Evaluation of the clinical and Ambulance Service .../file/MCRU-LIVESrep… · Outcomes from out of hospital cardiac arrest 30 4.1 Introduction 30 4.2 Methods 30 . 3 4.3 Results 32

Evaluation of the clinical and Ambulance Service operational impact of

the Lincolnshire Integrated Voluntary Emergency Service (LIVES)

Janette Turner Medical care Research Unit University of Sheffield Regent Court 30 Regent Street Sheffield S1 4DA

2

Contents Executive Summary 4

1.1 Introduction 6

1.2 Objectives 6

1.3 Background to the LIVES Scheme 6

1.4 Callout procedures 8

2. LIVES activity and impact on Lincolnshire Ambulance Service NHS Trust

response time performance

2.1 Introduction 9

2.2 Methods 9

2.3 LIVES activity 12

2.4 Ambulance service activity and response time performance 13

2.5 Impact of LIVES on response time performance for the period July 2001 – June

2003 15

2.6 Summary of Main Findings 20

3. User Satisfaction and Acceptability of the First Responder Scheme 22

3.1 Introduction 22

3.2 Methods 22

3.3 Response rates 23

3.4 Caller/patient characteristics 23

3.5 The 999 telephone call 23

3.6 The LIVES response 24

3.7 The ambulance service response 25

3.8 Satisfaction with the service 25

3.9 Summary of main findings 26

4. Outcomes from out of hospital cardiac arrest 30

4.1 Introduction 30

4.2 Methods 30

3

4.3 Results 32

4.4 Summary 36

5. Economic Implications of the LIVES scheme 37

5.1 Introduction 37

5.2 Methods 37

5.3 Results 38

5.4 Summary of findings 41

References 42

4

Executive Summary

Ambulance Services in England have to meet response time targets for emergency

(999) calls. Currently these are to respond to 75% of category A calls in 8 minutes or

less and 95% of all other calls in 19 minutes or less. For mixed urban and rural

services with limited resources this poses a dilemma. To maximise performance

resources can be concentrated in urban, high call volume areas thereby ensuring

that the largest possible proportion of calls can be responded to within target times.

Alternatively resources can be spread more equitable across the service

geographical area, however this means that in low demand rural areas resources are

not utilised efficiently and there is a consequent loss of performance in high demand

areas. An alternative is to supplement ambulance service resources with community

based voluntary first response services in areas of low demand. In Lincolnshire such

a service is provided by LIVES (Lincolnshire Integrated Voluntary Emergency

Service).

This study has assessed the impact of a community first response service on

ambulance service performance and patient outcomes. It has also measured patient

and caller satisfaction with the service and has examined whether the service

represents value for money in terms of the funding currently provided by local

Primary Care Trusts.

The main findings are:

• Lives activity is increasing over time as the number of schemes also continues to

increase. Up to 25% of ambulance service category A calls now receive a LIVES

response and for 60% of these calls the LIVES response arrives first on scene.

• There is a corresponding increase in the contribution to response time

performance. If lives responses are removed ambulance service performance

falls by 6% over the year and without this contribution Lincolnshire Ambulance

Service NHS Trust would find it difficult to achieve the Category A 8 minute

performance standard.

• LIVES improves response time performance by 35% in the rural areas where

they provide a service thus contributing to the provision of an equitable service for

life-threatening category A calls.

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• The return to spontaneous circulation rate of patients in cardiac arrest is 20% for

cases attended by LIVES and receiving defibrillation. Response times to these

cases are considerably shorter than the first ambulance service response. No

difference in ROSC rates was detected between LIVES attended cases and

ambulance service cases however the data provided did not allow a more

detailed examination of outcomes in rural areas with and without first responder

schemes.

• Users of the ambulance service who receive a LIVES response show a high level

of satisfaction with the LIVES service , the way their 999 call was handled by

ambulance service control centre staff, ambulance crew who arrived at the scene

and the speed of response.

• There were very low numbers of individuals who indicated any dissatisfaction with

LIVES responders or the service in general and the characteristics of ambulance

and LIVES personnel were highly rated.

• The principal of providing a voluntary medical response service in rural

communities seems to be acceptable to the public.

• Lives responds to a fifth of ambulance service category A calls with a relatively

modest sum of money (1% of the ambulance service A&E budget) and as such

provides good value in terms of the contribution it makes to ambulance service

performance and the level of service within rural communities where it has a

substantial impact on performance.

• The introduction of new technology into the ambulance service control room

provides an opportunity for further improvement in terms of both the number and

speed of LIVES activations. There is therefore potential to further improve LIVES

performance, ambulance service performance and patient outcomes for life-

threatening conditions in an environment where continued annual increases in

demand for emergency ambulance services produce further pressure on already

stretched resources.

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1.1 Introduction

The Lincolnshire Integrated Voluntary Emergency Service (LIVES) provides a pre-

hospital medical response to serious emergencies within rural areas of Lincolnshire.

The service has strong links with Lincolnshire Ambulance Service NHS Trust

providing an adjunct response to ambulance service emergency calls. Following the

1996 review of ambulance service performance standards1, responses made by

LIVES to ambulance service 999 calls now count in the measurement of the

Category A 8 minute response time standard and hence contributes to ambulance

service response time performance.

Although LIVES is a longstanding service there has never been any formal

evaluation of the contribution the scheme makes to the clinical care of patients or

ambulance service operations. The expansion of the scheme and increased

involvement in responding to 999 calls provides an ideal opportunity to assess the

impact of LIVES on pre-hospital care in Lincolnshire.

1.2 Objectives

The objectives of this evaluation are to:

1. Measure the contribution of LIVES responses to the achievement of the Category

A 999 calls response time standard

2. Measure LIVES response time performance

3. Assess the impact of early patient management by LIVES responders on

outcome from out of hospital cardiac arrest

4. Measure patient satisfaction with the LIVES service

5. Assess the control room operational costs of providing the LIVES callout service

and conduct a simple appraisal of the value for money LIVES provides in terms of

current PCT funding.

1.3 Background to the LIVES Scheme LIVES is a voluntary pre-hospital medical service that has been in operation for over

25 years. The purpose of the scheme is to provide early medical care in a

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predominately rural county where access to secondary care may be delayed.

Originally the service was provided by GP’s but in 1999 the scheme expanded to

include paramedics and, in association with Lincolnshire Ambulance service NHS

Trust, a community first responder scheme provided by members of the public and

the fire service. As a consequence LIVES now provides two levels of response;

1. LIVES doctors and paramedics provide cover on a voluntary basis using their

own vehicles. They respond to any acute trauma or medical incident

occurring in Lincolnshire. They carry an extensive range of equipment

enabling them to provide Advanced Trauma and Cardiac Life Support in the

pre-hospital setting. LIVES doctors can also cancel ambulances if they are

not required and the patient can be left at home, certify death at scene

negating the need to transfer a patient to hospital and direct ambulance crews

to take patients to the most appropriate rather than the nearest hospital.

2. LIVES First Responders are members of the public and Fire Service

personnel who provide cover in their immediate community. The boundaries

of the community covered are determined as geographical areas within which

a response time of 6 minutes from time of callout to arrival on scene can be

achieved. First Responders are organised as teams for each area. The

community groups give their time voluntarily and use their own vehicles. The

Fire Service personnel callouts are paid for by Lincolnshire Fire Service, they

respond with a minimum of 3 personnel and use a Fire Service vehicle.

However they are equipped and trained by LIVES.

The aim of the First Responders is to provide rapid emergency aid including

Basic Life Support and early defibrillation. They attend Ambulance Service

category A calls, that is the following types of incidents within their agreed

geographical area;

• Cardiac Arrest

• Collapse

• Breathing Difficulty

• Chest Pain

First Responders are equipped with a Heartstart Automatic External Defibrillator

(AED), face masks for ventilation, oxygen and a basic first aid pack.

Funding for the scheme is provided primarily by public donations although there is

some Health Service funding from 3 Primary Care Trusts.

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1.4 Callout procedures

LIVES responses are activated via the ambulance service control room. On receiving

a 999 call an ambulance is deployed. If a LIVES response is also appropriate these

can be activated in two ways.

LIVES doctors and paramedics are called out via a group pager system. Ambulance

control calls a single pager number alerting all doctors and paramedics who then

respond depending on their location at the time of the call. This system allows a

quick response as there is a single call negating the need to make individual calls to

specific geographical areas. However in some instances there may be no LIVES

cover available in the incident area leading to a non-response.

The First Responder fire service personnel are called out by fire service control

following an alert from ambulance control. Community First responder schemes are

contacted by ambulance control by mobile telephone for calls within their defined

geographical areas. This means that calls are only made to areas where are potential

response can be made. However it provides some additional work for ambulance

control as a control assistant has to first identify if a scheme is available in the area of

the incident and then alert the appropriate scheme. This also makes the callout

process slower. These issues are discussed more fully in section 2 and 5.

The LIVES service provides an additional response resource for the ambulance

service, particularly in the most rural areas of the county. Section 2 describes an

assessment of LIVES activity and the contribution the LIVES service makes to

ambulance service response time performance.

9

2. LIVES activity and impact on Lincolnshire Ambulance Service NHS Trust

response time performance

2.1 Introduction

Since its inception LIVES has significantly increased in size and activity. The service

contributes to pre-hospital care and specifically, responses made by the organisation

contribute to ambulance service response time performance.

Since 2001 all ambulance services have been required to report their response time

performance for 999 calls against two performance standards. These are:

For category A (immediately life-threatening) calls 75% should be responded to

within 8 minutes

For category B and C calls 95% should receive a response within 14 minutes (urban

services) or 19 minutes (rural services).

Lincolnshire Ambulance service NHS Trust is a classified as a rural service.

Previously only responses made by the ambulance service were included in the

reporting of response times. However, with the introduction of the new performance

standards there was a corresponding change in reporting rules so that emergency

responses other than a fully crewed ambulance could be counted for response time

performance returns. This included the use approved first responders despatched by

and accountable to the ambulance service. Consequently responses made by

LIVES, including those made by the first responder schemes, now contribute to

ambulance service response time performance.

The aim of this assessment is to identify the size of the contribution LIVES makes to

the ambulance service Category A 999 call response time standard.

2.2 Methods

Data was supplied by LIVES and Lincolnshire Ambulance Service NHS Trust (LAS).

LAS provided details of all category A 999 calls. The items used were:

Call date

Call Time

AMPDS code

Responding vehicle codes (up to four)

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Time call passed to each vehicle

Time vehicle(s) arrived on scene

Data was retrieved from the ambulance service Computerised Dispatch system and

supplied as Excel spreadsheets. Initially data for the period 1st July 2001 to 30th June

2002 was provided. However, during 2002/3 the LIVES scheme rapidly expanded so

additional data for the period April-June 2003 was obtained. The assessment of

changes over time as LIVES activity increased became the focus and for simplicity

data has been analysed for 3 time periods, July – September 2001, April – June

2002 and April-June 2003.

The analysis has focused on Category A response time performance as it is to these

calls the first responder schemes are Targeted. The datasets for each time period

were adjusted to only include calls with the AMPDS dispatch codes included in the

Department of Health minimum dataset for reporting of category A calls. LAS

includes other codes, most notably road traffic accidents, for internal reporting but for

consistency these were not included in the main analysis. However, exclusion of

these calls also excludes some LIVES doctor and paramedic responses as these are

targeted to all calls not just category A. A separate analysis of response time

performance for these calls has also been carried out for 2003.

Only calls where a response arrived on scene were used in the analysis. Aborted

calls where any resource was mobilised but stood down before arrival at the scene

were excluded.

For each dataset response times were calculated for each vehicle mobilised to and

arriving at an incident scene. Response time was calculated as the difference

between the time of the call and the time of arrival on scene. This differs from the

ambulance service measurement where response time performance is not measured

from the time of the call but from the time the chief complaint is determined by the

Emergency Medical Dispatcher (EMD). As a consequence all response times used in

this analysis will differ from ambulance response times by about 1 minute (i.e. a

response time of 8 minutes in this analysis would be calculated as a 7 minute

response time by the ambulance service).

Activation time was calculated as the difference between the time of the call and the

time passed to the responding crew or LIVES responder.

11

LIVES also provided data on all calls during the same time periods. From this dataset

LIVES own response time performance was assessed using the time difference

between the time the call was received by LIVES and arrival on scene. LIVES also

provided data on the number of operating schemes form 2001 – 2003.

Changes in response time performance and activity have been calculated for each of

the 3 time periods to show trends over time. Additional analysis has been carried out

for the 2003 period to illustrate the most up to date position.

All analyses were conducted using the Statistical Package for Social Sciences

(SPSS) version 11.5.

2.3 LIVES Activity

Lives activity has increased significantly over the last two years. In particular the first

responder scheme has grown from 19 groups in April 2001 to 59 groups in June

2003. There has been a corresponding increase in callouts over the same period.

Table 1 and Figure 1 summarises activity over this period

Table 1 – Lives activity 2001 – 2003 (ambulance service data)

Time period

Number of LIVES schemes (min-max)

Total number of CAT A calls

Number of all LIVES responses

Number of responses by First Responders

% of ambulance service responses to Cat A calls (All LIVES)

% of ambulance service responses (First responder)

July 01 – Sept 01

22 - 26 4761 365 302 7.5 6.3

April 02 – June 02

36 - 42 4565 375 261 7.6 5.7

April 03 – June 03

59 4854 786 674 16.2 13.9

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Figure 1 - LIVES contribution to ambulance service category A responses

Ambulance service activity has increased by 8% for the year 2002/2003. The

proportion of ambulance service calls responded to by the LIVES service has

increased over and above ambulance service activity increases so that it now

provides a response to a substantial 16% of all category A calls. The majority of

these responses are made by community first responders and the large increase in

activity from 2002 – 2003 reflects not only the increase in the number of LIVES

schemes but also greater utilisation by the ambulance service.

LIVES own data shows additional activity to that recorded within the ambulance

service dataset. For the period April – June 2003 LIVES activated 1521 first

responses and 356 doctor and paramedic responses, a total of 1877 activations

compared to the 786 responses recorded in the ambulance service data using DH

category A dispatch codes. Some of this can be accounted for by the activation of

LIVES responses to calls with AMPDS codes not included in the DH minimum

dataset. Analysis of all calls during the same time period with AMPDS codes used by

LAS to trigger a category A response shows1300/7146 calls (18.4%) had a LIVES

response activated of which 1101 were first responders and 272 doctor or paramedic

responses, that is 1373 responses. In 70 cases more than one LIVES response was

activated to the same call. This means 420 first responder activations and 84 doctor

and paramedic activations are unaccounted for within the ambulance service dataset.

Some of these will be doctor and paramedic calls who are tasked to category A & B

calls. However as first responders are targeted at life-threatening (category A calls)

this does not account for the discrepancy in first responder activations. It may be that

Percentage of Category A calls responded to by

LIVES 2001 - 2003

0

2

4

6

8

10

12

14

16

18

1 2 3Year

% r

es

po

ns

es

% Responses

by LIVES

% responses

by First

Responders

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not all LIVES activations are actually recorded on the ambulance service CAD

system. As a consequence the percentage of category A calls receiving a LIVES

response may be underestimated and if LIVES own figures are used the proportion

would rise to 25%. LIVES therefore provides a response to at least one fifth of all

ambulance service defined Category A calls and this may be as higher.

2.4 Ambulance service activity and response time performance

The impact of LIVES attendance on category A ambulance calls has been measured

in terms of the proportion of all calls attended and response time performance. Table

2 summarises this activity and the proportion of calls responded to first by a LIVES

response. All LIVES responses are included, that is first responders and LIVES

doctors and paramedics. The yearly comparisons are for all Category A calls using

only the DH minimum dataset AMPDS codes. The second group of calls for 2003

uses the ambulance service Category A codes.

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Table 2 – Summary of LIVES contribution to category A responses

Category A calls

Ambulance only response

LIVES response

% of all calls responded to first by LIVES

% of dual responses where LIVES arrived first

Total number of calls July 01 – Sept 01

4761 4484 360 5.4 71

Mean response time (mins:secs)

8:40 8:59 8:56

Median response time (mins:secs)

7:33 7:42 8:13

Total number of calls April 02 – June 02

4565 4182 349 5.2 67

Mean response time

8:10 8:43 9:11

Median response time 7:05 7:12 8:06

Total number of calls April 03 – June 03

4858 4072 786 10 63

Mean response time

8:27 9:09 8:34

Median response time 7:23 7:45 07:54

Total number of calls with a LIVES response April 03 – June 03

786 Fastest

ambulance

response

61

Mean response time

7:45 12:08

Median response time 7:16 10:46

Total number of calls April 03 – June 03 LAS A calls

7146 5846 1300 11.1 61

Mean response time

8:27 9:13

Median response time 7:22 7:44

All times are calculated from the time of the call not from when the control room clock

starts.

Ambulance service mean and median response times performance has remained

unchanged over the 3 year period. The year 2002 times show a reduction but this

15

may be a reflection of less demand during that time period. LIVES mean and median

response times are comparable to ambulance service times and median response

time has reduced over the three time periods from 8:15 to 7:54. This is despite the

longer activation for these calls as the ambulance service activates its own vehicle

first and has a separate dispatch desk within ambulance control to activate LIVES

responses. Analysis of 2003 data shows that the median time from the time of the

call to mobilising the first ambulance is 01:30 (mins:secs) compared to 02:21 for

mobilisation of the LIVES response. The rural characteristics of LIVES responses is

illustrated by the difference in median response times for calls with a LIVES response

where the median ambulance service response time is 3.5 minutes longer than the

LIVES response.

Of cases where there was a dual (ambulance and LIVES) the LIVES response is

consistently first on scene. The proportion of all category A calls attended first by

LIVES has increased over the 3 years to 10% in 2003.

2.5 Impact of LIVES on response time performance for the period July 2001 – June 2003 The contribution that LIVES responses make to the key category A performance

target of 75% of calls responded to within 8 minutes has been investigated in more

detail. Ambulance service response time performance has been calculated with and

without LIVES responses. The difference between the two provides a measure of the

actual contribution made by LIVES to overall ambulance service response time

performance. As multiple responses are made to incidents response times have

been calculated as the minimum response time for any response (Ambulance service

or LIVES) and the minimum response by the ambulance service only. Table 3

summarises the differences in response time performance for these two measures at

the key time intervals of 7-10 minutes and 19 minutes over the three time periods.

16

Table 3 - Cumulative proportions of response at key time points Cumulative Responses (%) 6:59

(min:sec)

7:59 8:59 9:59 18:59

All responses Jul-

Sep 2001

42.4 56.1 69.0 75.5 95.5

Fastest Ambulance 40.5 53.8 66.2 72.5 94.6

Difference -1.9% -2.4% -2.8% -3.0% 0.9%

All responses Apr -

June 2002

48.8 62.5 73.2 79.7 96.4


Difference -1.8% -2.5% -2.8% -3.0% -1.0%

All responses Apr –

June 2003

44.5 58.0 69.5 76.6 96.4


Difference -4.1% -5.0% -5.8.% -5.8% -2.0%

All calls with a

LIVES responses

Apr – June 2003

46.8 61.4 73.5 79.9 98.6


Difference -25.2% -31.1% -35.7% -35.7% -12.9%

All responses Apr –

June 2003 LAS cat

A codes

45.1 58.3 69.4 76.4 96.4


Difference -4.2% -5.2% -6.0% -6.3% -2.3%

The contribution LIVES makes to ambulance service response time performance is

illustrated by the difference between response time performance with and without

Lives responses. Over the whole service this accounts for about 6% of response time

performance. The real impact of LIVES is seen by examining only those calls they

respond to. Here response time performance is reduced by 35% if LIVES responses

are not considered. This also reflects the usefulness of the strategy of providing first

response schemes in geographical areas where ambulance journeys are long and

suggests that ambulance control is appropriately targeting LIVES responses to

incidents where an ambulance response would not be achievable within the

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response time target. As a consequence the availability of first response schemes in

these rural areas makes a significant contribution to providing an equitable service in

locations where there is low demand and hence fewer ambulance service resources

available.

Table 4 gives the detailed cumulative response time figures for the fastest response

and the fastest ambulance service response. Figures 2-5 provide a graphical

summary of overall response time performance for the year 2001 – 2003 and the

impact of LIVES on cumulative response times over the three time periods in 2001 –

2003. All times are calculated from the time of the call not from when the clock starts

so all values could shift back by at least one minute. For example, the value for 9

minutes is probably equivalent to the value for 8 minutes if time from call to

identification of chief complaint (when the ambulance service clock starts) is 45

seconds.

Table 4 – Cumulative response times for 2003 ambulance service data

Cumulative Percent Cumulative Percent

Time (min:sec) Fastest response Ambulance response Difference

00:00:59 0.5 0.4 -0.1

00:01:58 1.1 0.9 -0.2

00:02:57 2.5 2.1 -0.4

00:03:59 7.1 6 -1.1

00:04:59 16.4 14.6 -1.8

00:05:59 30.1 27.3 -2.8

00:06:59 44.5 40.4 -4.1

00:07:59 58 53 -5

00:08:59 69.5 63.7 -5.8

00:09:59 76.6 70.8 -5.8

00:10:59 81.2 75.7 -5.5

00:11:59 84.6 79.4 -5.2

00:12:59 87.1 82.3 -4.8

00:13:59 89.3 85 -4.3

00:14:59 91.3 87.4 -3.9

00:15:59 92.8 89.4 -3.4

00:16:59 94.4 91.4 -3

00:17:59 95.6 93 -2.6

00:18:59 96.4 94.4 -2

18

Figure 2 - Ambulance Service response time

performance (all responses) April - June 2003

0

100

200

300

400

500

600

700

800

1 3 5 7 9

11

13

15

17

19

Time (mins)

Nu

mb

er

of

resp

on

ses

Figure 3 - Ambulance Service response performance

(ambulance responses only) April - June 2003

0

100

200

300

400

500

600

700

800

1 3 5 7 9

11

13

15

17

19

Time (mins)

Nu

mb

er

of

resp

on

ses

Figure 4 - LIVES response time performance April -

June 2003

0

50

100

150

200

250

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Time (mins)

nu

mb

er

of

resp

on

ses

Figure 5 - LIVES response time from alert to arrival

at scene - 2003

0

50

100

150

200

250

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Time (mins)

Nu

mb

er

of

resp

on

ses

19

Figures 2 and 3 illustrate response time performance calculated from ambulance

service data. Where LIVES responses are included performance peaks at 6 minutes

compared to 8 minutes when these are excluded. LIVES makes it’s major

contribution to the left side of the curve with the shortest response times and reflects

the strategy of deploying first responders only within small, defined geographical

areas where response time can be kept to under six minutes. The ambulance

service, of course, responds to all calls regardless of location.

Figures 4 and 5 use LIVES own data for first responders. These peak at 8 minutes

when response time is calculated from the time of the call to ambulance control. If

response time is calculated from the time LIVES is alerted performance peaks at 6

minutes. Median response time from alert to arrival on scene is 5minutes 36

seconds, 55.7% of first responder calls are attended within 6 minutes and 76.2%

within 8 minutes.

The response time performance reported here differs from Lincolnshire Ambulance

Service NHS Trust figures reported to the Department of Health. The 2003 data used

in this analysis shows that 58% of category A calls are responded to within 8 minutes

Figure 6 - Percentage difference in response time

with LIVES response

0

1

2

3

4

5

6

7

7 8 9 10

Response time band (mins)

% L

IVE

S f

as

tes

t

Jul-Sept 01

Apr-June 02

Apr-June 03

20

compared to 76.4% reported in the 2002-03 Ambulance Services Statistical Bulletin2.

The analysis here shows this level of response at 10 minutes. This is probably the

result of using the time of the call as the baseline for response time calculations. As

previously stated for DH reporting the clock starts for ambulance response time when

the callers telephone number, an exact incident location and the chief complaint have

been obtained. At least some of the discrepancy can be accounted for by this

difference in data handling. However, the purpose of the analysis was not to measure

response time performance of the ambulance service but to estimate the contribution

to performance made by LIVES and the extent to which this has changed as LIVES

has grown as an organisation. In this respect the analysis performed is robust in that

the data has been examined consistently across all three time periods in order to

detect changes over time.

2.6 Summary of Main Findings

• Lives activity is increasing over time as the number of schemes also continues to

increase.

• At least 18% and possibly up to 25% of ambulance service category A calls now

receive a LIVES response.

• For 60% of these calls the LIVES response arrives first on scene.

• There is a corresponding increase in the contribution to response time

performance. If lives responses are removed ambulance service performance

falls by 6% over the year. Early and late year comparisons show this performance

loss increased from 2.5 % in 2001 to 5 % in 2003 at the 8 minute level and 3% to

6% at the 10 minute level.

• LIVES improves response time performance by 35% in areas where they provide

a service

• LIVES responses make an increasingly valuable contribution to ambulance

service activity and response time performance. Without this contribution

Lincolnshire Ambulance Service NHS Trust would not achieve the Category A 8

minute performance standard.

• The impact is greater in rural areas where the first responder schemes make a

large contribution to provision of an equitable service for life-threatening category

A calls.

• The figures here may underestimate the impact of LIVES as not all LIVES

responses were accounted for within the ambulance service data.

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• Activation times for LIVES are almost a minute longer than ambulance service

activation times. If this could be reduced then a greater proportion of calls would

be attended within 8 minutes.

22

3. User Satisfaction and Acceptability of the First Responder Scheme

3.1 Introduction

The introduction of first responder schemes represents a change in emergency

service provision in the communities they serve. This strategy is being adopted by

numerous ambulance services, particularly those which, like Lincolnshire, have rural

communities. However, there has been no published research that has assessed

service users views of first responder schemes and particularly whether the use of

trained volunteers to provide medical aid before the arrival of an ambulance is

acceptable to the public.

This study has conducted a survey of users of the LIVES service to try and answer

these questions and assess satisfaction with the service and whether the public think

first responder schemes are an acceptable form of medical help.

3.2 Methods

A postal questionnaire was developed to assess the views of users of the ambulance

service and to measure their satisfaction with different aspects of the service

including:

• The 999 telephone call

• The LIVES response

• The ambulance service response

The questionnaire was adapted from work previously carried out by the Medical Care

Research Unit, Sheffield to measure satisfaction and acceptability of ambulance

service Emergency Priority Dispatch systems3 and a nurse led telephone advice

service4.

The questionnaire is simple to complete with the majority of questions only requiring

a tick box answer. Space is provided for comments should respondents have specific

views they wish to record. Questionnaires were anonymised and respondents could

not be identified. A reply paid envelope was provided for questionnaire return.

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3.3 Response Rate

A total of 300 questionnaires we sent out to consecutive users of the service by the

LIVES office. No reminders were sent. One hundred and eighty questionnaires were

returned giving a response rate of 60%. Some respondents did not complete all items

on the questionnaire. Results are reported as the percentage of respondents who

completed the item under consideration.

3.4 Caller/patient characteristics

There were more male than female respondents (56.5% v 42.9%). Callers ranged in

age from 13 years to 92 years with a mean age of 62 years.

The majority of callers knew the person for whom they were calling an ambulance:

47.1% called for a friend or relative, 32 % for themselves and 19.2% were for

residents of care homes. Only 1.7% of calls were for a stranger.

3.5 The 999 telephone call

Most callers thought their 999 call was answered very promptly (87.3%) or promptly

(10.9%).

Table 5 summarises users views of the characteristics of the ambulance service call

takers.

Table 5 – Description of call takers answering the 999 call

Characteristic Strongly

agree (%)

Agree (%) Not sure

(%)

Disagree

(%)

Strongly

disagree

(%)

Friendly 75.8 21.5 1.3 0 1.3

Helpful 83.6 16.4 0 0 0

Sympathetic 70.2 24.2 4.8 0.8 0

Efficient 82.7 15.8 0.8 0.8 0

24

Callers to the ambulance service reported a very positive experience in terms of the

handling of their 999 call. In particular they found call takers to be helpful and

sympathetic. There were few (1%) negative experiences.

Users were asked how important it was for help to arrive quickly. 70% thought it very

important and 27 % important. 2.4% thought it was not important.

3.6 The LIVES response

In 81% of cases the LIVES response was the first to arrive at the incident. Eighty

seven % of respondents thought LIVES arrived very promptly and 11.7% thought

they arrived promptly. In contrast 63.4% thought the ambulance arrived very promptly

and 34.3% promptly and 98.8% thought that help arrived quickly enough. In 61.4%

of cases a first responder attended. A doctor attended 10% of cases and a nurse or

paramedic 25.3%. Table 6 summarises users views of the LIVES response.

Table 6 – Description of users views of LIVES responders


agree (%)

Agree (%) Not sure

(%)

Disagree

(%)

Strongly

disagree

(%)

Friendly 82.5 16.9 0 0 0.6

Helpful 81.2 16.7 1.4 0.7 0

Sympathetic 78.6 19.1 0 0.8 1.5

Professional 83.9 13.1 2.2 0 0.7

Efficient 82.9 15.0 1.4 0.7 0

Again, respondents expressed a high level of satisfaction with the LIVES responders

with very few negative experiences. Users also reported the LIVES responders as

being very helpful (85.5%) or quite helpful (12.6%). Only 3 respondents (1.9%)

reported the LIVES response as being not very helpful. Over 97% of users strongly

agreed or agreed that the LIVES responder was friendly, sympathetic, professional

and efficient.

In 99.4% cases an ambulance also attended and 93.8 % of patients were

subsequently taken to hospital with 3.1% staying at home and 3.1% some other

25

disposition. This contrasts to LIVES data which shows that 11% of patients are left at

home.

3.7. The ambulance service response

Users were also asked for their views on the ambulance service response. Ninety

four percent thought the ambulance arrived quickly enough.

Table 7 summarises users views of the ambulance service crew.

Table 7 – Description of users views of the ambulance response


agree (%)

Agree (%) Not sure

(%)

Disagree

(%)

Strongly

disagree

(%)

Friendly 83.9 12.5 0.6 1.8 0.6

Helpful 86.8 9.4 1.9 1.3 0.6

Sympathetic 80.3 16.4 0.7 0.7 2.0

Professional 89.5 8.0 1.2 0.6 0.6

Efficient 87.5 9.4 1.9 0.6 0.6

Users rated the ambulance crew very highly with all characteristics rated as strongly

agree in over 80% of responses. Ninety four percent of respondents reported the

crew as very helpful and 4.1% as helpful whilst 2.4% thought they were not very

helpful.

2.8 Satisfaction with the service

Users were asked to give their views on the overall service provided. Table 8

summarises their responses.

26

Table 8 – Users views of LIVES and the ambulance service

Item Strongly

agree (%)

Agree (%) Not sure

(%)

Disagree

(%)

Strongly

disagree

(%)

Importance of LIVES scheme

91.5 6.2 0.6 0.6 1.1

Satisfaction with 999 call

88.0 11.4 0 0.6 0

Acceptability of community providing help

74.9 20.6 4.0 0 0

Satisfaction with LIVES

81.4 12.4 1.7 1.1 0.6

Satisfaction with ambulance service

88.8 8.4 0 1.7 1.1

Help arrived quickly

87.8 10.6 1.1 0 0

Service could not be improved

76.7 13.6 5.7 3.4 0

There was a very high rating on all items. In particular almost 98% thought the LIVES

scheme to be important and no respondent reported the view that the community

providing medical help is unacceptable.

Ninety eight percent of respondents strongly agreed or agreed that they were

satisfied with the service they had received and 90% that the service could not be

improved.

3.9 Summary of main findings

• Users of the ambulance service who receive a LIVES response show a

high level of satisfaction with the LIVES service

• They were also very satisfied with both the way their 999 call was handled

by ambulance service control centre staff and the ambulance crew who

arrived at the scene.

• There was a high level of satisfaction at the speed of response.

• Characteristics of ambulance and LIVES personnel were highly rated and

there were very low numbers of individuals who indicated any dissatisfaction

with LIVES responders or the service in general.

27

• The majority of users think the service cannot be further improved

• No responders considered providing a volunteer based service to be

unacceptable.

• The principal of providing a voluntary medical response service in rural

communities seems to be acceptable to the public.

Some comments made by respondents to the questionnaire are provided below to

illustrate more fully the views of users of the service.

General comments received on patient satisfaction questionnaire.

“My husband had great difficult breathing. I was very stressed, all the people who came were

wonderful, and helped us when we needed it. I can’t speak too highly of them.”

“They kept me in good spirits and made me feel very confident in their ability to assess a

situation quickly”

“He looked after me until the ambulance arrived, he also helped my wife get things organised

for the ambulance arriving.”

“Everything was done in a calm and professional manner which prevented me from

panicking. Although my husband passed away on the following day, I felt that everything that

could have been done was actually done by everyone concerned.”

“They took control in a friendly professional way and reassured the patient and relatives”.

“The First Responder arrived before the ambulance and gave assistance. She was very good

and calming. Living in the country (20 mins to the nearest hospital) this is a brilliant idea.”

I was extremely satisfied with every aspect of the services received, from the first responder

through to the service at Lincoln hospital. I was dealt with promptly and efficiently by friendly

members of staff”.

“No panic, no fuss, very very professional, sympathetic and efficient to me (the patient) and to

my wife. They couldn’t have done more”.

“Both arrived together, they had a good attitude, both teams worked well and complemented

each others involvement”.

“The ambulance crew arrived first, with the first responder seconds afterwards. Although not

involved, they asked if they could stay and observe. This showed initiative and would help

with future call outs.”

“Lives doctor wasn’t very sympathetic or friendly, which didn’t help the situation”.

“The fire service arrived very quickly and did the treatment at once.”

28

“First responders were very enthusiastic armed with all their equipment”.

“The lack of an adequate road map of a newly developed estate, caused a lot of delay in the

ambulance.”

“She gave the support and confidence needed at that time, as I have no first aid knowledge to

help my husband.”

“LIVES had the equipment ie oxygen tank which I needed immediately and helped my

condition, I am pleased that we have LIVES active in our community.”

“A very nice lady but she was pushed out of the way when the ambulance crew arrived.”

“The person who arrived from LIVES provided a calming influence to an otherwise traumatic

time”.

“It was reassuring to have someone on the scene who had oxygen, even if it wasn’t the

ambulance.”

“She exuded confidence which we badly needed and was very calm and reassuring that she

was qualified if the situation deteriorated. She stayed with me after the ambulance had taken

my husband and made sure that I contacted members of my family.”

“Because my husband had a stroke, the firemen who came as first responders were all very

good and I became much more at ease until the ambulance arrived and I am sure it all helped

as he made a full recovery”.

“I was impressed by how all the emergency crews worked together”.

“Help arrived VERY quickly, as I was alone when taken ill and the chap who arrived was

kindness itself.”

“The ambulance arrived within 2 minutes of my call which I believe was very important as

the heart pain was getting worse by the minute, and of course the constant reassurance by the

crew that they had the situation in had does help. The LIVES doctor was not needed in this

case although he did arrive just as my husband was leaving in the ambulance, a great service

and a must to keep going”.

“I am only very grateful that we have a service such as this available to us, others are not so

lucky”.

“The calm manner was very reassuring and I knew my mum was in good hands”.

“From the initial phone call through to the ambulance and LIVES doctor attending was very

quick and efficient. Their prompt action at the beginning saved my mum’s life.”

“At my hospital discharge the doctor congratulated me on a “good recovery” from my heart

attack – I told him that this was undoubtedly due to the prompt and professional attention I

had received in the first 45 minutes.”

“My next of kin – son and daughter-in-law live quite near. Whilst the ambulance crew was

taking over my panic stopped and I wish the first responder had asked me for their name and

address so that he could have advised them of the situation. As it was the first responder who

locked up the house, then put the key through the letterbox. Later that day the police had the

29

trouble of breaking into my home through a back window which they had repaired to make

my property safe – a waste of police time and expense.”

“The first responders in the village are the local part time fire service. They can be here in

minutes, have all the kit and are trained in its use.”

“I think the paramedics are worth their weight in gold”.

“I have had to call out the first responders twice in the last month, both times a fire engine

and six firemen turned out. I cannot help thinking that the community would be better served

by fully trained paramedics with their own fast response vehicles”.

“It was the early hours of Sunday morning, and I was immensely impressed that voluntary

members of the local community were so quick of the mark and ready to help, I cannot be too

grateful to them”.

“Living in a remote area I think the service of First Responder is a huge step forward in

getting medical attention to someone.”

30

4. Outcomes from out of hospital cardiac arrest

4.1 Introduction

An important issue in assessing the impact of first responder schemes is the potential

clinical benefits to patients. The principle of providing a fast response to 999 calls for

life-threatening emergencies is based on the assumption that early intervention will

save additional lives. This is particularly true for out of hospital cardiac arrest where

the relationship between speed of response and survival is well established5 and this

is therefore one patient group where there is potential for LIVES to have a clinical

impact.

Ideally, the effect of providing a rapid response to out of hospital cardiac arrest

should be assessed by measuring survival to discharge from hospital. However, the

current difficulties in accessing hospital based clinical information on individual

patients made this approach impractical within the time scales and resources

available for this project. As a result the assessment can only use the information

already available from the ambulance service and LIVES. The impact of the LIVES

scheme on patients with out of hospital cardiac arrest has been investigated using

Return of Spontaneous Circulation (ROSC) as the clinical outcome measure. This is

not as robust a measure as survival to discharge from hospital but has been used as

a proxy measure in a number of studies6 and provides a useful indicator of the

relationship between speed of response and the reversal of cardiac arrest.

4.2 Methods

It was initially planned to take a random sample of 200 patients in areas where lives

services are available and identified as having out of hospital cardiac arrest and

retrieve patient report forms for each case. However, practically it was difficult to

identify forms on the basis of both geography and clinical condition. Lincolnshire

Ambulance Service was at the time developing its own cardiac arrest audit with a

computerised database of relevant cases and thought this would be a better

information source. Information already recorded for 2001 did not allow identification

of the first response on scene. From 2002 cases were recorded using a national

minimum dataset which did record first on response scene. In the first instance LAS

provided a dataset of cardiac arrest cases from 1st July 2002 to 8th April 2003

although 2 months data (Jan/Feb 2003) were missing. Ideally it would have been

useful to add cardiac arrest data for the same time period in 2003 used for the

31

response time analysis (April – June 2003) but despite several requests this data

was never provided. Instead LIVES provided their own data corresponding to the

same time period as that supplied by LAS.

An attempt was made to match cases and combine the data from the two services

but because of differences in the information provided this proved impossible to

achieve. For example, the LAS dataset included all cardiac arrests whereas the

LIVES data only included those where a defibrillator was used so there were some

cases in the LAS data where a LIVES first responder was first on scene but, if a

defibrillator was not used, this case did not appear in the LIVES data. Similarly there

were cases in the LIVES data for which no corresponding case could be found in the

ambulance service data. As a result the datasets have been analysed separately.

The assessment of outcomes from out of hospital cardiac arrest is based on

recorded information rather than original clinical data and therefore provides only a

description of the current ROSC rates reported by each service.

Information used

Data was from both services was provided as an excel spreadsheet and included:

a) LAS data

• Date, first response on scene times of call, response, on scene, first shock,

scene to shock

• If resuscitation was attempted, witnessed arrest and CPR attempted,

aetiology and presenting rhythm

• Outcome (return of spontaneous circulation), if resuscitation suspended

and whether patient was moved to hospital.

This data set included all identified cases of out of hospital cardiac arrest.

b) LIVES data

• Date, times of call to ambulance service, call to LIVES, arrival on scene for

first responder, arrival on scene of ambulance service

• Incident type, and outcome (recorded as survived to hospital, lived or pulse

returned)

This data set included only cases attended by a first responder and where a

defibrillator was used. It excludes responses by LIVES Doctors.

32

LAS data included a recorded response time. For LIVES data a response time was

calculated from both the time of the call to the ambulance service and the time LIVES

was alerted to the time of arrival on scene.

Response times and the proportions of ROSC rates have been calculated for each

group and, where possible, compared.

4.3 Results

a) LIVES activity

As expected, the number of defibrillations carried out by LIVES first responder

schemes has increased as the number of schemes has increased. Figure 7 shows

the increase in number of defibrillations for the period 2001 – 2003.

b) LIVES response time performance and outcomes from out of hospital cardiac

arrest

There were 77 cases of cardiac arrest where a defibrillator was used by a LIVES first

responder during the period 01/07/02 – 08/04/03. Outcome was not known for 10

cases, 54 cases died and there were 13 cases reported as being alive or with pulse

returned at the scene. This gives an ROSC rate of 16.8% of all cases and 19.4% of

Figure 7 - LIVES schemes & defibrillation activity

0

10

20

30

40

50

60

70

Jul-Sept 2001 Apr-June 2002 Apr-June 2003

Year

Nu

mb

er

sch

em

es &

defi

bs

Number of defibs

No of schemes

33

cases where outcome is known. The presence of cases with unknown outcome

means that the true rate could be higher or lower.

Response time performance and % calls responded to within 8 minutes were

calculated for all calls, deaths and survivors. Response time performance is reported

as the median. Table 9 summarises the findings.

Table 9 – Response time performance and outcome for cardiac arrest

Response time measure All cases with known outcome (n=67)

Deaths (n=54)

Survivors (n=13)

Call to ambulance service – LIVES on scene

Median response time

% responses in 8mins (Hr : min)

8:0

52.9

8.0

53.4

7.56

54

LIVES alerted – LIVES on scene



5:4

77.1

5.5

75.9

4.42

91.7

Call to ambulance service – ambulance on scene



13:6

17

14:0

18

12.25

16

The impact of a LIVES response is shown by the short response times for survivors

and in particular the median response time of 4minutes 42 seconds from LIVES

receiving a call to arriving on scene. There is a 3minute delay between the

ambulance service receiving the call and LIVES being alerted. If this could be

reduced, given the time dependant nature of out of hospital cardiac arrest, there

would be scope for further improvement in cardiac arrest survival. The relatively long

ambulance service response times again illustrates the difficulties of providing a rapid

response in predominantly rural areas. Without the LIVES response cardiac arrest

patients in the areas currently served by first responder schemes would receive

responses in excess of 12 minutes and less than 20% could be expected to receive a

response within 8 minutes.

34

c) Lincolnshire Ambulance Service response time performance and outcomes from

out of hospital cardiac arrest

The Lincolnshire Ambulance Service dataset contained 741 cases of cardiac arrest.

Of these 427 ( 57.6%) cases had some form of resuscitation carried out. The

remainder were characterised as dead on arrival of the ambulance crew. Two

hundred and eleven (28.7%) cases were moved to hospital with the remainder left at

the scene. The ambulance service arrived first on scene (FOS) in 620 (83.5%) of

cases and a LIVES response in 121 (16.5%) of cases. Table 10 gives response time

performance for these cases.

Table 10 – LAS cardiac arrest case characteristics and response time

performance

All cases (n=743)

Ambulance FOS (n= 620)

LIVES FOS (n= 121)

Attempted resuscitation 427 349 (81.7%) 78 (18.3%)

All cases

Median response time (Hr:min)

% responses in 8 minutes

6:1

71.7

6:2

70.6

6.0

78.0

Attempted resuscitation

Median response time (Hr:min)

% responses in 8 minutes

6:0

70.7

6:0

69

5:9

78.2

Ambulance service median response times are shorter and the proportion of cases

attended within 8 minutes greater than that reported in the LIVES data. However this

dataset contains all cases including those in urban areas where response times are

much faster than the rural areas where LIVES schemes operate. LIVES response

times are marginally shorter and the proportion of calls responded to in 8 minutes is

greater than ambulance calls in all cases and those where resuscitation was

attempted.

35

Return of spontaneous circulation rates were calculated for all cases, attempted

resuscitation cases and those where the patient was moved to hospital. These are

given in table 11.

Table 11 – Outcomes from out of hospital cardiac arrest

All cases Ambulance FOS

LIVES FOS

All cardiac arrests

Number of cases

Number of ROSC

ROSC rate

741

44

6.0%

620

36

5.8%

121

8

6.6%

Attempted resuscitation

Number of cases

Number of ROSC

ROSC rate

427

44

10.4%

349

36

10.3%

78

8

10.2%

Moved to hospital

Number of cases

Number of ROSC

ROSC rate

211

44

22.0%

177

36

20.3%

36

8

22.2%

ROSC rates are comparable across all 3 groups with no obvious difference between

survival rates for LIVES attended patients and ambulance patients. However, this

does include all cases over the entire LAS operating area. If differences do exist

these could only be detected by separately analysing cardiac arrest survival rates for

urban and rural areas or by comparing rural areas with no first response scheme to

those that do.

It is difficult to compare the rates reported here with other ambulance services as no

national comparative dataset is currently available (although there will be in the

future). Other services have reported survival rates from out of hospital cardiac arrest

but each has different inclusion and exclusion criteria (for example, some include all

cases of cardiac arrest, others only include ventricular fibrillation arrests). A previous

study examining ROSC rates in Staffordshire ambulance service reported a ROSC

rate of 11.7% of all cardiac arrest cases7 compared to 6% in this sample. However, at

the time Staffordshire had the highest response time performance in the country with

36

87% of category A calls being responded to in less than 8 minutes. Also, a higher

proportion of cases were moved to hospital (39% compared to 28% in this sample)

suggesting fewer cases where the patient was dead on arrival of the ambulance crew

although, of course, this may just reflect different operational policies on the transport

of patients to hospital.

4.4 Summary

• The number of cases of cardiac arrest in which LIVES first responders can

intervene with early defibrillation has increased as the number of first

response schemes has increased.

• The rate of return of spontaneous circulation in LIVES attended patients

who receive defibrillation is 20%.

• Response times are considerably shorter for LIVES responses compared to

ambulance responses in cases where there is a dual response.

• The ROSC rate for all cases of cardiac arrest in Lincolnshire is 6% and

10% in those patients who were moved to hospital.

• Further work comparing outcomes in rural areas with and without first

responder schemes would provide a more accurate assessment of the real

impact of these schemes.

37

5. Economic Implications of the LIVES scheme

5.1 Introduction

LIVES is primarily a voluntary service funded by charitable donations. Funding of the

callout service has a complex history. Originally LIVES had its own control room

which the ambulance service contacted and requested a LIVES response. The

LIVES control staff would then activate a response if one was available. This

arrangement changed, the LIVES control centre ceased to function and responsibility

for activating LIVES responses moved to the ambulance service control centre.

LIVES then paid the ambulance service to provide this call out service although it is

ambulance service 999 calls LIVES responds to.

The justification for this charge is that providing a LIVES callout service increases

workload within the ambulance service control centre. Information on LIVES

schemes is currently run on a separate computer to the dispatch system and

additional staff are required to identify if a LIVES scheme is operating within the

geographical area of an incident and then callout the response. The increase in the

number of first responder schemes has had a consequent increase in ambulance

control centre workload. This not only includes the callout process but also additional

work to collate return information to LIVES and update computer records and

mapping systems as new schemes come on line. Currently the ambulance service

recharges LIVES for control room costs of £32,000 per year. This recharge has in the

past threatened the viability of the LIVES service and Primary Care Trusts have

provided funds to LIVES to cover this cost and to support the service. For the

financial year 2003/4 three PCT’s have contributed a total of £150,000 to LIVES.

There remains some debate as to where this money would be best spent, that is

should the PCT support of LIVES continue or would these funds be better spent by

the ambulance service. An assessment has been made of the potential impact of

transferring this funding stream with particular reference to response time

performance.

5.2 Methods

A cost consequence analysis has been conducted to assess the effects of moving

current PCT funding to the ambulance service. The assessment has been made on

the following assumptions:

38

• If LIVES were to lose PCT funding it would not be able to continue to provide

a voluntary response service

• If the LIVES service were to cease there would be a decrease in ambulance

response time performance equivalent to that detected in section 2, that is of

6% at the 10 minute standard. This can be translated as the 8 minute

standard given the additional time added in the analysis by using the call time

as the baseline for response time calculations and assuming LAS reported

response time performance of 76.2% of category A calls responded to within

8 minutes is correct.

• That as most calls receive a dual ambulance service and LIVES response the

ambulance service could not retrieve this performance loss with the current

number and configuration of vehicles. Additional vehicles in areas currently

served by LIVES would be required.

• If there is no LIVES callout service the ambulance service charges for

additional control room staff would no longer be necessary and the additional

funding could all be spent on providing additional vehicles to recoup some of

the response time performance loss

• LIVES provides 3200 responses to 999 calls with Department of Health

designated category A priority dispatch codes and 5200 responses to LAS

designated category A calls each year.

Lincolnshire Ambulance Service NHS Trust provided data on cost per unit hour for a

fully crewed ambulance, average call cycle time and average service unit hour

utilisation. This is a measure of efficiency for use of ambulance resources. A unit

hour is one fully crewed emergency ambulance available or tasked for one hour. Unit

hour utilisation (UHU) reflects the use of these unit hours in terms of patient

transports and measures unit hours including surplus and wasted hours.

Measurement and understanding of how hours are produced and then utilised and

where and why differences between demand and production exist provides

information for planning and the efficient use of resources. LIVES provided data on

funding from PCT’s and charitable donations.

5.3 Results

The number of additional ambulance responses that could be provided with the PCT

funding current has been calculated. This can then be compared to current LIVES

activity to estimate if LIVES responses could be replaced by ambulance responses.

39

Table 12 – Estimate of additional ambulance service responses provided with

equivalent PCT funds

Item Value Formula

Unit Hour cost (C) £51.41

Average LAS call cycle time (T) 66.5 minutes

Average LAS service UHU (U) 0.29

PCT funding to LIVES (F) £150,000

Unit hours purchased (P) 2918 P = F / C

Unit hours utilised (A) 846 A = P x U

Number of additional responses (N) 763 N = A /T

Additional ambulance service funding equivalent to that provided to LIVES by PCT’s

would purchase an additional 2918 unit hours. This would provide one additional fully

crewed ambulance for 24 hours for 121 days in one year (2.3 days per week). When

call cycle time and UHU are considered this can be translated as a response to an

additional 763 emergency calls per year. This can then be compared to LIVES

activity.

Table 13 – Comparison of LIVES activity and additional ambulance service

responses

Call category Annual LIVES

responses

LIVES

responses

attending first

Additional

Ambulance

responses

available

Shortfall (%)

Cat A DH codes 3200 1920 736 1184(61.6%)

Cat A LAS codes 5200 3120 736 2384(76.4%)

All calls LIVES data 7500 4500 736 3764 (83.6%)

40

The additional ambulance service responses available with resources equivalent to

LIVES PCT funding would not adequately replace the current level of LIVES activity.

An ambulance does already attend the majority of calls and even when accounting

for a LIVES first on scene rate of 60% the additional ambulance service responses

would provide less than half of the responses currently provided by LIVES in rural

areas.

The UHU value uses patient transports as the numerator and in some respects the

ambulance service needs to make few additional transports as most calls also result

in an ambulance arriving at scene and most patients are then transported to hospital.

The LIVES data shows 11% of patients are left at home. However, many of these

resources do not arrive within the time standard and hence the need for a dual

response strategy in rural areas. If the ambulance service provided this dual

response and UHU was calculated using arrivals on scene rather than patient

transports as the numerator UHU would increase to 0.4 and the number of additional

responses possible would increase to 1052. This would still not be sufficient to

replace all of the current LIVES responses. Further more as these responses occur

in areas of low demand then response UHU is unlikely to reach that level.

Lives has an annual income of £203,200 - £150,000 from PCT’s and £53,200 form

charitable donations. This money pays the ambulance recharge, costs of running the

scheme (premises, staff, office costs etc) and training and equipment. If they make

4500 responses a year then this is at a cost per call of £45.00. This seems

comparable to ambulance service costs of £51.41 per unit hour (£56.90 for an

average call cycle of 66.5 minutes). However the unit hour cost is the marginal cost

of providing a crewed ambulance. It does not include organisational costs of

overheads and management, estate, training etc. The actual cost of a patient journey

by emergency ambulance has been estimated as £205 (Unit Costs of Health & Social

Care 2003).

In this respect LIVES provides very good value for money in terms of their cost and

the number of responses they are providing each year.

There are alternative strategies the ambulance service could use to maintain

response time performance.

• The additional resources could be concentrated in areas of high demand

and improve performance in these areas thereby gaining back some

response time loss from rural areas. This does however have implications for

equity.

41

• The loss of performance would be in rural areas. As an ambulance

response already attends most calls a cheaper alternative would be to

provide single manned rapid response vehicles as a first response in rural

areas currently serviced by LIVES. This would allow more responses to be

made from the additional funds. However, rural areas are also low demand

and the UHU is consequently lower in these areas than the service average.

The additional responses available would be offset by lower utilisation so the

actual number of calls responded to would remain low.

5.4 – Summary

LIVES makes a substantial contribution to Ambulance service 999 call responses

and contributes some 6% to response time performance. If LIVES responses were

not available this performance would be lost and LAS response time performance

would fall below the national standard of 75% of responses to Category A calls within

8 minutes. Importantly, LIVES operates in low demand, rural areas and therefore

also contributes to providing an equitable service to communities where there is no

immediate ambulance resource.

There is an argument that the funding provided to LIVES through local health

economies could be better spent by improving ambulance service provision. This

analysis has shown that the additional ambulance responses that could be made

available with equivalent funding would be far below the current levels of LIVES

activity and would be unlikely to be sufficient to retain the level of response time

performance currently achieved with a LIVES contribution. Lives responds to a fifth of

ambulance service category A calls with a relatively modest sum of money (1% of the

ambulance service A&E budget) and as such provides good value in terms of the

contribution it makes to ambulance service performance and the level of service

within rural communities where it has a substantial impact on performance.

There is also potential for further improvement. The analyses presented here are

based on data generated by the callout system described in section 1. This system,

in which identification of available first responders and alerting them requires a

separate dispatch function in ambulance control, results in some inevitable time

delays between receipt of the 999 call and activating a LIVES response. It also

requires additional control room manning so that, at times, if there are not sufficient

control room staff available then calls where a LIVES response could be activated do

not receive this response.

42

In 2004 Lincolnshire Ambulance Service NHS Trust have purchased and introduced

a new Computer Aided Dispatch (CAD) system. This provides a much more

sophisticated integrated dispatch, mapping and communication system. The location

and availability of LIVES first response schemes is built into the system along with

standard ambulance resources so that activation of a first responder is part of the

normal dispatch process rather than a separate function. In addition, the improved

communication system allows the location of an incident to be immediately sent as a

text message to first responder mobile telephones negating the need for the

dispatcher to make a separate telephone call.

The new system should therefore allow both more activations of LIVES as it is now

an integral part of the system, and also quicker activation times with a potential

consequent improvement in response time performance. Potentially this will then

impact on LIVES performance response time performance, ambulance service

response time performance and patient outcomes for life-threatening conditions. If

this proves to be the case then the LIVES first responder schemes would make an

even greater contribution to the provision of emergency medical care in this rural

county.

References

1. Chapman R. Review of ambulance performance standards. Final report of steering group. 1996; NHS Executive, England.

2. Department of Health. Annual statistical bulletin: Ambulance services, England: 2002-03. Government Statistical Service, London; June 2003.

3. O'Cathain A, Turner J, Nicholl JP. The acceptability of an Emergency Medical Dispatch system to people who call 999 to request and ambulance. Emergency Medical Journal 2002; 19:160-163.

4. O’Cathain A, Munro J, Nicholl J, Knowles E. How helpful is NHS Direct? Postal survey of callers. BMJ, 2000; 320: 1035.

5. Turner J, Nicholl J. The performance of Staffordshire Ambulance Service – a review. Medical Care Research Unit, University of Sheffield; 2002.

6. Cummins R.O, Ornato J.P, Thies W.H, Pepe P.E. Improving survival from sudden cardiac arrest: the “Chain of Survival” concept. A statement for health professionals from the advanced cardiac life support subcommittee, American Heart Association. Circulation 1991; 83:1833-47.

7. Mann J.C, Guly U.M. Paramedic interventions increase the rate of return of spontaneous circulation in out of hospital cardiac arrests. J Accid Emerg Med 1997; 14:(3) 149-150.

Documents

Evaluation of the clinical and Ambulance Service .../file/MCRU-LIVESrep… · Outcomes from out of hospital cardiac arrest 30 4.1 Introduction 30 4.2 Methods 30 . 3 4.3 Results 32