MONITORING VISIT REPORT Service/ward monitored: Date/time: Monitoring team: UHB/Trust staff: Purpose of visit Brief description of area visited: Cardiff East Ambulance Station 14 th January 2015 2.00pm 4.10pm Francesca Creighton Griffiths (Lead) Malcolm Hackman Greg Lloyd WAST Locality Manager Anthony Rich Paediatric Retrieval Team Geraint White Clinical Team Leader Paul Burrows Advanced Paramedic Practitioner Monitoring Visit The Organisation The Welsh Ambulance Service NHS Trust is a national organisation, and is aligned to UHBs though there is flexibly regarding borders, for example: if an ambulance is needed in Caerphilly and the only ambulance available is in Cardiff then the Cardiff Ambulance will attend. There are 3 control centres in Wales: one in the North; One Central; and one in Cwmbran. The Ambulance control centre in Cwmbran is the newest control centre. At the control centre, when a call comes in a series of set questions (MPDS) is used to determine the best course of action e.g. dispatching an emergency ambulance. The control centre staff are not clinically trained though the plan is to bring in paramedic and nursing staff. Cardiff East Ambulance Station receive instructions from Cwmbran. Cardiff East Ambulance Station is one of 5 sites, in the Cardiff and Vale of Glamorgan area the other sites being Barry, Cowbridge, Llantwit Major, and Blackweir; in addition there are stand-by areas for example in Ely, Roath and Whitchurch Fire Stations. 1
Location - Cardiff East Ambulance Station Cardiff East Ambulance Station opened in September 1994. It is 20 years old, and is felt to have outgrown its footprint. The traffic in and around the current location has increased significantly and this is having an impact on egress from the site. Blackweir station is in a good location but also has poor ingress and egress. A 3 acre site is needed with good access and egress. The plan is to have a new purpose-built facility, however a site for this has not been identified. An Outline Business case has been submitted to Welsh Government (WG) and WG have agreed to fund a new purpose built facility. The Building Cardiff East Ambulance Station is housed in a converted warehouse, and whilst it is felt to be adequate, could do with modernising. The station has a vehicle bay, rest area, dining area, kitchen, shower, storage spaces, and small room for the Paediatric Retrieval team, with filing cabinet and television. About 70% of the staff are male, and 30% are female. There are separate toilets, though no changing facilities. Infection Control systems are in place and auditing is carried out routinely. Staffing Cardiff and Vale WAST has one Head of Service, and 2 Locality Managers: one for Cardiff, and one for the Vale. Cardiff East Ambulance Station has the following staff: 22 EMS (now recruited via Higher Education) Clinical Team leaders 2 Advanced Paramedic Practitioners 7 10 Patient Care Services Staff (PCS) 10 Urgent Care Staff, and 5 vehicles, for low acuity patients are based in Barry and respond to GP demand 5 Paediatric Retrieval Service Vehicle and Staff It was explained that rapid response cars have better access and can get to the scene quicker, so they are despatched initially if there is an immediate threat to life. 2
The station is manned 24/7, with Staff currently working 12 hour shifts and 4 days on/ 4 days off; a rota system is to be initiated in February 2015. Recruiting into the service is not a problem: Paramedics are recruited every September; and there are many applicants for the EM technician posts Paediatric retrieval service covers Mid and South Wales The visiting team were shown the Paediatric Retrieval Service Ambulance, which is the only such vehicle for the whole of Wales. The 5 staff team provide a service which retrieves very unwell children i.e. 16 year olds and under. Staff have on-site training. The team for each call out includes: ambulance member of the Paediatric Retrieval Service ambulance, consultant and specialist paediatric retrieval nurse. The equivalent team from Bristol which includes an unqualified ambulance technician; a nurse practitioner, and a registrar is not as specialised. The Wales service has been running for 13 years, and not one shift has been missed. The Royal Gwent Hospital does not have a paediatric ICU, the nearest paediatric ICU is at Bristol. Working Practices Paramedics Role Paramedics make decisions about where to direct patients, for example to the GP, District Nurse, CRT or Hospital. Despite initiatives to reduce the number of people taken to Hospital the same problems are being encountered. For example the Conveyance Rate for Cardiff and Vale UHB is 61% with 61 out of every 100 patients go into hospital. Change in Working Practices The significant change in the nature of Paramedics work was commented on: in the past paramedics dealt mainly with serious trauma or cardiac arrests, however now patients are presenting with multiple disease pathways. Previously ambulance teams would have attended 10 12 call outs per shift, but now might be able to attend 5 call outs in 3 shifts. 3
Administrative Workload In addition, as a result of additional policies, pathways, safeguarding procedures and documented risk assessments there is a lot of administration and forms to be completed. Patient Pathways Ambulance staff work with the A&E controller who coordinates flow through the Unit from admission to finding beds. Elderly sick patients admitted by GPs can go directly to the Surgical Admission Unit (SAU), or Medical Admission Unit (MAU). The SAU is open 9am 5pm; the MA is open 24/7. Alternative Patient Pathways are being developed to ensure that patients are directed appropriately, rather than into hospital. The 2 latest pathways under development are as follows: Mental Health Pathway as of 1/12/2014 patients are directed either to the Mental Health Crisis team, or to Whitchurch Hospital. Previously these patients would have gone to the Emergency Medicine Unit. Obstetrics and Gynaecology Pathway is still being developed Frequent Callers Work being carried out to meet the needs of frequent repeat callers was described and it was noted that frequent calls can either be due to unmet need, or abuse of the system. A clinical support officer leads this work and arranges Multi-Disciplinary Teams etc. as necessary. Patients views: Matters to be commended: Not Applicable as Ambulance Station is not a site to which patients go. It is clear that: Staff are highly committed to meeting patients needs and strive to achieve the optimum standards possible Staff are working on continuous improvement of their service. In addition to the initiatives described in the report, we were told of an open discussion involving staff, that was held at the station, over a change in the shift patterns. Everyone appeared to join in the vote and the results are on the notice-board for all to see. 4
There was a clear desire to change the existing shift pattern and the one supported by the majority will be implemented soon. The staff are confident that it will lead to an improvement in the patient experience. Matters of concern: Implications of Delays for Patients and Staff Hospital Delays with Ambulance Staff looking after patients until they are admitted to the hospital; this results in ambulances not being able to attend emergency calls, and staff finishing late. Ambulance staff can be waiting outside MAU or SAU for several hours. There are a range of unfortunate consequences that can arise from this frequently occurring situation: There is no privacy for patients waiting on stretchers in these areas Patients are given bedpans whilst waiting in the corridor Ambulance staff are limited in what they can give as analgesia to these patients When the Ambulance staff members shift ends, a replacement crew will take over from ambulance staff accompanying a patient waiting outside SAU/ MAU An example was given to the visiting team of staff starting a shift at 6am to find twenty 999 calls waiting, and for the length of wait to be 4 or 5 hours. Staff are regularly over running their shifts by 2 hours, and working without breaks. The Future of the Paediatric Retrieval Service There is uncertainty about the future of this Service, and staff are feeling unsettled. Apparently this has been under discussion for about a year, but the team have not been called into meetings about this. GL commented that the situation is not clear, other than a clear concern that the Service unsustainable. It is anticipated that the Wales Paediatric Retrieval Service will finish in March/ April 2015, and from then the Bristol service will cover Wales. It was explained that the reason for this change is because of an insufficient number of Paediatric intensivists in Cardiff. It would appear that: discussions between Cardiff and Vale UHB and Bristol are underway no decisions have been taken yet 5
Complaints Procedure Staff are required to record complaints, near misses patient safety issues, and serious incidents on the IT Datix system. However because staff can only do this from the Ambulance Station, then often they can only do this in their own time. There is a concern that this situation is resulting in under-reporting of incidents. The visiting team were advised that UHW are hoping to get protected software for Ambulance Staff to use on site. Implications of negative public perception of the ambulance service 1. Concern was expressed about the negative public perception of the ambulance service, and the negative portrayal of the service it offers in the local media. The need for the WAST public relations department to change was mentioned. However it was noted that this may change with the new WAST Chief Executive. 2. The inadequacy of response time targets without clinical outcome data was highlighted and the following illustration was given: a. if an ambulance reached a person with a cardiac arrest in 6 minutes but failed to resuscitate the patient this would be judged a positive outcome (within target). b. if an ambulance reached a person with a cardiac arrest in 8 minutes and succeeded in resuscitating the patient then this would be judged as a negative outcome. 3. It would appear that the combination of 1) and 2) are having a significant negative impact on staff morale. Lack of Blankets in Winter The lack of blankets in the winter remains a problem. Blankets are ordered in from Llanfechfra Laundry but blankets stay with patients when they are admitted. Recommendations to Council: Highlight concerns to Cardiff and Vale UHB about Implications of Delays for Patients and Staff. Find out: o progress of discussions about the plans for the Future of the Paediatric Retrieval Service in Wales. 6
o details of planned communication cascade regarding the future plans for the Paediatric Retrieval Service in Wales. Express concern about the practical difficulties for staff in logging concerns on Datix, and the potentially serious consequences of such difficulties. Explore the range of targets used for the ambulance service, and support the use of clinical outcome targets. Inquire of C&V UHB Laundry about the lack of blankets in Winter for this ambulance station. Explore ways to support communications that: o Present to the public the problems the ambulance service is having with emergency services o Direct the public know who to go to when they are unwell CHC possibly to visit the Ambulance Control Centre in Cwmbran Comments: Grateful thanks are extended to Greg Lloyd, WAST Locality Manager and his team for their welcome, the tour of the ambulance station, and their time in answering the visiting team s questions. A briefing paper had been requested from the Ambulance Service for Cardiff East Ambulance Station but was not available to the CHC visiting members either in advance nor on the visit, or at the time of writing the report. The availability of a briefing paper in advance of the visit regarding Cardiff East Ambulance Station detailing current staffing levels, facilities etc., would have been very helpful and would in particular would have enabled more time to be available for discussion about issues of concern and challenges with staff. CHC Member: Francesca Creighton-Griffiths Date: 27.01.15 7