“Okay, tell me exactly what happened.”
New performance measures give EMDs more time for questions
Prime Minister Theresa May was among many dignitaries praising London Ambulance Service paramedics and emergency medical dispatchers (EMDs) for their response in 2017 to the two terror attacks in London and the Grenfell Tower fire: “You are the ones who run towards devastation, while others run as fast as they can the other way,” said the Prime Minister at a reception she hosted at Downing Street. “And every day you go to work knowing you could be called on to face things which most of us would never want to confront.”1
And how right she was.
LAS handled over 1.8 million emergency calls from across London and attended more than 1.1 million incidents in 2017. LAS employs over 5,100 staff across 70 sites in London to respond to the health needs of over eight million people who live and work in the capital2 (and, during the same year, 39.2 million visitors to the UK). Emergency medical dispatchers in two emergency operations centres in Waterloo, central London, and in Bow, East London answer more than 5,000 calls daily.
It’s no wonder the Prime Minister praised their work.
Emergency medicine is a stressful profession with superhuman expectations while, at the same time, it’s facing ever increasing levels of public demand. In 2017, overall LAS response increased 6.6 percent over the previous year; incidents involving the most critically ill or injured patients rose by 21 percent over the past two years (2016/2017), while non-life- threatening incidents rose by 8 percent over the same period.3
A similar picture can be drawn for the other nine regionally based ambulance services in the NHS, as identified by the National Audit Office (NAO) in 2011 and subsequent audits. Ambulance services are finding it increasingly difficult to manage rising demand for urgent and emergency services, requiring new response models and resource strategies to provide quality patient care. As a result of the audit and recommendations, each trust has since developed its own operating framework to include workforce and fleet mix.
Shift in performance measures
According to the 2011 audit, ambulance trusts were performing satisfactorily against national response time targets for serious, life-threatening incidents, although targets for less urgent cases had been missed in recent years.
Fundamental reform in their business practices called for performance measures that focused on clinical quality of care indicators and targets for increased efficiency, rather than “time response.” Patient outcome was the new way to look at performance and rather than buy more ambulances to meet clinical quality of care indicators (such as outcomes from cardiac arrest and strokes) and, in the interest of efficiency, reducing unnecessary ambulance dispatch.
“For many years the main measure used to assess the quality of the ambulance service was how quickly an ambulance gets to a patient,” said Janette Turner, Director of Health Services Research at the University of Sheffield’s Centre for Urgent and Emergency Care Research (South Yorkshire, England). “The ambulance response time targets were exacting, and, over time, services were failing to meet them.”
Where it all starts
Like everything else, the process started at 999 where the drive for shorter and shorter call processing times was their responsibility in the response time performance measure. Time was measured from within 60 seconds of the phone ringing to the time an ambulance arrived on the scene. Ambulance responses were split into categories.
Understandably, response time drove the emergency dispatchers to get the ambulance moving as fast as possible by categorizing every call as life threatening. To decrease overall response time, emergency dispatchers started each call at the highest level A, assuming the worst prior to accurately assessing the patient’s situation. If more questions led to assigning a lower category, it was too late. The ambulance response had already started. The best equipped ambulance was on the way, and often more than one resource sent, but it now had more time to get there.
“There was a lot of inefficiency in the old system,” Turner said. “It [inefficiency] wasn’t the fault of the ambulance service. It was the target. So, we asked what could we do to improve while ensuring people in the most critical condition got the quickest response.” Turner was the lead researcher in a Sheffield study to evaluate changes by NHS England as part of the Ambulance Response Programme (ARP), prompted by the continual decline in response performance as demand continued
to increase. Essentially, the audit suggested a new set of measures for ambulance services focusing on making sure the best, high-quality, appropriate response is provided for each patient, and that included 999.
ARP was divided into two phases, beginning in 2015. Phase 1 involved changes to the triage of calls to allow more time for call handlers in cases that are not deemed as immediately life threatening (Dispatch on Disposition, or DoD).
The DoD program was piloted in six ambulance services in England—LAS and South Western Ambulance Service NHS Foundation Trust (SWAST), North East Ambulance Service, South Central Ambulance Service, West Midlands Ambulance Service, and Yorkshire Ambulance Service. The other four services continued to operate normally as control sites.
Under the plan, the key was adding in the pre-triage questions to identify life-threatening calls early so there was no delay in dispatch. For all other calls, there was extra time to triage and decide on the right resource. In some cases, EMDs resolved the call over the phone by referrals to clinicians in the area without the need for an ambulance. The system reduced the number of dispatches, and ambulance capacity was reserved for the more critical patients.
Phase 2 involved the introduction of a new code set that has four key response categories, rather than three. In this phase, three services (Western, West Midlands, and Yorkshire) piloted the revised call categories.
In the categorization of calls, a new code set with new response time standards was established4:
- Category 1 (life-threatening calls): people needing treatment for life- threatening illnesses or injuries with response in an average of seven minutes. (90th percentile of 15 minutes)
- Category 2 (emergency calls): potentially serious conditions that might require rapid assessment, urgent on-scene intervention and/or urgent transport, with response in an average of 18 minutes. (90th percentile of 40 minutes)
- Category 3 (urgent calls): non-life- threatening problems that often can be managed at the scene, with 90 percent responded to within 120 minutes.
- Category 4 (less urgent calls): problems requiring assessment either face-to-face or by telephone, with
90 percent responded to within 180 minutes.
An evaluation on the use of DoD following a six-month pilot period across six ambulance services in England reported a wide range of benefits from the trial to date, particularly the anticipated gains in ambulance service efficiency.
The ARP’s Expert Clinical Reference Group unanimously recommended the extension of the DoD pilot to all NHS Ambulance Trusts, following the six- month evaluation. This decision was supported by the ambulance services, clinicians, and independent analysis, demonstrating a methodology and evidence base upon which to build further improvements.5
This was followed by implementing the new call categories in all services in July 2017 following approval by the Department of Health. These changes are the biggest initiated in ambulance service delivery for 40 years.
The study doesn’t stop here. Turner and her fellow researchers at Sheffield University are now at the point of filtering what they’ve already learned. “We are getting to a place where we can better prioritize calls, and we want to take a closer look at MPDS® (Medical Priority Dispatch SystemTM) determininants to make sure people are aligned to the right category,” she said. “There will probably be more shifting around as we gather more evidence to refine the process.”
A 2017 NAO Audit of the NHS Ambulance Services found that introducing new models of care, such as resolving calls over the phone by providing advice to callers, has helped.”6 The LAS has been recognized by the International Academies of Emergency Medical Dispatch® (IAEDTM) as a Medical Accredited Centre of Excellence (ACE) since 2002.