Balancing patient outcomes with target times

One of the major challenges facing the ambulance services is balancing patient outcomes with target times, Damien McCallion, HSE National Director responsible for ambulance services tells Maureen Browne.

Damien McCallion
Damien McCallion

The HSE commissioned a report of the National Ambulance Service of Ireland, Emergency Service Baseline and Capacity Review to determine the capacity required to deliver the target Ambulance response times set out by HIQA in 2011. These targets stipulated that 80% of ECHO/Delta calls should receive a first response in eight minutes or 19 minutes depending on their urgency.

The National Ambulance Service deals with about 300,000 emergency calls each year but the eight and 19 minute targets only apply to about half of these, which are classified as potentially life threatening.

Mr. McCallion said that the report concluded that for potentially life threatening calls, Ireland could only achieve an eight minute performance target in 60.6% of the time (once all the recommendations of the report have been implemented), compared to around 79% for a typical English ambulance service. The reason that Ireland could not meet these targets was because of the immense difficulties with rurality in Ireland.

In its 2014 report, HIQA highlighted that international experts had started to move away from target times and were starting to look at outcome measures for patients.

“In its 2014 report, HIQA highlighted that international experts had started to move away from target times and were starting to look at outcome measures for patients. When a patient has a witnessed cardiac arrest somebody needs to start CPR immediately to enhance the possibility of survival. Having an ambulance arrive within 8 minutes which is the target, could be too late, as CPR is required within minutes of a cardiac arrest. This is why we are supporting Community First Responders. If there is a CFR group in the area, they will be available to get to the patient in a more timely manner and can start CPR while the ambulance is on route. This CPR will greatly enhance the patient’s chances of survival, as every minute counts.

“In 2015, we put an outcome measure in place for patients with a cardiac arrest with the objective of improving the proportion of patients who would have a pulse when they got to hospital. This has shifted the emphasis from getting the ambulance to the patient within eight minutes, to getting a responder to the patient as quickly as possible (which could be an NAS responder or a CFR Group responder), starting CPR as quickly as possible and transporting the patient to a major cardiac centre within 90 minutes which in line with best practice. This often includes the emergency call taker instructing the person who made the call, how to providing CPR immediately, while a first responder or ambulance is travelling to the patient.

“We need to find a set of measures that balance response times with patient outcomes and we have a group working on this with the help of Dr. Philip Crowley, National Director HSE Quality Improvement Division to define an appropriate set of measures.”

Mr. McCallion said that the Report identified scope for improvement in targets and in other areas. “We need improved operational processes through further investment in ambulance and related vehicles and control room technology, which we are implementing at present.

The solution in many of those areas is that the ambulance service would work much more closely with communities and support communities.

“The second area highlighted in the report is additional resources. The ambulance services would require another 600 paramedics to bring it up to the level in the report. Some of the posts could be self-financing, as we will be able to use money we currently spend on overtime and convert this to new staff posts. We have commenced this investment in 2016, as NAS will have 100 staff in training by the end of this year.

“The report also highlights the need to deploy ambulances to reduce the distances required for emergency vehicles to respond.   This would mean not maintaining all ambulances at specified static bases but using them in a more flexible manner that reflects population needs. At certain times of the day or night in large towns or cities it might be necessary to move ambulances to other locations to provide a more flexible and efficient response to calls.   The key to this would be to have sufficient capacity.

“The report identifies 100 towns where it would greatly enhance our capacity if we could get a first responder to a patient. First responders only respond to certain types of calls such as ECHO and cardiac arrest calls. They do wonderful work and we have many examples of where they have been very successful. CFR Ireland do sterling unpaid work in this area.’

“We are also looking at the Irish community rapid response where doctors or other health professionals act as first responders. They can obviously provide a higher level of care and there are already good examples of this in Wicklow, Cork and Mayo. The solution in many of those areas is that the ambulance service would work much more closely with communities and support communities. This is a big responsibility for a community. There are already 150 Community First Responder schemes in place but the report identifies an immediately priority list of about another 100.”

Mr. McCallion said the HSE had an action plan in place to implement the report recommendations. “We have secured a multi million investment in terms of ICT, we have increased the numbers in training from 11 two years ago to 100 this year. We have also made an extensive investment in the fleet to get the average age to seven years and we will further invest to get this average to five years in 2017. This is supported by a multiyear capital plan. In relation to Community First Responder (CFR) schemes we are putting in place community engagement officers to work with CFR, the public and communities, to establish and develop these schemes.