Pre-hospital emergency care - where now? Prof. Gerard Bury Department of General Practice Vice-Chairman

1. Pre-hospital emergency care - where now? Prof. Gerard Bury Department of General Practice Vice-Chairman University College Dublin Pre-Hospital Emergency CareCouncil

2. Pre-hospital emergency care Drivers for change • Comhairle - Report of the Committee on A&E Services Close pre-hospital and hospital links • Improved postgraduate training for doctors and nurses Structured, multidisciplinary training • National Health Strategy Consultant delivered services • Medical Council Interim Criteria for A&E Departments

3. Pre-hospital emergency care Where now? • Ambulance service integration into the health system • Regionalisation of A&E services • Third level training of EMTs • Advanced care provision by EMTs • GP co-ops • ICT – new medical technology • Professionalisation, competence assurance and evidence based practice for pre-hospital care

4. Pre-hospital emergency care Scenario 1 • 49 year old woman collapses in city centre flat, Dublin 8 • Initial chest pain, then LOC • Niece phones 999 • Two major hospitals within three miles • Issues Dispatch Traffic Triage First responders Pre-arrival instructions

5. Pre-hospital emergency care Scenario 2 • Two car RTA between Clifden and Leenane, Co. Galway • Three people are injured • Clifden and Castlebar WHB ambulances respond • Issues Response times 15mins/30 mins Retrieval time 1 hour+ Local District Hospital GP response

6. Pre-hospital emergency care Ambulance Services response times • 1 week national census of 999 calls: 3436 calls • 73% emergency, 24% rural • At best, 47% of emergencies had a response in 8 minutes • At worst, 10% of emergencies had a response in 8 minutes Breen N, Woods J, Bury G, Murphy A, Brazier H. A national census of ambulance response times to emergency calls in Ireland. JAEM 2000;17:392

7. Pre-hospital emergency care Spatial analysis of RTAs & ambulance service responses 1 • NWHB, WHB study by NUIG and consultants: 1996-2000 • 5550 accidents • 420 deaths • 1926 serious injuries • 7351 minor injuries Moore D, Murphy A. Spatial analysis of road traaffic accidents in the Western and North Western Health Boards. NUIG, 2002

8. Pre-hospital emergency care Spatial analysis 2

9. Pre-hospital emergency care Spatial analysis 3 WHB • 17% of fatalities (26% at night) , 17% of serious injuries (25% at night) not reached within 25 minutes • 27% of fatalities can’t reach hospital within an hour NWHB • 5% of fatalities (9% at night), 5% of serious injuries (8% at night) not reached within 25 minutes • 31% of fatalities can’t reach hospital within an hour

10. Pre-hospital emergency care Spatial analysis 4: conclusions • ‘Golden hour’ care – not by hospitals • First responders role – during ambulance response • Long retrieval times – extended care skills • Use Regional EDs – additional retrieval time • Integrated care: AS, EDs, GPs, PHNs, 1st Responders…

11. Pre-hospital emergency care EMT training • PHECC registration: new entrant & conversion training • Diploma in EMT (UCD) • Standard Operational Procedures • EMT-A training – 2003

12. Pre-hospital emergency care EMT training development • Audit/QA/QI • CME • Competence Assurance • Primary degree training

13. Pre-hospital emergency care EMT-Advanced training • Protocol driven carers – AOPs • ACLS provision, fluid replacement, MIMMS trained • Some advanced paeds, obs care • Extended care skills

14. Pre-hospital emergency care EMT-A development • Dispatch/triage • Operational deployment • Further development

15. Pre-hospital emergency care Service developments • Regionalisation of ED services: welcome but implications+ • Appropriate selection of cases NB • Retrieval and extended care NB • Bypass of some centres (for some problems?) • Integrated responses with GPs, PHNs, Fire & Police… • Audit

16. Pre-hospital emergency care Scenario 1 • Prioritised dispatch, PAI, community defib scheme, 12 lead telemetry, direct access to CPAU Scenario 2 • GP response, prioritised EMT-A response, trauma team en route, bypass DGH, team care at UCHG

17. Pre-hospital emergency care Conclusions • Multi-sectoral developments in pre-hospital care • EMT/Ambulance Services developments in training, deployment and services • Dispatch • Teamwork • Audit and evidence!

18. Pre-hospital emergency care Effectiveness of pre-hospital trauma care Cochrane Injuries Group/WHO – Jan 01 • Reviews of: Early fluid administration Hypertonic versus isotonic resuscitation Spinal immobilisation Advanced versus basic life support • No clear evidence of benefit Bunn F, Kwan I, Roberts I, Wentz R. Effectiveness of pre-hospital trauma care. Cochrane Injuries Group, 2001

19. Pre-hospital emergency care Cochrane Review conclusions • These results highlight the neglect of injury as a global health issue • Injury research is unfunded and has little good quality research even in widely practised areas • There are widespread social, health and economic consequences