Exciting innovations in the Ambulance Service

Exciting innovations were being introduced in the Irish ambulance service, with more planned, to provide services for the radically altered society we could expect by 2030, Dr. Cathal O’Donnell, Medical Director of the National Ambulance Service told a meeting of HMI South in the Erinville Hospital, Cork last Wednesday. Maureen Browne reports.

Dr. Cathal O’Donnell
Dr. Cathal O’Donnell

Dr. O’Donnell said that the demand on the national ambulance service had increased by ten per cent in 2013, and averaging 6% annually since then, and they did not see it tailing off anytime soon.

By 2031, the population of Ireland would increase by 613,000 people. Births would decrease by 25% and the number of persons over the age of 65 would grow from 562,000 to 999,100 and the service had to make provision for this major demographic change.

“Our current model of going out, assessing, treating and bringing patients to hospital may not be fit for purpose in this scenario,” he said.

“We are working to see how we can adapt our model of care to meet the challenges which will arise in this context.

We are working to see how we can adapt our model of care to meet the challenges which will arise in this context

“At present our refusal of care rate (those who refuse to go to hospital when an ambulance is called) is seven to eight per cent each year. These are generally very reasonable – people who faint, stable epileptics or Saturday night revellers, where passers-by call an ambulance. That is currently the only circumstance in which a 999 caller is not transported to hospital

“However the model of care where we take 93% of patients to hospital will not deal with the problems we will face in years to come with our demographic changes and with the increasing number of older people who actually do not need to go to hospital when the ambulance service is called.

“The model of care for tomorrow will require a Clinical Hub in our National Emergency Operations Centre that will take the 999 call and identify an alternative pathway of care in appropriate cases.

For example, patients may be advised on self-care, or referred to their own GP or to the doctor on call services or the community pharmacist. A patient might also be referred to the specialist service or a community paramedic dispatched to the patient’s location might see and treat the patient. We will also of course refer to the Emergency Department or the specialist care centre, where appropriate.

“Our priority will be to take decisions which are both safe and convenient for the patient.

Dr. O’Donnell said that by the end of this year the ambulance service would be piloting a Clinical Hub in its National Emergency Operations Centre which would allow the service to see if alternative care pathways could be more appropriate for low acuity cases.

“The Clinical Hub will be staffed by emergency nurses and potentially advanced paramedics with additional training (GPs are used in Northern Ireland). We have already advertised for nursing staff and we hope to have this hub up and running on a pilot basis by the end of the year.

“We are working through to a situation where we can see and treat, where we send out a regular crew and they will do an assessment of patients where transport to hospital may not best thing for them. We have done some pilot work around this in the South East and the initial results are promising that it could be done safely and appropriately.”

Dr. O’Donnell said that the community paramedic would be a new clinical grade, trained to go to low acuity calls and carry out assessments, treatments and interventions designed to keep the patient in home without transport to hospital. “They might do things like sutures, change a catheter and they will be integrated with the local community health services, so patients will be dealt with in their own homes.

“Will this solve EDs overcrowding?  I don’t think so as the numbers will be, relatively speaking, quite small and some of them might never be admitted anyway.  We are doing this because it is the right thing for patients and because of the demographic changes anticipated in the coming years. We are piloting a Community Paramedic project next year. It is a cross border project in partnership with the Scottish and Northern Ireland ambulance services, where they have some experience with this already.”

We are doing this because it is the right thing for patients and because of the demographic changes anticipated in the coming years

Dr. O’Donnell said the ambulance service wanted to change how it did business in future with the use of technology.  “We are moving very quickly into a technological space to support what we are doing in future.

“At present, we have caller line identification (it populates your address automatically) for 999 calls from a landline and in the next six months using mobile phones we will be able to establish the location of the caller.”

Dr. O’Donnell said that the dispatch centres of the National Ambulance Service and the Dublin Fire Brigade Service  are two  of only six European accredited centres of excellence in Europe.

“This is a huge achievement.  Our computer system is now mapping, in real time, where our ambulances are in relation to a caller.   In addition, if callers have had an accident and do not know where they are, have a smart phone we can send them a text message and if they press accept, it comes back to us and we can see exactly where they are using the GPS function in the phone.

“In our vehicles, we have also have digital radio network, automatic vehicle location, vehicle telemetry and 12 lead ECG transmission which allow us to transmit live into our PCI centres in real time to cardiologists.

“Within the next 12 months, all our vehicles will be mobile Wi-Fi hubs, they will have axis camera, vehicle computer, dash camera and an electronic patient care report (ePCR).

“We are generating over 35 million pieces of clinical information from 300,000 calls per year.  Within months we will have an electronic patient report deployed by way of tablet devices in each ambulance where we can capture information in a far more detailed way compared to the current paper record.

When the crew get a call all information gathered by the dispatcher will be pushed to the tablet, and the paramedic will then continue to add clinical information on assessment and treatment provided.  We will print a record in the vehicle before handing the patient over to ED, but there is a web viewer associated with this product as well which will be installed in all Emergency Departments allowing the electronic record to be securely transmitted to the “cloud” and integrated with the clinical record in the hospital, We will be going live with this in the second half of this year,  and in my view it is a game changer for us and a generation changer for how the ambulance service manages our patents.”