Ambulances and overcrowded emergency departments

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

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NHS Service Delivery And Organisation RD
Programme SDO/29/2002

• Acknowledgment

3
Background

• 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.

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Background

• ED overcrowding
• 12 hour waits for admission
• 4 hour total time in ED

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Background

• Ambulances waiting outside EDs
• Decreased response times
• Staff morale
• Patient care compromised

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TARGETS

• AMBULANCE
• 15 minutes maximum time to handover
• CONFLICT WITH
• 4 hours maximum stay in the ED

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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
Method

• 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.

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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

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Possible solutions

• Divert non serious 999 calls to Nurse Advice
• Ambulance crew treat and discharge
• Ambulance crew choose most appropriate destination

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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

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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

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• Standard ED triage cannot be used
• AMPDS not designed for this (26 of non
  transports were delta)

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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)

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• 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)

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• 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)

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Limitations

• International variation
• Training given for role
• Short time series
• Expert opinion rather than actual outcome

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Conclusions from Literature

• Safety is not confirmed for these changes and
  doubts have been raised
• Should proceed with caution
• Full evaluation is required

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WORKING TOGETHER

• Access to data
• Combined escalation plans
• Neutral Referee

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CAPACITY MANAGEMENT

• Control flows
• Spreading the workload
• Which patients
• When to start
• Problems

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DIVERSIONS

• Recognised as bad for patients (Schull 2004)
• What benefit?
• Can create artificial variability in a system
• Variation creates poor performance

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DIVERSIONS

• Should be for exceptional circumstances
• If used regularly suggests failure to use
  predictive analysis and failure to plan

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• Early intervention, not waiting until the crisis
• EDs can tell you several hours in advance of the
  crisis

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DIVERSIONS

• Should be last resort
• REMEMBER
• Different from planned bypass

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BYPASSING THE ED

• Obvious admissions obviously need admitting
• So 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 DIFFERENT

• Why do something different when it is busy?
• If it is best for patient when it is busy..?

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DECREASING VARIABILITY

• Smoothing the workload
• GP urgent transfers at lunchtime
• Flexible catchment areas

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Ambulance Solutions are long term

• Help reduce attendances
• Not a fire fighting measure

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Ambulance turnaround delays

• Getting ownership
• Not an ambulance solution!
• BUT.

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Essex Ambulance

• Action 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
BAN IT

• ALL EDs accept patients all the time
• All Hospitals accept patients from ED
• All Homes accept discharges
• www.warwick.ac.uk/go.edwaits

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Freeways

• Find the bottleneck
• Dont just make bigger roads and more vehicles

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GETTING TO THE SOLUTION

• Patients perspective
• Eliminating artificial barriers between
  healthcare organisations

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The future of ambulance services

• Why 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 Cooke
• Warwick Medical School, UK
• www.warwick.ac.uk/go/ambulance