Welsh Ambulance Services NHS Trust: Patient Pathway Guidelines: For Fallers, Resolved Hypoglycaemia and Resolved Epileptic Seizures aged 18 years and over Version 1.7
DOCUMENT CONTROL SHEET Document Version History Version Number Date Author Summary of changes Document Status 1.0 July 12 LC New Document DRAFT 1.1 July 12 LC Distribution / Approvals lists amended DRAFT 1.2 July 12 LC Updated based on comments DRAFT 1.3 Aug12 LC Amended based on feedback from KW DRAFT 1.4 Aug12 LC Removal of Care Co-ordination Point replaced by Coordination Point DRAFT 1.5 Aug 12 LC APPROVED 1.6 Sept 12 LC Version status and approvals amended APPROVED 1.7 Dec 12 JP ABMU references removed ready for use in other HBs APPROVED Approvals This document requires the following approvals: Name Title Date Dr. Paul Hughes Medical Director 16/08/12 Andrew Jenkins Assistant Clinical Director/ Consultant Paramedic Aug 12 Grayham Mclean National Unscheduled Care lead Aug 12 Distribution This document has been distributed to: Name Title Date Andrew Jenkins Assistant Clinical Director/ Consultant Paramedic Sept 12 Sue Jenkins Director of Service Delivery Sept 12 Carl James Director of Strategy, Planning and Performance Sept 12 Mike Collins ABMU Head of Service WAST Sept 12 See CRG terms of reference Clinical Reference Group Sept 12 Aileen Evans Assistant Nurse Director Sept 12 Grayham Mclean National Unscheduled Care lead Sept 12 Nicki Maher Head of Health Informatics Sept 12 Leanne Hawker Partners in Healthcare Lead Sept 12 Review Date This document will be reviewed and updated as and when necessary in line with service and organisational requirements. Paper copies of this document may not be the most up-to-date version. The live version will always be available on the Trust intranet. Patient Pathway Guidelines v1.7 Page 2 of 12
CONTENTS Page Front Page 1 Version Control 2 Contents Page 3 1. PURPOSE 4 2. BACKGROUND 4 3. SCOPE 4 4. PROCESS 5 4.1 STEP 1 - Patient Assessment 5 4.2 STEP 2 - Apply Referral Criteria 6 4.3 STEP 3 - Call Co-ordination Point 7 4.4 Call process 7 4.5 Database management 8 4.6 Clinical support 8 4.7 Refusal of Pathway/ Treatment 8 4.8 Notes for Emergency Medical Technicians 9 5. EVALUATION AND DATA MONITORING 9 6. LIST OF APPENDICIES 6.1 PATIENT PATHWAY OPERATIONAL FIELD GUIDE 10 6.2 PRINTABLE VERSION OF FIELD GUIDE 12 Patient Pathway Guidelines v1.7 Page 3 of 12
1. PURPOSE 1.1 The purpose of this document is to provide Paramedics with guidelines on how to safely assess, and subsequently arrange alternative care pathways for appropriate patients. 1.2 Specifically, these guidelines are focused upon care pathways relating to patients who have fallen, had a resolved hypoglycaemic episode or resolved epileptic seizure. 1.3 This document will be updated and reviewed as and when necessary in line with service and organisational requirements. 2. BACKGROUND 2.1 Demand for ambulance services across the UK increase year on year, the Department of Health 1 estimate an approximate 6% rise in demand per year. 2.2 Within Wales the picture is similar, since 1996-7 demand for ambulance services has risen by almost 90%. 2.3 Despite an increase in demand, there is no clear increase in patients presenting with life-threatening conditions - remaining at around 10%. 2.4 It is becoming increasingly clear that transporting patients to emergency departments who do not need to go there is neither in the best interests of the patient nor sustainable. 2.5 Throughout Wales, there is a clear initiative to develop community based services which can improve the quality of life for patients, by re-focussing NHS resources from reactive to pro-active hospital admission prevention. 2.7 A key first step is to improve and re-energise the existing patient pathways that are currently in operation within the Welsh Ambulance Services NHS Trust (WAST). 2.8 As part of its Annual Delivery Plan, the WAST is committed to delivering a minimum of 8% patient referrals to alternative providers of the total 999 demand. 3. SCOPE 3.1 This guidance is applicable to Emergency Medical Services (EMS) Paramedics who have received pathways training and the pathways process is available within the patients Health Board area. 3.2 It is important to note that the pathway processes detailed within this document are a refinement of current processes being undertaken by Paramedics in Wales, and are in accordance with JRCALC Guidelines and (p7). 3.3 In addition, the guidelines are applicable to the Clinical Contact Centre staff who will be involved in the pathway co-ordination elements of the process, predominantly NHSDW Health Information staff. 3.4 These guidelines are suitable for patients aged 18 years and over only. 1 Department of Heath 2007 Patient Pathway Guidelines v1.7 Page 4 of 12
4. PROCESS 4.0 The following section provides detail around the process of identification of a suitable pathway and the steps to achieving the right outcome for the patient. An overview of the process is provided in figure 1 below: Figure 1: Process Overview N.B. the process guide in its entirety is available at Appendix 1: Patient Pathway Operational Field Guide. 4.1 STEP 1 - PATIENT ASSESSMENT AND TREATMENT 4.1.1 Initial patient assessment at scene will be carried out in accordance with current JRCALC and WAST operational guidelines. 4.1.2 The decision process whether to consider an alternative pathway is summarised in figure 2 below: Figure 2: Step One Patient Pathway Guidelines v1.7 Page 5 of 12
4.1.3 Paramedics will conduct Primary and Secondary surveys in line with current practices. 4.1.4 problem relates to a fall, a hypoglycaemic episode or an epileptic seizure. 4.1.5 At this stage the Paramedic will consider whether the patient s signs and symptoms clearly require transport to the Emergency Department (ED). 4.1.6 If signs and symptoms do not indicate that immediate transport to ED is required, the Paramedic will proceed to STEP 2 Apply Referral Criteria. 4.2 STEP 2- APPLY REFERRAL CRITERIA 4.2.1 The full criteria list is available in the operational field guide at Appendix 1. 4.2.2 When the Paramedic has determined that the patient is not time critical and may be suitable for an alternative care outcome which is not ED, the pathway criteria for the relevant problem will be considered. 4.2.3 If a patient pathway is initiated, the following actions will happen: FALLS the community based intervention team will contact the patient within an agreed timescale to assess as appropriate. RESOLVED HYPOGLYCAEMIA information is shared with the P to inform them of the episode. The GP will decide whether any additional input is required. RESOLVED EPILEPTIC SEIZURE - information is shared with the P to inform them of the episode. The GP will decide whether any additional input is required. 4.2.4 If the patient fulfils the criteria for a pathway the Paramedic will continue to STEP 3 Call Co-ordination Point. 4.2.5 There may be occasions where the patient fulfils the criteria but the Paramedic feels in their professional judgement the patient is not suitable for an alternative pathway. This is acceptable as long as the clinical decision is justified and fully documented within the Patient Clinical Record (PCR). 4.2.6 If a Paramedic is unsure about the application of the criteria or the process, they should seek advice initially from the duty Clinical Team Leader (CTL) more detail about Clinical Support is provided in point 4.6. 4.2.7 It is important to note that if the patient does not meet the criteria for a pathway they should be advised to attend ED for further assessment and treatment. Again if the Paramedic is unsure they should seek Clinical Support. Patient Pathway Guidelines v1.7 Page 6 of 12
4.3 STEP 3- CALL CO-ORDINATION POINT 4.3.1 Once a patient has been identified as appropriate for a pathway, the Paramedic will gain their consent prior to continuing. 4.3.2 If consent has been obtained the Paramedic will call the Co-ordination Point and initiate an alternative pathway. 4.3.3 If the patient does not provide consent but is suitable for a pathway the paramedic will log the incident with the Co-ordination Point as suitable but no consent given, in order to log the episode of care as a potential pathway use and to indentify multiple contacts should the patient call again. 4.3.4 There may be occasions where a patient is suitable for an alternative pathway but there is no service provision in the area. In these cases, the Paramedic must continue to log the incident with the Co-ordination Point and the Co-ordination Agent will log that no provision was available to the service user. This information will be collated and fed-back to the HB about any gaps in service provision for its patients. 4.4 CALL PROCESS 4.4.1 The Paramedic will contact the Co-ordination Agent on the dedicated number 0845 4599545 - please note that the Co-ordination Agent is unable to assist with process or clinical queries. Please see section 4.6 on Clinical Support. 4.4.2 Once the call has been answered, the Paramedic will identify themselves and inform the Co-ordination Agent of the type of referral required. 4.4.3 The Co-ordination Agent takes basic address information and searches the database to confirm service provision in the area. 4.4.4 If the service is suitable, the Co-ordination Agent will collect all the relevant information from the Paramedic about the patient and input onto the pathway database. 4.4.5 The Co-ordination Agent will confirm that the details have been completed and provide a reference number. 4.4.6 The Paramedic or Co-ordination Agent may identify multiple records or multiple calls for the patient - which may require further investigation into the most appropriate ongoing care provision for the patient. 4.4.7 The Paramedic will complete the PCR (including the pathway reference number), any additional documentation, and confirm pathway with the Patient, confirming typical timescales of follow up by the team as appropriate. 4.4.8 The Paramedic will leave a copy of the PCR with the patient and provide an advice leaflet for the patient together with call back advice clearing the scene as appropriate. Patient Pathway Guidelines v1.7 Page 7 of 12
4.4.9 The Co-ordination Agent will ensure all documentation is correct on the database and send the patient details to the relevant team to initiate action for the patient. 4.4.10 Confirmation of transfer of patient details will be undertaken in real time during accepting teams working hours and for out of hours via follow up calls to teams the next working day. This will be carried out by the Care Co-ordination Team. 4.5 DATABASE MANAGEMENT 4.5.1 All contacts with the Co-ordination Point will be logged within the pathway database, whether the patient details are being passed on to other agencies or not. 4.5.2 Any transfer of patient identifiable data to external agencies will be made in accordance with Trust Information Governance policies and procedures. 4.5.3 The information held within the database will be used to develop data reports relating to the number of pathways used, the types of pathway, identifying areas where there may be gaps in service provision, individual and team performance in relation to pathway usage this list is not exhaustive. 4.5.4 It will be the responsibility of the Partners in Healthcare team to ensure that the details of pathway services listed within the Directory of Services are accurate and up to date. 4.6 CLINICAL SUPPORT 4.6.1 If a Paramedic requires clinical support, they will access the Duty CTL in the first instance. If the CTL is unavailable the Paramedic will contact Control to discuss other alternatives. 4.6.2 If more specialist advice is required, this will be escalated as appropriate on discussion with the CTL. For example, support from Advanced Paramedic Practitioners, GP or ED services. 4.6.3 In respect of pathways, clinical support may be accessed for the following reasons: Paramedic is unsure if patient meets pathway criteria Patient symptoms do not require ED assessment/ treatment Paramedic is unsure of best pathway for patient 4.6.4 Prior to calling for support, as a minimum the following must be completed by the attending Paramedic: A full set of observations is completed PCR is completed as far as practically possible Patient is aware and consents to action. Patient Pathway Guidelines v1.7 Page 8 of 12
4.7 REFUSAL OF TREATMENT/ PATHWAY 4.7.1 The Co-ordination Point should NOT be used to access urgent medical assistance for patients who refuse ED but do agree to an urgent GP contact normal processes/ actions should be undertaken to facilitate this. 4.7.2 Issues arising which relate to RTT and CAPACITY must be managed in accordance with the Trust Policy:. 4.8 NOTES FOR EMERGENCY MEDICAL TECHNICIANS (EMT) 4.8.1 This field guide is for use by Paramedics. 4.8.2 However, there may be occasions when a double EMT crew attends a patient who may be suitable for a pathway other than ED. On these occasions, the double EMT crew must request support from the on duty CTL. 4.8.3 If an alternative pathway is still indicated, a face to face Paramedic assessment is required to assist the EMT crew to initiate the pathway for the patient. 5. EVALUATION AND DATA MONITORING Evaluation 5.1 This process will be reviewed regularly. 5.2 In the first 3-4 days, daily review will occur, based on user feedback and service feedback relating to the process, use of the tool etc. 5.3 It is anticipated that the review periods will then broaden to weekly. 5.4 An evaluation of activity will be undertaken following the first month of operation within a new Health Board area. Data Monitoring 5.5 Data will be collected on a daily basis for the first 3-4 days, dependant on results will then be extended to weekly. Patient Pathway Guidelines v1.7 Page 9 of 12
6.1 APPENDIX 1: PATIENT PATHWAY OPERATIONAL FIELD GUIDE (MOST CURRENT VERSION IS AVAILABLE ON THE INTRANET)
Patient Pathway Guidelines v1.7 Page 11 of 12
6.2 APPENDIX 2: PRINTABLE COPIES OF FIELD GUIDE Intranet link to File Guide:»CLICK HERE«All Patient Pathways Documentation is available on the Intranet. If you enter Home Page.