Management of nonserious calls to the emergency ambulance service: issues in provision of advice in

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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_at_swan.ac.uk

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Structure of talk

• Background
• Call triage
• Call diversion for further assessment and advice
• TAS study
• OMEGA study
• Discussion of implications

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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

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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 AE
• reassurance and self-care advice for those who do
  not need to attend medical services

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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

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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

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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

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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

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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

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TAS conclusions

• Ambulance journeys can be saved
• Telephone advice appears to be safe
• Further evaluation required in clinical trial

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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

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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

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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

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OMEGA operational outcomes

• Conveyance to hospital
• Intervention 49 (n 1097) control 78 (n
  1679) p lt .001
• Job cycle time
• intervention 41.5 mins control 50.5 minutes p lt
  .001

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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

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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

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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 hadnt been sent as it would have
  wasted their time

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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 everyones time

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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

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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

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999 EMS RESEARCH FORUMto encourage, promote and
disseminate research andevidence based policy
and practice in 999 healthcare
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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 200413 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 200320178-83
• 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 RD programme, august 2005