PRIORITY 3 TRANSPORTSPRIORITY 3 TRANSPORTS

Josh AtkinsJosh AtkinsManager Sustainable Access and Patient Flow

June 2013

Priority 3 TransportsPriority 3 Transports

Backgroundg• Adverse Outcomes• RCA recommendations

What are we trying to achieve?• Increased emergency response capacityIncreased emergency response capacity• Improved responsiveness to P1 incidents• Better management of paramedic fatigueBetter management of paramedic fatigue

Priority 3 TransportsPriority 3 Transports

What are we using?

• Ambulance Protocols - to identify high risk injuries, mechanisms of injury or significant medical conditionsmechanisms of injury or significant medical conditions

• A triage tool based on “Between the Flags” to identify the deteriorating patientdeteriorating patient

P3 Triage Tool

Not to be used for paediatric maternity or psychiatric patients | Level of staffing at facility is not a criterion of urgency

P3 Triage Tool

Not to be used for paediatric, maternity or psychiatric patients | Level of staffing at facility is not a criterion of urgency Patient Name: DOB or Age:

Abdo: pelvic tenderness; restraint/abrasion/contusion; rigidity; severe pain; swelling 

Burns: all circumferential burns; inhalation injury; involving head/ neck/face/hands/feet/groin; partial or full thickness burns Adult >20%; partial or full thickness burns Child >10%; patient with comorbidities;  

Chest: Paradoxical breathing; restraint abrasion / contusion; severe pain

Burns Epiglottitis Foreign Bodies

Chest injuries with deterioration Chest: Paradoxical breathing; restraint abrasion / contusion; severe pain

Face: potential airway risk; Severe haemorrhage Limbs: >2 proximal long bone frac; amputation proximal to digits;

degloving injury; ischaemia  Head: Minor with LOC and >2 vomits or seizure; Minor with LOC and on

anticoagulants; open, depresses skull frac or signs of BOS frac Neck: bruising; hoarseness or stridor; swelling; swelling, bruising,

hoarseness or stridor

Severe pulmonary oedema Asthma or COPD unresponsive to treatment

Uncontrollable haemorrhage Penetrating trauma (excluding isolated injury to hands and feet) Severe shock of any type

hoarseness or stridor Spinal/Back: visible deformity Other:

Dysrhythmias with poor perfusion Cardiac arrest Return to spontaneous circulation following cardiac arrest

<16 & >65 years of age Any rapid deceleration mechanism that results in a large inertia change at

If level of consciousness V,P or U Head injuries

impact Crush Injury excluding fingers/toes Falls >3m or paediatrics twice the child's height Focal blunt trauma to head or torso High voltage injury Patient with pre-existing disease or on anticoagulants Penetrating Trauma: excluding isolated injury to hands or feet

Overdose unresponsive to naloxone Uncontrolled fitting

Prolapsed umbilical cord Severe poisoning Uncontrolled severe pain A t C d g g j y

MVA: Death in same vehicle; Ejection; Entrapment with compression; Intrusion into occupant department >30cm; Patient side impact; Steering wheel deformity; Vehicle V Pedestrian/Cyclist/MBC Obstetric patients >20 weeks gestation

Other

Acute Coronary syndrome Gastrointestinal haemorrhage Eye injuries, penetrating or chemical Stroke or sudden onset headache or neurological deficit Fever with lethargy

P3 Triage ToolP3 Triage Tool

Indicate the pt’s obs & note trends Red Yellow Normal Trends

Respiratory Rate <5 or >30 5-9 or 25-29 10-24

Respiratory Effort  Severe Moderate Normal Sp02 (sats)  <89 90-94 95-100

Blood Pressure  <89 or >200 90-99 or 180-199 100-180

Heart Rate  < 39 or >140 40-49 or 120-139 50-119

LOC / GCS =   Pain / Unresponsive Verbal Alert Pain Score  Moderate (4-6) or Severe (7-10) Nil Temperature  <35.5 or >38.5 35.6-38.4

Blood Glucose =  

Emergency Response Criteria Clinical Review Criteria All respiratory and cardiac arrests HR <40 or >140 bpm Poor peripheral circulation Excess or increasing blood loss Airway obstruction or stridor Systolic BP <90 or >200 Resp Rate 5-10 or 25-30 bpm Temperature <35.5 or 38.5 Seizures Uncontrolled Pain Failure to pass urine in past 24hrs Blood Glucose Level <4 mmol/L p p Resp Rate <5 or >30 bpm Sp02 <90% and/or increasing O2

requirements Systolic BP 90-100 or180-200 HR 40-50 or 120-140 bpm

Only responds to central pain (P) or unresponsive (U), or sudden decrease in LOC of ≥2 GCS points

Blood Glucose Level <4 mmol/L and not responding to treatment

Sp02 90-95% and/or increasing O2 requirements

New or increasing pain (including chest pain)

Decrease in Resp Rate in association Pt deteriorates further before or Decrease in LOC from Alert (A) to rousable only by voice (V) in the AVPU or Decrease in Resp Rate in association with decreasing LOC or exhaustion

Pt deteriorates further, before or during review

Decrease in LOC from Alert (A) to rousable only by voice (V) in the AVPU or new onset of confusion/disorientation

REMEMBER: 1.Abnormal observations typically indicate a severe injury or illness AND 2. An adverse trend in observations, even within normal range usually indicated deterioration.

FREQUENT USER MANAGEMENTFREQUENT USER MANAGEMENT PROJECT

Kevin McLaughlinManager Mental HealthManager Mental Health

June 2013

Context

Performance Review (2008): increase for low acuity patients significantly higher than for high acuity

Do low acuity patients require ambulance attendance and/or transport to ED?

Would a reduction in multiple responses (frequent users) provide better patient care and be more operationally efficient?efficient?

Initial focus on mental health patientsp

The literature on frequent users

No standard definition of ‘frequent’

Assumption that most frequent callers are either abusing the system

Chronic disease may legitimately require more frequent care

Case management is a feature of all interventions (and must involve the patient)must involve the patient)

NSW Ambulance experience (activity)

“Frequent’ = 10 or more calls in 12 month period

2009/10 938 patients = 14 578 calls2009/10 – 938 patients = 14,578 calls

Resulted in 11,428 transports to ED

NSW Amb lance e perience (reso rceNSW Ambulance experience (resource implications)

Call-out = $582 x 11,428 = $6,651,096

There will be additional costs in EDThere will be additional costs in ED

86 mins x 14,578 calls = 20,855 ambulance hours per year

Number of patients and number of calls forNumber of patients and number of calls for frequent callers in each call range

No of calls per patient No of patients Total no of calls Total no of transports

10 to 14 605 6,834 5,349

15 to 19 179 2,983 2,365

20 to 29 104 2,450 1,932

30 to 39 22 749 577

40 to 49 12 524 407

50 to 59 8 420 357

60 to 69 4 253 230

70 to 149 4 365 211

Total ≥ 10 938 14,578 11,428Total ≥ 20 154 4,761 3,102, ,

Frequent User Interventions

1)Notification to existing care providers only.) g p y

2)Notification to Patient only.) y

3)Notification to Patient, LHD and development of multi-agency plan.

4)Designated Case Management.

5)A t f A i t A b l U5)Agreement of Appropriate Ambulance Use.

2011/12 497 patients = 10,124 calls

Red = 1541 calls; Amber = 3936 calls; Green = 4647 calls

Red (18) patients pre and post intervention

Engagement with LHDsEngagement with LHDs

• Sydney LHD

• South East Sydney LHD

• South West Sydney LHDSouth West Sydney LHD

• Western Sydney LHD

• Hunter New England LHD

M bid LHD• Murrumbidgee LHD

• North Coast LHD

Case Studies

Case Study 1Case Study 1

• 38 year old female with Non-Hodgkins lymphoma

• 35 Uses between Jul 11 – Jun 12

• 30 uses July 12 – Nov 1230 uses July 12 Nov 12

• 30 uses of Methoxyflurane between May – Nov 12

• Complex Pharmacological Regime

InterventionsInterventions

• Engaged the patient, GP and local hospital

• Facilitated a multi-agency meeting including the patient

• Identified patient safety / risk issuesIdentified patient safety / risk issues

• Liaised with ASNSW Medical Advisor, Pharmacist and A /

Director Clinical Governance

• Developed Authorised Care Plan for assessment and• Developed Authorised Care Plan for assessment and

transport only for pain presentations

Impact on Ambulance UseImpact on Ambulance Use

ResultsResults

• 60% Reduction in call rate in the 3 months post Intervention vs 3 months pre-intervention.p

• In the 6 months prior to Intervention Pt. K’s Ambulance e 6 o s p o o e e o s bu a cecost the service $20,952.

• In the 3 months since Intervention Pt. K has used Ambulance 6 times at a cost of $4074

Case Study 2Case Study 2

Background 48 year old female with

Patient Issues Significant self-neglecty

SOB, chest paing g

Poor Health Literacy 220 uses since 2010

y

Substance Dependence 57 uses July 12 – Nov 12

p(Alcohol)

Very low transport rate, often refuses transport

Significant anxiety issues

Living in absolute squalor

InterventionsInterventions

Generic Interventions Undertook a patient

Clinical Interventions Distress Tolerance

assessment with support of the local DOM

Engaged the Patients GP

Motivational Interviewing Behaviour Activation Engaged the Patients GP

Attempted to engage other care providers

Psycho-Education Challenging Negative

Worked with the patient on addressing her most immediate concerns / stressors

g g gAutomatic Thoughts

Exposure

ResultsResults

• 65% Reduction in call rate in the 3 months post pIntervention vs 3 months pre-intervention

• In the 6 months prior to Intervention Pt K’s used Ambulance 62 times at a cost of $36,084

• In the 3 months since Intervention Pt K has used Ambulance 13 times at a cost of $7,566

Impact on Ambulance UseImpact on Ambulance Use