergency Health
Corinne Begg, is continuous improvement manager for Patient
Services who helped with this initiative.
Care Communication and Planning at BC Emergency Health
Services. During the project, she was the Manager of BCEHS
Notes Vancouver Dispatch Operations Centre. Corinne can be contacted
1. As per BCEHS Dispatch Procedures, an ambulance will be by e-mail at corinne.begg@bcehs.ca.
assigned to an Omega call that satisfies one or more of the Janice Butler, CRM, MA, is corporate director of Quality, Safety,
following criteria: Risk Management and Accreditation for BC Emergency Health
Incomplete call assessment; Services. Jan can be contacted by e-mail at janice.butler@bcehs.ca.
The caller is a third- (e.g., caller not directly with the Leanne Thain, BSN, MHS, is director of Nursing Services for
patient) or fourth-party caller (e.g., Police, Fire); HealthLink BC. Leanne can be contacted by e-mail at leanne.
Patients who are incarcerated; thain@gov.bc.ca.

76 Healthcare Quarterly Vol.20 No.3 2017


Call for abstracts
Q u a l i t y I m p r o v e m e n t I n i t i at i v e s
The editors of Healthcare Quarterly are pleased to announce a new quarterly series profiling quality
improvement initiatives that have demonstrated improvement in the delivery of health services.

Sharing accounts of locally successful quality improvement initiatives across the country could have a
profound impact on the overall Canadian healthcare system. We are seeking submission of abstracts from
healthcare facilities and organizations across Canada that propose manuscripts describing local efforts that
resulted in improved service delivery and patient care. We are specifically interested in quality improve-
ment projects, improvement science and similar initiatives that engage staff and improve how services are
delivered and the outcomes for patients, clients and communities.

We will review a range of manuscript formats research papers, case studies, and practice and evidence-
informed perspectives,highlighting:

Strategies for staff engagement


Key change ideas and levers for change
Sustaining and spreading improvement
Measurement and monitoring of improvements
Leadership strategies

We are initially looking for a 150-word abstract that provides details on the proposed paper, including key
messages and potential value to readers. Abstracts may be submitted at any time. Please feel free to contact
us if you have comments, questions or suggestions. We look forward to receiving many interesting and
important submissions.

For more information, and to submit an abstract, please contact:

Dianne Foster Kent


Editorial Director
Longwoods Publishing
dkent@longwoods.com

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