Ambulance Response Programme

Ambulance Response Programme

Introduction NHS England announced its recommendations for changes to the ambulance service operating model and associated standards, developed through the Ambulance Response Programme (ARP). The redesigned system for ambulance services in England will focus on ensuring patients get rapid life-saving, life-changing treatment for conditions such as cardiac arrest, stroke and heart attack, rather than simply sending ambulances to stop the clock. Currently, as many as one in four patients who needs hospital treatment, more than a million people each year, undergo a hidden wait beyond the current 8 minute target because the vehicle dispatched cannot transport them there.

Evaluation An evaluation has been undertaken by the Sheffield School of Health and Related Research (ScHARR). The results highlighted have been impressive and once ARP is adopted nationally, it should: Improve early recognition of life-threatening conditions, particularly cardiac arrest. Based on figures from London Ambulance Service, they predict up to 250 additional lives could be saved in England every year. Improve waiting times; as many as 750,000 patients every year will receive an immediate ambulance response, rather than joining a queue. Reduce the differences in response time between patients living in rural areas, and those living in towns and cities. ARP evaluation has been the largest of its kind in the world, and has included 14 million 999 calls with no patient safety or adverse incidents attributed to the programme.

New System Under the new system ambulance call handlers will change the way they assess cases and have slightly more time to decide the most appropriate clinical response. At the same time, changes to the early call handling process mean that cardiac arrest patients will be identified quicker than ever before with evidence in London showing this will save more lives each year. Ending the out-dated 8 minute target will free up more vehicles and staff to respond to emergencies. Under the existing standards three or even four vehicles may be sent to the same 999 call in attempt to meet the target, meaning that across the country one in four ambulances are stood down before reaching their destination. These changes mean that more than half a million calls annually that would currently go into a queue will get an immediate response.

New System For patients with a serious condition such as heart attack or stroke, Dispatchers will send the most appropriate response to deliver treatment to the patient at scene and then transport them rapidly to the right specialist centre. A new set of clinical indicators will be introduced that will put improving outcomes central to demonstrating the impact that ambulances can have when the right resource is sent to patients in a timely manner, ensuring that patients are taken to the hospital offering the most appropriate emergency treatment that they need. We expect to see steady gains in patient outcome, including mortality, as a result. The changes also introduce a mandatory response standard for all patients who dial 999. Currently, half of all ambulance calls (around five million a year) are classed as green and not covered by a national response time standard. Response times for these patients, who are often frail and elderly, have risen by up to 100% in some ambulance services during the past two years, with some patients waiting over 8 hours.

New System The ARP changes have been strongly endorsed by expert organisations such as the Royal College of Emergency Medicine, the Stroke Association, and the College of Paramedics.

ARP Principles The ARP follows the principles below What does the patient need? What does NWAS need? The right vehicle Less on scene time for RRVs The right skill Less diverts The right time Less multivehicle deployments

New Categories 999 calls will be prioritised into one of four new categories: Category 1 (Purple) Life threatening Category 2 (Amber) Emergency Category 3 (Yellow) Urgent Category 4 (Green) Less Urgent

Performance Standards NWAS performance is measured on the ability to reach patients as quickly as possible. Performance will be based upon the (mean) average time for all Category 1 and 2 incidents. Performance will also be based upon meeting the standard (90th percentile) 9 out of 10 times for Category 1, 2, 3 and 4 incidents. Therefore, for Category 1 and 2, NWAS need to achieve the mean (average) and the 90th percentile (9 out of 10 times). For Category 3 and 4, NWAS have to achieve the 90th percentile (9 out of 10 times).

Performance Standards RED 1 Life Threatening RED 2 CURRENT FUTURE ARP 3% of calls 75% response Clock starts at point call CATEGORY 1 8% of 7 mins mean (NWAS 3%) within 8 mins connected from 999 calls response time 47% of calls (NWAS 41%) 75% response within 8 mins Emergency Calls ALL RED 95% within 19 minutes GREEN 1 (NWAS 5%) NW local target 20 mins response Emergency Care GREEN 2 Emergency Care GREEN 3 Urgent Care GREEN 4 Urgent Care ALL GREEN (NWAS 29%) (NWAS 7%) (NWAS 14%) 50% of calls NWAS (56%) NW local target 30 mins response NW local target Tel assessment 60 mins / 180 mins response NW local target Tel assessment 60 mins / 240 mins response No national targets (local apply) From Oct 16: Clock started 240 secs from call connect or problem identified 60 secs from call connect / ambulance dispatched / problem identified Life Threatening CATEGORY 2 48% of calls Emergency Calls If conveyed, transporting vehicle stops the clock CATEGORY 3 34% of calls Urgent Calls CATEGORY 4 Less Urgent Calls If conveyed, transporting vehicle stops the clock 10% of calls 90% in 15 mins 18 mins mean response time 90% in 40 mins Clock starts 30 secs from call connect or problem identified Clock starts 240 secs from call connect or problem identified 90% in 120 mins Clock starts 240 secs from call connect or problem identified 90% in 180 mins Clock starts 240 secs from call connect or problem identified The new response system will: Change the dispatch model, giving staff slightly more time to identify patients needs and allowing quicker identification of urgent conditions Further prioritises a time critical response for the most life threatening conditions Introduce new target response times which cover every single patient, not just those in immediate need. For the most urgent patients we will collect mean response time in addition to the 90th percentile, so every response is counted. Change the rules around what stops the clock, so targets can only be met by doing the right thing for the patient, where possible first time.

Performance Standards Category Percentage of calls in this category Category 1 8% National Standard When does the clock start? What stops the clock? 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 48% 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 service-dispatched emergency responder arrives at the scene of the incident Category 3 34% 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 service-dispatched emergency responder arrives at the scene of the incident Category 4 10% 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.

NHSE Category 1 Video https://youtu.be/7ylegzdt9ny

Category 1 Explained Identifier Clock Start Response Measure Category 1 Purple Definition Problem identified Allocation 30 seconds Mean (7 mins) 90 th Percentile (15 mins) Time critical life-threatening event needing immediate intervention and/or resuscitation. Example Cardiac or respiratory arrest; airway obstruction; ineffective breathing; unconscious with abnormal or noisy breathing; hanging. Mortality rates high, a difference of one minute in response time is likely to affect outcome and there is evidence to support the fastest response. Sub-category of C1T (transport) will be monitored with a view to a future standard regarding transport.

NHSE Category 2 Video https://youtu.be/cu3dad-fkbk

Category 2 Explained Identifier Clock Start Response Measure Category 2 Amber Definition Allocation MPDS Code 240 seconds Mean (18 mins) 90 th Percentile (40 mins) Potentially serious conditions (ABCD problem) that may require rapid assessment, urgent on-scene intervention and/or urgent transport. Example Probable MI, serious injury, stroke, sepsis, major burns, fits, unconscious with normal breathing. Mortality rates are lower; there is evidence to support early dispatch.

NHSE Category 3 Video https://youtu.be/31uawnjhzvq

Category 3 Explained Identifier Clock Start Response Measure Category 3 Yellow Definition Allocation MPDS Code 240 seconds 90 th Percentile (120 mins) 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. Example serious injury modalities without systemic compromise; burns (not major); non-emergency late pregnancy/childbirth problems; uncomplicated diabetic hyper/hypoglycaemia; not immediately at risk drug overdoses; non-emergency injuries; abdominal pain. Mortality rates are very low or zero; there is evidence to support alternative pathways of care.

NHSE Category 4 Video https://youtu.be/71lbniktdsa

Category 4 Explained Identifier Clock Start Response Measure Category 4T (Transport) GreenT Category 4H (Hear & Treat) GreenT Definitions Allocation MPDS Code 240 seconds 90 th Percentile (180 mins) Problems that are not urgent but need assessment (face to face or telephone) and possibly transport within a clinically appropriate timeframe. C4T 999 or 111 calls that may require a face to face ambulance clinician assessment, or requests for transport by health care professionals. C4H Calls that do not require an ambulance response but do require onward referral or attendance of non-ambulance provider in line with locally agreed plans or dispositions, or can be closed with advice (hear and treat).

ARP 2.3 Response Standards Overview Category Mean 90 th Percentile Life threatening Category 1 Emergency Category 2 Urgent Category 3 Less Urgent Category 4 7 minutes 18 minutes - - 15 minutes 40 minutes 120 minutes 180 minutes

How will NWAS Control Systems Look? C3 and C3 Web will be used in the same manner, however the system colours have been updated to reflect the new categories (see example picture taken from C3 Training of mock incidents). You won t yet see the words Category 1 (for example), but instead incidents will be referred to by colour, the word Purple or the letter P.

How will Ambulance MDT Look? The Ambulance display terminal (MDT) will be used in the normal manner and will look very similar. However, instead of the category, you will see the colour of the category instead.

Summary - Understanding ARP Standards For the most life-threatening incidents (Category 1) ambulance performance is measured on the ability to reach patients as quickly as possible. The clock will start on: Problem identified Allocation of vehicle 30 seconds from call connect whichever of these occurs first And measured: with a mean time of 7 minutes and 90th percentile of 15 minutes so ambulances need to be dispatched immediately!

Summary - Understanding ARP Standards For all other grades of call the clock starts on: Dispatch code (T5) First resource allocated 240 seconds whichever occurs first!

Summary - In a nutshell Category 1 calls NWAS need to allocate as soon as possible. These patients are time critical and require immediate clinical intervention Category 2 calls NWAS need to make sure they are sending the right resource and not just stopping the clock.

NWAS Implementation NWAS go live date was on 7 th August 2017. All systems were in place in preparation for the go live date. NWAS have developed and rolled out a targeted training programme for dispatchers, clinicians and managers in emergency operation centres. NWAS have conducted briefings with managers and senior clinicians across the trust. This tailored approach has ensured that staff are prepared to effectively implement the programme. NWAS published a series of weekly update articles in the regional bulletin in the run up to going live and are issuing further information to staff through communication bulletins.

Points To Note ARP provides a focused approach to ensuring that the right response is delivered to patients the first time. As such the targets and reporting cannot be compared with historical performance. The classification of incidents (the code-sets ) may be subject to further change as ARP is embedded. A period of grace has been granted to NWAS to make the necessary changes to its reporting systems, which includes reporting to NHS England. High level reporting to Lead Commissioners is expected from October onwards. Lead Commissioners are having weekly discussions with NHS England on the implementation of ARP.

References NHS England Release: https://www.england.nhs.uk/urgent-emergency-care/arp/ NHS England ARP Easy Read: https://www.england.nhs.uk/wpcontent/uploads/2017/07/new-ambulance-standards-easyread.pdf ScHARR Report: https://www.england.nhs.uk/publication/arp-evaluation/