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Warwick Emergency Care and Rehabilitationwww.warwick.ac.uk/go/ambulanceWarwick Emergency Care and

Rehabilitation1

Ambulances and overcrowdedemergency departments

Prof Matthew CookeWarwick Medical School, UK

Emergency Medicine Advisor,Government Dept of Health, UK



Warwick Emergency Care and Rehabilitationwww.warwick.ac.uk/go/ambulanceWarwick Emergency Care andRehabilitation 2

NHS S ervice Delivery AndOrganisation R&D Programme

S DO/29/2002

Acknowledgment




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




ED overcrowding

12 hour waits for admission 4 hour total time in ED

Background




Ambulances waiting outside EDs

Decreased response times S taff morale

Patient care compromised

Background




TARGETS

AMBULANCE

15 minutes maximum time to handover

CONFLICT WITH4 hours maximum stay in the ED




Missing the point ExampleWhen more than 4 ambulances are waiting to

handover patients, then an ambulanceofficer will be allocated to care for these

patients in the corridor to free up the other

crews?? Patient centred solution??




- Systematic Review according toguidelines from NHS Centre for Reviewsand Dissemination

- Search strategy - 61860 studies.- Initial sift of titles and abstracts - 3178 - 334 were fully reviewed- 109 met the selection criteria.

Meth od




BackgroundCall 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




Possible solutionsDivert non serious 999 calls to NurseAdviceAmbulance crew treat and dischargeAmbulance crew choose most appropriatedestination




Divert calls to Nurse Advice52% triaged as not requiring emergencyambulance and a third of these did requireED. BUT 9% of those triaged as notrequiring ambulance were admitted tohospital (Dale 2003)

US study showed 98% negative predictivevalue for ED attendance




Divert calls to Nurse Advice NHS Research ± soon to be published

13% of all 999 calls67% returned, of which 25% needed 999

Callers satisfiedAdverse events 4 in 1552




Standard ED triage cannot be usedAMPDS not designed for this (26% of nontransports were delta)




Different DestinationLondon- extra protocols introduced for transport to MIU. No change in turnaround

times, no decrease in ED usage. (LAS 2002)London - treat and refer protocols. Nochange in conveyance to hospital; 6 minutes

longer cycle time; 9% of those left at homewere admitted within 14 days (Snooks,2001)




3% had critical incident when paramedicthought appropriate to leave at home and

11% potential incidents(Schmidt, 2000)9.6% undertriage, half due to guidelineviolations. 8.4% incorrectly stated not toneed ED. (Pointer 2001)22% of non transported were inappropriate(Selden 1991)




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)




LimitationsInternational variationTraining given for roleShort time seriesExpert opinion rather than actual outcome




Conclusions from LiteratureSafety is not confirmed for these changesand doubts have been raisedShould proceed with cautionFull evaluation is required




WORKING TOGETHER Access to dataCombined escalation plansNeutral Referee




CAPACITY MANAGEMENTControl flowsSpreading the workloadWhich patientsWhen to start

Problems




DIVERSIONSRecognised as bad for patients (Schull2004)

What benefit?Can create artificial variability in a systemVariation creates poor performance




DIVERSIONSShould be for exceptionalcircumstances

If used regularlysuggests failure to

use predictiveanalysis andfailure to plan

Hou rly rriv ls by y f o r: irmi h m Hea r t land s & S o lih u ll N HSTr u s t (Teac hi ng)

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Warwick Emergency Care and Rehabilitationwww.warwick.ac.uk/go/ambulance

Warwick Emergency Care andRehabilitation

25

BYPASSING THE EDObvious admissions obvious ly need admittingSo why do they have to go through the

emergency department





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What is the role of the ED?





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NOTHING DIFFERENTWhy do something different when it is busy?

If it is best for patient when it is busy«..?





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DECREASING VARIABILITYSmoothing the workloadGP urgent transfers at lunchtimeFlexible catchment areas





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Ambulance Solutions are long termHelp reduce attendancesNot a fire fighting measure





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Ambulance turnaround delaysGetting ownershipNot an ambulance solution!BUT«.





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Essex AmbulanceAction when turnaround times increased ± Help get patients out of hospital ± Unclog the system





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The main solution = ED performance





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THE solution to diversion

ALL EDs accept patients all the timeAll Hospitals accept patients from EDAll Homes accept discharges

www.warwick.ac.uk/go.edwaits

BAN IT





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Freeways

Find the bottleneck Don¶t just make bigger roads and morevehicles





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GETTING TO THE SOLUTIONPatient¶s perspective

Eliminatingartificial barriers

betweenhealthcareorganisations





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The future of ambulance servicesWhy do we need ambulance services as a

separate entity?

One emergency healthcare service





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One final thought

Local solutions are best

But hopefully some of the UK experience will be helpful





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Reducing ED attendances -can ambulance services

help?Prof Matthew CookeWarwick Medical School, UK

www.w ar w ick . ac . uk/go/a ulanc e

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