Treat in place: An ET3 implementation case study

ET3 and COVID-19 have increased telehealth utilization to the benefit of patients and the healthcare system in rural Colorado


You are toned out at 0200 for a 62 y/o female with difficulty breathing. You pull on your boots, trudge out to the truck and roll over to the address. You have been here before. The female patient you encounter is anxious, lonely and hyperventilating. The patient asks if you can take her to the ER for a shot of Ativan. You carry Ativan on your unit; wouldn’t it be nice if you could just handle this right here and not have to transport and tie up an ER bed for a case of anxiety?

Enter ET3, (the Emergency Triage, Treat and Transport Model), the brainchild of CMS and the current topic of numerous EMS discussions. A pilot program which was supposed to launch in the fall of 2019, ET3 was delayed right up until COVID-19 hit EMS. After further delays, EMS agencies are now fresh off the lessons learned secondary to the utilization of telemedicine during the pandemic and launching ET3 pilot programs.

ET3 was designed with a simple goal: keep patients out of the emergency room who don’t need to be there. The hang up for EMS has always been payment – if no transport occurs, no payment is made. ET3 seeks to provide payment to agencies for doing what is best for the patient, rather than transport decisions being dictated by lack of payment for non-transport.

The greatest challenge with telehealth in the rural environment has been challenges with cellular connectivity.
The greatest challenge with telehealth in the rural environment has been challenges with cellular connectivity.

Launching ET3 in rural Colorado

One such program, located in a rural patch of Colorado, between the adobe deserts creeping toward the Utah border and the Rockies rising to the east, is one of the 184 or so agencies selected for the ET3 pilot program. Delta County Ambulance District (DCAD) is a tax-based EMS agency, responding to roughly 4,300 calls for service per year. The only hospital in the county is a level IV trauma center. The nearest level II trauma center is 45 minutes to an hour away and is the only level II center between Denver and Salt Lake. The nearest children’s hospital, burn center or level I trauma center are also located in these urban centers, each roughly 5-6 hours by ground to the east and west respectively.

For DCAD, early challenges in the ET3 implementation process related primarily to navigating the CMS system and becoming compliant with all necessary supporting documentation required to initiate the program. The only urgent care in the area closed down just prior to implementation, requiring a change in the alternative transport destination, delaying launch for another month.

Telehealth in action

In such a rural area, the urgent care clinic provides minimal services beyond those available from a 911 crew, leaving telemedicine as the primary delivery model utilized. The greatest challenge with telehealth in the rural environment has been challenges with cellular connectivity. Several solutions have been implemented, including utilizing the patient’s in home Wi-Fi, when possible, as well as the use of a mobile modem which connects to all three major cellular carriers and seamlessly moves between carriers as the signal waxes and wanes.

In choosing a telehealth provider, DCAD was focused on retaining a group that was willing to innovate and really think outside of the box in regards to the new care delivery paradigm. Ultimately, there was no other choice than Hippo Health, and the results have been excellent to date.

Responding 911 crews identify patients that do not require an ER visit, but do require treatment and will benefit from physician input. The responding paramedic identifies these patients and sends a quick text message through the PHI secure platform to alert the on-duty physician to an imminent telehealth call, providing a brief description of the patient’s complaint (e.g., 65 y/o male with COPD exacerbation, 63 y/o female with anxiety, etc.).

After completing a thorough assessment and coming up with a potential plan of care, the paramedic initiates a video call with the physician. The paramedic provides a report, similar to a hand-off in the ER, answers any questions the physician may have, and then the physician speaks to the patient. The physician approves or modifies the care plan, gives any instructions for follow-up and calls in any scripts necessary to the patient’s pharmacy of choice. The 911 team then treats the patient, clears the scene and documents the call as EMS has done for years. The ET3 program is like treat in place with refusal on steroids.

Elevating patient care

The ET3 Model is still in its infancy and there are many lessons left to be learned. Early indications for this particular agency are promising. Patients are being treated in their homes, which the patients are ecstatic about, and EMS clinicians are providing the needed care and not feeling that they are tied to an ER transport for everyone that is sick, but not really sick.

Perhaps most important of all, there is a paradigm shift happening in this rural community, wherein patient care is being elevated; innovation is occurring daily; and the way we deliver medical care to patients is evolving to the benefit of the system, the patients and the community.

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