Oxfordshire Clinical Commissioning Group Oxfordshire Clinical Commissioning Group Board Meeting Date of Meeting: 28 September 2017 Paper No: 17/62 Title of Paper: Ambulance Response Programme Paper is for: (please delete tick as appropriate) Discussion Decision Information Purpose and Executive Summary: The presentation is to provide the OCCG Board with details of the ambulance response programme (ARP) implementation of new call prioritisation clinical codes and revised ambulance quality indicators for South Central Ambulance Service (SCAS). Financial Implications of Paper: Not applicable. Action Required: The OCCG Board is asked to note the content of the presentation. OCCG Priorities Supported (please delete tick as appropriate) Operational Delivery Transforming Health and Care Devolution and Integration Empowering Patients Engaging Communities System Leadership Equality Analysis Outcome: Not applicable. Link to Risk: Not applicable. Paper 17/62 28 September 2017 Page 1 of 2
Author: Luci Stephens, Director Of Operations Clinical Coordination Centres, SCAS; Rob Ellery, Head of Planning (Ops), SCAS Clinical / Executive Lead: Date of Paper: 20 September 2017 Paper 17/62 28 September 2017 Page 2 of 2
AMBULANCE RESPONSE PROGRAMME IMPLEMENTATION OF NEW CALL PRIORITISATION CLINICAL CODES & REVISED AMBULANCE QUALITY INDICATORS 28 SEPTEMBER 2017
Content ARP principles and objectives Pilot site findings and benefits Key changes What are the new national standards What are the new national categories 1-4 What are the revised ARP codes for each category Revised Ambulance Quality Indicators (AQI) Revised Clinical Quality Indicators (CQI) What will this change involve What will be the staff training and support be SCAS implementation timetable Next steps
ARP Principles What does the patient need? What does SCAS need? The right vehicle Less on scene time for RRVs The right skill Less diverts The right place for care (Home, A&E, stroke centre.) Less multivehicle deployments on CAT 2,3&4 The right time
ARP Objectives Prioritising the sickest patients, to ensure they receive the fastest response; Driving clinically and operationally efficient behaviours, so the patient gets the response they need first time and in a clinically appropriate timeframe; Putting an end to unacceptably long waits by ensuring that resources are distributed more equitably amongst all patients. The Secretary of State for Health indicated that any proposed changes must be beneficial for patients, operationally efficient, and supported by a clinical consensus.
Key Changes Dispatch on Disposition Changes have already been made to allow Ambulances to be despatched on disposition rather than whilst the call was taking place by allowing additional triage time. SCAS have been carrying this out since Oct 2015. Clinical Prioritisation (SCAS plan to implement Oct 2017) A new clinical coding system will come into place when ARP goes live with SCAS that allows effective prioritisation based on patient clinical need Ambulance Service Measures (SCAS plan to implement Oct 2017) Ambulance response targets have been revised to measure median time to patients rather than a percentage of achievement which will lead to long wait reduction.
Findings from the pilot sites undertaken by Sheffield University (Yorkshire, South West and West Midlands Ambulance Trust) Giving call handlers more time to assess a call works; The most urgent emergency calls do not receive a slower response when call handlers have this extra time available; The ambulance service becomes more efficient, and there are less long waits for an ambulance to arrive; Patients in rural areas get a response more like urban areas; Over 14 million 999 calls analysed no patient came to harm as a result of the ARP; Ambulance staff agreed with the changes and recognise that they are beneficial to patients and to staff.
Benefits - Patients/Ambulance Trust / Staff The sickest patients receive the fastest response; Patients receive the response they need first time, and in a clinically appropriate timeframe ; Resources are spread more equally amongst all patients contacting the ambulance service to reduce long waits People living in rural areas receive a more equitable response. Improved workload management Staff recognise the service is more patient focused The appropriate resource is sent to the incident more often resulting in better clinical outcome and staff satisfaction Reduction in stand downs of resources Improved staff morale EOC and Field OPs
What are the new categories CATEGORY 1 - LIFE-THREATENING Time critical life-threatening event needing immediate intervention and/or resuscitation e.g. cardiac or respiratory arrest; airway obstruction; ineffective breathing; unconscious with abnormal or noisy breathing; hanging. CATEGORY 2 - EMERGENCY Potentially serious conditions (ABCD problem) that may require rapid assessment, urgent on-scene intervention and/or urgent transport. CATEGORY 3 URGENT Urgent problem (not immediately life-threatening) that needs treatment to relieve suffering (e.g. pain control) and transport or assessment and management at scene with referral where needed within a clinically appropriate timeframe. CATEGORY 4 NON-URGENT Problems that are not urgent but need assessment (face to face or telephone) and possibly transport within a clinically appropriate timeframe. TYPE S SPECIALIST RESPONSE (HART) Incidents requiring specialist response i.e. hazardous materials; specialist rescue; mass casualty
Changing standards & demands EXISTING RESPONSE STANDARDS TYPE % Calls / Demand Red 1 3% National Standard 75% within 8 mins 95% within 19 mins NEW RESPONSE STANDARDS TYPE % Calls / Demand Cat 1 8% National Standard Standard mean <7 mins <15 mins 90 th centile response Red 2 47% 75% within 8 mins 95% within 19 mins Cat 2 48% Standard mean <18 mins <40 mins 90 th centile response time Green 50% No National Standard Locally agreed Green 30 mins or Green 60 mins Cat 3 34% Cat 4 10% <120 mins 90 th centile response time <180 mins 90 th centile response time % of activity many vary slightly and is dependent on which call triage assessment tool in use by each Trust (NHS Pathways or AMPDS)
Categories National Standard How long does the ambulance service have to make a decision? What stops the clock? Category 1 7 minutes mean response time 15 minutes 90 th centile response time The earliest of: The problem is identified An ambulance response is dispatched 30 seconds from the call being connected The first ambulance service-dispatched emergency responder arrives at the scene of the incident (There is an additional Category 1 transport standard to ensure that these patients also receive early ambulance transportation) Category 2 18 minutes mean response time 40 minutes 90 th centile response time The earliest of: The problem is identified An ambulance response is dispatched 240 seconds from the call being connected If a patient is transported by an emergency vehicle, only the arrival of the transporting vehicle stops the clock. If the patient does not need transport the first ambulance servicedispatched emergency responder arrives at the scene of the incident Category 3 120 minutes 90 th centile response time The earliest of: The problem is identified An ambulance response is dispatched 240 seconds from the call being connected If a patient is transported by an emergency vehicle, only the arrival of the transporting vehicle stops the clock. If the patient does not need transport the first ambulance servicedispatched emergency responder arrives at the scene of the incident Category 4 180 minutes 90 th centile response time The earliest of: The problem is identified An ambulance response is dispatched 240 seconds from the call being connected Category 4T: If a patient is transported by an emergency vehicle, only the arrival of the transporting vehicle stops the clock.
New Ambulance Disposition Categories Codes ARP Revised National Pathways Codes Dx010 Existing Emergency Ambulance Response for Potential Cardiac Arrest C 1 Dx0101 Existing Emergency Ambulance Response for Potential Cardiac Arrest C 1 Dx0102 NEW Emergency Ambulance Response for Potential Cardiac Arrest Post Delivery C 1 Dx0103 NEW Emergency Ambulance Response for Fitting Now C 1 Dx0104 NEW Emergency Ambulance Response for Major Blood Loss under 5 C 1 Dx0105 NEW Emergency Ambulance Response for Potential Shock under 5 C 1 Dx0106 NEW Emergency Ambulance Response for Respiratory Distress under 5 C 1 Dx0107 NEW Emergency Ambulance Response for Unconsciousness under 5 C 1 Dx011 Existing Emergency Ambulance Response C2 Dx0111 NEW Emergency Ambulance Response for Acute Abdomen Pregnant C2 Dx0112 NEW Emergency Ambulance Response Acute Coronary Syndrome C2 Dx0113 NEW Emergency Ambulance Response Anaphylaxis C2 Dx0114 NEW Emergency Ambulance Response Aortic Aneurysm Rupture/Dissection C2 Dx0115 NEW Emergency Ambulance Response Labour Complications C2 Dx0116 NEW Emergency Ambulance Response Major Blood Loss C2 Dx0117 NEW Emergency Ambulance Response Possible Stroke Time Critical C2 Dx0118 NEW Emergency Ambulance Response Potential Shock C2 Dx0119 NEW Emergency Ambulance Response Respiratory Distress Non-Trauma C2 Dx01120 NEW Emergency Ambulance Response Respiratory Distress Trauma C2 Dx01121 NEW Emergency Ambulance Response Septicaemia C2 Dx01122 NEW Emergency Ambulance Response Unconsciousness C2 Dx0181 Existing Emergency Ambulance due to Clinical Reasons C2 Dx014 Existing Crew Arrived on Scene C2
Dx012 Existing Emergency Ambulance Response C3 Dx0121 NEW Emergency Ambulance Response C3 Dx0122 NEW Emergency Ambulance Response C3 Dx0125 NEW Emergency Ambulance Response (override from non ambulance disposition) C3 Dx0126 NEW Emergency Ambulance Response for Trauma Emergency C3 Dx0127 NEW Emergency Ambulance Response for Pregnancy/Labour problem C3 Dx0123 NEW Emergency Ambulance Response C3 Dx0162 Existing Transport to an Emergency Treatment Centre within 1 hour C3 Dx0128 NEW Non-emergency Ambulance Response(override from non ambulance disposition) C4 Dx017 Existing Ambulance for Clinical Reasons C4 Dx018 Existing Ambulance for Transport Reasons C4 Dx016 Existing Non-emergency Ambulance Response C4 Dx013 Existing Assistance needed at home due to inability to get off the floor C4 Dx024 Existing Assistance is being dispatched to arrive within 2 hours C4 Dx025 Existing Assistance is being dispatched to arrive within 4 hours C4 Dx026 Existing Deferred dispatch is being arranged C4 Dx028 Existing Assistance is being dispatched to arrive within 1 hours C4
Changes to Ambulance Quality Indicators and Clinical Indicators Changes are being introduced into how Hear and Treat and See and Treat is being counted to ensure consistency across Trusts. There will also be changes to the clinical indicators (Stroke, Stemi) these are expected to be implemented in April 2018 There will be more focus on outcome measures and these will be reported quarterly which will enable better monitoring of trends.
What will it involve? Work programme set up to oversee this major change within 999 Service Communication Strategy Impact Assessment (Quality, Clinical) Operational Re-Modelling (Continual Process) Pre & Post Go Live
Staff training & support 999 EOC Staff incl CSD clinicians - receive one day new standards training including: Revised NHS Pathways Dx codes Revised Standard Operating Procedures (SOPs) Computer Aided Despatch (CAD) changes Support documentation provided. 999 operational staff / managers / NHS 111 staff - familiarisation cascade training All new staff entrants (999 EOC/Ops/111) will also be trained / familiarised During the go live period mentorship/coaching/floorwalking in place within both 999 Emergency Operations Centres
KEY MILESTONES ARP 2.3 IMPLEMENTATION RAG COMPLETION DATE Undertake full impact assessment operational change model i.e. simulations using optima applying (new Cat 1 to 4 and AQIs) BASELINE COMPLETED / REFINEMENT 26 SEPTEMBER 2017 Undertake mapping exercise new call prioritisation code set changes alongside version 14 release (issued by NHS Pathways) possible implications 999 & 111 COMPLETED 11 AUGUST 2017 Assess amendments to AQIs to be implemented COMPLETED 11 AUGUST 2017 Assess, develop revised deployment criteria / plans for response, transportation COMPLETED 10 SEPTEMBER 2017 Determine 999 CAD technical changes, agree configuration/ development COMPLETED 24 AUGUST 2017 Review and update EOCs/CCCs, CSD, U&E operational processes changes (CFRs) NR COMPLETION / REFINE W/C 25 SEPT 2017 Assess potential changes to Workforce, Financial review IN PROGRESS OCTOBER 2017 Assess potential changes to Fleet BASELINE COMPLETED 12 SEPTEMBER 2017 999 CAD Supplier completes development ready for testing COMPLETED 29 AUGUST 2017 Undertake Factory Acceptance Testing 999 CAD, MDT / BI changes COMPLETED 08 SEPTEMBER 17 Site Acceptance Testing and User Acceptance Testing 999 CAD / BI changes COMPLETED 20 SEPTEMBER 2017 Provide EOC/ CCC staff training& field ops staff awareness(indirect Resources) IN PROGRESS 31 OCTOBER 2017 Engage and communicate with local key stakeholders of ARP 2.3 changes i.e.; CCGs, acute setting other 999 services and where change is affected IN PROGRESS 30 OCTOBER 2017 Prepare detailed operational readiness plans(and subsequent NHSE requirements) IN PROGRESS 20 OCTOBER 2017 Undertake operational team review(pre go live) ON TRACK 20 OCTOBER 2017 Undertake final technical checks(pre go live) ON TRACK 23-27 OCTOBER 2017 Undertake final SCAS Execs/ NHSE gateway review(for go/no go decision) ON TRACK 24 OCTOBER 2017 ARP 2.3 OPERATIONAL IMPLEMENTATION ON TRACK 31 OCTOBER 2017 Post go live monitoring -Executives / NHSE post go live daily / weekly updates FROM 1 NOV
Next Steps SCAS undertaking service modelling against the new targets. There is expected impact on the fleet mix where ambulance trusts have a larger car to ambulance fleet mix. New model will require refinement SCAS have notified NHSE they will go live by the end of Oct 17 subject to final technical and operational readiness All ambulance trusts must be live by the end of November NHSE have said that it will not be possible to dual report or compare measures against current targets and therefore a new baseline of activity and categories will be measured NHSE have informed Commissioners that a period of Grace is required whilst all ambulance trusts implement ARP and therefore there should be no performance management until Aril 2018 contract variation to be issued.
Thank you Any questions