240 likes | 396 Views
Structure of talk. BackgroundCall triageCall diversion for further assessment and advice?TAS' study?OMEGA' studyDiscussion of implications. Background. Rising demandIncreasing evidence of mismatch between clinical need and response provided by emergency ambulance serviceCall prioritisation
E N D
1. Management of non-serious calls to the emergency ambulance service: issues in provision of advice in place of an ambulance Helen Snooks
Swansea University
h.a.snooks@swan.ac.uk
2. Structure of talk Background
Call triage
Call diversion for further assessment and advice
‘TAS’ study
‘OMEGA’ study
Discussion of implications
3. Background Rising demand
Increasing evidence of mismatch between clinical need and response provided by emergency ambulance service
Call prioritisation with further telephone assessment and advice advocated as potential solution for less serious callers
4. Potential benefits to patients and the NHS faster response to those with life-threatening injuries or illness
more convenient treatment for those who do not need to travel to hospital
a point of referral that avoids the need to attend A&E
reassurance and self-care advice for those who do not need to attend medical services
6. Sorting patients: triage
critical hinge – efficient and effective triage
Triage (French: to sort) needs to be carried out, often remotely – and usually by telephone – quickly and accurately
Those with a life-threatening condition, such as patients with a myocardial infarction or serious injury, must be identified without delay if tight time-based standards that improve their chances of survival stand any chance of being met
Those with less serious conditions need to be identified in order to trigger an alternative response
7. Prioritising calls Evidence shows that although most triage is cautious (and therefore somewhat ineffective), serious cases are missed
Prioritisation systems were not designed to do what is being asked of them
Triage is difficult at each end of the spectrum – to identify calls that need the highest response; and calls that could benefit from an alternative response
8. Telephone Advice StudyDale et al Shadow trial (ambulance dispatch unaffected) in two ambulance services
Matched intervention and control sessions
Nurses and paramedics using CDSS to assess and advise callers within non-serious codes
Multi-disciplinary expert panel reviewed safety of triage decision using records from:
Ambulance service
ED
Hospital inpatient
General practice
Call transcripts
9. TAS results: operational 635 intervention calls, 611 controls
52% of intervention calls triaged as not requiring an emergency ambulance response
37% of these (n = 119) did not attend the ED vs 18% (n = 55) of those triaged as needing an ambulance
Patients triaged as not needing an ambulance were less likely to be admitted (OR 0.55, CI .33 to .93), but still, 9% (n = 30) were admitted
10. TAS results: safety 239 cases triaged to ‘no ambulance required’ were further explored
96% (n = 231) majority of panel agreed with triage decision
8 patients reviewed again
2 rated by majority as requiring emergency ambulance within 8 minutes, but not at life-risk
11. TAS conclusions Ambulance journeys can be saved
Telephone advice appears to be safe
Further evaluation required in clinical trial
12. OMEGA study RCT comparing processes and outcomes of calls transferred for nurse advice with calls receiving standard ambulance response
3 ambulance services
Intervention group calls transferred to NHS Direct – 24 hour nurse led health information and advice line
Outcomes:
pass back rates
Conveyance rates
Ambulance service job cycle times
Safety
Patient satisfaction
13. OMEGA results – patient recruitment
2,250 allocated to intervention group
1766 consented to call transfer
642 consented to follow up
318 completed follow up questionnaire
2,158 randomised to control group
529 consented to follow up
266 completed follow up questionnaire
14. OMEGA results: call return Pass back rate: 67%, n = 1196
Requires 999 ambulance 44%
Urgent transport 25%
Requires lift and assess 9%
Caller request 5%
Public place/not with caller 3%
Refused assessment/hung up 2%
GP advised 999 4%
Technical problems 4%
15. OMEGA: operational outcomes Conveyance to hospital
Intervention 49% (n = 1097): control 78% (n = 1679) p < .001
Job cycle time
intervention 41.5 mins: control 50.5 minutes p < .001
16. OMEGA: patient outcomes Safety
Adverse event rate low: 2/3975 reported by patients, clinical review: 4/1552 delayed responses ‘may have been clinically important’
4 fractures reported
Satisfaction with service:
Happy with service
Intervention 79%
Control 94%
Made to feel wasting time
Intervention 18%
Control 9%
17. OMEGA: patients comments Generally positive in both groups
‘Pleasant, friendly approachable service’
‘Great service all round. Thanks’
‘The ambulance arrived within minutes of the call, a very satisfactory service’
18. OMEGA patient comments – intervention group Most comments positive
‘Clear and concise instructions from both the ambulance service and the NHS Direct nurse. Very professional confident service’
‘The people on the phone were very helpful and pleasant. I had panicked and called 999 bit I was reassured and felt very happy when I had spoken to the nurse. I was glad afterwards that an ambulance hadn’t been sent as it would have wasted their time’
19. Not so happy… ‘The problem was not one that NHS Direct could really resolve – I needed help to get an 80 year old off the floor’
‘People in severe pain should not be transferred to NHS Direct but to let the ambulance come immediately’
‘I was told and not asked about the transfer of my 999 call to the NHS Direct nurse. I was made to feel I was wasting everyone’s time’
20. OMEGA conclusions Safe and effective for some calls
Difficult to identify appropriate calls at EMD triage
Small proportion of 999 workload
High pass back rate
Telephone advice can provide a useful part of emergency system
21. Discussion of implications Triage remains an issue
Range of responses required
Further telephone assessment and advice needs to be tailored more closely to fit the services available
Change management issues are important in ensuring success of new model of care
Joint working necessary – but challenging when across organisations
22. 999 EMS RESEARCH FORUMto encourage, promote and disseminate research andevidence based policy and practice in 999 healthcare
24. References Dale J, Williams S, Foster T, Higgins J, Snooks H, Crouch R, Hartley-Sharpe C, Glucksman E, George S. Safety of telephone consultation for ‘non-serious’ emergency ambulance patients.
Qual Saf Health Care 2004;13: 363-73
Dale J, Higgins J, Williams S, Foster T, Snooks H, Crouch R, Hartley-Sharpe C, Glucksman E, Hooper R, George S. Computer assisted assessment and advice for ‘non-serious’ 999 ambulance service callers: the potential impact on ambulance despatch.
Emerg Med J 2003;20:178-83
Turner J, Snooks H, Youren A, Dixon S, Fall D, Gaze S, Davies J. The costs and benefits of managing some low priority 999 ambulance calls by NHS Direct nurse advisers.
Final report to SDO R&D programme, august 2005