The Role of the Ambulance Service in Reducing

Avoidable AdmissionsAndy Collen

Consultant ParamedicHead of Clinical Development

South East Coast Ambulance Service NHS Foundation Trust

Considerations Trying to avoid generalisations, but…..

Ambulance services are under massive pressure Response time targets are resource hungry, and Red (8 min) calls

provide limited time to process the actual needs of the patient Tasking is broadly unfocused and leads to variation Ambulance clinician education is based on ALS and trauma care Specialist & Advanced Paramedic programmes are successful but

need to grow further There is limited and inconsistent access to supervision and support Conveyance decisions are usually made without the need to seek

approval

Content Changing demography and epidemiology

linked to 999 call volume Education and Competency vs. Beliefs and

Behaviours Inter-professional relationships: more than

just paramedics? Pathways of care: Providing a “Shop Front”

for urgent care The “Known Patient Cohort”: Avoiding

Goldfish Syndrome? Conclusions

Changing demography and epidemiology linked to 999 call volume Over the 40 year period 1974 to 2014, the median age of the UK

population has increased from 33.9 years to 40.0 years; an increase of over 6 years. (ONS, 2015)

Faster improvements in mortality rates for men mean that the number of men aged >=75 has increased by 149% since mid-1974 while the number of women in that age group has grown by 61%. (ONS, 2015)

Long-term conditions are more prevalent in older people (58% of people >60 compared to 14% in those <40)

People in the poorest social class have a 60% higher prevalence than those in the richest social class and 30% more severity of disease (DH, 2012)

999 calls to the ambulance services in the UK has more than doubled in the last ten years - 8.5m in 2013/14 (HSCIC, 2015)

A Coincidence??

Education and competency vs. Beliefs and Behaviours Ambulance conveyance rates have fallen but the increase in demand

makes volume reduction almost impossible Non-specialist Paramedics and other ambulance clinicians have limited

education and training in managing patients with LTCs – exacerbations are often treated as de-novo and without the context of the underlying disease

Hospitals are often viewed as “place of safety” regardless of severity of presentation and/or long term disease progression

Pressure on ambulance staff, and work intensity, sometimes leads to poor decision making (sometimes leaving sick people at home, and taking well people to hospital unnecessarily)

“If we don’t convey them, the hospital cant admit them!”

Inter-professional relationships: more than just paramedics? Many ambulance trusts are diversifying their workforces successfully This doesn’t mean less paramedics responding to patients It does mean more expertise and focus on supporting complex patients

in the community as a resource to guide and support practice from the Emergency Operations Centre (EOC) and manage emerging caseloads (i.e. frequent callers)

Roles in the ambulance service now, and some for the future too? Disease-specific Specialist Nurses (diabetes, respiratory) Occupational Therapists (assessment of patients with LTCs) Pharmacists Mental Health Nurses/AMHP’s Social Workers GPs

Pathways of care: Providing a “Shop Front” for urgent care

Patients at risk of avoidable admissions may need “intermediate” assessment - +/- step up

Conveyance to acute hospital sites can still mean an avoidable admission – avoiding ED and the 4 hour target – maximising use of Ambulatory Emergency Care pathways

Delayed conveyance/scheduled conveyance – moving the patient when the system is optimised to receive them

Providing choice to patients, and maximising safe and effective care – reducing risk of iatrogenic harm

Create “pull” in other parts of the health economy. The “push” towards ED is usually the strongest force

The “Known Patient Cohort”: Avoiding Goldfish Syndrome? The Known Patient Cohort is a new phenomenon to the ambulance

service, and is a different group to “frequent callers” The known patient cohort has urgent care needs at times of crisis and

the ambulance service is often the first port of call Even accessing via 111 or GP may generate an emergency ambulance

response (due to triage and/or actual acuity at the time – i.e. SOB) SECAmb holds 32,000 care plans in the IBIS system, in a population of

4.5m people (0.7% of population) IBIS patients make up 4% of c750,000 999 calls made each year IBIS patients have a 35% conveyance rate. 80%+ of calls to IBIS

patients relate to their LTC/issue We have to use intelligence and information sharing tools We cannot go once around the goldfish bowl and forget each episode

Conclusions Ambulance services can contribute to reducing avoidable admission

Current performance measures limit the ability to optimise patient flow

Multi-professionalism and inter-professional working needs to be increased

Paramedic education must continue to reflect the changing patient profile

New ways of working must be embraced, and the status quo must be challenged

The “known patient cohort” is growing and makes up a large proportion of 999

callers, and are at higher risk of avoidable admission

Be Proud Show Respect Have Integrity Be Innovative Take Responsibility

Thank you for listening.Any questions?

References• HSCIC 2015

http://www.hscic.gov.uk/catalogue/PUB14601• ONS 2015

http://www.ons.gov.uk/ons/rel/pop-estimate/population-estimates-for-uk--england-and-wales--scotland-and-northern-ireland/mid-2014/sty-ageing-of-the-uk-population.html

• DH 2012 Department of Health (2012). Report. Long-term conditions compendium of Information: 3rd edition