Alternatives to the standard emergency ambulance response: a review of costs and benefits

Alternatives to the standard emergency ambulance response: a review of costs and benefits Helen Snooks Swansea University h.a.snooks@swan.ac.uk

Structure of talk • Context – background • Current practice • Innovations • In ambulance control • On scene • Will draw on research literature and several studies from personal involvement • Will highlight implications for policy, practice… and future research

Context • Rising pressure across emergency systems • Ambulance service demand in UK increasing 6 – 7% per year • 250,000 extra 999 calls per year in England • Response time targets increasingly difficult to achieve

Casemix • 10% of patients with life threatening problem • 50% need to go to A&E • Many callers have primary or social care need • Older people who fall • Patients with mental health problems • Patients with long-term conditions e.g. COPD • Mismatch between service provided and patient need

‘Traditional’ service • Training and service provision organised around needs of patients with life-threatening emergencies • Automatic dispatch of lights and sirens ambulance to all calls • Paramedic staff, patient carrying vehicles only option • Response time targets for all calls • All patients conveyed to hospital unless they refuse to travel

Innovations • Tomorrow’s talk: • Prioritised dispatch • Telephone assessment and advice in place of ambulance • Today’s talk • Alternative responses: • Non-patient carrying vehicles (cars, motorbikes, pushbikes) • Emergency care practitioners (PPOPS) • Alternative destinations • Minor Injury Units • ‘Fit to be left’ • Treat and Refer

Alternative responses • Non-patient carrying vehicles • Local evaluation only carried out for motorbikes/pushbikes, no comparators included • Emergency care practitioners • Various studies currently underway • Definitions vary

Paramedic Practitioner Older People Study (PPOPS) Study lead: Suzanne Mason • Cluster randomised controlled trial • 56 weeks randomly allocated to ‘on’ (PP available) or ‘off’ (standard service) • 1549 intervention, 1469 control patients aged 60 and over were included. • Follow up was through • Routine ambulance service records • Emergency Department (ED) records • Self-completed questionnaire at 3 and 28 days, covering: • satisfaction • health status • subsequent health care contacts

Findings Patients in the intervention group: • were less likely to attend the ED (OR 0.24, 95% CI 0.19 - 0.29) • and less likely to be admitted to hospital within 28 days (OR 0.78, 95% CI 0.68-0.89) • experienced a shorter total episode time (235.07 vs. 277.78 minutes, 95% CI -59.5 - -24.9) • were more likely to be highly satisfied (OR 2.09, 95% CI 1.58-2.77) • No difference in 28 day mortality (OR 0.87, 95% CI 0.62-1.22). • or health service costs at 28 days (£3966 vs. £4116, 95% CI -765-+464)

Interpretation • Paramedic practitionerswith extended skills can provide a clinically and cost effective alternative to standard ambulance transfer and treatment in an ED for older patients with acute minor conditions

Alternative destinations: Minor Injury Units Snooks et al • Cluster randomised controlled trial + qualitative interviews with staff • ‘On’ weeks (protocols allowed conveyance to MIU) and ‘off’ weeks (standard practice – patients to ED) • Outcomes of interest: • Ambulance performance • Patient satisfaction • Clinical safety • Factors influencing destination decision

MIU study findings • Randomisation … patients equally likely to be taken to MIU in ‘off’ weeks as ‘on’ weeks • Analysis plan changed • Compared outcomes of those taken to MIU with those taken to ED, controlling for case mix

Key results • Fewer patients were taken to MIU than anticipated • Patients taken to MIU were: • more likely to rate their care as excellent (OR 7.2, 95% CI 2.0 to 25.8) • Resulted in shorter ambulance service ‘job cycle’ times (-7.8 minutes, 95% CI -11.5 to – 4.1) • Spent less time in hospital (-222.7 minutes, 95% CI -331.9 to -123.5)

Crew reported factors affecting destination decision • Distance to unit • Uncertainty about MIU acceptance of patient • Opening times of MIU • Patient age • Underlying medical condition • Patient preference • Service delivery • Reduced job cycle time • Improved handover • Study design confusion

MIU study conclusions • When patients were taken to MIU, job cycle times shorter and patient satisfaction high, and costs saved • However, change in practice difficult to achieve • RCT with randomisation by week difficult to operationalise

Treat and Refer study Snooks et al • Methods • Controlled study • Two neighbouring ambulance stations • Patients attended within inclusion criteria were followed up through • Ambulance service care • ED and hospital care • Patient satisfaction and quality of life • Qualitative interviews with crews

Minor allergic reactions Insect bites and stings Boils/abcesses Splinter removal Post-operative wound problem Dressing problem Wounds (minor) Soft tissue injuries (minor) Epistaxis Sore throat Cold or flu symptoms Toothache Faints Falls Diarrhoea Fit in known epileptic Resolved hypoglycaemia in known I.D. diabetic Lower back pain Constipation Blocked urinary catheter Emotional/hysterical reaction Alcohol intoxication Social problems 23 protocols developed:

Key findings • 251 intervention and 531 control patients • No impact on conveyance rate (37.1%, 36.3%) • Job cycle time longer for intervention patients, especially when not conveyed 59 vs 54 minutes; 35 vs 27 minutes • Higher satisfaction in non-conveyed patients in intervention group • 5/93 intervention and 12/195 patients left at home were admitted to hospital during following 14 days • Clinical review: 3 in each group should have been taken to ED at time of ambulance attendance

Findings from focus groups • Factors influencing conveyance decisions: • Experience • Intuition • Training • Time of call • Patient preference • Home situation • Views concerning intervention • Positive – should be introduced across service • Difficulties with persuading patients to stay at home • More training and support needed

Conclusions • ‘Treat and Refer’ protocols feasible, acceptable to crews and patients • Operational impact • Safety issues identified • Introduction complex • Change management required

Fit to be Left ?Halter et al • Developed and tested protocols for ambulance crews to assess older people who have fallen to non-conveyance • Controlled before and after study • Outcomes • Conveyance rates • Safety - adverse incidents

Fit to be left: Key findings • Baseline data – standard practice • 2003/4, 8% of all 999 calls in London were for older people who had fallen (n = 60,064), with 40% not conveyed to hospital. • Of 2151 emergency calls attended in the study areas during September/October 2003, 534 were for people aged 65 or over who had fallen. • Of these, 194 (36.3%) were left at home • 86 (49%) made health care contacts within the two-week follow up period • 83 (47%) called 999 again at least once • increased risk of death (SMR) of 5.4 and of hospital admission of 4.7 compared with the general population of the same age in London

Fit to be Left: main study findings • 1224 cases were identified, 488 (40%) were non-conveyed, no change from baseline • Clinical review: • 78% of non-conveyed cases - use of the tool had led to a correct clinical decision • 94% of conveyed cases - application of the tool had led to the correct decision • In 67% of cases care could not have been currently accessed elsewhere

Fit to be Left: study conclusions • easily identifiable high risk population who are not being adequately cared for within existing health care systems. • formalised assessment can be implemented to enable clinically appropriate conveyance decisions and reduce adverse event rates. • large gaps in services for this population and the potential solutions and alternative models of care lie outside the remit of the ambulance service • In the absence of a strategic whole systems approach to the redesign of care pathways, this patient population will continue to use disproportionately high levels of emergency services and fail to access alternative care which the evidence would suggest may lead to better outcomes both for the individual and the health and social care system.

Discussion and implications • Need for alternatives to traditional emergency response • Ambulance service care needs to be integrated into emergency system • Change can be hard to achieve • Assumptions about effects are not always found in practice • Research and evaluation need to take place before and alongside innovation

References/contacts • PPOPS study: Suzanne Mason, University of Sheffield s.mason@sheffield.ac.uk • MIU study: Snooks H, Foster T, Nicholl J. Results of an evaluation of the effectiveness of triage and direct transportation to minor injuries units by ambulance crews. Emerg Med J 2004;21:105-111 • Treat and Refer study: Snooks H, Kearsley N, Dale J, Halter M, Redhead J, Cheung WY. Towards primary care for non-serious 999 callers: results of a controlled study of ‘Treat and Refer’ protocols for ambulance crews. Qual Saf Health Care 2004;13:435-443 Snooks HA, Kearsley N, Dale J, Halter M, Redhead J, Foster J. Gaps between policy, protocols and practice: a qualitative study of the views and practice of emergency ambulance staff concerning the care of patients with non-urgent needs. Qual Saf Health Care 2005;14:251-257 • ‘Fit to be Left’ study: Mary Halter, Kingston University mhalter@hscs.sgul.ac.uk

Alternatives to the standard emergency ambulance response: a review of costs and benefits