Alternatives to the standard emergency ambulance response: a review of costs and benefits

1
Alternatives to the standard emergency
ambulance response a review of costs and
benefits

• Helen Snooks
• Swansea University
• h.a.snooks_at_swan.ac.uk

2
Structure of talk

• Context background
• Current practice
• Innovations
• In ambulance control
• On scene
• Will draw on research literature and several
  studies from personal involvement
• Will highlight implications for policy, practice
  and future research

3
Context

• Rising pressure across emergency systems
• Ambulance service demand in UK increasing 6 7
  per year
• 250,000 extra 999 calls per year in England
• Response time targets increasingly difficult to
  achieve

4
Casemix

• 10 of patients with life threatening problem
• 50 need to go to AE
• Many callers have primary or social care need
• Older people who fall
• Patients with mental health problems
• Patients with long-term conditions e.g. COPD
• Mismatch between service provided and patient need

5
Traditional service

• Training and service provision organised around
  needs of patients with life-threatening
  emergencies
• Automatic dispatch of lights and sirens ambulance
  to all calls
• Paramedic staff, patient carrying vehicles only
  option
• Response time targets for all calls
• All patients conveyed to hospital unless they
  refuse to travel

6
Innovations

• Tomorrows talk
• Prioritised dispatch
• Telephone assessment and advice in place of
  ambulance
• Todays talk
• Alternative responses
• Non-patient carrying vehicles (cars, motorbikes,
  pushbikes)
• Emergency care practitioners (PPOPS)
• Alternative destinations
• Minor Injury Units
• Fit to be left
• Treat and Refer

7
Alternative responses

• Non-patient carrying vehicles
• Local evaluation only carried out for
  motorbikes/pushbikes, no comparators included
• Emergency care practitioners
• Various studies currently underway
• Definitions vary

8
Paramedic Practitioner Older People Study (PPOPS)
Study lead Suzanne Mason

• Cluster randomised controlled trial
• 56 weeks randomly allocated to on (PP
  available) or off (standard service)
• 1549 intervention, 1469 control patients aged 60
  and over were included.
• Follow up was through
• Routine ambulance service records
• Emergency Department (ED) records
• Self-completed questionnaire at 3 and 28 days,
  covering
• satisfaction
• health status
• subsequent health care contacts

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Findings

• Patients in the intervention group
• were less likely to attend the ED
• (OR 0.24, 95 CI 0.19 - 0.29)
• and less likely to be admitted to hospital within
  28 days (OR 0.78, 95 CI 0.68-0.89)
• experienced a shorter total episode time
• (235.07 vs. 277.78 minutes, 95 CI -59.5 -
  -24.9)
• were more likely to be highly satisfied
• (OR 2.09, 95 CI 1.58-2.77)
• No difference in 28 day mortality
• (OR 0.87, 95 CI 0.62-1.22).
• or health service costs at 28 days
• (3966 vs. 4116, 95 CI -765-464)

10
Interpretation

• Paramedic practitioners with extended skills can
  provide a clinically and cost effective
  alternative to standard ambulance transfer and
  treatment in an ED for older patients with acute
  minor conditions

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Alternative destinations Minor Injury Units
Snooks et al

• Cluster randomised controlled trial qualitative
  interviews with staff
• On weeks (protocols allowed conveyance to MIU)
  and off weeks (standard practice patients to
  ED)
• Outcomes of interest
• Ambulance performance
• Patient satisfaction
• Clinical safety
• Factors influencing destination decision

12
MIU study findings

• Randomisation patients equally likely to be
  taken to MIU in off weeks as on weeks
• Analysis plan changed
• Compared outcomes of those taken to MIU with
  those taken to ED, controlling for case mix

13
Key results

• Fewer patients were taken to MIU than anticipated
• Patients taken to MIU were
• more likely to rate their care as excellent
• (OR 7.2, 95 CI 2.0 to 25.8)
• Resulted in shorter ambulance service job cycle
  times
• (-7.8 minutes, 95 CI -11.5 to 4.1)
• Spent less time in hospital
• (-222.7 minutes, 95 CI -331.9 to -123.5)

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Crew reported factors affecting destination
decision

• Distance to unit
• Uncertainty about MIU acceptance of patient
• Opening times of MIU
• Patient age
• Underlying medical condition
• Patient preference
• Service delivery
• Reduced job cycle time
• Improved handover
• Study design confusion

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MIU study conclusions

• When patients were taken to MIU, job cycle times
  shorter and patient satisfaction high, and costs
  saved
• However, change in practice difficult to achieve
• RCT with randomisation by week difficult to
  operationalise

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Treat and Refer study Snooks et al

• Methods
• Controlled study
• Two neighbouring ambulance stations
• Patients attended within inclusion criteria were
  followed up through
• Ambulance service care
• ED and hospital care
• Patient satisfaction and quality of life
• Qualitative interviews with crews

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23 protocols developed

• Toothache
• Faints
• Falls
• Diarrhoea
• Fit in known epileptic
• Resolved hypoglycaemia in known I.D. diabetic
• Lower back pain
• Constipation
• Blocked urinary catheter
• Emotional/hysterical reaction
• Alcohol intoxication
• Social problems

• Minor allergic reactions
• Insect bites and stings
• Boils/abcesses
• Splinter removal
• Post-operative wound problem
• Dressing problem
• Wounds (minor)
• Soft tissue injuries (minor)
• Epistaxis
• Sore throat
• Cold or flu symptoms

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Key findings

• 251 intervention and 531 control patients
• No impact on conveyance rate
• (37.1, 36.3)
• Job cycle time longer for intervention patients,
  especially when not conveyed
• 59 vs 54 minutes 35 vs 27 minutes
• Higher satisfaction in non-conveyed patients in
  intervention group
• 5/93 intervention and 12/195 patients left at
  home were admitted to hospital during following
  14 days
• Clinical review 3 in each group should have been
  taken to ED at time of ambulance attendance

19
Findings from focus groups

• Factors influencing conveyance decisions
• Experience
• Intuition
• Training
• Time of call
• Patient preference
• Home situation
• Views concerning intervention
• Positive should be introduced across service
• Difficulties with persuading patients to stay at
  home
• More training and support needed

20
Conclusions

• Treat and Refer protocols feasible, acceptable
  to crews and patients
• Operational impact
• Safety issues identified
• Introduction complex
• Change management required

21
Fit to be Left ?Halter et al

• Developed and tested protocols for ambulance
  crews to assess older people who have fallen to
  non-conveyance
• Controlled before and after study
• Outcomes
• Conveyance rates
• Safety - adverse incidents

22
Fit to be left Key findings

• Baseline data standard practice
• 2003/4, 8 of all 999 calls in London were for
  older people who had fallen (n 60,064), with
  40 not conveyed to hospital.
• Of 2151 emergency calls attended in the study
  areas during September/October 2003, 534 were for
  people aged 65 or over who had fallen.
• Of these, 194 (36.3) were left at home
• 86 (49) made health care contacts within the
  two-week follow up period
• 83 (47) called 999 again at least once
• increased risk of death (SMR) of 5.4 and of
  hospital admission of 4.7 compared with the
  general population of the same age in London

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Fit to be Left main study findings

• 1224 cases were identified, 488 (40) were
  non-conveyed, no change from baseline
• Clinical review
• 78 of non-conveyed cases - use of the tool had
  led to a correct clinical decision
• 94 of conveyed cases - application of the tool
  had led to the correct decision
• In 67 of cases care could not have been
  currently accessed elsewhere

24
Fit to be Left study conclusions

• easily identifiable high risk population who are
  not being adequately cared for within existing
  health care systems.
• formalised assessment can be implemented to
  enable clinically appropriate conveyance
  decisions and reduce adverse event rates.
• large gaps in services for this population and
  the potential solutions and alternative models of
  care lie outside the remit of the ambulance
  service
• In the absence of a strategic whole systems
  approach to the redesign of care pathways, this
  patient population will continue to use
  disproportionately high levels of emergency
  services and fail to access alternative care
  which the evidence would suggest may lead to
  better outcomes both for the individual and the
  health and social care system.

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Discussion and implications

• Need for alternatives to traditional emergency
  response
• Ambulance service care needs to be integrated
  into emergency system
• Change can be hard to achieve
• Assumptions about effects are not always found in
  practice
• Research and evaluation need to take place before
  and alongside innovation

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References/contacts

• PPOPS study Suzanne Mason, University of
  Sheffield
• s.mason_at_sheffield.ac.uk
• MIU study
• Snooks H, Foster T, Nicholl J. Results of an
  evaluation of the effectiveness of triage and
  direct transportation to minor injuries units by
  ambulance crews. Emerg Med J 200421105-111
• Treat and Refer study
• Snooks H, Kearsley N, Dale J, Halter M, Redhead
  J, Cheung WY. Towards primary care for
  non-serious 999 callers results of a controlled
  study of Treat and Refer protocols for
  ambulance crews. Qual Saf Health Care
  200413435-443
• Snooks HA, Kearsley N, Dale J, Halter M, Redhead
  J, Foster J. Gaps between policy, protocols and
  practice a qualitative study of the views and
  practice of emergency ambulance staff concerning
  the care of patients with non-urgent needs. Qual
  Saf Health Care 200514251-257
• Fit to be Left study Mary Halter, Kingston
  University mhalter_at_hscs.sgul.ac.uk