Helen Snooks

Effects of London helicopter emergency medical service on survival after trauma

Abstract Objective: To assess the effect of the London helicopter emergency medical service on survival after trauma. Design: Prospective comparison of outcomes in cohorts of seriously injured patients attended by the helicopter and attended by London ambulance service land ambulances crewed by paramedics. Setting: Greater London. Subjects: 337 patients attended by helicopter and 466 patients attended by ambulance who sustained traumatic injuries and died, stayed in hospital three or more nights, or had other evidence of severe injury and who were taken to any one of 20 primary receiving hospitals. Main outcome measure: Survival at six months after the incident. Results:After differences in the nature and severity of the injuries in the two cohorts were accounted for the estimated survival rates were the same (relative risk of death with helicopter=1.0; 95% confidence interval 0.7 to 1.4). An analysis with trauma and injury severity scores (TRISS) found 16% more deaths than predicted in the helicopter cohort but only 2% more in the ambulance cohort. There was no evidence of a difference in survival for patients with head injury but a little evidence that patients with major trauma (injury severity score >/=16) were more likely to survive if attended by the helicopter. An estimated 13 (−5 to 39) extra patients with major trauma could survive each year if attended by the helicopter. Conclusion: Any benefit in survival is restricted to patients with very severe injuries and amounts to an estimated one additional survivor of major trauma each month. Over all the helicopter caseload, however, there is no evidence that it improves the chance of survival in trauma.

NHS emergency response to 999 calls: alternatives for cases that are neither life threatening nor serious

Ambulance services and emergency departments are under increasing pressure as the number of emergency calls continues to rise—but in many cases, patients do not need immediate clinical care. Helen Snooks and colleagues consider the alternatives to the standard NHS response and review the current literature The number of emergency (999) calls received by ambulance services in the United Kingdom has risen consistently over recent years. Ambulance services must respond to calls immediately by sending vehicles staffed by paramedics, with flashing lights and sirens. All patients have to be taken to an accident and emergency department. This response is not always appropriate, and it can resultin inefficient use of resources and unnecessary risks to the general public, patients, and paramedics. The NHS Plan and the recent consultation document Reforming Emergency Care have emphasised the importance of trying new approaches to deliver appropriate care. 1 2 They highlight the need to consider new ways to integrate the ambulance response to 999 calls into the overall system that deals with emergencies. ### Summary points Demands on emergency services and inappropriate requests for emergency ambulances are increasing Ambulance services must respond to calls immediately by sending vehicles with flashing lights and sirens, staffed by paramedics Many ambulance services want to develop alternatives to the standard response to all 999 calls Evidence about the safety and effectiveness of alternatives is weak and few rigorous trials have been reported Studies show that alternative responses are needed but that the work involved in their development is complex In England, demand through the 999 telephone system for services has risen by 40% since 1990.3 Problems of overcrowding and high attendance have also been noted in emergency departments and in primary care. Concerns have been expressed over the number of home visits requested at night and whether all such visits are …

Emergency care of older people who fall: a missed opportunity

Introduction: A high number of emergency (999) calls are made for older people who fall, with many patients not subsequently conveyed to hospital. Ambulance crews do not generally have protocols or training to leave people at home, and systems for referral are rare. The quality and safety of current practice is explored in this study, in which for the first time, the short-term outcomes of older people left at home by emergency ambulance crews after a fall are described. Results will inform the development of care for this population. Methods: Emergency ambulance data in London were analysed for patterns of attendance and call outcomes in 2003–4. All older people who were attended by emergency ambulance staff after a fall in September and October 2003, within three London areas, were identified. Those who were not conveyed to hospital were followed up; healthcare contacts and deaths within the following 2 weeks were identified. Results: During 2003–4, 8% of all 999 calls in London were for older people who had fallen (n = 60 064), with 40% not then conveyed to hospital. Of 2151 emergency calls attended in the study areas during September and October 2003, 534 were for people aged ⩾65 who had fallen. Of these, 194 (36.3%) were left at home. 86 (49%) people made healthcare contacts within the 2-week follow-up period, with 83 (47%) people calling 999 again at least once. There was an increased risk of death (standard mortality ratio 5.4) and of hospital admission (4.7) compared with the general population of the same age in London. Comment: The rate of subsequent emergency healthcare contacts and increased risk of death and hospitalisation for older people who fall and who are left at home after a 999 call are alarming. Further research is needed to explore appropriate models for delivery of care for this vulnerable group.

On-scene alternatives for emergency ambulance crews attending patients who do not need to travel to the accident and emergency department: a review of the literature

With rising demand and recognition of the variety of cases attended by emergency ambulance crews, services have been considering alternative ways of providing non-urgent care. This paper describes and appraises the research literature concerning on-scene alternatives to conveyance to an emergency department, focusing on the: (1) profile and outcomes of patients attended but not conveyed by emergency crews; (2) triage ability of crews; (3) effectiveness and safety of protocols that allow crews to convey patients to alternative receiving units or to self care. The literature search was conducted through standard medical databases, supplemented with manual searches. Very few “live” studies were identified, and fewer still that included a control group. Findings indicated a complex area, with the introduction of protocols allowing crews to leave patients at scene carrying clinical risk. Robust research evidence concerning alternatives to current emergency care models is needed urgently to inform service and practice development.

Safety of telephone consultation for “non-serious” emergency ambulance service patients

Objective: To assess the safety of nurses and paramedics offering telephone assessment, triage, and advice as an alternative to immediate ambulance despatch for emergency ambulance service callers classified by lay call takers as presenting with “non-serious” problems (category C calls). Design: Data for this study were collected as part of a pragmatic randomised controlled trial reported elsewhere. The intervention arm of the trial comprised nurse or paramedic telephone consultation using a computerised decision support system to assess, triage, and advise patients whose calls to the emergency ambulance service had been classified as “non-serious” by call takers applying standard priority despatch criteria. A multidisciplinary expert clinical panel reviewed data from ambulance service, accident and emergency department, hospital inpatient and general practice records, and call transcripts for patients triaged by nurses and paramedics into categories that indicated that despatch of an emergency ambulance was unnecessary. All cases for which one or more members of the panel rated that an emergency ambulance should have been despatched were re-reviewed by the entire panel for an assessment of the “life risk” that might have resulted. Setting: Ambulance services in London and the West Midlands, UK. Study population: Of 635 category C patients assessed by nurses and paramedics, 330 (52%) cases that had been triaged as not requiring an emergency ambulance were identified. Main outcome measures: Assessment of safety of triage decisions. Results: Sufficient data were available from the routine clinical records of 239 (72%) subjects to allow review by the specialist panel. For 231 (96.7%) sets of case notes reviewed, the majority of the panel concurred with the nurses’ or paramedics’ triage decision. Following secondary review of the records of the remaining eight patients, only two were rated by the majority as having required an emergency ambulance within 14 minutes. For neither of these did a majority of the panel consider that the patient would have been at “life risk” without an emergency ambulance being immediately despatched. However, the transcripts of these two calls indicated that the correct triage decision had been communicated to the patient, which suggests that the triage decision had been incorrectly entered into the decision support system. Conclusions: Telephone advice may be a safe method of managing many category C callers to 999 ambulance services. A clinical trial of the full implementation of this intervention is needed, large enough to exclude the possibility of rare adverse events.

Appropriateness of use of emergency ambulances.

General practice secondments are being increasingly undertaken by specialist registrars in accident and emergency (A&E) medicine. This paper describes how two A&E trainees arranged general practice secondments and the experiences gained. There follows a discussion ofthe benefits to the general practice and trainees involved, together with a contemporary consideration of the interaction between general practice and A&E services in the UK. (J7Accid Emerg Med 1998;15:215-218)

It could be a ‘Golden Goose’: a qualitative study of views in primary care on an emergency admission risk prediction tool prior to implementation

BackgroundRising demand for health care has prompted interest in new technologies to support a shift of care from hospital to community and primary care, which may require clinicians to undertake new working practices. A predictive risk stratification tool (Prism) was developed for use in primary care to estimate patients’ risk of an emergency hospital admission. As part of an evaluation of Prism, we aimed to understand what might be needed to bring Prism into effective use by exploring clinicians and practice managers’ attitudes and expectations about using it. We were informed by Normalisation Process Theory (NPT) which examines the work needed to bring an innovation into use.MethodsWe conducted 4 focus groups and 10 interviews with a total of 43 primary care doctors and colleagues from 32 general practices. All were recorded and transcribed. Analysis focussed in particular on the construct of ‘coherence’ within NPT, which examines how people understand an innovation and its purpose.ResultsRespondents were in agreement that Prism was a technological formalisation of existing practice, and that it would function as a support to clinical judgment, rather than replacing it. There was broad consensus about the role it might have in delivering new models of care based on active management, but there were doubts about the scope for making a difference to some patients and about whether Prism could identify at-risk patients not already known to the clinical team. Respondents did not expect using the tool to be onerous, but were concerned about the work which might follow in delivering care. Any potential value would not be of the tool in isolation, but would depend on the availability of support services.ConclusionsPolicy imperatives and the pressure of rising demand meant respondents were open to trying out Prism, despite underlying uncertainty about what difference it could make.Trial registrationControlled Clinical Trials no. ISRCTN55538212.

Computer assisted assessment and advice for "non-serious" 999 ambulance service callers : the potential impact on ambulance despatch

Objective: To investigate the potential impact for ambulance services of telephone assessment and triage for callers who present with non-serious problems (Category C calls) as classified by ambulance service call takers. Design: Pragmatic controlled trial. Calls identified using priority dispatch protocols as non-serious were allocated to intervention and control groups according to time of call. Ambulance dispatch occurred according to existing procedures. During intervention sessions, nurses or paramedics within the control room used a computerised decision support system to provide telephone assessment, triage and, if appropriate, offer advice to permit estimation of the potential impact on ambulance dispatch. Setting: Ambulance services in London and the West Midlands. Subjects: Patients for whom emergency calls were made to the ambulance services between April 1998 and May 1999 during four hour sessions sampled across all days of the week between 0700 and 2300. Main outcome measures: Triage decision, ambulance cancellation, attendance at an emergency department. Results: In total, there were 635 intervention calls and 611 controls. Of those in the intervention group, 330 (52.0%) were triaged as not requiring an emergency ambulance, and 119 (36.6%) of these did not attend an emergency department. This compares with 55 (18.1%) of those triaged by a nurse or paramedic as requiring an ambulance (odds ratio 2.62; 95% CI 1.78 to 3.85). Patients triaged as not requiring an emergency ambulance were less likely to be admitted to an inpatient bed (odds ratio 0.55; 95% CI 0.33 to 0.93), but even so 30 (9.2%) were admitted. Nurses were more likely than paramedics to triage calls into the groups classified as not requiring an ambulance. After controlling for age, case mix, time of day, day of week, season, and ambulance service, the results of a logistic regression analysis revealed that this difference was significant with an odds ratio for nurses:paramedics of 1.28 (95% CI 1.12 to 1.47). Conclusions: The findings indicate that telephone assessment of Category C calls identifies patients who are less likely to require emergency department care and that this could have a significant impact on emergency ambulance dispatch rates. Nurses were more likely than paramedics to assess calls as requiring an alternative response to emergency ambulance despatch, but the extent to which this relates to aspects of training and professional perspective is unclear. However, consideration should be given to the acceptability, reliability, and cost consequences of this intervention before it can be recommended for full evaluation.

Towards primary care for non-serious 999 callers: results of a controlled study of “Treat and Refer” protocols for ambulance crews

Objective: To develop and evaluate “Treat and Refer” protocols for ambulance crews, allowing them to leave patients at the scene with onward referral or self-care advice as appropriate. Methods: Crew members from one ambulance station were trained to use the treatment protocols. Processes and outcomes of care for patients attended by trained crews were compared with similar patients attended by crews from a neighbouring station. Pre-hospital records were collected for all patients. Records of any emergency department and primary care contacts during the 14 days following the call were collected for non-conveyed patients who were also followed up by postal questionnaire. Results: Twenty three protocols were developed which were expected to cover over 75% of patients left at the scene by the attending crew. There were 251 patients in the intervention arm and 537 in the control arm. The two groups were similar in terms of age, sex and condition category but intervention cases were more likely to have been attended during daytime hours than at night. There was no difference in the proportion of patients left at the scene in the intervention and control arms; the median job cycle time was longer for intervention group patients. Protocols were reported as having been used in 101 patients (40.2%) in the intervention group; 17 of the protocols were recorded as having been used at least once during the study. Clinical documentation was generally higher in the intervention group, although a similar proportion of patients in both groups had no clinical assessments recorded. 288 patients were left at the scene (93 in the intervention group, 195 in the control group). After excluding those who refused to travel, there were three non-conveyed patients in each group who were admitted to hospital within 14 days of the call who were judged to have been left at home inappropriately. A higher proportion of patients in the intervention arm reported satisfaction with the service and advice provided. Conclusions: “Treat and Refer” protocols did not increase the number of patients left at home but were used by crews and were acceptable to patients. The protocols increased job cycle time and some safety issues were identified. Their introduction is complex, and the extent to which the content of the protocols, decision support and training can be refined needs further study.

Complexity of the decision-making process of ambulance staff for assessment and referral of older people who have fallen: a qualitative study

Background Older people who fall commonly present to the emergency ambulance service, and approximately 40% are not conveyed to the emergency department (ED), despite an historic lack of formal training for such decisions. This study aimed to understand the decision-making processes of emergency ambulance staff with older people who have fallen. Methods During 2005 ambulance staff in London tested a clinical assessment tool for use with the older person who had fallen. Documented use of the tool was low. Following the trial, 12 staff participated in semistructured interviews. Interviews were recorded and transcribed. Thematic analysis was carried out. Results The interviews revealed a similar assessment and decision-making process among participants: Prearrival: forming an early opinion from information from the emergency call. Initial contact: assessing the need for any immediate action and establishing a rapport. Continuing assessment: gathering and assimilating medical and social information. Making a conveyance decision: negotiation, referral and professional defence, using professional experience and instinct. Conclusions An assessment process was described that highlights the complexity of making decisions about whether or not to convey older people who fall and present to the emergency ambulance service, and a predominance of informal decision-making processes. The need for support for ambulance staff in this area was highlighted, generating a significant challenge to those with education roles in the ambulance service. Further research is needed to look at how new care pathways, which offer an alternative to the ED may influence decision making around non-conveyance.