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Andy Collen-Urgnet Care conference
1. The Role of the Ambulance
Service in Reducing Avoidable
Admissions
Andy Collen
Consultant Paramedic
Head of Clinical Development
South East Coast Ambulance Service NHS
Foundation Trust
2.
3. 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
4. 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
5. 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??
6. 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!”
7. 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
8. 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
9. 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
10. 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
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