Management of non-serious calls to the emergency ambulance service: issues in provision of advice in place of an ambulan

1. Management of non-serious calls to the emergency ambulance service: issues in provision of advice in place of an ambulance Helen Snooks Swansea University h.a.snooks@swan.ac.uk

2. Structure of talk • Background • Call triage • Call diversion for further assessment and advice • ‘TAS’ study • ‘OMEGA’ study • Discussion of implications

3. Background • Rising demand • Increasing evidence of mismatch between clinical need and response provided by emergency ambulance service • Call prioritisation with further telephone assessment and advice advocated as potential solution for less serious callers

4. Potential benefits to patients and the NHS • faster response to those with life-threatening injuries or illness • more convenient treatment for those who do not need to travel to hospital • a point of referral that avoids the need to attend A&E • reassurance and self-care advice for those who do not need to attend medical services

6. Sorting patients: triage • critical hinge – efficient and effective triage • Triage (French: to sort) needs to be carried out, often remotely – and usually by telephone – quickly and accurately • Those with a life-threatening condition, such as patients with a myocardial infarction or serious injury, must be identified without delay if tight time-based standards that improve their chances of survival stand any chance of being met • Those with less serious conditions need to be identified in order to trigger an alternative response

7. Prioritising calls • Evidence shows that although most triage is cautious (and therefore somewhat ineffective), serious cases are missed • Prioritisation systems were not designed to do what is being asked of them • Triage is difficult at each end of the spectrum – to identify calls that need the highest response; and calls that could benefit from an alternative response

8. Telephone Advice StudyDale et al • Shadow trial (ambulance dispatch unaffected) in two ambulance services • Matched intervention and control sessions • Nurses and paramedics using CDSS to assess and advise callers within non-serious codes • Multi-disciplinary expert panel reviewed safety of triage decision using records from: • Ambulance service • ED • Hospital inpatient • General practice • Call transcripts

9. TAS results: operational • 635 intervention calls, 611 controls • 52% of intervention calls triaged as not requiring an emergency ambulance response • 37% of these (n = 119) did not attend the ED vs 18% (n = 55) of those triaged as needing an ambulance • Patients triaged as not needing an ambulance were less likely to be admitted (OR 0.55, CI .33 to .93), but still, 9% (n = 30) were admitted

10. TAS results: safety • 239 cases triaged to ‘no ambulance required’ were further explored • 96% (n = 231) majority of panel agreed with triage decision • 8 patients reviewed again • 2 rated by majority as requiring emergency ambulance within 8 minutes, but not at life-risk

11. TAS conclusions • Ambulance journeys can be saved • Telephone advice appears to be safe • Further evaluation required in clinical trial

12. OMEGA study • RCT comparing processes and outcomes of calls transferred for nurse advice with calls receiving standard ambulance response • 3 ambulance services • Intervention group calls transferred to NHS Direct – 24 hour nurse led health information and advice line • Outcomes: • pass back rates • Conveyance rates • Ambulance service job cycle times • Safety • Patient satisfaction

13. OMEGA results – patient recruitment • 2,250 allocated to intervention group • 1766 consented to call transfer • 642 consented to follow up • 318 completed follow up questionnaire • 2,158 randomised to control group • 529 consented to follow up • 266 completed follow up questionnaire

14. OMEGA results: call return • Pass back rate: 67%, n = 1196 • Requires 999 ambulance 44% • Urgent transport 25% • Requires lift and assess 9% • Caller request 5% • Public place/not with caller 3% • Refused assessment/hung up 2% • GP advised 999 4% • Technical problems 4%

15. OMEGA: operational outcomes • Conveyance to hospital • Intervention 49% (n = 1097): control 78% (n = 1679) p < .001 • Job cycle time • intervention 41.5 mins: control 50.5 minutes p < .001

16. OMEGA: patient outcomes • Safety • Adverse event rate low: 2/3975 reported by patients, clinical review: 4/1552 delayed responses ‘may have been clinically important’ • 4 fractures reported • Satisfaction with service: • Happy with service • Intervention 79% • Control 94% • Made to feel wasting time • Intervention 18% • Control 9%

17. OMEGA: patients comments • Generally positive in both groups • ‘Pleasant, friendly approachable service’ • ‘Great service all round. Thanks’ • ‘The ambulance arrived within minutes of the call, a very satisfactory service’

18. OMEGA patient comments – intervention group • Most comments positive • ‘Clear and concise instructions from both the ambulance service and the NHS Direct nurse. Very professional confident service’ • ‘The people on the phone were very helpful and pleasant. I had panicked and called 999 bit I was reassured and felt very happy when I had spoken to the nurse. I was glad afterwards that an ambulance hadn’t been sent as it would have wasted their time’

19. Not so happy… • ‘The problem was not one that NHS Direct could really resolve – I needed help to get an 80 year old off the floor’ • ‘People in severe pain should not be transferred to NHS Direct but to let the ambulance come immediately’ • ‘I was told and not asked about the transfer of my 999 call to the NHS Direct nurse. I was made to feel I was wasting everyone’s time’

20. OMEGA conclusions • Safe and effective for some calls • Difficult to identify appropriate calls at EMD triage • Small proportion of 999 workload • High pass back rate • Telephone advice can provide a useful part of emergency system

21. Discussion of implications • Triage remains an issue • Range of responses required • Further telephone assessment and advice needs to be tailored more closely to fit the services available • Change management issues are important in ensuring success of new model of care • Joint working necessary – but challenging when across organisations

22. 999 EMS RESEARCH FORUMto encourage, promote and disseminate research andevidence based policy and practice in 999 healthcare

24. References • Dale J, Williams S, Foster T, Higgins J, Snooks H, Crouch R, Hartley-Sharpe C, Glucksman E, George S. Safety of telephone consultation for ‘non-serious’ emergency ambulance patients. Qual Saf Health Care 2004;13: 363-73 • Dale J, Higgins J, Williams S, Foster T, Snooks H, Crouch R, Hartley-Sharpe C, Glucksman E, Hooper R, George S. Computer assisted assessment and advice for ‘non-serious’ 999 ambulance service callers: the potential impact on ambulance despatch. Emerg Med J 2003;20:178-83 • Turner J, Snooks H, Youren A, Dixon S, Fall D, Gaze S, Davies J. The costs and benefits of managing some low priority 999 ambulance calls by NHS Direct nurse advisers. Final report to SDO R&D programme, august 2005