2012-13 Resource Allocation Plan Review Michael MacDougall Les Fisher George Papadopoulos
Background BCEHS is the legislated authority to provide emergency health services in British Columbia BCEHS coordinated over half a million emergency responses and inter-facility transfers in 2012-13
Purpose of review To provide the right resource to the right patient in the right amount of time To increase specificity (exclude true negatives) of the Resource Allocation Plan in the interest of patient and public safety
BCEHS Dispatch 2 parts Medical Priority Dispatch System (MPDS) Determines complaint/event and acuity Resource Allocation Plan (RAP) Determines qualification and response type
Medical Priority Dispatch System (MPDS) Scripted caller interrogation tool used at BCEHS since 1997 Used internationally in over 2,300 agencies Valid and reliable; improves accuracy, safety and efficiency of call interrogation Sets international standards for emergency dispatch curriculum, certification and accreditation
Medical Priority Dispatch System (MPDS) Caller interrogation is codified into three parts, e.g.: Protocol: 06 Breathing Problems Determinant: 06 D 02 D (Delta) Sub-determinant: 02 Difficulty speaking in between breaths
Resource Allocation Review (RAP) Determines response qualification, lights and sirens and first responders to a given MPDS code Provincial in scope First BCEHS RAP (1997) determined by physicians; reviewed five times since, most recently in 2010
Resource Allocation Review (RAP) RAP is codified into three parts, e.g.: ALS HOT FR ALS: HOT: FR: Advanced Life Support required Lights and sirens response First Responders attend
MPDS and RAP together MPDS: 06 D 02 RAP: ALS HOT FR BCEHS responds to a caller complaining of breathing problems and difficulty speaking between breaths utilizing Advanced Life Support, lights and sirens, and First Responders
2012-13 RAP Review Provide the right resource to the right patient in the right amount of time Evidence-based Patient-centric Statistically-predicated Assumptions: MPDS and ATS are valid/reliable Resources are not used efficiently No current option for patient treat and release Reviews are done in the interest of safety, continuous improvement, stewardship and efficiency
2012-13 RAP Review In order to match MPDS with clinical indicators, the working group: 1. Derived the Australasian Triage Scale (ATS) A valid and reliable clinical triage scale Based in clinical indicators, not potential resource use Used Patient Care Record elements to derive the ATS 2. Developed indicators to inform decision making Examined over 630,000 calls over two years Transport statistics and vital signs recorded Match of ATS to MPDS priority Cardiac arrest incidence
2012-13 RAP Review Modified Delphi methodology Examined and discussed data and indicators for each MPDS protocol Voted each RAP element (Advanced Life Support, lights and sirens, First Responders) Less than full agreement resulted in discussion and re-voting (twice maximum) Consensus-based (> 50%) changes Unresolved elements deferred to adjudication group
RAP Working Group Membership had an average of over 20 years of experience with EHS/FR Physicians, Paramedics, Dispatchers, Managers and First Responders All participants were satisfied to very satisfied with the RAP review process facilitation, methodology and overall process
By the numbers 32 unique pre-hospital protocols 128 unique protocols/determinants 1,213 unique protocols/determinants/sub-determinants The working group reviewed 868 valid combinations Senior leadership from Medical Programs and Operations reviewed and adjudicated recommendations from the working group, including items without consensus
Examples of RAP changes 29 D 02 Traffic/Transportation Incidents (Major incident) Old RAP: ALS HOT (with FR) 5,500 calls per year 70% transported to hospital by BLS <1.5% required critical intervention New RAP: BLS HOT (with FR)
Examples of RAP changes 17 B 01 Falls (Possibly dangerous body area) Old RAP: BLS HOT (with FR) 12,000 calls per year 84% transported to hospital by BLS <1% required critical intervention New RAP: BLS COLD (no FR)
Results By applying the approved changes to 2012 data, one can generally anticipate: 22% reduction in ALS calls 29% reduction in HOT responses 35% reduction in FR responses 800,000 km reduction in BCEHS lights and sirens response driving (annualized)
Selected References 1. Rowe, B (ed.) Evidence-Based Emergency Medicine. 2. Clawson, et al. Principles of Emergency Medical Dispatch. The National Academies of EMD, fourth edition, 2009 3. Monash Institute of Health Services Research. Consistency of Triage in Victoria s Emergency Departments. Victorian Department of Human Services, 2001 4. Craig A, et al. Evidence-Based Optimization of Urban Firefighter First Response to Emergency Medical Services 9-1-1 Incidents. Prehospital Emergency Care, 2010;14:109-117 5. Pardey T. The clinical practice of Emergency Department Triage: Application of the Australasian Triage Scale: An Extended Literature Review. Master's thesis, University of Newcastle, 2005. 6. Farrohknia N, et al. Emergency Department Triage Scales and Their Components: A Systematic Review of the Scientific Evidence. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011, 19:42 http://www.sjtrem.com/content/19/1/42 7. Dean JM, et al. Probabilistic linkage of computerized ambulance and inpatient hospital discharge records: a potential tool for evaluation of emergency medical services. Ann Emerg Med. 2001;37(6):616-26 8. Newgard CD. Validation of probabilistic linkage to match de-identified ambulance records to a state trauma registry. Acad Emerg Med. 2006;13:69-75 9. Newborn, et al. Allocating resources in health care: alternative approaches to measuring needs in resource allocation formula in Ontario. Health & Place, Vol. 4, No. 1, pp. 79-89, 1998
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