Sunday, March 8

The way

A few days back our friend Mark over at Medicblog999 responded to a request to explain how the NHS system categorizes and responds to calls for service.

Although many of you reading this may shudder at the idea of "socialized" or state run healthcare, if you draw a paycheck from a public agency for supplying healthcare, you already perform a socialized state run service.

Let's put all the political labels and bias aside for a few moments and really look at the options and services available to the persons served by the NorthEast Ambulance Service.

Start by reading Mark's entire post HERE, then return and let's have an honest discussion about this system and some of it's components.

Welcome back, let's begin. I'll post snippets from Mark's post in NeeNaw blue and my comments in black.

999-In September of 2007, NHS pathways, a new triage and assessment tool for emergency and urgent calls to the ambulance service went live for it’s pilot trials. This replaced the US system that was in use previously called CBD (Criteria Based Dispatch).The call is taken by one of our services EMSOs (Emergency Medical Services Operator). These are staff that have undergone an intensive 6 week course to familiarize themselves with the systems, triage, basic medical terminology and understanding of basic emergency medical conditions. The course now also focuses on using the pathways system to assist in getting the right patient to the right services at the right time, and also various prompts for the EMSOs to give out some prudent medical advice as scripted from the system, such as advising the patient to take 300mg of aspirin if a cardiac chest pain is suspected.

911-This looks like a good place to start indeed. The CBD places calls into categories by severity based on criteria given by the caller, then recorded by the call taker. In my system, which I believe is very similar to most US systems, the call taker and dispatcher have limited, if any, medical training and are experts at asking and recording questions and answers. The new 999 system has calls adressed by persons who can "see through the crap" and actually triage a call based on their training and not what a group of lawyers decide. Already the 999 system is ahead of us and all they've done is answer the phone.

999-Once the allocator recieves that information, they have 45 seconds to dispatch a vehicle to the detail. The computer system automatically shows a list of the nearest vehicles in order of distance from the job but it still remains the responsibility of the allocator to choose a vehicle depending on various service demands such as meal breaks, start/finish times etc.

911-This allocator position seems similar to what is carrie dout in our service by a "fleet seat" who monitors the status of medic units, fire engines, trucks with AEDs and police cars with AEDs. One drawback is that not all the vehicles have GPS locators so there is usually confusion when closer units are not activated simply because they can not be seen on the screen. I do see a conflict in the allocator judging a resource based on meal breaks but that reason becomes clear later in the system explanation.

The goal of pathways is that at the end of the triage and assessment process, the end disposition will be displayed to the EMSO.

Some of these are :
  1. Ambulance response within 8 mins
  2. Ambulance response within 19 mins
  3. Ambulance response within 1 hour
  4. Refer to GP services (or out of hours service)
  5. Refer to clinical nurse adviser (more about them in a minute)
  6. Patient to make own way to hospital
  7. No vehicle required
911-Here is where the 999 system breaks away from just being a glorified taxi service and actually starts to give medical care. Let's address the obvious glaring red flag many of you will scream about. Number 3: Ambulance response within 1 hour. Before everyone goes crazy about waiting for an ambulance for an hour and repeating the horror stories we've all read about old ladies left on the floor for an hour waiting for an ambulance, think about it. The last time you went on the BS "my foot hurts, I want to goto the hospital" you took that person in, by law. In the 999 system, it seems the call taker can give that caller a choice to seek alternate appropriate care or wait their turn.
This is no different than the way the hospital triages patients in the ER. Their baseline is established and regardless of complaint or protest they often wait hours for a physician to see them. Did they need that 911 red lights and siren paramedic for a non emergency call the ER won't see them right away for? Of course not.
Numbers 1 and 2 seem very similar to our current system, except that there is a blanket response priority for "emergency" calls. Our call center upgrades calls to get them out of the system faster, padding numbers and making more calls appear to be "emergent." I would like to see an evaluation system where someone compares the recorded call, the call taker's notes, the dispatch code, the paramedic's judgment at the scene and the final disposition at end of total care.

Numbers 4 and 5 will never exist in a for profit, pass the buck, health care system. Imagine a 911 call taker calling a physician and asking them to talk to a patient on the phone, or even VISIT THEM AT HOME? Every physician I've ever met would say, "sorry they're not in my group" laugh and hang up. Not to say there aren't patient driven physicians out there, far from it, but most are overloaded with patients as it is.
But the idea that a call taker can be trained, and legally allowed to tell a caller they do not need an ambulance and that they should speak to a doctor is mind blowingly simple and makes perfect sense.

Why wouldn't we want to get the proper resources to the proper people?

With dozens of for profit companies fighting for market share, none of them will allow a civil service employee with a telephone tell their patients what to do.
Obviously there are items on this list that simply will not work with the current system in place. It would take at least a decade for people to realize the ambulance is an assessment and treatment tool that happens to be mobile, instead of a free taxi.

999-The whole purpose of pathways was to reduce the number of Cat A calls (which have to be responded to in less than 8 minutes from connection of the call to the contact centre), Reduce the number of Cat B calls (response times of less than 19 minutes),increase the number of Cat C calls (response in less than 1 hour), and overall decrease the amount of ambulance journeys required

911-And that makes perfect sense to me. Getting the resources to those who need them and withholding them from those who don't. What could be simpler? As with any system, there are exceptions. For every story of a UK medic unit arriving late to a fall victim, we can find another from the US. Each NHS rig that gets lost has a US counterpart as well, often myself. I work in a big place and even after all the time I've been there I still get turned around and lost sometimes. It happens.

Often in our system an ambulance will be sent code 3 to a "sick eval" which the CBD considers a low priority. In fact, in my understanding, the CBD doesn't even recommend a dispatch for such a low criteria call. Sometimes the call takers will misinterpret a caller's history as part of their chief complaint and upgrade the call so the computer will create a priority dispatch and they can send the call out the door, keeping their numbers strong. Then I arrive lights and sirens to the patient who has an infected laceration, has for weeks, but mentioned they also have asthma.

That's why the "sick eval" turned into the "shortness of breath/asthma."

I think the 911 system needs a major overhaul to get medically trained people answering the telephone and triaging calls. Just like an MCI we need to help the ones who need it and tell the ones who don't they'll have to wait their turn.
It will cost more in a time when budgets are razor thin as it is, but if we can take some of the profit from health insurance companies who instruct their customers to call the government run ambulance service at the first sign of a fever, we could afford to do it no problem. I'm not for "redistribution", the cause dejour, but they're making a profit while providers outside their circle pick up their slack, at tax payer's expense. Maybe they should start up their own ambulance services if they have all that extra money. Government bureauocracy is better than private profit beurocracy in my opinion, but rereading this, that's obvious.

Thank you Mark for the detailed explanation of the new system in place at NorthEast Ambulance Service and keep the blog going!

Hiding from the bells,
the Happy Medic

We're really not all that different when the bells won't ring...

Sorry, I had to.


Big Show said...

Quick question, do insurance companies make any money off of ambulances? It seems to me that a patient simply driving themselves, or being driven by an insurance company/hospital sponsored courtesy van to a doctor or hospital would in the long run save them money...and attract more patients. For example, say my hospital offers a free courtesy van to MY hospital for all people who want to go to the hospital. You feel pain, feel sick, want your drugs, you would call up my van, it would come pick you up at some point, and take you to MY hospital, dropping off customers on my doorstep, rather than having to pray that the highly trained ambulance staff would hopefully decide that a patient was right for my facility. just a thought...

The Happy Medic said...

Big Show,
Insurance companies do reimburse municipalities for ambulance serves, but never at cost, always by a government determined scale. Most profit in ambulance service comes from pre-arranged and approved transfers.
The key to your question was " would come pick you up at some point..."
That is the key. For the insurance/hospital to staff a van and make appointments costs money. Telling them to call 911 and worry about the bill later is free and guaranteed within 8 minutes.
Like I said, we need a complete change in people's idea of what an ambulance is to see any real improvement in 911 efficiency and health care accuracy.

Anonymous said...

Hi HM,

Great comparison of the two systems. Just thought I would add another couple of points:

1) Yes, the Pathways system and our EMSOs are trained to negotiate with patients and get to the actual problem concerned and decide on an appropriate response. However, as I am sure is the case over on your side of the water, there are many people who know the magic words to say that will get them a high priority ambulance and that still happens over here. The EMSO can only act on what he/she is being told and ultimately pathways will come out with a “Ambulance Response within 8 mins” if the caller says those magic words.

2) As for the meal break issue…..This has been going on for the last couple of years and finally got resolved last year. Up until 2005 (ish) our 2 x 30min meal breaks were paid and part of our working hours. With that arrangement we could be pulled off our 30min stand down times if a Cat A or Cat B job came in, then we would be returned to have our break afterwards. After 2005 the meal breaks became unpaid and are now classed as outside of our working hours, therefore the agreement changed so that when we are stood down, we cannot be disturbed unless a major incident occurs. There was a time when some staff were allowed to volunteer to be available during their breaks but this obviously caused a fair amount of disharmony.
As it stands now, we have 2 windows of approximately 2 hours in which to be stood down for our breaks and if we do not get stood down within that time frame we are entitled to a late meal break allowance. There also comes a point that if we have worked more than 5hrs 45 mins from the start of our shift and have yet to have had a break, we are taken out of the system and are unavailable until after we have had a break. This all obviously can have an effect on which vehicles are tasked for which jobs and has to be taken into consideration by the allocators for the division.

3) You mention : “I would like to see a system where someone compares the recorded call, the call takers notes, the dispatch code, the paramedics judgement at the scene and the final disposition at the end of total care”. This actually happens already.
On our patient report forms, we have a section for the original Category Code, A, B or C and then a second box for what it actually was once we are on scene (A, B or C). All of these forms are ultimately scanned into a database and are routinely audited to see the percentage correctly triaged by the system compared with the paramedics triage. The EMSOs are also performance managed on a individual basis. Another part of the Clinical Supervisors job in the control room is to ensure that the Pathways are being followed and the correct dispositions are being arrived at. Any paramedic can query a call and the category given to it, and a clinical supervisor will listen to the recorded call and give feedback on why the call came out with that certain disposition and either explain that reasoning to the crew or if the end disposition was incorrect then the EMSO will be taken through the call again and see if anything could have been assessed or asked differently.

Im sure you can see how complicated this all is but it really is making a difference in what we are achieving and how emergency and urgent healthcare needs are managed.


Anonymous said...

One further thing:

"Like I said, we need a complete change in people's idea of what an ambulance is to see any real improvement in 911 efficiency and health care accuracy."

Thats the holy grail of Ambulance and EMS success. Imagine how quick we could get to really poorly patients if all we did was genuine patients!

As much as I would hope that one day it will happen, I really dont think it will.


The Happy Medic said...

Mark, in reference to your 3rd issue, the tracking of call type and disposition, our system uses a primary impression and a secondary impression qualifier, not to improve the delivery of care, but to make sure we are following protocols from our first impression through changing conditions.
Luckily we find our gray areas like GMWD - General Medical Weak Dizzy.
That's my catchall.
I was able to find research that may have spurred your change away from CBD-
It is just a thesis, but has GREAT info about CBD. The only other positive reviews of CBD are from the early days of it's inception.

Oh how slow we are to accept change.
See you in the streets,