Tuesday, 21 September 2010

More on Change

Following on from my previous post - here's one of the changes that are going to be trialled in London in the very near future. The Evening Standard, a London daily newspaper, has titled it "UK paramedics sent to emergency calls without ambulances". Slight newspaper sensationalisation is evident in the title and may scare the public a little, so briefly - here's the plan and how it'll work. Single responders will be sent in FRUs (fast response units) to the calls that are deemed as appropriate. Having recently completed an 18-month secondment on such a vehicle, I see no problem with that.

As a single responder, you are in an emergency vehicle that carries pretty much everything that an ambulance does, except the transport devices such as trolley, carry chair, spinal boards and the like. FRUs up until now have been tasked to respond quickly, start treating the patient, and then hand over to a crew that is sent to back them up. The thinking behind it is that the FRU paramedic/EMT is then free to attend another call. Whereas a call turnaround time for an ambulance is somewhere around the hour mark, on the FRU it was often less than half that.

The difference with the new model is that a transporting vehicle will not be automatically dispatched at the same time (in theory) as the FRU, except in the most serious cases, but that those in control will wait for instructions from the FRU paramedic on scene who can give a better assessment as to what sort of further response is needed. This, to me, is a small admission that the dispatch system we use is somewhat flawed. Having said that, the system can only go by what the call-taker inputs, and the call-taker in turn can only go by what they are being told over the phone.

There are other flaws. Calls to serious RTCs and other traumatic injuries are very often not categorised in the highest banding, and could in theory leave a lone paramedic dealing with a multi-casualty incident. I understand that any intelligent dispatcher will take one look and send the ambulance anyway, but in an era where there is more and more intention to rely on computer systems, turning around and asking for human input smacks of a contradiction.

Despite all my reservations at this point, I'd be glad to be one of the first paramedics to trial it had it have been trialled in the area in which I work. I would, however, have certain conditions that I'd like to ensure were adhered to. The main one would be that if I turned up on scene and requested immediate back-up, that it'd be on the way there and then. Too many times as an FRU paramedic I've had to wait for the transport to arrive despite repeatedly pleading with the control centre to find me someone to take the patient.

It's not a lack of confidence in my skills or treatment abilities. It's not that I'm desperate to "get rid" of the patient and hand responsibility to somebody else. I like and accept the responsibility, I enjoy treating patients, and I thrive on the extra challenge that is often presented when dealing with a critical patient on your own. But I recognise when the patient needs more care than I can give them.

Equally, if I decided that a patient didn't need transport to A&E, I'd like to know that the system was in place whereby other medical professionals would recognise and accept any diagnoses or referrals, and I'd like the public to be aware that I'm trained and qualified enough to make those decisions. This was the idea of the Emergency Care Practitioner (ECP) role that has been running in London for the last few years, but was never fully put into successful operation. The staff that took on the role were and still are dedicated, motivated paramedics who undertook a large amount of extra study and training, and are now being left high and dry as the role is phased out. It just never had the understanding and backing that it needed, and was never fully accepted by external agencies.

I'd love to think that this trial is being undertaken at least partially from a clinical point of view. I suspect economics has had more of a say. I may be an optimist, but I'm not naive. I have my reservations about this trial, but am more than happy to give it a go. No-one yet knows a full job description or scope of practice for this new role (probably entitled Advanced Paramedic), or whether there will be extra training involved, more pay, or any other details. But we know it's coming. This is one of those things where front-line crews need to be involved in the decision making process, and as far as I know, they haven't been, certainly not to any great extent.

More communication between the sides might surprise us all. The front-line staff might find that they want to be a part of the changes, even pioneer them, and management might find that they have willing partners, rather than unwilling subordinates.

Overall, change is a necessary thing for an evolving profession such as the one of a paramedic. Change breeds teething problems. These will exist at every level, public understanding, call taking, dispatch, front-line and external agencies. The trick will be to iron out these problems and turn them into a viable, working model, that will ultimately benefit not only the target-setters and finance department, but also the most important people.

Our patients.

12 comments:

I said...

All the usual variables come into play once again.

Will FRU cold respond crews?

Is this simply a target busting strategy? Achieved by freeing up ambos.

Who's responsible if a PT that's advised not to go then subsequently dies?

How many PTs are actually advised not to go to hospital?

What were the results from earlier trials?

Kelvin said...

Will be interesting to watch and monitor the outcome of this trial - this what the Bradley report pointed to isn't it?

Anonymous said...

If this works and it's a big IF, then this should become the de facto standard for the whole of the UK, and I hope it does work.

The level of neurotic people out there nowadays is unbelievable and the service just cannot provide the best level of care to those who really need it - hopefully this is a step in the right direction!

TR.

Lizzie said...

Very interesting...please keep us updated on how this works out. I realize it will take awhile, but it's a very different way of doing things than we do them and I always like to see the differences in other services/countries.

nickopotamus said...

That seems to happen around here, especially on an evening at night - not sure if that's official policy though, so don't quote me on that! Cat B calls I've made, admittedly in a VAS capacity*, tend to get an RRV response, who then decides if/how to transport. It works quite well, and especially for me, when I'll just want someone to turn up and give a drug or perform some diagnostic that Voluntary Aid Society Not To Be Named won't let me use then leave the patient with me.

On the other side, the trust I used to work for were phasing in "paramedic practitioners" - essentially ECPs without the high pay packet. They were training them when I left - I'd be interested to see how it's working out, and what role the ECPs now have.


* Which means I luckily have the ability to overule AMPDS puts my call cat C :)

oneunder said...

I can see the logic behind this but I do feel some trepidation.
With the increasing call rate there is no way we can sustain the level of response we all want, an ambulance, as the costs will become unsustainable, especially in the present financial climate.

A lot of my reservations about this is a question of back up.
Will you be backed by the service if you leave a patient at home and they die?
Who will be manning the Ambulances?
I am happy if I know that I will be backed up by a truck with an EMT/Paramedic crew but I have been on a few jobs recently where I was backed up by crews and on serious jobs this is not enough. We do rely on each other to spot if we make a mistake or miss something, ECA/EMT1/A&E support do not have the training.

It was only a few years ago that the medical director was saying that we were leaving too many people at home and that it was a clinical risk. I have to ask has the training we get increased our skills significantly in the last few years? Everyone is crying out for training and it is in short supply. Clinically we, as a service, are improving year on year but we are trained to work as part of a team that will transport to hospital. ECP's were trained to be able to leave patients at home and define the best care pathway but now they are going.

I am a firm believer that ambulances should be waiting for call not patients waiting for ambulances, as we have now.
There is a lot I hate about this idea but I can't see an alternative.

oneunder said...

With correction:

I can see the logic behind this but I do feel some trepidation.
With the increasing call rate there is no way we can sustain the level of response we all want, an ambulance, as the costs will become unsustainable, especially in the present financial climate.

A lot of my reservations about this is a question of back up.
Will you be backed by the service if you leave a patient at home and they die?
Who will be manning the Ambulances?
I am happy if I know that I will be backed up by a truck with an EMT/Paramedic crew but I have been on a few jobs recently where I was backed up by ECA/EMT1/A&E support crews and on serious jobs this is not enough. We do rely on each other to spot if we make a mistake or miss something, ECA/EMT1/A&E support do not have the training.

It was only a few years ago that the medical director was saying that we were leaving too many people at home and that it was a clinical risk. I have to ask has the training we get increased our skills significantly in the last few years? Everyone is crying out for training and it is in short supply. Clinically we, as a service, are improving year on year but we are trained to work as part of a team that will transport to hospital. ECP's were trained to be able to leave patients at home and define the best care pathway but now they are going.

I am a firm believer that ambulances should be waiting for call not patients waiting for ambulances, as we have now.
There is a lot I hate about this idea but I can't see an alternative.

medic999 said...

Hi Ben,

We have been doing exactly this is NEAS for the past 5 years and I have to be honest and say that in the vast majority of cases it works very well.

There will always been a minority where things dont go to plan and you can wait longer than you would like for back up,but in that case we just radio in and upgrade the crew request to a Cat A.

To clarify, when im on the car, if I am sent to a Cat A, i know a crew will be following. Any thing else and I have to call in when I am on scene and request the appropriate vehicle response (which may be an a&e crew, urgent crew, or pts). I can also request a crew to travel whilst en route if I am not happy with what I am going to (like your RTC example)

All in all, great system which works!

Mark Ronson said...

Christ how behind are you lot? In sunny south west until very recently rrv's were expected to assess and advise on all grades of call except echo codes and patients with chest pains. This has just changed to rrv's being sent backup on all red calls (due to whinging and whining from some of the less....confident.... Clinicians) which I feel is a great shame as applied properly it worked very well. You should move down here mate, we just put on another round of ECP training. Here they work 999 and static primary care in the day, then OOH gp service and 999 red/Amber overnight. Excellent PGD's and integration with other services.

SaintPara said...

As Ben will probably know, I am one of those who looks forward to change. I believe we as a profession have much more to offer if given the chance. I am enthusiastic and try not to let the grumpy farts of this world pull me down.

However I, like many have numerous reservations about this:

1) Why are we changing? Is this to satisfy some pen pushing accountant or is it devised for the benefit of patients? I have found in the past that change based on the former does not equal the latter! So long as it is being done for the latter then great.

2) How come this trial is starting yet we can't get proper info like the training program and pay banding? Has this been fully thought out?

3) Backup A: When I get on scene and say "I want a cat A response from a truck, will the truck be sent? Will it be ring fenced so that it will definately come to me or will it be diverted to another call our AMPDS system has deemed cat A but may well not be? If I say a patient is sick, they are sick. AMPDS however...

4) Backup B: What backup will there be if we deem a patient not to need / warrant an ambulance? Will we be able to refuse to have one sent? Will we be able to say "well you don't really need one but if you insist we will send one but it might take 4 hours"

5) Backup C: What happens when it goes wrong? When a patient dies after being seen and being left at home / left waiting for green transport / gp / other HCP? Will we be backed? Can we trust in this? Without the trust then I can't see people being left that much.

6) As I have mentioned, a large international study covering 20 other pilots concluded the system doesn't work. This worries me. The fact NWAS and south west seem to make it work is good news tho...

Personally, I like the sound of this. This is what paramedics should be doing. Assessing patients and making descisions about what is best for them. I would love to do this. I woud love for this system to work. I am slightly worried by the points above and I think there will need to be a lot of trust that management will deal with these issues. Unfortunately I don't meet many that trust management that much.

I hope this is a new future that is going to improve evryones lives, staff, patients, hospitals, NHS as a whole. I don't see it being an easy journey tho. But then again, who wants easy??

InsomniacMedic said...

So - it seems the north east and the south west have got it sorted already. I hope that the same can apply in a model as large as London's! I have to say that I'm actually in favour of the trial, and look forward to it's implementation! Lets just hope that it works!!!

Ambulance Amateur said...

In EMAS this is not uncommon. Whether a crew is sent rather than/as well as a Community Paramedic depends on the type of accident/illness and the availability of an ambulance.

As a CFR, I'm often there before the paramedic, who will often call Control to let them know whether a crew is required or not.