ambulances and overcrowded emergency departments prof matthew cooke warwick medical school, uk emergency medic

1. Warwick Emergency Care and Rehabilitation 1 Ambulances and overcrowded emergency departments Prof Matthew Cooke Warwick Medical School, UK Emergency Medicine Advisor, Government Dept of Health, UK

2. Warwick Emergency Care and Rehabilitation 2 This 14-month project was submitted to and funded by the service delivery organisation with the aim of ……This 14-month project was submitted to and funded by the service delivery organisation with the aim of ……

3. Warwick Emergency Care and Rehabilitation 3 For patients, most important area for improvement - waiting time (Cooke & Jenner, 2002). Long wait in ED commonest cause of complaints (Trout et al., 2000). Improving emergency care - UK government priority. Background Research has shown that for patients the most important area for improvement in emergency departments is waiting time. Long waiting times in emergency departments is the commonest cause of complaints (Trout et al., 2000). And improving emergency care is a government priority in the UK. Research has shown that for patients the most important area for improvement in emergency departments is waiting time. Long waiting times in emergency departments is the commonest cause of complaints (Trout et al., 2000). And improving emergency care is a government priority in the UK.

4. Warwick Emergency Care and Rehabilitation 4 ED overcrowding 12 hour waits for admission 4 hour total time in ED Background Research has shown that for patients the most important area for improvement in emergency departments is waiting time. Long waiting times in emergency departments is the commonest cause of complaints (Trout et al., 2000). And improving emergency care is a government priority in the UK. Research has shown that for patients the most important area for improvement in emergency departments is waiting time. Long waiting times in emergency departments is the commonest cause of complaints (Trout et al., 2000). And improving emergency care is a government priority in the UK.

5. Warwick Emergency Care and Rehabilitation 5 Ambulances waiting outside EDs Decreased response times Staff morale Patient care compromised Background Research has shown that for patients the most important area for improvement in emergency departments is waiting time. Long waiting times in emergency departments is the commonest cause of complaints (Trout et al., 2000). And improving emergency care is a government priority in the UK. Research has shown that for patients the most important area for improvement in emergency departments is waiting time. Long waiting times in emergency departments is the commonest cause of complaints (Trout et al., 2000). And improving emergency care is a government priority in the UK.

6. Warwick Emergency Care and Rehabilitation 6 TARGETS AMBULANCE 15 minutes maximum time to handover CONFLICT WITH 4 hours maximum stay in the ED

7. Warwick Emergency Care and Rehabilitation 7 Missing the point Example When more than 4 ambulances are waiting to handover patients, then an ambulance officer will be allocated to care for these patients in the corridor to free up the other crews ?? Patient centred solution??

8. Warwick Emergency Care and Rehabilitation 8 Systematic Review according to guidelines from NHS Centre for Reviews and Dissemination Search strategy - 61860 studies. Initial sift of titles and abstracts - 3178 334 were fully reviewed 109 met the selection criteria. Method The search strategy generated a total of 61860 studies. Following the initial sift the tilites and abstracts of 3178 were reviewed and of these 334 were fully reviewed, and 109 met the selection criteria. The search strategy generated a total of 61860 studies. Following the initial sift the tilites and abstracts of 3178 were reviewed and of these 334 were fully reviewed, and 109 met the selection criteria.

9. Warwick Emergency Care and Rehabilitation 9 Background Call prioritisation evidence of safety is poor (Wilson, 2002) up to 30% error rate (Cooke 1999, Nicholl 1996) 30-52% do not require emergency ambulance (Snooks, 1998) Most are transported to ED

10. Warwick Emergency Care and Rehabilitation 10 Possible solutions Divert non serious 999 calls to Nurse Advice Ambulance crew treat and discharge Ambulance crew choose most appropriate destination

11. Warwick Emergency Care and Rehabilitation 11 Divert calls to Nurse Advice 52% triaged as not requiring emergency ambulance and a third of these did require ED. BUT 9% of those triaged as not requiring ambulance were admitted to hospital (Dale 2003) US study showed 98% negative predictive value for ED attendance

12. Warwick Emergency Care and Rehabilitation 12 Divert calls to Nurse Advice NHS Research – soon to be published 13% of all 999 calls 67% returned, of which 25% needed 999 Callers satisfied Adverse events 4 in 1552

13. Warwick Emergency Care and Rehabilitation 13 Standard ED triage cannot be used AMPDS not designed for this (26% of non transports were delta)

14. Warwick Emergency Care and Rehabilitation 14 Different Destination London- extra protocols introduced for transport to MIU. No change in turnaround times, no decrease in ED usage. (LAS 2002) London - treat and refer protocols. No change in conveyance to hospital; 6 minutes longer cycle time; 9% of those left at home were admitted within 14 days (Snooks, 2001)

15. Warwick Emergency Care and Rehabilitation 15 3% had critical incident when paramedic thought appropriate to leave at home and 11% potential incidents(Schmidt, 2000) 9.6% undertriage, half due to guideline violations. 8.4% incorrectly stated not to need ED. (Pointer 2001) 22% of non transported were inappropriate (Selden 1991)

16. Warwick Emergency Care and Rehabilitation 16 Alberquerque study suspended. (1998) Low agreement between paramedics and ED physicians on need for ED care (Hauswald 2002) 32% of those determined by paramedic to not need treatment were deemed incorrect (Silvestri 2002)

17. Warwick Emergency Care and Rehabilitation 17 Limitations International variation Training given for role Short time series Expert opinion rather than actual outcome

18. Warwick Emergency Care and Rehabilitation 18 Conclusions from Literature Safety is not confirmed for these changes and doubts have been raised Should proceed with caution Full evaluation is required

19. Warwick Emergency Care and Rehabilitation 19 WORKING TOGETHER Access to data Combined escalation plans Neutral Referee

20. Warwick Emergency Care and Rehabilitation 20 CAPACITY MANAGEMENT Control flows Spreading the workload Which patients When to start Problems

21. Warwick Emergency Care and Rehabilitation 21 DIVERSIONS Recognised as bad for patients (Schull 2004) What benefit? Can create artificial variability in a system Variation creates poor performance

22. Warwick Emergency Care and Rehabilitation 22 DIVERSIONS Should be for exceptional circumstances If used regularly suggests failure to use predictive analysis and failure to plan

23. Warwick Emergency Care and Rehabilitation 23 Early intervention, not waiting until the crisis EDs can tell you several hours in advance of the “crisis”

24. Warwick Emergency Care and Rehabilitation 24 DIVERSIONS Should be last resort REMEMBER Different from planned bypass

25. Warwick Emergency Care and Rehabilitation 25 BYPASSING THE ED Obvious admissions obviously need admitting So why do they have to go through the emergency department

26. Warwick Emergency Care and Rehabilitation 26 What is the role of the ED?

27. Warwick Emergency Care and Rehabilitation 27 NOTHING DIFFERENT Why do something different when it is busy? If it is best for patient when it is busy…..?

28. Warwick Emergency Care and Rehabilitation 28 DECREASING VARIABILITY Smoothing the workload GP urgent transfers at lunchtime Flexible catchment areas

29. Warwick Emergency Care and Rehabilitation 29 Ambulance Solutions are long term Help reduce attendances Not a fire fighting measure

30. Warwick Emergency Care and Rehabilitation 30 Ambulance turnaround delays Getting ownership Not an ambulance solution! BUT….

31. Warwick Emergency Care and Rehabilitation 31 Essex Ambulance Action when turnaround times increased Help get patients out of hospital Unclog the system

32. Warwick Emergency Care and Rehabilitation 32 The main solution = ED performance

33. Warwick Emergency Care and Rehabilitation 33 THE solution to diversion ALL EDs accept patients all the time All Hospitals accept patients from ED All Homes accept discharges www.warwick.ac.uk/go.edwaits

34. Warwick Emergency Care and Rehabilitation 34 Freeways Find the bottleneck Don’t just make bigger roads and more vehicles

35. Warwick Emergency Care and Rehabilitation 35 GETTING TO THE SOLUTION Patient’s perspective Eliminating artificial barriers between healthcare organisations

36. Warwick Emergency Care and Rehabilitation 36 The future of ambulance services Why do we need ambulance services as a separate entity? One emergency healthcare service

37. Warwick Emergency Care and Rehabilitation 37 One final thought Local solutions are best But hopefully some of the UK experience will be helpful

38. Warwick Emergency Care and Rehabilitation 38 Reducing ED attendances - can ambulance services help? Prof Matthew Cooke Warwick Medical School, UK www.warwick.ac.uk/go/ambulance . .