Every year organizations struggle with the impacts of influenza and the common cold. Employees on sick leave create gaps in shift plans and headache for shift leaders. One of the reasons for this situation is the so-called “ping-pong effect,” where people work even if they are carrying an infection because they are not sick enough to stay at home, then infect other employees—and so on.
What if we could ensure these people do not enter the dispatch center, but do their work/shift from home and help keep the center “clean”? This is an overview of how we handled peak dispatch times during the early days of the novel coronavirus/COVID-19 crisis in lower Austria, using the possibilities of mobile, home, and tele-offices to keep our dispatch center, Notruf Niederösterreich, running.
Notruf Niederösterreich (NNOe) is the emergency command and control center of the federal state of Lower Austria, with a focus on rescue services. Over the years, NNOe has taken over more and more tasks in the healthcare sector of Lower Austria; today it is an important hub for numerous tasks. Lower Austria’s population is almost 1.7 million, served by 27 hospitals, 221 EMS stations, and 889 EMS vehicles. In 2019 NNOe handled more than 1.5 million events (more than 297,000 via online services) and averaged up to 6,000 dispatches a day.
NNOe functions as a gatekeeper to manage patient flows more efficiently. Its functions include dispatch for all medical emergencies, mountain rescue, and after-hours doctor services; it also coordinates cross-border response, flight monitoring and safety, public health services, psychological emergencies, and search and rescue services. It provides other health and health-technology support too, as well as hospital service calls and complaints. The philosophy behind the center is to route the caller to the right point of care for his or her concern.
NNOe is organizationally and personnelwise built upon five pillars:
Classic control center personnel—Call center agents (CCAs), emergency medical dispatchers (EMDs), emergency community nurses (ECNs), and supervisors;
Back-office personnel—Responsible for all activities to enable undisturbed and up-to-date control center operations;
IT—Responsible for technical performance of the systems, development and implementation of web portals and apps, 24/7 technical support, and more;
Pager network—All activities in the field of radio and pager communications, installation, operation, and support;
Administration—Personnel, finances, and more.
Back-office functions are of particular importance. Generally, working at home has been possible for years now for back-office personnel and used accordingly. In the last decade NNOe invested in the development and expansion of technical possibilities for the control center. Investments were not merely financial but also concerned staff and organizational structures.
NNOe is active at four locations in Lower Austria. However, these four locations and dozens of home office workstations are located in a single (virtual) call-receiving room. This means calls aren’t necessarily answered by the nearest location. By means of a sophisticated telephony system, calls are delivered to employees best suited for the needed service (emergency call, transport registration, telephone health advice, etc.).
For each employee corresponding “personal skills” are stored in the background of the system. These skills include the training of the call taker that determines the calls he/she is all allowed to take, information on which hotlines can be informed, foreign-language skills, and more. Thus calls coming into the dispatch center are automatically routed to an appropriate call-taker.
The delivery of calls to employees can be changed by management at any time and thus adapt to changing situations. Peaks in extraordinary events can be intercepted quickly and therefore processed efficiently.
Back-office employees are also integrated into this system. In sudden events these employees are alerted via a code system. Depending on the code level, they implement measures from increased readiness to joining the operations control system.
Call 1-4-5-0 for COVID
With the pandemic, says the center’s managing director, Christof Constantin Chwojka, “The main focus was on the increased and expanded use of the health advice hotline 1-4-5-0 as a contact and processing point for people suspected to have the virus. During regular operation, 40 call-takers work 24/7 to answer calls from the hotline, at peak times up to 100. In addition, 14 back-office staff members are deployed to handle the calls. Also, up to 15 ECNs are currently working on the telephone (normally only 5–7 are planned for regular operation), and doctors from the 1-4-1 hotline are also deployed in support. This was connected with an increase of the necessary infrastructure such as workstations, technical equipment, and telephone connections, including technical and service personnel as protection and to ensure the secure operation of the Notruf Niederösterreich. Home office possibilities were massively expanded—around 100 home office workstations had to be equipped for this purpose.”
At the beginning of the crisis, authorities communicated 1-4-5-0 as a first contact point for medical questions. In Austria 1-4-5-0 is the number for free telephone health counselling; call-takers provide health recommendations or determine what facility should be accessed.
During the conversation, the ECN (a certified nurse with additional training) will assess the level of care needed and refer the caller to a point of care. This point is dynamic and depends on the place, time, and day of the week, if necessary. The aim of the system is to relieve the burden of hospital outpatient units and use healthcare facilities in a resource-saving manner.
One of the core features of the CAD system in Lower Austria is the so-called “web call assist” (WCA). As soon as a control center staff member has processed the initial questions (i.e., evaluates whether it is an acute emergency), he/she can open the corresponding WCA by selecting from a drop-down menu. The WCA will guide the call-taker step by step through the entire conversation. It includes mandatory text formulations to be used, dynamic click boxes, and background information.
The WCA can be quickly adapted to new information, which was done during the COVID-19 situation. This let the whole staff work with the latest information without extensive training.
When the first rush of calls came in, the entire back-office was alerted and put into service (home office) to forward only “real” health advice/urgent assessments to ECNs. Control center staff was reduced to a minimum, home-work opportunities expanded, and duty rosters created around assigned teams to ensure only one team would have to be replaced in case of infection. New employees whose sole task was the initial assessment of COVID suspicion were trained to relieve back-office staff. We also added internal childcare facilities and expanded mental support services for employees.
Supporting the System
In Lower Austria the district administrative authority (specifically the public health officer) is responsible for numerous decisions during a pandemic, including who gets tested and who is subject to contact restrictions.
It soon became apparent there had to be an efficient combination of the results of the 1-4-5-0 queries and measures taken by the public health officer. As well, the public health officer had to be continuously available for upcoming decisions and issuing notifications. Therefore, the following measures were implemented within short notice:
Presence of a public health officer at the control center in St. Pölten exclusively for processing COVID-19 decisions;
A second supervisor put into service;
Direct forwarding of 1-4-5-0 query results to the public health officer in the control center, who clarifies with the caller whether a test or special permission to bypass contact restrictions is necessary.
With their caller queries, the CCAs collect names and basic information, then select the applicable WCA and follow its queries. If the result is suspected COVID-19, the data are transmitted to the public health officer for further processing. If the result is an urgent assessment, the data are additionally transmitted to the ECN for further processing. If an acute emergency cannot be ruled out, the data and the conversation are forwarded to an emergency call expert (EMD) without further delay.
After about one week, the measures described above led to a relief of the BO staff and a slow normalization of everyday tasks. At present decisions on measures to be taken are still being made exclusively via the NNOe operational staff. The remaining BO employees are doing corresponding tasks as required but also have an increased standby to compensate for failures or sudden peaks in volume.
To support the ECNs, doctors are available during the day to deal with patients’ concerns on the phone. To process cases in a structured and documented manner, NNOe has developed a web-based platform. Home visits with general practitioners are set up and executed by volunteer doctors and the emergency services (vehicle and driver/paramedic).
Due to technical, personnel, organizational, and structural developments in recent years, Lower Austria’s emergency call center was able to cope with the rush of COVID-19 calls and provide the Lower Austrian healthcare system with technical solutions for a better and faster handling of necessary processes. This was achieved without relevant impairment of the daily business of emergency call processing, telephone health advice, and the disposition of rescue and patient transport.
The following points can be derived from the knowledge gained so far:
A home office option for control center employees (CCAs and ECNs) increases the reliability of operations in times of pandemics and similar events and protects employees from mutual infection and the feared ping-pong effect.
Reduction of staff to a minimum creates short and efficient information and communication channels.
Compressed communication with the most important information for the back office keeps these employees up to date without creating an information overflow. As a result these employees are available for their normal areas of activity.
As an “iron reserve,” back-office employees can support the ongoing control center operation at any time.
Siegfried Weinert, MSc, is responsible for special projects and serves as data-protection officer for Notruf Niederösterreich. He started his career in EMS in 1983 as civil servant EMT for the Austrian Red Cross and still serves as a volunteer paramedic. Reach him at Siegfried.email@example.com.
Susanne Ottendorfer, MD, BBA, began her EMS career in 1979 as a volunteer EMT for the Austrian Red Cross. After med school and internship, she started working as prehospital emergency physician at the County Hospital Moedling, where she currently holds the position of senior emergency physician in charge. She has also served as medical director for Notruf Niederösterreich since 2005. Reach her at Susanne.firstname.lastname@example.org.