Paramedic Pathfinder and Community Care Pathways

North West Ambulance Service - Paramedic Pathfinder and Community Care Pathways

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04 Foreword05 Collaborative Commissioning for the Future06 The Challenge 07 How can we provide better care?08 The Solution08 Paramedic Pathfinder 08 General Principles09 Paramedic Pathfinder (Trauma) V810 Paramedic Pathfinder (Medical) V711 Clinical Pathfinder General Discriminator Dictionary16 Decision making16 Knowledge and Experience16 The Decision Process 17 Pre-Hospital Early Warning Score 18 Pre-Hospital Early Warning (PHEW) Score Table 19 PHEW Case Study 20 Next Steps 21 Trauma Pathfinder 23 Trauma Case Study 1 24 Trauma Case Study 2 25 Medical Pathfinder 27 Medical Case Study 1 28 Medical Case Study 2

29 Paramedic Pathfinder Summary 29 Community Care Pathway 29 Individual Care Plan 30 Paramedic Pathfinder – Community Care Pathways Referral Flowchart 31 Community Care Pathway – Care Plan V11 (front) 32 Community Care Pathway – Care Plan V11 (rear) 33 Community Care Pathway Referral Process 34 E-Learning materials 34 Operational and Clinical Bulletins35 Summary of key benefits and outcomes36 Key Contacts37 Notes:38 Confirmation of Completion

Table of Contents


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Urgent and emergency services in the North West are facing an unprecedented challenge; to maintain quality services within restricted budgets, whilst the complexity and volume of urgent and emergency cases continues to increase.

Urgent and emergency care pathways are often fragmented and complex, resulting in confusing care journeys for the many patients not able to understand where and when to access urgent and emergency care.

Public expectations of access and quality of care, married with increased mobility and changes to GP out-of-hours services has led to increased 999 call volumes and associated attendance at Emergency Departments (ED).

Attendances at ED continue to rise across the UK with over 21 million reported last year.

The impact and pressure of ED attendance on hospitals is well documented. Across the North West hospital admission as a result of ED attendance is an average of 24.5%, which is higher than the national average of 22.3% for the whole of England. So it is becoming clear that the ED attendance rate depends on the range of care services available as a safe alternative to ED.

Logically, if alternatives are available, only the more serious cases will attend ED.

Ambulance arrivals are currently responsible for approximately one third of all ED attendances and therefore the ability of NWAS to positively impact on admission rates, as the provider of first contact and urgent care, is vitally important.

Mean waiting times in ED are increasing. The North West average of 125 minutes is exceeded in Greater Manchester at 133 minutes. This leads to a traffic jam of patients and NWAS resources (ambulance and clinicians), within ED.

The case for a system that provides the right care, at the right time, in the right place, has never been greater.

NWAS recognises that as the first point of contact it has a major influence on integrating the urgent and emergency care system, which is patient focused, based on good clinical outcomes and delivers a quality patient experience; right first time.

In developing urgent and unplanned care pathways it is critical to ensure that appropriate and effective care pathways are in place; that they are compliant with the specification and form part of a coherent set of services which work together for the benefit of all.

NWAS, alongside commissioning networks throughout the North West, are working together working towards a principle-led and outcomes-focussed approach to collaborative commissioning for the future.

Collaborative Commissioning for the FutureThe demand for emergency ambulances is increasing every year and the range of conditions and changing clinical patterns of patients continue to challenge us as pre-hospital practitioners.

Urgent Care activity is also rising rapidly and the introduction of Urgent Care Centres, Specialist and Community referral pathways, as a safe and effective alternative to the Emergency Department are a crucial development in addressing the demand.

Success in combating this increasing workload will rely upon our ability to accurately assess, treat and refer patients to the most appropriate care providers.

We will continue to be faced with stabilisation and transportation of time-critical patients such as major trauma or acute cardiac events. However, there is a growing awareness that many patients could be treated in a pre-hospital environment by Urgent Care Centres or Community services.

The average A&E attendance to admission ratio in urban areas across the North West is higher than the national average and the challenge is on to reduce A&E attendances for those patients appropriate for treatment by alternative services.

This document has been produced to familiarise external stakeholders and colleagues with the Paramedic Pathfinder Decision Support Algorithms and individual Community Care Plans, within Community Care Pathways.

Mark Newton Consultant ParamedicNorth West Ambulance Service

Foreword


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The challenge is to secure significant system wide benefits and quality improvements by reducing the number of inappropriate ambulance calls and journeys, unnecessary ED attendances and hospital admissions.

Some patients repeatedly access 999 services, often when an alternative care pathway would be more appropriate.

These patients often have complex health and social care needs which if unmanaged will often result in an unnecessary transportation to ED.

The average cost of each 999 emergency ambulance journey is £249 plus an ED attendance tariff of £59 to £117 incurred by the Clinical Commissioning Group (CCG).

By working together, we can identify frequent callers and put a case management process in place including establishing care plans for particular patients with long term health conditions, care home residents or patients requiring additional care support.

In many cases the patient’s primary care provider, establish a care plan for appropriately managing individuals on a case by case basis. This plan might include referral to the community matron team or social care support, arranging care planning for long term conditions or referral for

support to address mental health or addiction issues.

Management of frequent 999 callers will deliver significant improvements to the patient’s quality of care and should help to address underlying care issues which may have been overlooked. NWAS can provide care providers and commissioners with data on frequent callers.

This data allows differentiation between unstable patients, frequently in need of emergency care and those frequent callers who may benefit from accessing an alternative care pathway.

This enables the care provider to identify a proactive approach to individual care management needs but also potential pathways, designed to provide care for specific illnesses and long term conditions. Urgent and emergency services in the North West are facing an unprecedented challenge, to maintain quality services within a restricted financial envelope, whilst the complexity, acuity and quantity of urgent and emergency cases continue to increase. This is not sustainable.

Each year the NHS spends in excess of £1.5bn on admissions for common ambulatory sensitive conditions. Many patients would benefit from referral to more appropriate care pathways.

The ChallengeIn many cases, patients with pre-existing morbidities, can be managed by community based specialist teams rather than acute hospital admission.

By promoting a system of partnership working and information sharing with key stakeholders, the safer care closer to home project aims to:

• reduce the number of high intensity users being admitted to in-patient care

• increase the numbers of patients accessing care away from Emergency Departments• increase the number of secondary conveyance by non PES resources• enhance quality of care for patients with non-time-critical presentations.

This will be achieved by:

• implementing enhanced on-scene assessment processes• improving levels of UCS use, direct referral into community based providers, primary and urgent care services• enhanced case management through active care planning• improved use of self-care pathways.

The core feature of this initiative is to share information across services and ensure ambulance clinicians are aware of pre-existing care plans for patients being managed by community services.

Community Teams will share information with NWAS using the using the Electronic Referral and Information Sharing System (ERISS) to place the patient on the Referral Management Database, create an alert, and ensure that responding ambulance practitioners are pre-alerted to the presence of a care plan.

Ambulance practitioners would then refer patients to community teams subject to application of appropriate clinically evaluated triage protocols such Pathfinder, Manchester Triage Systems (MTS) or AMPDS. This clearly presents an opportunity for a solo response model given the likely reduction in secondary transfer.

The Paramedic Pathfinder and Community Care Pathway (CCP) Team are working with CCGs and a range of Health and Social Care Providers to identify patients who may benefit from improved case management via the utilisation of a care plan which is left in the patient’s home.

The agencies are working together using a risk stratification process that identifies patients who are high intensity users because of their co-morbidities and social needs.

These patients will be on a defined community care pathway and have a care plan completed for them by their lead clinician / case manager that clearly defines the care to be provided and onward referral process should the patient request assistance from the ambulance service and be assessed as Amber or below (mid-acuity).

How can we provide better care?


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9Paramedic Pathfinder (Trauma) V8Paramedic Pathfinder; an award winning consistent and clinically safe triage and evidence-based processes designed to enable accurate face-to-face assessment of individual patient needs, on scene.

Community Care Pathways (CCPs) is one of a number of clinical outcomes linked to the Paramedic Pathfinder, enabling ambulance

paramedic staff to determine the most effective referral and treatment options for known patients via the use of individual community care plans that have been instigated by the patients ‘case worker’ or lead clinician. Once a patient is placed on a CCP, their personal care plan will be generated and maintained by the healthcare professional. The care plan will be kept at the patient’s address.

Paramedic Pathfinder is a key element of the NWAS Urgent Care Strategy and Quality Strategy, developed to enable NWAS clinicians to conduct a face to face assessment when they arrive at the scene and, using a flow chart of specific symptoms, determine the most appropriate care pathway for the individual patient.

Paramedic Pathfinder won the Health Service Journal Clinical Service Redesign Award 2011.

Pathfinder will generate four key outcomes, all of which are aimed at accurate streaming and direction of patients, to the most appropriate care for their needs, including:

• Emergency Department • Urgent Care Centres or Kite marked equivalents• Community or Primary Care Pathways• Self-Care Pathways

Use of the Paramedic Pathfinders is restricted to staff of NWAS Emergency Medical Technician 2 and above.

The Pathfinders are designed for assessment of patients across all categories of emergency.

The following categories of patients are excluded from the Pathfinders:

• Stroke patients• Non traumatic chest pain• Patients < 5 years of age• Obstetric and gynaecological presentations• Acute mental health presentations• Pre-Hospital early warning Score > 4

There are currently Paramedic Pathfinders available for medical and trauma patients, with three new Pathfinders currently being developed, to cover obstetric and gynaecological, children and mental health patients.

NWAS understands that acutely unwell patients will always require early intervention by Emergency Department and Pathfinder will ensure these patients are recognised at an early stage in the assessment process.

Other key developments in patient and healthcare management throughout the NHS include Community Care Pathways; an alternative pathway of care for patients retained in their own home, which enables NWAS crews to identify the patients on-going care plan and history in order to determine and deliver the most effective referral, treatment and care for the patient’s needs.

Community Care Pathways are one of a number of clinical outcomes linked to the Paramedic Pathfinder.

The Solution

Paramedic Pathfinder

General Principles

Transport to EmergencyDepartment

Transport to UCC oraccess Community CarePathway if available

Consider Self CarePathway

Proceed to next priority box

Paramedic Pathfinder (Trauma) V8 February 2013North West Ambulance Service NHS Trust

This process does not apply to the following patient categories :Cerebrovascular Accident (CVA)

Non-Traumatic Chest PainPatients < 5 Years of Age

Obstetric and Gynaecological PresentationsAcute Mental Health Presentations

PHEW > 4

Complete Primary SurveyABCD

Complete Primary SurveyABC Airway Compromise

Progressive or Sudden Worsening of BreathingShock

Uncontrollable BleedingNew Neurological Deficit

Acute Loss of MobilityReduced Level of Consciousness

Severe PainSignificant Mechanism of Injury (inc Spinal

Immobilisation )Head injury with loss of consciousness / amnesia in a

patient aged over 65 OR has a history of coagulopathy

Fulfils criteria for Self Care Pathway

Complete Self CarePathway Process including relevant

documentation

Stabilise and immediate

transportation to ED

YES

NO

YES

Transport to UrgentCare Centre

(Kitemark 1 Only)If Patient has a current

Community CarePathway in situ , please

consider referral

Clear and leave Scene

NO

Think !Do you need toConvey?

➜➜

➜➜

➜

➜ ➜

Penetrating Injury of Head , Neck or TorsoGross Deformity /Open Fracture

History of UnconsciousnessVascular Compromise

Critical SkinInhalation Injury

Direct Trauma to the Neck or BackFacial Oedema

Temp ≥ 35 Deg CElectrical or Chemical Injury

NO

Emergency DepartmentYES

➜➜

➜ ➜

➜ ➜

➜➜➜

Pauseand

review


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11Clinical Pathfinder General Discriminator Dictionary

Discriminator Group Description Questions / Advice

Abdominal pain radiating to back

Abdominal pain in adults

Any abdominal pain associated with back pain that is felt either intermittently or constantly.

Do you have pain in your tummy?

Does the pain go through to your back?

Abnormal pulse Abnormal pulse

Current palpitations

A bradycardia (<60 min in adults), a marked tachycardia (> 120 min in adults) or an irregular rhythm. A feeling of the heart racing that is still present.

Does your heart feel like it is fluttering?

Acute loss of mobility

Unable to walk

Inability to weight bear

Patient whose normal ability to mobilise is compromised. Inability to carry the full weight of the body through one or both limbs.

Patients who are normally unable to walk due to chronic illness or disability are not included in this category.

Can they walk?

Can they hobble about?

Does it hurt to walk?

Acute mental health presentations

Mental illness An acute mental health presentation is characterised by sudden or rapid onset of significant and distressing symptoms of a mental illness requiring immediate treatment.

This may be the person’s first experience of mental illness, a repeat episode or the worsening of symptoms of an often continuing mental illness. The reason for the inclusion of ‘Acute’ in Pathfinder as opposed to just ‘mental health presentations’ was to ensure that patients with other acute problems that co-exist with chronic mental illness, such as dementia, are not excluded from alternative pathways of care.

Does the patient have a history of mental health problems and or a named community mental health worker?

Does the patient take medication for mental health problems? If so have they recently stopped talking this?

Have the patients symptoms changed suddenly / progressively worsened?

Does the patient present a risk to themselves or others?

Has the patients self-harmed or do they have a history of self harm?

Is the patient acutely distressed or disruptive?

Airway compromise

Airway compromise

Stridor

Drooling/inability to swallow

An airway may be compromised either because it cannot be kept open or because the airway protective reflexes (that stop inhalation) have been lost. Failure to keep the airway open will result in intermittent or total obstruction or in partial obstruction. This will manifest itself as snoring or bubbling sounds during inspiration or expiration. Saliva running from the mouth due to inability to swallow.

Are they awake?

Are they struggling to breathe?

Can they get their breath in?

Do they make a gurgling sound when they breathe?

Cerebrovascular accident (CVA)

Cerebro-vascular accident (CVA), is the rapid loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage. As a result, the affected area of the brain cannot function, which might result in an inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field.

FAS Test -

Is the face drooping?

Is there any arm weakness?

Or

Any speech difficulty?

Paramedic Pathfinder (Medical) V8Transport to EmergencyDepartment

Transport to UCC oraccess Community CarePathway if available

Consider Self CarePathway


Paramedic Pathfinder (Medical) V8 October 2013North West Ambulance Service NHS Trust

This process does not apply to the following patient categories :Cerebrovascular Accident (CVA)

Non-Traumatic Chest PainPatients < 5 Years of Age

Obstetric and Gynaecological PresentationsAcute Mental Health Presentations

Overdose with Possible lethalityPHEW > 4


History of UnconsciousnessHeadache as Primary Presentation

Purpura/Non Blanching RashVascular Compromise

Tachycardia > 120Temp ≤ 35 or ≥ 40 Deg C

Vomiting BloodHaematuria /First Episode Retention

Abdominal Pain Radiating to BackSignificant PR Bleed

Temperature ≥ 38.5 Deg CHistory of Acutely Vomiting Blood

Hyperglycaemia > 17 mmol (without Ketosis )Retention of Urine

Inability to Weight BearVertigo

Abnormal PulseFacial /Tongue Oedema

Significant Cardiac History



documentation

YES

Emergency Department


YES

Pauseand

review


➜

NO

➜➜

➜➜

Transport to Urgent Care Centre(Kitemark 1 Only) If Patient

has a current Community Care Pathway in situ , please

consider referral

NO➜ ➜

➜ ➜

Airway CompromiseSudden Worsening of Breathing

ShockUncontrollable Bleeding

History of New Neurological DeficitUnable to Walk

Reduced Level of ConsciousnessSevere Pain



YES

NO

➜➜

➜ ➜

➜➜➜

NO

➜➜

Consider Transport to Urgent Care Centre (Kitemark 1 Only)

If Patient has a current Community Care Pathway in situ ,

please consider referral

YES➜ ➜


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13Discriminator Group Description Questions / Advice

Frank haematuria / haematuria

Haematuria Red discolouration of the urine caused by blood

Is there blood in your urine?

Is your urine red?

First episode retention

Retention of urine

Inability to pass urine per urethra associated with an enlarged bladder. This condition is usually very painful unless there is altered sensation.

When is the last time you passed urine?

Do they have abdominal pain with distension?

Headache as primary presentation

Abrupt onset headache

Headache

Any patient whose main presenting symptom is headache or who experienced symptoms of headache with onset within seconds or minutes. May cause wakening from sleep.

Do you have a headache?

Is your headache your main symptom?

How long ago did it start?

When did it come on?

Did it come on suddenly?

History of acutely vomiting blood

Frank heamatemesis, vomiting of altered blood (coffee ground) or of blood mixed in the vomit within the past 24 hours.

Have you vomited any blood?

Have you vomited up any brown stuff?

How long ago did the vomiting start?

History of unconsciousness

There may be a reliable witness who can state whether the patient was unconscious (and for how long). If not a patient who is unable to remember the incident should be assumed to have been unconscious.

Were you (they) unconscious?

Have you (they) been knocked out?

Hyperglycaemia > 17 mmol (without Ketosis)

Glucose > 17mmol/l without signs of acidosis (deep sighing resps etc.)Do you test your blood for glucose?

What is it?

Do you have ketones in your urine? (If available)

History of New Neurological Deficit

New Neurological Deficit

Acute Neurological Deficit

These may include altered or lost sensation, weakness of the limbs (either transiently or permanently), or alterations in bladder or bowel function. This includes symptoms that may have come on in the past 24 hours.

Can you move all your arms and legs?

Do you have any tingling or numbness?

When did this start?

Significant cardiac history

The patient has a history of a cardiac event / surgery / condition or a long term condition that impacts upon cardiac function. The most common and most important cardiac symptoms and history are:

Chest pain, tightness or discomfort.

Shortness of breath.

Palpitations.

Syncope (‘blackouts’, ‘faints’, ‘collapse’) or dizziness.

Related cardiovascular history, including transient ischaemic attacks, stroke, peripheral vascular disease and peripheral oedema.

Any history of raised blood pressure, heart problems, fainting fits, dizziness or collapses?

Any history of MI, angina, cardiac procedures or operations - type and date of intervention and outcome?Has the patients levels of lipids if ever checked or known?

Does the patient have a history of stroke or diabetes?

Any history of rheumatic fever or heart problems as a child?

Significant PR bleed

Passing fresh or altered blood PR

Black or redcurrant stools

In active massive GI bleeding dark red blood will be passed PR. As GI transit time increases this becomes darker, eventually becoming malaena. A dark red stool is classically seen in intussusception. Flecks of fresh blood seen after defaecation is not classed as significant PR Blood loss.

Are you passing blood from the back passage at the moment?

What colour is it?


Coagulopathy Coagulopathy (also called clotting disorder and bleeding disorder) is a condition in which the blood’s ability to clot is impaired.

This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.

Does the patient have a history of anti-coagulant therapy or clotting disorder?

Facial/tongue oedema

Facial oedema

Facial swelling

Oedema of the tongue

Diffuse swelling around the face usually involving the lips. Any swelling around the face which may be diffuse or localised. Swelling of the tongue of any degree.

Is your face swollen?

Is it swollen in a particular place or all over?

How swollen is it?

Is their tongue swollen?

Overdose with possible lethality

Overdose and poisoning

Overdose with possible lethality What has been ingested?

How much has been ingested?

How long ago was the substance been taken?

Patients < 5 years of age

Patients < 5 years of age Ascertain the age of the child.

PHEW > 4 Pre Hospital Early Warning Score (PHEW) See PHEW scoring sheet

Progressive or sudden worsening of breathing

Inadequate breathing

Acutely short of breath

Unable to talk in sentences

Exhaustion

Breathing which is increasing in severity or extent in relation to their normal respiratory pattern and depth. This includes shortness of breath that comes on suddenly or a sudden exacerbation of chronic shortness of breath. They may be unable to talk in sentences as they are so breathless. Exhausted patients appear to reduce the effort they make to breathe despite continuing respiratory sufficiency. This is pre-terminal.

Are they breathing?

What colour are their lips/tongue?

Can they talk to you in sentences?

Are they fighting for their breath?

Is their breathing faster than usual?

Are there signs of exhaustion?

Are they grunting or using accessory muscles?

Have you suddenly become short of breath?

Are you more short of breath than normal?

Purpura/non blanching rash

Rashes A rash on any part of the body that is cause by small haemorrhages under the skin. A purpuric rash does not blanche (go white) when pressure is applied to it.

Does the rash blanch when pressure is applied?

Reduced level of consciousness

Not fully alert. Either responding to voice or pain only or unresponsive.

Do they open their eyes or move when you speak to them, or gently shake their shoulders?

Retention of urine

Urinary problems Inability to pass urine per urethra associated with an enlarged bladder. The condition is usually very painful unless there is altered sensation.

Can you pass water?

When did you last pass water?

Is it painful?

Severe pain Pain that is unbearable - often described as the ‘worst ever’.

Can you describe how bad the pain is? Use normal pain assessment tools.

Shock Shock is inadequate delivery of oxygen to the tissues. The classical signs include sweating, pallor, tachycardia, hypotension, and reduced levels of consciousness.

Are they pale and sweaty?

Do they have a rapid, weak pulse?

Is their breathing shallow?


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15Discriminator Group Description Questions / Advice

Gross deformity/open fracture

This will always be subjective. Gross and abnormal angulation or rotation is implied. All wounds in the vicinity of a fracture should be regarded with suspicion; if there is any possibility of communication between the wound and the fracture then the fracture should be assumed to be open.

Is there a cut near the broken bone?

Is there bone sticking out?

Inhalation injury A history of being confined in a smoke filled space is the most reliable indicator of smokeinhalation. Carbon deposits around the mouth and nose and hoarse voice may be present. History is also the most reliableway of diagnosing inhalation of chemicals - there will not necessarily be any signs.

Were they (you) confined in a place that was filled with smoke?

Is there any soot in the nostrils ormouth?

Obstetric andgynaecologicalpresentations

Obstetrics and Gynaecological presentations are any symptoms / pathology associated with the female reproductive organs in their pregnant and non-pregnant state, respectively. They do not include symptoms / pathology associated with the urinary tractor system.

Is the patient pregnant / possiblypregnant?

Is the blood loss PV (per vaginum)?

Are there clots present?

Penetrating injury of head,neck or torso

Penetrating eye trauma

Penetrating trauma

A recent physically traumatic event involving penetration of the globe.

A recent physically traumatic event which involves discrete penetration of any body area stated by a knife, bullet or otherobject.

Has it gone into your eye?

Has anything stuck into your eye?

Have you been shot?

Have you been stabbed?

Significant mechanismof injury

Significant mechanism of injury

Significant incident history

Significant factors include falls from a height, ejection from a vehicle, the death(s) of othervictim(s) of the accident and significant deformation of a vehicle.

A mechanism suggesting the potential for severe injury to have occurred. This mayinclude falls from heights, highspeed RTAs and stabbing or shooting incidents.

How did the injury occur?

How far did you (they) fall?

Were you (they) thrown from the car?

What happened to the others in the accident?

This discriminator dictionary will be available on every frontline Paramedic Emergency Service vehicle and should be a point of reference if there is any uncertainty of the discriminator definition or whether the criteria for each discriminator have been fulfilled. The questions are simply suggestions and should be modified as necessary.


Tachycardia > 120

Heart Rate above 120 bpm See PHEW scoring sheet

Temp ≤ 35 or ≥ 40 Deg C

Very hot adult

Cold

Any temp in the range ≤ 35 or ≥ 40 Deg C is considered very hot or cold. If the skin feels cold the patient is clinically said to be cold (a core temperature should be taken as soon as possible)

See PHEW scoring sheet

Temperature ≥ 38.5 Deg C

Hot adult Any temp above 38.5 Deg C is considered hot

See PHEW scoring sheet

Uncontrollable bleeding

Uncontrollable major andminor haemorrhage

Exsanguinating haemorrhage

A haemorrhage that is not rapidly controlled by the application of sustained direct pressure, and which continues to bleed or soak through large dressings.

Are they bleeding a lot?

Where is the blood coming from?

Is the bleeding torrential or pumping out?

Can you stop the bleeding?

Vascular compromise

There will be a combination of pallor, coldness, altered sensation and pain with or without absent pulses distal to the site affected.

Does the limb look a different colour below the injury or when you compare it to the other side?

Vomiting blood Vomiting blood


Vomited blood may be fresh (bright or dark red) or coffee ground in appearance.

Can you see a sample of the vomited fluid?


Critical skin A fracture or dislocation may leave fragments or ends of bone pressing so hard against the skin that the viability of the skin is threatened. The skin will be white and under tension.

Direct trauma to the neck or back

Direct trauma to the neck

Direct trauma to the back

Back-This may be top to bottom (loading) for instance when someone falls and lands on their feet, bending (forwards, backwards or to the side) or twisting.Neck-This may be top to bottom (loading) for instance when something falls on the head, bending (forwards, backwards or to the side), twisting, or distracting such as in hanging.

Have you been hit on your back/neck?

Electrical injury Any injury caused or possibly casued by electric current. This includes AC and DC and both artificial and natural sources.

Is the source of the injury still present?

Is it a domestic or industrial source?

How long ago did the incident occur?

Is there any evidence of a burn or local inflammation?

Chemical injury

Exposure to chemicals

Any substance splashed onto or placed onto the body that casues stinging, burning, reduced vision or any other symptoms.

Have you been exposed to a chemical or unknown liquid / gas / product?

Is there any skin blistering, shortness of breath, stridor, facial or tongue oedema?

When was the contact?

Additional Trauma Discriminators


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Accuracy of triage decisions is a major influence on patient outcomes. Triage is an area in whichyou must know what you are doing, why you are doing it, and which actions to take to achieve a

satisfactory outcome. Through initial on- scene assessment, you must be able to prioritise thepatient on the basis of appropriate decision making.

Decision making

Knowledge and experience are often cited as influential factors in triage decision-making. However, whilst numerous studies have shown that factual knowledge is an important factor, none have found a significant relationship between experience and triage decision-making. Factual knowledge appears to be more important than years of frontline experience. The Trust is embarking on a period of educational change, based on the foundation that knowledge

acquisition will result in improved patient care, assessment, and triage decisions. The ability to interpret, discriminate, and evaluate the information gathered during patient assessment, and critically reflect upon actions following the decision, is essential for good patient care. Until such time, the Trust must rely on a protocol driven approach in order to ensure the safety and protection of both its patients and staff.

Knowledge and Experience

The Clinical Pathfinders are designed to enable the assessing practitioner to confidently andaccurately determine the most appropriate pathway, based on the clinical need of the patient. The algorithms contain a number of exclusions, as listed above, together with a physiological early

warning score, all of which preclude entry to the main algorithm. It is essential that patients in thosecategories or with a physiological score of > 4 are conveyed to the nearest Emergency Departmentor Specialist Treatment Centre.

The Decision Process

The pathfinders are designed to distinguish between patients who can be managed in the urgent care setting and patients who need admission to the Emergency Department. It is accepted that physiological deterioration precedes critical illness, but NWAS practitioners will require the tools to establish a critical level of deterioration.

The Pre Hospital Early Warning (PHEW) score aims to filter those patients with critical physiologicaldeterioration by generating an indicative score based on those patient observations that areroutinely performed by NWAS practitioners.

How does it work?The PHEW score relies on observation parameters that suggest deviation from normal levels.Small changes in individual observations may predict deterioration in the seriously unwell patientbefore obvious, and often too late, critical changes in condition occur. It does not predict patientoutcome.

In order to calculate the PHEW Score it is necessary to perform a series of observations.

The PHEW adapted for pre- hospital use in NWAS does not require any additional training orequipment in order for practitioners to generate a physiological score.

These are as follows:

• Heart rate (BPM)• Respiratory rate• Systolic blood pressure (mmHg)• Sats (percentage with O2 therapy)• Central nervous system• Temperature tympanic• BM mmol/l (capillary)• Pain score (0-10)

Pre-Hospital Early Warning Score


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19Pre-Hospital Early Warning (PHEW) Score Table

Each parameter (vital sign) will generate a score ranging from 0-3 respectively. On the PHEW tool,you will notice that abnormal variants start from the left and gradually become normal to the centreand subsequently deviate away from the norm again as you move to the right hand side. For eachvital sign you check, add up the scores and record the total on the Patient Report Form.

If the total score exceeds 4, the patient should be conveyed to the nearest Emergency Department

You are called to a 19 year old male, Peter.

Peter’s mother has called 999 because he has been unwell for a few weeks, complaining of general tiredness and lethargy. He had been managing to just about get up and go to college, because he is a really committed student, but today he can’t get out of bed.

Attempts to contact his GP have been unsuccessful, and his mother is very concerned about him.

On arrival you find Peter in bed. He is rouseable to speech, and once roused is able to answer your questions accurately.

His colour and temperature are normal.

Patient InformationPeter has been feeling fatigued for two to three weeks, but has just thought that he had a bit of avirus, and has been working hard at college too.

A is normalB is not laboured, but is more rapid than normal, 24 rpmC 115 bpm, regularD is V on AVPUBP is 110/70SpO2 is 96% on airTemp is 37.2deg CBM is 23.2 mmol/L

Peter is previously well, with no medical history. He drinks recreationally and denies takingany non prescription drugs.

PHEW Case Study

Now calculate the patient’s PHEW Score?Answer (Appendix 2).

Parameter/Score

3 2 1 0 1 2 3 IndividualScores

Heart Rate(bpm) <40 41-50 51-59 60-100 101-119 120-129 >130

Respiratory Rate >30 20-29 11-19 9-10 <8

Systolic BP(mmHg) <80 81-90 91-99 100-170 171-199 >200

02 Sats (%)(with oxygen

therapy)>92 90-92 85-89 <85

Central NervousSystem

Newagitation

orconfusion

Alert Respondsto voice

Respondsto pain Unresponsive

TemperatureTympanic >38.5 35.1-

38.4 <35

BM mmo1/1(Capillary) >20 11-19 5-10.9 4.1-4.9 <4

Pain score(0-10) >or=7 5-6 <or=4

TOTAL


20


21

Each Pathfinder should be applied on a reductive basis, i.e. work from the top (time critical) to thebottom, eliminating all preceding discriminators before proceeding to the next step. The process iscolour coded as follows:

Any discriminator eliciting a red directional arrow must be transported to the nearest A&E Department. Patients eliciting an amber arrow can be considered for transport to Urgent CareProviders…. and so on.

The primary survey is the initial part of the patient assessment, intended to rapidly and systematically identify and treat anyimmediately life threatening problems. It follows the standard ABCD format. Assessment and treatment proceed simultaneously – as a problem is identified, appropriate action should be taken before moving on. After any intervention, or ifthere is any sign of a change in condition, repeat the primary survey.

The primary survey relates to patient assessment and treatment, and should only be started after ensuring safety of self and scheme.

You have now reached this phase of the Pathfinder.

There are no differences between the medical and trauma pathfinders at this stage of the algorithm.

It is important to establish which Pathfinder you are going to use for triage purposes. The MTS discriminators have been mapped against the 50 presentation algorithms and subsequentlyseparated into trauma and medical filters. The first part of the triage process requires the practitioner to select the appropriate pathfinder based on the presenting condition of the patient. By identifying the correct pathfinder, the appropriate discriminators will be identified, allowing the clinical priority and destination to be determined.

It is recognised that some patients may present on each pathfinder. For example a patient collapsing may have sustained a traumatic injury as a result of the fall. Where traumatic injuries are sustained secondary to a medical cause, both algorithms should be applied to the patient.

Next Steps

The second phase of the trauma algorithm is to eliminate the presence of potentially time criticalconditions that may require hospital standby or courtesy call. Inability to exclude all discriminatorswithin this box should result in stabilization and immediate transportation to the nearest Accidentand Emergency Department.

If all time critical discriminators are eliminated, simply follow the colour coded directional arrows to the next step of the Pathfinder. In this case, the following box indicates those patients who may not be immediately life threatening but where conveyance to an Accident and Emergency Department is still the required destination.

You will notice that the red star at the top left corner of this box is suggesting a ‘pause and review’. This is to ensure that consideration is given to all life threatening presentations before moving on, a safety prompt to ensure all previous discriminators have been eliminated.

If any symptom discriminators are present, follow the red colour coded arrow and convey to thenearest Accident and Emergency Department.

Trauma Pathfinder

Transport to EmergencyDepartment

Transport to UCC or access Community Care Pathway if available

Consider Self Care Pathway


This process does not apply to the following patient catagories:

Cerebrovascular accident (CVA)

Non-Traumatic chest pain

Patients < 5 Years of age

Obstetric and gynaecological presentations

Acute mental health presentations

PHEW > 4


Airway compromise

Progressive worsening of breathing

Shock


New neurological deficit



Severe pain

Significant mechanism of injury

Head injury with loss of consciousness/

amnesia etc.

NO

➜



YES➜ ➜

Penetrating injury of head , neck or torso

Gross deformity /open fracture


Vascular compromise

Critical skin

Inhalation injury

Direct trauma to the neck or back

Facial oedema

Temp ≤ 35 Deg C

Electrical or chemical injury

NO

➜


YES➜ ➜

Pauseand

review


22


23

At this point, any patient with all preceding discriminators eliminated can be considered forapplication of NWAS NHS Trust approved self-care pathway. The blue prompt star to the top leftcorner of the box simply asks you to ensure that any patient meeting Trust approved guidelines may self-care and not require conveyance to a receiving unit. In these cases, the clinical guidelines process should be completed in accordance with the normal procedure. The assessing crew should then clear and leave scene in order to maximise resources.

If the presenting condition is not covered by clinical guidelines, assessing staff should considerwhether the patient is on an approved ambulance

care-pathway that specifically relates to theircondition. For trauma based presentations the existence of a ‘falls’ pathway should be considered.

Failing this, the patient should be conveyed to the nearest Urgent Care Centre. Patients exiting thePathfinder at the ‘amber’ indications should be considered for transportation by non-PES resources subject to local Service provision. It is crucial to ensure appropriate transport modes are used to maximise availability of PES resources for potentially life threatening incidents.



documentation

YES



➜➜

Transport to Urgent Care Centre(Kitemark 1 Only) if patient


consider referral

NO➜ ➜

➜➜➜

NO➜

You are called to a 46 year old female, Lucy. On a walking trip Lucy has fallen 2-3metres down a steep slope.

She didn’t lose consciousness but gave a howl of pain and sat back up, more annoyed than anything else. She was reluctant to get up though. Lucy is breathing with no difficulty and is talking in full sentences.

On examination you find an already swollen right ankle with tenderness over the lateralmalleoli. You try to get Lucy to her feet but she can’t weight bear.

Patient InformationLucy denies any dizziness prior to the fall. She claims this was a simple slip.

ABC and D are normalLucy has a pain score of 6There is no critical skin.There is no vascular compromise.There is no haemorrhage.Lucy’s Observations are as follows:Heart Rate 88 RegularRespiratory Rate 22BP 136/88Sats are not available. She is not cyanotic or pale.GCS 15Temp 36.7 Deg CBM 6.7 mmol

Lucy has a previous medical history of eczema and uses an emollient when hercondition flares up.

Trauma Case Study 1

What is the patient’s PHEW Score?

What is the appropriate destination for this patient?


24


25Trauma Case Study 2You are called to a 33 year old male, Stuart, who has been fitting a laminate floor in his lounge.

He has been using a circular saw to cut the lengths of laminate and has dropped the saw against his right leg. Blood is seeping through his trousers but since the incident he has been holding a tea towel against his leg and has been scared to look at the wound.

On arrival at scene Stuart is lying on his left side holding the towel against his leg. There is some blood on the floor beside his leg and the tea towel seems soaked. He has not tried to weight bear since the incident approximately twenty minutes ago. Stuart is a good colour and has remained conscious throughout. He is communicating normally.

On initial examination Steven has an 8-10 cm laceration to the lateral aspect of hisright lower leg with visible contamination of the wound by shredded trouser material. Blood continues to seep from the wound site.

Patient InformationStuart advises that he simply dropped the saw in a rush to complete the job. There has been no loss of consciousness. He seems to be managing the pain well and when asked admits to a pain score of 7/10. You apply several bandages to the wound site which struggles to control the haemorrhage. Stuart has full range of movement to his ankle and foot which are a good colour. His CRT is < 2 seconds and he has palpable distal pulses.

A ClearB NormalC Pulse 102 Regular, BP as belowD None.Observations are as follows:Heart Rate 102 RegularRespiratory Rate 22BP 122/72Sp02 97% on air.GCS 15Temp 36.9 Deg CBM 5.7 mmol

Stuart is previously well. He takes no current medication. He is a five year, one pack cigarette smoker and consumes > 20 units of alcohol per week.



The exclusions to the Medical Pathfinder remain consistent with the Trauma Pathfinder andtherefore this BLM commences at the first box, that is, primary survey and time critical EmergencyDepartment discriminators.

The second phase of the medical algorithm is to eliminate the presence of potentially time critical

conditions that may require hospital standby or courtesy call. Inability to exclude all discriminatorswithin this box should result in stabilization and immediate transportation to the nearest Accidentand Emergency Department.

Adopting exactly the same reductive method as for the trauma patients, assessing practitionersshould then proceed to the next series of discriminators. This box contains discriminators designed to filter cohorts of patients who have been identified as potentially high risk in previous studies. The ‘headache as primary presentation’ and ‘Tachycardia > 120’ discriminators have beenincorporated into the box to capture patients with

potentially life threatening conditions such assub-arachnoid haemorrhage or cardiac arrhythmias such as ‘pulsed VT’ or ‘SVT’ which would not have been captured by the PHEW score. Patients presenting with certain ‘abnormal pulses’ may not be displaying acute rhythm changes and therefore suitable for first assessment in Urgent Care Centres i.e. Atrial Fibrillation.

Medical Pathfinder

Airway compromise

Progressive or sudden worsening of breathing

Shock


New neurological deficit



Severe pain

NO➜



YES➜ ➜


Headache as primary presentation

Purpura/non blanching rash

Vascular compromise

Tachycardia > 120

Temp ≤ 35 or ≥ 40 Deg C

Vomiting blood

Haematuria /first episode retention

Abdominal pain radiating to back

Significant PR bleed

NO

➜


YES➜ ➜


26


27

In the next phase of the algorithm you will see the red prompt star asks you to ‘pause and review’before moving through the next set of discriminators. This is primarily because patients in the preceding boxes will be transferred to the Accident and Emergency Department, and would not be considered suitable for Urgent Care Centres. Any patient presenting with symptoms captured in the latter stages of the algorithm will now be considered suitable for Urgent Care assessment and NWAS Practitioners should be confident that all previous discriminators have been eliminated. When prompted, take a minute to ensure you have been thorough in your assessment.

Patients who display any of the presentations in the above box should be conveyed to an UrgentCare Centre but consideration must also be given to accessing approved Ambulance Care Pathways. Patients with long term conditions such as Chronic Obstructive Pulmonary Disease (COPD) or Diabetic related illness may have been identified as suitable for treatment byspecialist respiratory or diabetic teams who operate in a pre-hospital community setting. Approved Ambulance Care Pathways are printed in standard ‘yellow’ format and will be available on scene. Crews should be pre-notified to the presence of a pathway, via the in vehicle communication system.

Elimination of discriminators in the first three boxes of the medical pathfinder should identify patients who can be considered for application of Self Care Pathway. The blue prompt star, as in the trauma pathfinder, asks the assessing practitioner to consider the need for conveyance. If the presenting condition is not covered by a Self-Care Pathway, assessing staff should consider whether the patient is on an Ambulance Care Pathway that

specifically relates to their condition. Failing this, the patient should be conveyed to the nearest Urgent Care Centre. Patients exiting the Pathfinder at the ‘amber’ indicators should be considered for transportation by non-PES resources subject tolocal Service provision. It is crucial to ensure appropriate transport modes are used to maximizeavailability of PES resources for potentially life threatening incidents.

Temperature ≥ 38.5 Deg C


Hyperglycaemia > 17 mmol (without ketosis )

Retention of urine

Abnormal pulse

Facial /tongue oedema

Significant cardiac history

Pauseand

review

NO

➜

Consider transport to Urgent Care Centre (Kitemark 1 Only)

If Patient has a current Community Care Pathway in situ , please consider referral

YES➜ ➜



documentation

YES



➜➜

Transport to Urgent Care Centre(Kitemark 1 Only) If patient


consider referral

NO➜ ➜

➜➜➜

You are called to a 51 year old female, Margaret, whose daughter is concerned.

Margaret has developed redness, warmth, and skin tightness to her lower left leg.

The area is becoming tender to the touch. She has been feeling feverish for the past day or two. On arrival at scene Margaret is sat in a chair, looks alert and orientated. She is breathing with no difficulty and is conversing normally.

On initial examination you find an area of hot, raised, tender skin extending to app. 75% circumferentially along the entire length of her lower left leg. The margins are relatively well demarcated. There appears to be signs of a pre-tibial abrasion although this is not a recent injury.

She has been feeling generally unwell and fatigued for 2-3 days but has not sought previous advice or assistance until now. Margaret denies rigors at this stage.

Patient InformationThe affected area has developed rapidly over the past 24 hours. Margaret denies nausea orvomiting. Margaret is complaining of pain to the affected area with a pain score of 4.

ABC and D are normal. Observations are as follows:Heart Rate 98 RegularRespiratory Rate 20BP 104/68Sp02 98% on air.GCS 15Temp 38.4 Deg CBM 5.4 mmol

Margaret has a previous medical history of Type 2 Diabetes. She is prescribed Metformin500mg bd. Her Diabetes is normally well controlled. Margaret also takes oestrogen only HRT as she has had a previous hysterectomy.

Medical Case Study 1




28


29Medical Case Study 2You are called to a 71 year old male, Malcolm, who is complaining that his breathing is more difficult than usual.

His wife is concerned and has called 999. Malcolm has apparently been suffering withURTI symptoms for the past week but is now struggling to breathe especially at nighttime. His cough is worsening and he is producing thick green sputum.

On arrival at scene Malcolm is sat in a chair leaning forward and coughing intermittently.You witness green- yellow purulent sputum with no visible sign of blood. Malcolm is notcomplaining of chest pain unless he coughs. His breathing is dyspnoeic and he is struggling to complete short sentences. His colour is slightly blue, although his wifestates that this is normal for him. He is overweight.

Patient InformationMalcolm has been worsening since his ‘cold’ began 7-10 days ago. He is drinking plentyof fluid but he has a reduced appetite. He is a known COPD patient with pre exacerbation ‘Sats’

of 92-94% on air. His GP is encouraging him to quit his 10-15 per day cigarette habit and he has managed to reduce to 5-10 in recent months. He has been offered ‘patches’ but declined. He has also been encouraged to take exercise andimprove diet as his current BMI is 32. AC and D are normal. Breathing rate has increased to 22 BPM with accessory muscle use.

Malcolm denies any pain unless he is coughing when his chest feels tight. Malcolm’sObservations are as follows:

Heart Rate 88 RegularRespiratory Rate 22BP 157/92Sp02 92% on room air.GCS 15PEFR 390Temp 37.8 Deg CBM 5.8 mmol

Malcolm has a previous medical history of COPD (Chronic Bronchitis). He is prescribed Combivent with good effect.



The Paramedic Pathfinders have been developed in response to challenges that we all face in thesechanging times.

It is not feasible for all hospitals to have the skills and facilities to treat all patients and therefore asreconfiguration of services across the North West accelerate; NWAS will be required to react with speed and efficiency, whilst ensuring patient care remains the upmost priority.

NWAS NHS Trust recognises that its operational staff must be confident, empowered, and fully supported, to respond to these challenges.

The Pathfinders are a single element with NWAS’ Urgent Care Strategy which also includes thedevelopment and implementation of Community Care Pathways and individual Care Plans, supported by ERISS (Electronic Referral and Information Sharing System) and Directory of Services.

Please complete the ‘Confirmation of Completion’ section on the back of this workbook and return to your local supervisory or training staff, or Advanced Paramedic.

Paramedic Pathfinder Summary

As previously stated the NHS spends in excess of £1.5bn to cover hospital admissions, for those suffering with long term conditions (LTC’s) such as COPD, angina, asthma and cellulitis.

On average, high users of 999 services such as those patients with LTCs are admitted to hospital three times or more, during the year at a cost of £3,000 per stay.

In 2010 alone, over 18,000 COPD patients were admitted to hospitals across the North West of which 11,000 could have been treated in their community via primary and community services.

A Community Care Pathway (CCP) is an alternative pathway of care for patients with LTCs that enables NWAS crew to identify when referral to expert community teams may be a better option for the patient.

Community Care Pathway

Once a patient is placed on a CCP, their personal Care Plan will be generated and maintained by thehealthcare professional. The Care Plan will be kept at the patient’s address.

Healthcare professionals will notify NWAS when a Care Plan is generated and an alert will be applied to the relevant address, via ERISS (Electronic Referral and Information Sharing System) on the Referral Management Database.

NWAS Clinicians will then be notified on-route to the patient that a Care Plan may be present on arrival.

NWAS Clinicians will then assess the patient using Paramedic Pathfinder and if an ‘amber’ outcome is generated; referral can be made in accordance with the instructions, on the Care Plan.

The core feature of this initiative is to share information across services and ensure ambulance clinicians are aware of pre-existing Care Plans for patients being managed by community services.

Community Teams will share information with NWAS using the Electronic Referral and Information Sharing System (ERISS) to place the patient on the Referral Management Database, create an alert, and ensure that responding ambulance practitioners are pre-alerted to the presence of a Care Plan.

The overall target for individual patient Care Plans across the North West is 54,000 by 2017.

Individual Care Plan


30


31Paramedic Pathfinder – Community Care Pathways Referral Flowchart

Community Care Pathway – Care Plan V11 (front)

Community Care Pathway Referral ProcessNorth West Ambulance Service NHS Trust

999 Call Received

RRV and PESAmbulance

Dispatched as per Normal Procedure

Paramedic Arrives On Scene and Completes Initial Clinical

Assessment

Paramedic Pathfinder

Outcome Amber or Below

Provide Clinical Treatment and

Transport to A&E in the Normal

Manner

Apply Self-Care Pathway ProcessCan Patient Be Left at Home to

Self Care?

Patient Accepts Self-Care Advice

Follow Self-Care Pathway Procedure

Provide Informtion Leaflet

Notify ECC that CG has Been Used and Stand Down Any Additional Resources

For COPD/Falls/Diabetes Complete Support Centre

Referral to PCT

Referral Accepted

Within Agreed

Timescales

Convey Patient to Appropriate

UCC or Emergency Department

For COPD/Falls/Diabetes

Complete Support Centre Referral to PCT

Advise Patient that Referral

to Care Pathway has

Been Accepted. Complete

Documentation and Leave

Scene

Covered by Self-Care Pathway

Appropriate for UCD Referral

Manage in accordance

with Standard Operating

Procedures

Suitable for Primary Care

Referral in Accordance with Patient Presentation

Matrix

➜ ➜ ➜Patient has Community

Care Pathway

Patient has Community

Care Pathway

Clinician to Clinician

Handover with Appropriate

AfC Band 6 HCP

YES

YES YES

YES

➜ ➜

➜ ➜ ➜ ➜➜➜

YES➜ ➜

➜

NO

NO

NO

NOYES

YES

YES

➜

➜

➜

➜

➜

➜➜➜

➜➜

➜➜

➜➜

➜ NO➜ ➜

COMMUNITY CARE PATHWAY - Care Plan (CCP)

PATIENT DETAILS LEAD PROFESSIONAL/ACM

Name: Agnes White

Address: 12 Another Road, Anytown

Postcode: WA14 5XX

D.O.B: 01/6/42

GP: Dr William Maxwell

GP Tel Number: 123 45678

NOK: Mrs Ann White

NOK Tel: 01925 999122

NHS Number: 2222222

Name: Mrs Jessica Bloggs

Contact Details:Tel 01925 121999The Family PracticeSmith StreetAnytownWA14 1BC

Frequency of Reviews byLead Clinician:Monthly

Patient Copy (To remain at patients address) Ambulance Copy (To accompany patient to receiving unit) Delete as appropriate

INFORMATION FOR NWAS NHS TRUST

ALLERGIES

None known

PREVIOUS MEDICAL HISTORY

COPD, Cellulitis

MEDICATIONBeclamethasone 2 puffs bd salbutamol 1-2 puffs prn

SELF ADMINISTERED MEDICATION IN ACUTE PHASENone

NORMAL BASELINE OBSERVATIONS

Blood Pressure 123/78 GCS 15

Heart Rate 88 Other: Please state

Respiratory Rate 20

Blood Glucose 5.0mmol

SpO2 92% in air LTOT Yes/No %/LPM

NWAS STAFF- IF THE PATIENT MEETS PARAMEDIC PATHFINDER AMBER OUTCOME CRITERIA, PLEASE REFER THE PATIENT IN ACCORDANCE WITH THE REFERRAL INSTRUCTION OVERLEAF.

Please also ensure that this Pathway accompanies the patient if they are conveyed to hospital


32


33Community Care Pathway – Care Plan V11 (rear)

Community Care Pathway Referral Process

Version 1 Community Care Pathway - Care Plans January 2013 NWAS EMT 2 / Paramedic CCP Referral Process

999 Call Received at EoC

RRV / PES Response Dispatched

EMT 2 or Above Clinical Assessment

Application of Paramedic Pathfinder

Agree Referral and Ensure 2hr Response

Referral Unsuccessful

If 2hr Response Unavailable Convey to Nearest UCC or ED

Inform the PatientConfirm Service Contact Details

and Esculation ProcessProvide Patient Information Leaflet

Complete PRFDocument Referral, Clinicians

Name and Time of Clinical HandoverLeave Copy of PRF at Scene

Ensure Access OpenClear the Scene

Referral Successful

Staff Notified by MDT of CCP in Place - “a community care plan is in place at this address please consider referral”

Contact Clinical Team Specified on the CCP and Undertake Clinician to Clinician Referral

➜➜

➜

➜➜ ➜

➜

➜➜

Patient Elicits and AMBER Outcome or Below for the Condition Specified on the CCP Or Elicits RED Outcome but is Within Specified Limitations of the CCP.

Patient Aged 16 Year or Above ➜➜

ACTION PLAN FOR NWAS CREW:

Presenting State: Exacerbation of COPD(Amber outcome on Medical Pathfi nder)

Action Required: Please ensure full contact information is included.• Stabilise the patient as per normal and re-assess presenting symptoms• Advise patient to take rescue medication• Inform the patients GP• Contact the Respiratory Team on 01925 442999 – in hours 8am – 4pm• Contact the District Nurse on 01925 121999 – out of hours 4pm – 8am

Presenting State:: Action Required:

Presenting State: Action Required:

The data controller of this completed form is ……………………………………(NAME) (provider organisation leading on the patients care)The data controller ensures that any processing of personal data for which they are responsible complies with the Data Protection Act 1998.

NAME/TITLE OF ISSUING HEALTHCARE PROFESSIONAL

ORGANISATION

HCP SIGNATURE

OTHER INFORMATION PLACE KEPT

PPC

DNAR

EOL PATHWAY

OXYGEN ALERT CARD With District Nursing Records

CHEMO RECORD CARD

OTHER:

DATE CARE PLAN ISSUED

DATE NWAS ADVISED

DATE OF EXPIRY / REVIEW (Max 12 Months)

PROFESSIONAL NETWORK DESIGNATION NAME CONTACT

FAMILIAL AND SOCIAL NETWORK

DESIGNATION NAME CONTACT

Nok etc

Date of review Name Designation Date of Next Review

Patient Agrees to Information Sharing Process Yes / No


34


35E-Learning materials

Operational and Clinical Bulletins

See NWAS Intranet page and contact Ian Mullineaux – E-learning Co-ordinator for access.

These will be distributed via the Weekly Bulletin, or when necessary and posted onto the appropriate area, within the NWAS Intranet Site.

Summary of key benefits and outcomes

Patient benefits• Right care, in the right place, at the right time; effective case management promotes clinically appropriate care for patients, closer to home.

• Reassurance and continuity of care via their individual Care Plan.

• Reduction in unnecessary trips to ED or hospital admissions; care closer to home.

• Care Plans are produced quickly by lead Health Professional, ensuring that all underlying health issues are identified and addressed quicker.

• Improved quality of life, greater patient knowledge and confidence in being able to cope with their condition, better use of medication and an overall improved quality of care. • Patients on the whole prefer personalised care planning.

• Personalised care planning for LTCs, falls and other high intensity users can mean fewer trips to the GP and a reduced risk of emergency hospital admission for patients.

• The care planning process has helped to identify gaps in patient education and misunderstandings which once filled enables better engagement and active selfcare.

• The time spent care planning with the patient has led in many instances to the patient having their ‘eureka moment’ which has transformed their whole approach to self-care.

• The care planning process saves the patient from having to attend on several occasions as their care is managed in an integrated way.

Quality benefits• Case management of frequent callers enables emergency resources to be more responsive to those individuals in a life threatening emergency.

• Care Plans and care planning supports patients and GPs working together, it supports moves towards self-care and personalisation of care.

• Patients receive a better quality of care that addresses real underlying problems.

• Quality benefits are felt by both frequent callers and other users of the urgent care system.

• Reduction in calls to 999 by 60%, for those patients with an active Care Plan.

• Care planning uses standardised documentation to ensure the right care is provided, in the right place by the right person every time. During this process all parameters relating to the patients normal function can be detailed so that it becomes easier for the attending clinicians of the future to identify when the patient’s condition deteriorates outside of their normal defined physiological parameters and either treat them at home, refer them to an appropriate community service or - transfer them to the appropriate place not just convey them to the emergency department.

• The process can also help to identify health needs of local communities and inform Joint Strategic Needs Assessment so that future services can be based on population need. Doing this enables providers, Inc. NWAS and community services, to be more responsive and efficient.

The benefits and outcomes of the Paramedic Pathfinder project include:


36


37NotesFinancial benefits• Reduced ambulance journeys, ED attendances and hospital admissions promote significant financial savings of up to £11m a year.

• Up to 40% reduction in conveyance to A&E.

• Patients receive a better quality of care closer to home that addresses the real underlying issues = reduced pressure on the urgent / social care system.

• Reduction in conveyance or conveyance to an alternative setting = faster response to emergencies and reduces congestion at A&E.

• Case management of frequent callers / complex cases enables effective integrated management = significant cost savings.

Efficiency Benefits• Savings are significant and a direct result of the reduction in emergency admissions for patients with care plans, examples of this are seen in Kirklees, who run a similar scheme and in Warrington locally where admissions for patients with a current care plan in place are 50% lower than pre-care plan.

• In some cases PES crews are on site with the patient for an increased length of time; these off set against the journey / wait times at many of our emergency departments which therefore results in a reduction of the overall incident times.

• Further improvements are also seen in NWAS conveyance rates as our nonconveyance rate will increase coming into line with other Ambulances Trusts and improving our performance against the National AQIs.

• The aim of the Pathfinder Team is to work closely with CCG’s and Providers to populate Care Plans for the 54,000 highest intensity health service users in the North West by 2017.

• The average hospital admission costs £2,500 and accounts for an average of three bed days, if we prevented one hospital admission for every person The health economy in the North West could potentially save £135m each year in admission costs and 162,000 bed days alone.

Key ContactsProgramme LeadSiobain Penpraze, Pathfinder ProjectImplementation [email protected]

Consultant ParamedicMark [email protected]

Pathfinder ManagerJulie ButterworthGreater [email protected]

Pathfinder ManagerDavid FletcherCumbria and [email protected]

Pathfinder ManagerSimon McCroryCheshire and [email protected]


38

Paramedic Pathfinder and Community Care Pathways Workbook

Please detach and return to your local supervisory or training staff, or Advanced Paramedic.I confirm that I have read and completed the case study scenarios within this booklet.

Confirmation of Completion

Name

Pin

Area

Sector

Date

Signature

Trust HeadquartersLadybridge HallChorley New RoadBoltonBL1 5DDTel: 0845 112 0 999 (local rate)Minicom: 0151 260 8628Email: [email protected]: www.nwas.nhs.uk

For further information visit the website, email or call

0845 112 0 999(charged at local rate)

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Paramedic Pathfinder and Community Care Pathways

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