by Cindy Leong
“Most people still expect when you call 911, you get an emergency ambulance, lights and sirens, with two paramedics, they put you on a stretcher and take you to the hospital,” says Ford Smith, former Director, Clinical Hub. “That status quo was great 50 years ago, but it doesn’t work now.”
The traditional approach needed to change as BCEHS is responding to more 911 patient events than ever before - both time-critical life-threatening (high-acuity) and non-urgent (low-acuity) calls.
To alleviate system pressures and help patients access care sooner, BCEHS launched the Clinical Hub to develop innovative ways to connect non-urgent patients to the right care, freeing up emergency ambulances to respond to the sickest patients.
“We are trying to shift the narrative towards BCEHS providing the right care for the right patient, not necessarily just sending an ambulance every time,” says Ford.
During the toxic drug crisis, BCEHS began experimenting with alternate 911 response models.
In 2017, a new role of Paramedic Specialist (PS) was trialed. In this role, which would later become permanent, experienced Advanced Care Paramedics work as single responders to assist with critical emergencies in the field. They also work half-time in the Vancouver Dispatch Operations Centre providing telephone support to paramedics around the province.
“One of the things we recognized during the toxic overdose crisis, through COVID-19 and through the heat dome, all of which put huge system pressures on our ambulance system as a whole, is that secondary triage was actually very effective in finding alternate resources for patients,” says Kathy Pascuzzo, of the first three Paramedic Specialists at BCEHS. “So, the Paramedic Specialist team started doing secondary triage off the side of their desks.”
Kathy, who is now Manager of Virtual and Integrated Care, Clinical Hub, says secondary triage was a ‘game-changer’ because of the capacity to call patients back and get a detailed clinical assessment of their needs to determine the most appropriate response. “You need to invest time and energy into each call, and you can’t rush it,” explains Kathy.
“Very early during the COVID-19 pandemic, we were keeping 40 or 50 patients a day from getting an ambulance to the hospital for such things like a basic fever. We were able to safely keep those patients at home and help the system pressures.”
From there, BCEHS started building out its secondary triage team with specially trained Primary Care Paramedics (PCPs) to focus on low-acuity patients to find alternate means, alternate destinations and alternate resources for patients, all while keeping the focus on their patients with the "right care the first time they contact the 911 sytem".
“We recognized that it would take pressure off the system, off the ambulances, off the emergency departments, but we really want to make sure we are always focusing on what’s best for the patients,” says Kathy.
In 2020, BCEHS piloted a new response resource, now known as a Link and Referral Unit (LARU), to respond to low-acuity calls in the Lower Mainland. The goal was to ease pressure on emergency ambulances responding to 911 calls.
The initial unit was a paramedic in a minibus who responded to low-acuity calls, providing care and assessment to less-urgent patients not requiring stretcher-transport.
This trial later transitioned to a substantiated program under the Clinical Hub, of 15 specialized LARU resources deployed in urban areas of the province staffed with specially trained paramedics responding solo in minivans to specific patients with less- urgent concerns.
“LARUS respond to select 911 calls, providing in-depth clinical assessments to determine the most appropriate care for less-urgent 911 patients. The variety of care options improves the patient experience while lessening the emergency ambulance workload,” says Kayla Welwood, Manager, Low Acuity and Integrated Care, Clinical Hub.
“Approximately 40% of British Columbians either do not have a family doctor or have great difficulty accessing primary care,” she adds. “We also know the population has been growing and aging so the demand on the entire health-care system is continually increasing.”
“LARUs are the link for non-urgent 911 patients to obtain the right care for their needs from the health-care system.”
During this time, BCEHS was also developing Assess, See, Treat, and Refer (ASTaR) pathways for patients who call 911 but do not always need or want an ambulance trip to the hospital. In 2019, BCEHS initiated the first ASTaR pathway to improve support for palliative patients. Since then, an additional 14 ASTaR pathways have been developed, in partnership with regional health authorities. These pathways are available for LARUs and to paramedics responding in ambulances.
“There was a lot of experimenting and trying things out,” remembers Ford. As the LARU program grew, BCEHS realized they needed another role to support these specialized paramedics and less urgent patients in the field.
In January 2022, after a trial of secondary triage, BCEHS launched the Clinical Hub with a dedicated team of eight Secondary Triage Clinicians (STCs) and two Low Acuity Patient Navigators (LAPNs).
“We needed somebody to be that quarterback to help with that low-acuity vision of getting patients who can go in LARUs to alternate destinations or ASTaR (Assess, See, Treat and Refer) pathways,” says Kathy.
Low Acuity Patient Navigators (LAPNs) filled that role. These Primary Care Paramedics work with LARUs and assist paramedics around the province who may need advice or enrollment support for alternate care pathways for non-urgent patients who call 911.
The team has since grown to 16 full-time Secondary Triage Clinicians (STCs) and six full-time Low Acuity Patient Navigators (LAPNs) who work alongside Paramedic Specialists in the Vancouver Dispatch Operations Centre.
When a person calls 911 for an ambulance, the call is triaged by an Emergency Medical Call Taker in one of BCEHS’ three dispatch centres, using the Medical Priority Dispatch System (MPDS). Based on information from the caller, the call is assigned a MPDS code. Certain non-urgent “teal” codes may be triaged again by a Secondary Triage Clinician (STC), who calls the patient back and does a detailed clinical assessment by phone or videoconference to determine what care the patient needs.
STCs can advise patients about at-home care plans, coordinate alternate transportation to an appropriate facility such as Urgent Primary Care Centre (UPCC), or reprioritize calls based on their clinical assessment.
“In order to do secondary triage, you have to be a clinician. We also want to ensure that they keep their clinical skills up so that’s why we have a hybrid role where they (STCs) rotate on to LARU vehicles. That allows them to keep their PCP skill set up,” says Kathy. Like STCs, LAPNs must also rotate to work on LARUs to maintain their clinical skillset.
If a Secondary Triage Clinician or Low Acuity Patient Navigator identifies that the call is appropriate for a LARU, the call is converted to a “Green” triage priority, letting the LARU dispatchers know that a LARU paramedic can be assigned to the call, if they are available.
If the call needs a more urgent response, it can be upgraded for a higher priority emergency ambulance response.
In the Clinical Hub, Low Acuity Patient Navigators (LAPNs) are also going through calls, looking for appropriate patients for LARUs. They make sure patients are suitable for non-stretcher transport and they also liaise with Urgent Primary Care Centres (UPCCs) and support paramedics across the province with accessing alternate destinations and care pathways for their patients.
“We want to make sure that when we do take the right patient to that alternate resource that it is still the right patient on that given day for that UPCC, and they have capacity to manage that patient.” explains Kathy.
As well as responding to 911 events, LARU paramedics also play an important role in monitoring pending low-acuity events in their respective regions, making use of their regional resource knowledge and clinical judgment to identify specific calls that would benefit from a LARU.
When they arrive on scene, LARU paramedics assess and treat patients. “They take the time necessary to sit with the patient and truly hear and understand their needs. From their assessment, they determine what the patient really needs, what is the most appropriate care, and discuss the care options with the patient,” says Kalya.
This may involve giving reassurance and education about the patient’s condition or enrolling them in an ASTaR pathway, such as a referral to a UPCC where they might be seen more quickly.
If a LARU paramedic determines that the patient is safe to stay at home, they may recommend that a Paramedic Specialist or virtual care clinician do a call-back assessment within 48 hours to check up on their condition.
“Ultimately, what the LARU can really provide is options for the patient, instead of defaulting to historical conveyance to an emergency room,” says Kayla.
“It can be a misconception that low-acuity events are minor or not as clinically complex.,” Kayla adds. “It’s not uncommon that they’ll (LARUs) respond to a patient and the patient is much sicker than was initially captured through MPDS, so the LARU paramedic uses their elevated training and critical thinking to manage the patient while they wait for backup – their role is so dynamic.”
Paramedic Specialists and Emergency Physician Online Support (EPOS) Physicians within the Clinical Hub provide additional support in secondary triage and to paramedics in the field. Paramedic Specialists connect with (EPOS) Physicians, as needed, for clinical consultations with paramedics on scene, or for inter-facility transfer planning.
Although the Clinical Hub primarily focuses on low-acuity patients, the team also supports higher acuity patients throughout the province.
While ambulances are enroute, Secondary Triage Clinicians, for instance, can use an online tool called GoodSAM to do real-time video consultations with patients over the phone.
GoodSAM is frequently used in the Clinical Hub and has been crucial in assisting with the delivery of babies and other emergencies, especially in remote locations.
“We had a Secondary Triage Clinician interact with a patient and recognize that they had a very significant bleed which the patient had understated in terms of severity. Through GoodSAM, the Secondary Triage Clinician quickly acknowledged it was a life-threatening injury, upgraded the call priority and provided advice to apply a home-made tourniquet. Ultimately it was a life-saving interaction,” says Ford.
Last summer, a Ministerial Order was signed giving BCEHS paramedics access to the provincial electronic health record (EHR), CareConnect. Ford says this legislative change is one of the team’s greatest achievements.
“This is a big win for paramedics as a professionalized health services because it really does recognize our role in the system in providing care for our patients. Prior to this important legislative change, we didn’t have any access to information in the e-health act.”
Clinical Hub staff can query a patient’s personal health number and pull records to facilitate their clinical decision making, referrals, and care plans.
“What it does is it gives us information on the patient’s entire history of interacting with the health system – their records, their results, their imaging. It gives us a more holistic image about their care needs and lets us see what advice they got from other clinicians,” explains Ford.
“If LARUs are doing a referral for a patient, they need to be sure that they understand the patient’s condition through and through,” adds Kayla.
“They will be able to do a deeper dive to put a full picture together, better informing their decision for what options are available for the patient and to be really confident in their clinical decision-making.”
Since launching, the Clinical Hub has been recognized with three awards for innovations in pre-hospital care.
“We were following a model out of Australia and the United Kingdom. They both had pretty well established and still have quite well-established Clinical Hub teams in terms of their scale and reach,” says Ford, noting that their teams have been in place for about 10 years. “In our 3 years, we’ve started to catch up to the services they provide.”
Today, the award-winning team has more than 100 full-time positions and continues to add new partnerships with virtual care teams, mental health teams, sobering centres, and Urgent Primary Care Centres (UPCCs) around the province, and to develop new ASTaR pathways.
Since January 1, 2022, more than 11,000 patients who were assessed by Secondary Triage did not require an ambulance or LARU resource. Also, there have been nearly 6,500 events where a Link and Referral Unit was dispatched to a 911 event and the event was resolved in a manner other than transporting a patient to an emergency department or dispatching an emergency ambulance.
“Many of their (LARU) calls result in no conveyance so they don’t even need a UPCC,” says Kayla. “About 50% of the ASTaR pathways (for all paramedics) do not require an alternate destination,” she explains.
Yet, there is room for growth and more referral options and pathways, especially when it comes to virtual care, says Ford.
“Our patient demographics and our calls are shifting. Today, we are actually seeing a rise in higher-acuity events. When we look at data, low-acuity calls have gone from 1/2 to 1/3 (of our 911 call volume). There’s still a lot of work to do in the low-acuity bucket because it’s big and still bigger than the Clinical Hub can handle right now. Because we are seeing higher-acuity patients calling 911, we need to get wise and strategic with our lower acuity resources to better free up the emergency ambulance fleet for higher-acuity events.”
Looking back, Ford says it’s been a great adventure working in BCEHS leadership because of the opportunity to take on a strategy and put it into action.
“I would encourage people to try to take on the opportunities and say yes to things. I think BCEHS is actively looking for new ways of thinking and leaders who bring something new to the table,” he says.
After three years with the Clinical Hub, Ford is now pursuing a career in medicine or post-graduate studies while working part-time as a paramedic. He looks forward to doing his first ASTaR referral on car and seeing further innovations in the Clinical Hub.
Pictured: Former Clinical Hub Director Ford Smith (on the right) at the bi-weekly Clinical Hub team huddle.
“They (LARU paramedics) are making such a big impact, and the patients are so appreciative of what they are doing, I’m consistently just blown away by how they’ve taken the strategy and implemented it,” says Kayla.
As for Kathy, she’s proud of the team’s skillset and is grateful to be part of the Clinical Hub legacy.
“I just feel so fortunate, because when I was a PS, I had the best job in the ambulance service. Now I’m leading that team and being innovative and able to adapt. It’s been a pretty awesome career I have to say.”
Pictured: Kathy Pascuzzo, Clinical Manager, Virtual & Integrated Care, Clinical Hub (front centre) with Ford Smith and Clinical Hub team members
- BCEHS trials new role of Paramedic Specialist
- First ASTaR pathway developed for palliative patients
- BCEHS launches first Link and Referral Unit (LARU) as a pilot program in the Lower Mainland
- 7 additional pilot LARUs are added through the Lower Mainland, bringing the total to 8
- Ministerial Orders changed enabling BCEHS to implement alternate care for 911 patients, outside of conveyance to an emergency department
- BCEHS launches the Clinical Hub, after a secondary triage trial
- Secondary Triage Clinicians and Paramedic Specialists start using a new virtual tool, GoodSAM, to enhance virtual assessments.
- 4 LARUs expanded to the Interior, in Kamloops and Kelowna, bringing the total to 12
- Health Standards Organization Leading Clinical Practice Award – BCEHS Clinical Hub
- LARU is substantiated to become a permanent role within BCEHS, by the Ministry of Health
- GoodSAM is used to assist with a baby birth in Northern B.C. It is the first time any ambulance service in Canada used the app in a labour and delivery pre-hospital transport scenario.
- 18 UPCC partnerships across the province
- Paramedic Chiefs of Canada Award of Excellence – BCEHS Clinical Hub
- Additional full-time Clinical Hub positions and staff added, bringing the total to more than 100 positions
- 6 additional LARUs are added between Nanaimo, Victoria, Vancouver, and Prince George, bringing the total to 18 LARUs operational throughout the province, in all 5 regional health authorities
- Ministerial Order signed allowing BCEHS to access the provincial electronic health record (EHR), CareConnect
- 2024 Health Care Innovation Team Award: BCEHS Clinical Hub
- 15 ASTaR pathways available for paramedics; 2083 enrollments throughout the province
- 24 UPCC partnerships across the province
- All Clinical Hub staff have access to CareConnect to elevate support for patients
- Additional ASTaR pathway linking patients to Community Health Services in development for Vancouver Island paramedics
- Additional 5 UPCC partnerships in progress to be launched in 2025
