Decision support in prehospital care

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Wednesday 26th November 2008 East Midlands
Conference Centre Nottingham Whats New in
Emergency Pre-hospital Care Research?
Decision support in pre-hospital care improving
the quality and consistency of care
Professor Jeremy Dale Warwick Medical School
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Background

• Demand for immediate care through the emergency
  ambulance service is increasing
• Up to half of callers do not have a clinical need
  to attend an Emergency Department (ED)
• Health policy in the UK encourages ambulance
  services to provide alternative responses to such
  callers
• Reforming Emergency Care and the DH ambulance
  service review services should take care to
  patients and avoid patients being taken
  unnecessarily to emergency departments

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Evidence base alternative responses

• The safety and effectiveness of alternative
  models of pre-hospital care is unclear (Snooks et
  al, BMJ 2002 325 330-3)
• Uncertainty about the abilities of ambulance
  staff to appropriately triage patients and treat
  at site
• Inconsistencies in practice and risk of adverse
  outcomes have been highlighted
• Avoiding transportation to hospital may benefit
  patients, avoid stress associated with ED
  attendance and/or admission
• However, may delay access to definitive care
• Lack of evidence about how decision support
  software may enhance crews decision-making

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Non-conveyance of patients

• Non-conveyance of emergency callers is recognised
  internationally as a safety and litigation risk
• Most UK ambulance services policies indicate
  that all patients should be conveyed to the ED
  unless the patient refuses to travel
• In practice, informal triage by ambulance staff
  to decide who can be left at home is commonplace
  and has been accepted by ambulance services
  across the UK
• 3 to 11 of patients determined not to need
  transportation to hospital have had a critical
  event (Schmidt et al, Am J Emerg Med
  20007663-9)
• 7 of patients who refused transportation to
  hospital were subsequently admitted to hospital
  within a week (Burstein et al, Am J Emerg Med
  1996 1423-6)
• Little is known about how, in the absence of
  specific protocols or training to not transport
  patients, decisions about non-conveyance are made

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Expected standards of practice

• Ambulance crews should
• Provide high standard of practice and care at all
  times
• Manage risk
• Keep clear and accurate records
• Use best available evidence
• Keep skills and knowledge up to date

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Treat and Refer study (Snooks et al, Qual Saf
HealthCare 200413435-443)

• Developed and tested 23 protocols which together
  covered about 75 patients who are left at scene
• Crews at intervention station were trained to use
  protocols
• Findings
• Resistance amongst some crews to using protocols
  used to assess only 40.2 of intervention group
  patients
• More detailed documentation occurred
• No difference in non-transportation rate between
  patients in intervention and control groups
• Job cycle length increased in intervention group
• Three (c 2) non-transported patients in
  intervention group were admitted to hospital
  within 14 days and judged to have been left at
  home inappropriately

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Implications

• Decision support needs to
• be integrated into practice, and routinely used
• Organisational, professional and training issues
  need to be addressed, including managerial
  commitment to supporting the introduction of
  decision support

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Why computerised decision support?

• Current situation
• Evidence of inconsistency of pre-hospital care
• Poor documentation
• Adverse outcomes
• Decision support should
• Systemise collection and interpretation of data
• Encourage appropriate interventions and responses
• Integrate documentation and patient care,
  minimise recall bias and reduce workload
• Enable communication and transfer of data between
  call centre, crews, ED and other providers
• Minimise clinical risk and improve outcomes

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Determinants of CDS success

• Haynes et al (2005, JAMA) reviewed 100 randomised
  and non-randomised trials testing wide variety of
  CDS
• Of the 97 controlled trials assessing
  practitioner performance the majority (64)
  improved diagnosis, preventive care, disease
  management, and prescribing
• Only 7 studies demonstrated improved clinical
  outcomes
• Better performance associated with
• Automatic prompting to use system compared to
  users being required to initiate the system
• Integration into practitioner workflow
• User acceptance
• the importance of local champions to facilitate
  implementation cannot be underestimated

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Evaluating the impact of Computerised Clinical
Decision Support

• Support and Assessment for Fall Emergency
  Referrals (SAFER) Trial

• An evaluation of the costs and benefits of
  computerised on-scene decision support for
  emergency ambulance personnel to assess and plan
  appropriate care for older people who have fallen
  

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Background to SAFER Trial

• Falls in older people are an issue of
  international importance
• Reduction in quality of life and physical
  activity leads to social isolation and functional
  deterioration with a high risk of resultant
  dependency and institutionalisation
• In the UK, the cost of falls accounts for 3
  (approximately 1 billion) total NHS expenditure
• Falls in older people account for a significant
  proportion of 999 calls in the UK (London 8)
• A study at EMAS found 22 were assigned an AMPDS
  delta code equivalent to a category A call (Marks
  et al, EMJ 200219449-452)
• Many of these patients are left at scene (London
  29 52), including around 15 that had been
  classified as category A calls
• Generally the role of intuition in clinical
  decision making has been considered to be a
  source of error and bias

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SAFER Trial

• Funded through
• DH Policy Research Programme focused on IT and
  chronic disease management (469,000)
• Clinical Research Collaboration Cymru
  (100,000)
• WORD funding for a linked PhD (61,000)

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The Research Team

• Helen Snooks
• Wai-Yee Cheung
• Jacqueline Close
• Jeremy Dale
• Sarah Gaze
• Ronan Lyons
• Suzanne Mason
• Yasmin Merali
• Julie Peconi
• Ceri Phillips
• Judith Phillips
• Stephen Roberts
• Ian Russell
• Antonio Sánchez
• Mushtaq Wani
• Bridget Wells
• Richard Whitfield

• Centre for Health Information Research and
  Evaluation, Swansea University
• Department of Geriatric Medicine at Prince of
  Wales Hospital, Sydney, Australia
• Warwick Medical School, University of Warwick
• School of Health and Related Research (ScHARR)
  University of Sheffield
• Warwick Business School, University of Warwick
• Centre for Health Economics and Policy Studies,
  Swansea University
• School of Human Sciences, Swansea University
• Department of Stroke Medicine, Morriston
  Hospital, Swansea
• Prehospital Emergency Research Unit (PERU), Welsh
  Ambulance Services NHS Trust

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• Study aim To assess costs and benefits of
  hand-held CDS technology for the on-scene
  assessment and care of older people who fall and
  call 999
• Objectives To compare between intervention and
  control group patients at one month and six
  months
• Time to first subsequent reported fall
• Time to first subsequent 999 call, AE attendance
  or death (event free period)
• Number of further reported falls and emergency
  health care contacts
• Subsequent fall related injuries
• Quality adjusted event free period
• Quality of life of patents including fear of
  falling, independence and satisfaction
• Operational process indicators on-scene times,
  job cycle times onward pathway of care
  compliance with protocols
• Impact on resource utilisation within the NHS and
  costs to patients and their families

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The SAFER intervention

• A complex package with four key components
• training both clinical and technology based
• decision support within the electronic patient
  record software
• hardware hand-held tablet PCs with printers and
  docking stations installed onto emergency
  ambulance vehicles
• route for direct referral to community-based
  falls service

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• Research Design
• Cluster RCT 24 paramedics at each of two study
  sites, randomly allocated to intervention or
  control groups
• 1 day IT training plus hardware and software to
  support assessment of patients for intervention
  paramedics
• Comparison of processes and outcomes of care of
  patients attended by intervention paramedics
  with those of patients attended by control
  crews delivering usual care
• Qualitative in-depth follow-up of a sample of
  older people who have fallen
• Focus groups and/or interviews with crews before
  and after implementation
• Other individual or group interviews to capture
  the views of other stakeholders concerning
  implementation issues

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• Progress to date
• Developments affecting the trial
• Ambulance service reorganisation in England
• New ambulance service management team in Wales
• Connecting for Health (CFH) planned roll out
  and then withdrawal of planned roll out - of
  electronic patient report form across England
• Measures taken to address these
• Maintained communications with ambulance service
  partners in England throughout the reorganisation
  
• Negotiated with CFH and one of its IT partners to
  work in partnership as CDS is an extension to the
  ePRF
• Agreed a years extension to the trial with the
  DH
• Impact on SAFER Trial
• No longer possible to conduct the trial at two of
  our original study sites (East Midlands and West
  Midlands) due to internal IT strategy and roll
  out of ePRF, so have had to recruit a new site to
  the study
• Increased IT complexity
• Service developments at the Welsh study site that
  have taken place during the on-hold period of
  the trial, specifically the introduction of paper
  decision support and referral pathways for older
  fallers to be introduced alongside SAFER
• A backdrop of uncertainty regarding roll-out of
  the CfH programme in England

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• Anticipated impact of SAFER Trial
• Extend the evidence base many service
  developments are introduced without proper
  research and evaluation concerning the safety and
  effectiveness of new models of care
• The study will identify whether it is possible to
  improve the outcomes for older fallers through
  using CDS and referral to a falls service
• The lessons from the trial will be disseminated
  to inform evidence based service developments and
  CDS implementation
• Inform the design of an HTA-funded trial of CDS
  for assessing at site the full range of Cat B and
  C calls

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Conclusions

• Evidence from research trials should inform
  service development, practice and policy
• Computerised decision support, alongside
  appropriate training and referral pathways, may
  offer a means of improving patient care
• Introduction of ePRF creates major opportunity
  for ambulance services to introduce such support
• However, there is a lack of evidence confirming
  improved efficiency, effectiveness and costs
  associated with CDS implementation
• Implementing complex IT interventions in
  complicated service settings poses many
  challenges for researchers, reflecting a vast
  array of governance, IT connectivity and
  interoperability issues together with
  organisational, structural and managerial
  perspectives that need to be addressed
• SAFER Trial will report results in late 2010

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• Thank you
• jeremy.dale_at_warwick.ac.uk