North West Ambulance Service Final Insight Summary Report July 2013 www.icegroupuk.com 1
ICE Creates and the North West Ambulance Service would like to thank the many people who have contributed to this report. Foremost among these are the paramedics and nursing home staff who participated in the research. We are extremely appreciative of the time spared and feedback given to help us to shape potential interventions, designed to reduce the number of non-life threatening calls from nursing homes across the North West. 2
Contents North West Ambulance Service... 1 1 Project Overview... 4 2 Methodology... 6 3 Background Data... 7 4 Paramedic Quantitative Survey... 10 4.1 Respondent Demographics... 10 4.2 Summary of Key Findings... 12 5 Nursing Home Staff and Paramedic Qualitative Interviews... 14 5.1 Summary of Key Findings... 14 5.1.1 Reasons to call an ambulance... 14 5.1.2 Making the decision to call 999... 14 5.1.3 Influence of health professionals and family members... 14 5.1.4 Policies and procedures... 15 5.1.5 Falls... 15 5.1.6 Confidence... 15 5.1.7 Best practice and care plans... 15 5.1.8 Training... 16 5.1.9 Interventions to help reduce calls from nursing homes... 16 5.1.10 Barriers to implementing interventions... 17 6 Conclusions... 18 7 Best Practice and Areas for Improvement... 21 7.1 Next Stages... 22 8 Appendix... 23 3
1 Project Overview In January 2013 Behaviour Change Agency, ICE Creates, was commissioned to work with the North West Ambulance Service (NWAS) to lead an insight research project to further understand the underlying issues related to high volumes of calls for ambulance support for incidents that were not serious or life-threatening. Research has suggested that the most common reason for calling an ambulance when there is no emergency is a lack of awareness of other sources of help. A study by Palazzo et al. (2002) investigated patients reasons for calling an ambulance, the proportion of patients ringing with a serious or life threatening condition was found to be 60%. Of those remaining calls, 16% were unaware that an emergency GP service was available, 15% had no means of reaching the hospital whilst 8% wanted to avoid the long wait in Accident and Emergency (A&E). Other reasons include perceptions that ambulances are the safest and most secure form of transport, along with perceptions that going to A&E in an ambulance shortens the length of time a person has to wait (Palazzo & Warner, 2002). Patients aged between 65 to 90 years have been found to be the most frequent callers to the ambulance service; however large proportions of these calls do not result in transportation to hospital (Marks et al. 2002). Falls have been found to account for over a third of cases and most are likely to result in non-transportation, in contrast to all 999 calls where accident and trauma was the most significant category. Older patients were significantly more likely to arrive during the morning and early afternoon, during the winter months, by ambulance and require admission to hospital. Older people were significantly more likely to attend with non-injury, particularly cardiac-related conditions. In addition, research suggests that there are groups of patients who use A&E on a very frequent basis these are sometimes referred to as frequent callers. Dr. Foster (2006) estimated that over a million emergency admissions a year result from people being admitted repeatedly through A&E. Initial exploratory work with the NWAS informatics team segmented the nature of calls and initial investigations highlighted nursing homes as being worthy of further research. It appears that there are high numbers of calls from this sector, with some nursing homes calling more frequently than others. Many incidents are categorised as falls and anecdotally it was felt that many falls are incidents that could be handled without requiring a 999 response from NWAS. The objective for this research comprised of conducting primary quantitative and qualitative research with the target audience of paramedics working for NWAS as well as nursing home staff working across three target areas in the North West of Wigan, Bolton and Blackpool. The rationale behind choosing these three locations to conduct interviews with nursing home staff was to compare findings across Wigan and Bolton, where frequent caller data showed that collectively calls to the ambulance service from nursing homes occurred more frequently, with those findings from interviews with nursing home staff in Blackpool, where overall a lower number of calls from nursing homes was found. This summary report will provide a top level overview of the key findings from the research as well as identified best practice and areas for improvement. It has been recommended that these findings 4
form the basis for potential interventions designed to reduce the number of calls from nursing homes that are not serious or life-threatening, that can be implemented across the North West. 5
2 Methodology Research was carried out across four distinct phases: Desk Based Research ICE worked with the informatics team at NWAS to analyse frequent caller data for the financial year from 2011-2012 to select the target areas for primary research conducted with nursing homes across the three target locations of Wigan, Bolton and Blackpool. Data was used to determine collectively which nursing homes in different areas in the North West region had higher number of incidents compared to others, particularly in relation to falls. This data was then used to provide a targeted approach to recruit for nursing home interviews. Quantitative Survey with Paramedics A questionnaire survey was developed by ICE researchers using the online survey development programme SurveyMonkey and disseminated online (via NWAS intranet) and also via hard copy (to ambulance bases in the Cheshire/Wirral area). Hard copy questionnaires were collated and sent to ICE researchers to be inputted. Qualitative Interviews with Nursing Staff and Paramedics A total of 9 telephone interviews were undertaken with paramedics across the North West region (including senior and advanced paramedics). A total of 15 interviews were undertaken with nursing home staff across 4 nursing homes situated in Wigan, Bolton and Blackpool. Nursing home managers were asked if they could provide 5 members of staff with a blend of care assistants, senior members of staff and managers to undertake the interviews. Nursing homes were given the option of researchers coming into the nursing home to conduct the interviews face to face or doing this over the telephone. Two nursing homes preferred that latter option and two requested that a researcher came into the home to conduct the interviews. Observational Research To contextualise the primary quantitative and qualitative research, ICE researchers conducted observational research during two ambulance observations with paramedics across the North West area. 6
3 Background Data Overall, across the North West during 2011-2012 falls were the top reason that an ambulance was requested, accounting for 11% of all incidents during this time period. Of these calls relating to falls, the majority (6.43%) were defined as incidents that were serious, but not life threatening (Category C Green Calls) requiring a face-to face response within 30 minutes. Around 2.0% of these calls were categorised as life threatening (Category A Red calls) that required a face-to-face response within 8 minutes. The top 10 reasons for 999 incidents, during this time period, are displayed in the table below. Other specific conditions that accounted for a high percentage of 999 calls during this time period included breathing problems and chest pains (9.04% and 8.94%, respectively) and fainting, fitting and haemorrhages (5.88%, 3.31% and 3.17%, respectively). Around 10% of all calls were categorised as of an unknown nature. 7
Table 1. Nature of 999 calls by category percentage (2011-2012) 1 Nature of calls Call Category Colour 2 Red1 Red2 Green1 Green2 Green3 Green4 No Colour Grand Total Falls 0.23% 1.85% 0.14% 6.43% 0.00% 2.37% 0.00% 11.03% Unknown Nature 0.00% 0.46% 0.00% 0.03% 0.00% 9.30% 0.02% 9.81% Breathing Problems 0.84% 6.63% 0.82% 0.00% 0.74% 0.00% 0.00% 9.04% Chest Pain 0.00% 8.06% 0.00% 0.80% 0.00% 0.08% 0.00% 8.94% NHSD 3 \UCD 4 Excl\Timescale Breach 0.01% 0.04% 1.05% 0.02% 7.69% 0.01% 0.00% 8.80% Sick Person (Specific Diagnosis) 0.00% 0.32% 0.01% 3.87% 0.21% 1.96% 0.00% 6.37% Unconscious/Fainting (Near) 0.13% 4.40% 0.00% 1.11% 0.01% 0.23% 0.00% 5.88% Convulsions/Fitting 0.01% 2.24% 0.34% 0.39% 0.00% 0.33% 0.00% 3.31% Haemorrhage/Lacerations 0.02% 1.29% 0.00% 1.11% 0.04% 0.71% 0.00% 3.17% Overdose/Poisoning (Ingestion) 0.00% 0.26% 0.02% 2.01% 0.31% 0.06% 0.00% 2.65% 1 Command and control data recorded at time of call. (Q3 April 2011 to March 2012 ) 2 See appendix for explanation of call categories 3 NHS Direct 4 Urgent Care Desk www.icegroupuk.com 8 together we make a difference
Three areas were chosen to conduct the primary research with nursing home staff. These areas were Bolton, Wigan and Blackpool. Overall across the nursing homes in these three areas there were a comparable number of incidents that were categorised as falls compared to the overall data from across the whole of the North West (12% compared to 11%, respectively). www.icegroupuk.com 9
4 Paramedic Quantitative Survey This section will provide an overview of the respondents to the survey and key findings. 4.1 Respondent Demographics A total of 71 paramedics and other ambulance staff responded to the survey either online or offline via paper-based questionnaires. The majority (57.4%) of respondents were paramedics, with other respondents including Assistant Operations Managers (13.1%) and Emergency Medical Technicians (9.8%). Table 2: Respondents by job title Job title Frequency Percentage of respondents Assistant Operations Manager (AOM) 8 13.1% Paramedic 35 57.4% Advanced Paramedic 3 4.9% Senior Paramedic 5 8.2% Student Paramedic 3 4.9% Emergency Medical Dispatcher (EMD) 1 1.6% Emergency Medical Technician (EMT) 1 3 4.9% Emergency Medical Technician (EMT) 2 3 4.9% Total 61 100.0% Figure 1: Respondents by job title EMT 2 EMT 1 EMD Student Paramedic Senior Paramedic Percentage of respondents Advanced Paramedic Paramedic AOM 0% 10% 20% 30% 40% 50% 60% Respondents were based at a wide number of ambulance stations across the North West in the following areas; Greater Manchester (10.7%), Blackpool (7.1%), Kendal (7.1%), Cumbria (5.4%) and Chester (5.4%). Over a third (36.7%) of respondents were aged between 36-45 years old, and more 10
than one in four were aged 26-35 years old (28.3%) or 46-55 years old (28.3%). Less than a tenth (6.7%) of respondents were aged 25 years old or less. Table 3: Respondents by age Age Frequency Percentage of respondents 18-25 years old 4 6.7% 26-35 years old 17 28.3% 36-45 years old 22 36.7% 46-55 years old 17 28.3% Total 60 100.0% The majority (65.6%) of respondents were male, with just less than a third (32.8%) female. Almost all respondents were also white British (96.9%), with only a small minority (3.1%) Chinese. Table 4: Respondents by gender Gender Frequency Percentage of respondents Male 42 65.6% Female 21 32.8% Transgender 1 1.6% Total 64 100.0% 11
4.2 Summary of Key Findings Key Findings High prevalence of calls relating to incidents that are not serious or lifethreatening Detrimental effect of calls that are not serious or life-threatening Over a quarter (26.9%) of respondents believed that they are called out to between 6-10 situations that are not serious or life threatening a week, with a large number of respondents suggesting that this figure could be more. Just over one quarter of respondents thought that frequent requests for an ambulance in these situations were generally related to a lack of public information, awareness and understanding of appropriate available care pathways. Some respondents also cited a lack of medical experience and/or training among nursing home staff, GP receptionists and 111 call-takers. Most respondents thought that a large proportion of their workload was spent on calls for incidents that are not serious or life threatening; around 50% of their time if not more. Just under one third of respondents said that they felt frustrated about receiving these calls. Some also felt that it was a strain/waste of resources and a result of poor public information and education on available care pathways. Nursing homes identified at frequent callers Based on their previous experiences, many paramedics thought that nursing homes were responsible for frequently requesting an ambulance when alternative care pathways could have dealt with the situation instead. The vast majority (86.2%) of respondents agreed that there was a high volume of calls to 999 from nursing homes and, furthermore, that a large number of these calls were for non-life threatening incidents. Reasons for calls that are not serious or lifethreatening from nursing homes Falls considered the most frequent incidents that are not serious or lifethreatening When asked why they thought staff at nursing homes tended to frequently call 999, most paramedics cited an underlying fear and risk of litigation from families for lifting patients after falls and a lack of confidence among nursing home staff to deal with these situations. Generally, the feeling was that some nursing home staff do not have the confidence to attend to the situation themselves and therefore seek support elsewhere. Across all situations, the highest number of calls for incidents that are not serious or life-threatening that ambulance staff are asked to attend was falls. Other common incidents included falls at nursing homes and calls regarding chest pains. In some cases it was felt that 12
Using training in nursing home interventions The role of the paramedic in interventions Best practice in nursing homes Positive effect of interventions Further application of interventions although nursing home staff may believe the fall to be an emergency situation, this is not the view of the ambulance staff. The vast majority (81.5%) of paramedics believed that there are potential interventions that could be introduced to reduce the number of ambulance calls from nursing homes. Just over one quarter of respondents suggested that interventions should address additional training, information and education for nursing home staff, particularly in regards to safe lifting and use of appropriate care pathways. When asked whether respondents felt that they had a role in helping to reduce the number of ambulance calls from nursing homes, the majority agreed that they should be involved in some way. 55.6% of respondents believed that they could assist in educating nursing home staff on appropriate alternative care pathways as well as correct use of ambulance services. There was mixed experience amongst respondents of best practice in regards to nursing homes providing patient care. Those that were able to think of examples of good practice highlighted the nursing homes that have fully trained and confident staff to deal with patient needs, including lifting. Other responses cited those nursing homes that have good working relationships with local GP surgeries, therefore minimising the number of ambulance calls to incidents that are not serious or life-threatening since patients follow a different care pathway. Respondents felt that the main long-term effect of implementing interventions in nursing homes, and other organisations/amongst other population groups, related to a better use of the ambulance service s time, resources and budget. Other effects included improved care and outcomes for patients, a reduction in the number of calls to non-life threatening situations and a greater availability of ambulances to attend more appropriate emergency calls. Overall ambulance staff expected that interventions would have a positive effect in relation to the use of ambulance services. A large majority (83.3%) of respondents believed that successful interventions for nursing homes should also be applied to other care settings and population groups. In particular, respondents suggested providing further education and training not only to nursing home staff, but also to carers, police, GPs and receptionists on alternative available care pathways. One quarter of respondents thought it was also important to improve public awareness and knowledge of the use of 999 as well as other, more appropriate care pathways to use in situations that are not serious or life threatening. 13
5 Nursing Home Staff and Paramedic Qualitative Interviews Qualitative, in-depth, face-to-face and telephone interviews were undertaken with a total of 15 nursing home staff across 4 nursing homes situated in Wigan, Bolton and Blackpool. These target locations were selected to compare different practices across the areas. A total of 9 paramedics also undertook in-depth telephone interviews. This section of the report will highlight the key findings by topic area across both paramedics and nursing home staff. 5.1 Summary of Key Findings 5.1.1 Reasons to call an ambulance Based on their previous experience, paramedics felt that often 999 calls that came from nursing homes were not life-threatening and therefore other care pathways could have been used. This was believed to mainly be because staff are not aware of the alternative care pathways. Other reasons included taking other health professionals advice to call for an ambulance, being unable to contact a GP, nursing home staff salary levels, fear of being at risk of litigation, lack of appropriate training, a lack of confidence in making decisions about appropriate care pathways, having non-english speaking care staff, a lack of confidence in Out of Hours GPs and transport issues. Nursing home staff thought that they would call an ambulance if they were unable to cope with the situation i.e. not having the resources to deal with the issue or needing a higher level of medical expertise. For nursing home staff, a key theme for calling 999 related to erring on the side of caution and calling an ambulance so that paramedics could check over their residents if they had an accident. Calling for an ambulance was often influenced by the time of day which coincided with the GP not being available. 5.1.2 Making the decision to call 999 Across all nursing home staff it was evident that it would be the nurse in charge of a shift that would make the decision if an ambulance was needed and would ring 999. Some care staff felt that making this decision was above their station and something that was not part of their job role. Some care assistants reported that they did not feel comfortable making decisions due to their perception of their own apparent lack of experience and qualifications. 5.1.3 Influence of health professionals and family members Some paramedics felt that nursing home staff who were unable to get through to a GP were often advised by a receptionist to call for an ambulance. Both paramedics and nursing home staff felt that the GP heavily influenced decisions on whether to call for an ambulance; as sometimes GPs do not have the time to visit the patient themselves. Even though this would sometimes cause conflict between the GP and nursing home staff, an ambulance would still be called out if advised to do so by a health professional. Family members were also felt in some cases to influence decisions if residents were to go into hospital, specifically when family members perceived the situation to be more of an emergency than nursing staff and wanted additional medical care for their relative. 14
5.1.4 Policies and procedures The majority of nursing home staff felt that the correct protocol if a resident had become ill or experienced a fall would be to monitor them to see if there were any changes in their condition. In the majority of situations that were not serious or life-threatening where staff felt that they lacked expertise to cope, the procedure that would be undertaken would be to contact a GP for a second opinion. Paramedics perceived that most calls from nursing homes following a fall were due to the no lifting policy in nursing homes; which interestingly was not discussed by care staff. Paramedics felt frustrated with this policy since all nursing home staff should have undertaken mandatory manual handling training. It was thought that the no lifting policy was perceived to protect the nursing home and avoid the family or patient from taking any action against them. The actions of nursing staff were found to be heavily influenced by their internal policies and procedures relating specifically to what action should be taken following a resident experiencing a fall. Nursing homes in Blackpool appeared to have more policies and procedures in place than the nursing homes in Wigan and Bolton, where the majority of staff at a care assistant level reported that they were not aware of the policies in place. 5.1.5 Falls Falls were the most frequently reported reason amongst nursing staff that an ambulance would be called out for and this finding was also supported by paramedics. Falls tended to occur during the night, when an elderly person wakes and forgets they have difficulties walking, and early morning when there is a shift change. However, it was emphasised by paramedics that the majority of falls do not warrant a call to the ambulance service and instead could be treated by nursing staff in the home. Blackpool nursing staff were confident in selecting the appropriate course of action to take when a resident experienced a fall as they had set procedures in place. 5.1.6 Confidence It was felt that confidence levels may vary according to the different areas of a home that carers are working in. This was mainly dependent upon the amount of time that care staff spend with patients and how well they get to know them as individuals. It was acknowledged that confidence levels of staff were a large influencing factor in the number of calls to 999 and that building on confidence and empowering staff to feel more confident in making decisions for their residents was needed. Having the confidence to determine the correct course of action was felt to be particularly important with regards to the fear that many staff members expressed relating to litigation. 5.1.7 Best practice and care plans Across all of the nursing home staff interviewed, participants stated that they had written care plans for each of the residents within their nursing home. The extent of the information contained within these care plans varied. Robust reporting was felt to be important to help staff make better decisions on what course of action to take and also to help paramedics by ensuring they had all the information needed readily available to them if they were called out. Examples of best practice 15
came from care homes in Blackpool where staff documented anything unusual to allow for better monitoring of the resident. One nursing home used visual reminders to prompt staff when making decisions of whether or not they needed to call 999. 5.1.8 Training Across all nursing homes it was clear that staff undertook mandatory training and that this was refreshed on average every six to twelve months. The topic areas covered by mandatory training were primarily; first aid, fire training, manual handling and health and safety. In most cases training was delivered internally, which appeared to be the favoured format amongst nursing home managers. Not all care assistants undertook training relating to emergency situations and not all had been trained in CPR. Optional training areas included health and social care, nutrition, infection control and end of life care. In addition, some staff had received specific training on falls. Nursing home staff were very enthusiastic about attending training about selecting the appropriate care pathway in response to a resident experiencing an accident, and felt that this would be worthwhile. It was thought that making the training sessions interactive with demonstrations on how to deal with situations was important. Additionally, it was felt that working in partnership with NWAS to deliver these training sessions would be the most effective way to learn about what course of action to take. There were mixed opinions about providing training to higher level care staff and managers and allowing this information to filter down to all members of staff. There were also mixed opinions of whether training should be made mandatory or whether care staff should be able to 'opt in' to specific training modules. There was a general consensus across different nursing home staff that materials and written resources would be helpful to serve as visual prompts and aids to give information on what to do in an emergency situation. 5.1.9 Interventions to help reduce calls from nursing homes The following ideas were suggested to help reduce calls across all nursing homes for non-life threatening incidents; Flow chart and written resources to determine correct healthcare pathway to be taken in different situations First aid and minor injury training Assessing injury/patient observations after falls; building confidence among nursing home staff in terms or whether an ambulance is needed and key questions to ask to help the paramedics when they arrive Educating nursing home staff about how to lift patients after a fall and how to use patient lifting devices Up to date care plans for patients and pathways of appropriate action for different situations. Talks to care homes by NWAS, community nurses and the falls team Up to date assessment of patients by the falls team Support line for nursing home staff about the most appropriate action to take. 16
5.1.10 Barriers to implementing interventions Three key areas that might cause barriers to implementing these interventions suggested by nursing staff included: current policies and procedures in nursing homes, staffing levels in the nursing home and the nursing home staff and paramedic relationship. The importance of joining up policies and procedures was noted by nursing home staff as a key barrier as currently their actions were limited by policies. Barriers identified by paramedics to implementing some of the suggested interventions included cost and time, the feasibility of using intervention materials in an emergency situation, language barriers and a fear of litigation. 17
6 Conclusions It was evident that incidents to situations that were not classed as an emergency, in which a person needed to be taken to hospital for further care were frequently experienced by paramedics during their typical shifts and that these type of calls took up a large proportion of their working week. On average, paramedics estimated that around half of their time was spent on calls for incidents that are not serious or life threatening, translating into the majority of paramedics attending at least six of these situations a week of which the average turnaround time was half an hour to an hour per incident. It was acknowledged that this could vary from shift to shift. Paramedics felt frustrated generally in relation to those incidents that were not serious or lifethreatening and commented that this tended to reduce morale amongst ambulance crews. This was largely because these incidents were felt to reduce capacity for genuine emergencies when they could be saving someone s life and also lead to frustration as it is not in the patient s best interest to be transported to hospital. Paramedics also commented on the risk that they take when putting on a blue light to an emergency, which can cause a higher risk to people driving on the roads. Typically the population groups and organisations that paramedics felt they attended a higher number of incidents that were not serious or life threatening were for BME groups, mental health patients, low socioeconomic groups, homeless people, people with minor ailments, people with long term conditions, individuals who had been drinking and nursing home staff. Paramedics agreed, that based on their experiences, amongst these population groups, nursing home staff frequently requested an ambulance when alternative care pathways could have been undertaken. Often in these situations it was felt that an alternative course of action should have been undertaken such as calling a GP to obtain a second opinion on a person s condition, requesting a district nurse to come into the home to deal with a minor injury, or simply having the correct procedures and training in place for staff to deal with situations that were not serious or life threatening e.g. lifting an individual back into bed after experiencing a fall. Across the majority of nursing home staff it was consistent that primarily the reasons they would call an ambulance would be due to the severity of the resident s condition and because they felt that they did not have the facilities needed to deal with the person s condition. It was also evident however that other factors played a role in determining whether or not an individual would call an ambulance, both internal factors relating to the nursing home s policies and procedures and external factors such as the advice of other health professionals. A common influencing factor that both nursing home staff and paramedics noted was the fear of litigation amongst nursing home staff, therefore resulting in staff members erring on the side of caution and often getting paramedics to check residents over to ensure that staff are covered if they don t spot something that might cause further problems for the resident. Paramedics noted that within some nursing homes that they had come across, calling an ambulance after a resident experienced a fall was one of their policies that staff had to follow. Nursing home staff also commented on their experiences of dealing with family members and how this can sometimes also determine a course of action that is taken for a resident as the family members want them to go into hospital, in spite of the advice from nursing home staff. In these situations it was noted that nursing home staff may be left feeling similar to paramedics in situations 18
were they are called out to incidents that are not serious or life-threatening, often feeling frustrated as they know it is not in the resident s best interest to go to hospital. Even in situations where nursing home staff may opt to undertake a different care pathway to calling out an ambulance, such as obtaining advice from a GP, this may also result in an ambulance being called out. This was because it was felt that often GPs and receptionists give the advice over the telephone to call an ambulance rather than going to the nursing home to assess the resident. Paramedics were also able to comment on their experiences of this. For nursing home staff, in situations where they felt a resident was unwell but this was not a life-threatening situation, it was predominately the GP that they would seek advice from if staff felt they could not deal with this themselves. It was noted that registered nurses within the nursing homes often call GPs to obtain a second opinion, particularly when faced with conflicting requests for care from family members. It appeared that nursing home staff value the relationship they have with the doctors that are affiliated to their homes and often trust this relationship to obtain advice from a more qualified individual. Therefore it was not surprising that amongst nursing home staff and paramedics, it was felt that an increased number of calls were received from nursing homes during out of hours. This was in part due to the acknowledgment that more residents may get up during the night or may be found having fallen during the early hours of the morning when staff undertake a shift change. Also during the night there are fewer staff members on duty at the nursing home, which may impact on the number of ambulance calls. It was also felt that during out of hours, nursing home staff may be more inclined to default to directly ringing an ambulance as they are not able to directly seek advice from their GP, who in most cases they have a trusted relationship with. The common practice across all nursing homes included in the research was for registered nurses to oversee and make any decisions relating to the care of residents. Many of the care assistants felt that this was beyond their remit and job role and therefore did not take on the responsibility of determining the correct course of action in an emergency situation for their residents. It was evident that both the paramedics and nursing home staff felt that training would help staff to make these decisions relating to the appropriate level of care for residents. CPR training, minor aliment training and generally educating staff of alternative pathways that are available, was felt to be lacking and was not mandatory across all care homes. Paramedics expressed their frustrations with particular policies and procedures within nursing homes, particularly in relation to no lifting policies that many of the paramedics were able to recall encountering at some point. This particular policy was felt to account for a large proportion of incidents, where a resident had fallen out of bed and had no visible injuries but nursing home staff did not want to lift them as they were worried they may cause further damage. Across the nursing home staff it was clear that generally amongst the care assistants there was no solid understanding of their policies and procedures generally relating to different care subjects, other than in one home in Wigan where there was a widely understood procedure that if a resident experienced a head injury resulting from a fall, an ambulance had to be called out. Generally, it appeared that the main policy that most of the care home assistants adhered to was to refer to their nurse in charge if they experienced any kind of problem or experienced anything that they believed was unusual. In both Blackpool care homes, sharing of protocols was common place amongst care 19
assistants and it was felt important to ensure that all staff have a good understanding of the procedures to adhere to, particularly agency and temporary staff members. The vast majority of paramedics believed that there are potential interventions which can be introduced to reduce the number of calls from nursing homes. Primarily, additional training on what to do in an emergency situation and information to raise awareness of alternative care pathways were felt to be needed for nursing home staff. Generally, the option of undertaking additional training in these areas was met with enthusiasm from staff, ultimately believing that if this would help to improve that standard of care for patients then it would be worthwhile for all staff to undertake. There was also an appreciation amongst staff that it was a very real possibility that one day they might find themselves in a situation where they had to make decisions about whether or not to call an ambulance for a resident. Both paramedics and nursing home staff felt that it was essential that they worked together to develop interventions to reduce the number of calls from nursing homes. Paramedics felt that they had a role to play to assist in educating nursing home staff about appropriate care pathways as well as the correct use of ambulance services. Nursing home staff agreed that they would like to work with the ambulance service and felt that it was important to gain an understanding of what the North West Ambulance Service would class as an emergency situation. The importance of working with other health professionals and community intervention teams, such as the falls intervention teams, was cited as an opportunity to join with current work taking place across the North West. It was felt that this will help to educate nursing home staff of the alternative care pathways that are available, e.g. community nurses, district nurses and advanced nurse practitioners and in what circumstances and for what conditions these health professionals can provide care. 20
7 Best Practice and Areas for Improvement The following section identifies areas of best practice and improvement to form the basis of effective interventions to be undertaken in nursing homes across the North West. The most effective ways in which to reduce the number of incidents from nursing homes were believed to be a combination of: Sharing best practice; including advanced care planning, initiating robust reporting procedures on a day to day basis for every resident and event analysis of emergency situations and incidents that are not serious or life-threatening and evaluation of how these were dealt with. Implementing an evaluation process; it was felt that this was important both to evaluate processes and make changes if needed, to ensure that this is as efficient as possible and also to celebrate and empower staff when they have made the right decisions about the care for their residents. Training all staff members; the preferred format for training is in-house preferably with external organisations coming in to do the training for staff members. It was felt that staff should be asked to undertake this training if they wished to and that this should be an opt-in process to encourage empower staff to increase responsibility and ultimately increase levels of confidence. Supporting written materials, visual aids and prompts to reinforce staff training. Easy to understand visual representations of key information such as flow charts and stickers to prompt staff on what to do in an emergency and non-life threatening situation were favoured. Written materials and information for other influencers such as family members to also understand what the most appropriate form of action would be to undertake in the event of an emergency and why nursing home staff should be trusted to make these decisions. Aligning policies and procedures; it is integral that any changes made in the behaviours of nursing home staff are supported by the policies and procedures of nursing homes. This is essential to remove any barriers to staff members taking the most appropriate course of action in these situations. Also to help staff feel confident in following procedures as there are strict guidelines in place to help assure them that they are doing the right thing. 21
7.1 Next Stages At this stage of the work programme, all of the key research findings have been analysed and a full written report as well as the current summary report have been produced and shared with the project team at NWAS, all research participants and with wider NHS community stakeholders. Moving forward, these research findings will be used to provide key recommendations to inform potential interventions designed to improve decision making for nursing home staff. A programme of work to address these next steps and apply these recommendations to reduce the number of calls to the ambulance service for incidents that are not serious or life-threatening, is currently in development. This will involve a creative and innovative approach to inform a range of intervention techniques and assist in the awareness and use of more appropriate alternative routes to patient care for nursing home staff. 22
8 Appendix 999 Call Outcomes A 999 call to NWAS will be prioritised, using AMPDS, into one of the following categories which will determine the speed and type of response: Category A Category C Red 1 Red 2 Green 1 Green 2 Green 3 Green 4 Face-toface response in 8 minutes Face-toface response in 8 minutes Face-toface response in 20 minutes Face-toface response in 30 minutes Telephone assessment in 60 minutes &, if necessary, transport in 180 minutes Telephone assessment in 60 minutes &, if necessary, transport in 240 minutes Category A calls (red) are defined as life-threatening. Category C calls (Green) are defined as incidents that are not life-threatening. Green 1 and Green 2 calls may be considered serious, but do not present an immediate threat to life. Green 3 and Green 4 calls are not serious and not life-threatening. Following the 999 call, the result will be that the incident: 1. Stays with NWAS for a response; 2. Is referred to the NWAS Urgent Care Desk for triage by a Specialist Paramedic, or; 3. Is referred to NHS Direct. For number 1, the ambulance crew will determine where the patient needs to be taken following a face to face assessment. This will either be an Emergency Department (A&E), an NHS Urgent Care Centre, a community care pathway such as a GP or District Nurse who already manages the patient s specific condition such as diabetes or COPD, or given self-care advice. For number 2, a Specialist Paramedic will call back patients in the Green 3 and 4 categories and assess over the phone to determine where to refer the patent. This could be an Emergency Department (A&E), an NHS Urgent Care Centre, a community based service such as a Dentist or a GUM clinic or they could be given self-care advice. 23