6th Annual Hospital Bed Management & Patient Flow Conference Melbourne 25 February 2013

Ambulance Emergency Department Diversion Strategies

Graeme Malone ASM

A/Executive Director Service Development and Planning

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Overview

About NSW Ambulance

Trends in demand

Consequence of demand

Changing role of paramedics

Diversion strategies - alternative care pathways and non-transport options

Future models

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NSW Ambulance Service is the 3rd largest in the world In 2011/12 provided: over 1,183,795 responses Average 3,234 responses/day ~ one every 26.7 seconds 865,725 emergency responses (2,365/day) 4,360 staff ( 90% paramedics)

Facts & Figures

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Emergency & time-critical ins & transports Projected

2.8% growth/yr

25% of all ED presentations arrive via ambulance as a result of 000 call

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demand for Ambulance Services is contributing to ED congestion Has a significant impact on Ambulance resources Increased : case cycle times timely availability to respond

Demand

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A consequence of demand

Every 27 seconds we need to respond to a 000 call

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RAMPING

…and the flow on effect

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Changing role of paramedics

Historically callers to Triple Zero “000” for assistance to address unplanned health care needs irrespective of health problem - 2 choices: 1.Transport to an ED 2. Decline transport The evolving Role of Ambulance has changed the paradigm: “From Driver to Clinician”

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The focus was on transporting some stabilising treatment occurred triage and treatment occurred at ED Paramedic curriculum was vocational

Old paradigm

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Paramedic education is in the tertiary system Patient assessment, triage and treatment occurs as the first priority Referral or transport are provided according to the clinical needs of the patient A smaller proportion of patients being transported to hospital care

New clinical paradigm

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Telephone Triage Dispatch Options Ambulance Release Teams Low Acuity Patient Pathways Extended Care Paramedics Authorised Care Plans Frequent Callers

Alternative care pathways and non-transport options:

Diversion Strategies

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Telephone Triage

.

Health Advisory Centre 5,867 calls given advice/referral (2010/11)

MPDS

? Resource Options

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Dispatch Options

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Ambulance Release Team (ART)

ART is a Qualified Paramedic (double) crew deployed to EDs experiencing offload pressures

Deployments based on pre agreed „triggers‟

Can take up to 4 low acuity patients to release crews into community to respond

Effective in releasing crews, do not assist with ED pressures or patient flow

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Low Acuity Patient Pathways

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Low Acuity Patient Pathway (LAP)

A broad intervention across the Ambulance workforce

Focuses on the provision of skills in clinical decision making

Assessment of patients‟ competence in decision-making

The application of a set range of clinical pathways that enhance safety and provide non-ED management options to low risk patients

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LAP training

Focuses on the provision of skills in: > clinical decision making (patient assessment; hx taking) > risk identification and mitigation (information to

patient/carer, information sharing, patient referral, documentation)

Provides paramedics with a safe and systematic approach to the management of non-transport situations

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LAP non-transport and referral

Patients fitting a clinical pathway profile who have no „red flags‟ may be presented with a non-transport option (self-care, recommendation for care, immediate referral or “third door” options when available)

Identification of medium and high risk patients for transport to an ED

Paramedics will not refuse transport if a patient requests transport

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Extended Care Paramedic (ECP)

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Extended Care Paramedic (ECP)

• Enhance clinical role of a group of paramedics

• Better meet the needs of the NSW community

• By providing safe & effective healthcare choices for non acute conditions.

Address the health needs of the Low

Acuity Patient

Calling Triple OOO

• By Paramedics providing treatment/discharge or referral for appropriately identified low acuity patients.

Reduce ED Presentations

Identify „sick‟ or high risk patients and ensure that these patients are transported to the ED Consequently, low risk patients identified and only these patients are offered alternatives to the ED

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Scope of practice

In addition to providing emergency care, ECPs:

> Replace catheters

> Provide wound assessment and care

> dressings / adhesives / sutures

> Replace PEG tubes

> Provide falls screening and assessment

> Provide aged care screening and assessment

> Provide care for minor injury / illness

> Commence pharmacotherapy

> Refer patients

> Discharge patients from care

ECP

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Outcomes

Activity 2007 – 2010:

31,696 responses

26,086 patient contacts

Non-transport rate of 39.5%

(Non transport rate for standard ambulance is 14%) Referrals: 47.1% of non-transported patients were referred to an alternate healthcare provider

90% of referrals were successful at the time of patient contact

72% of referrals were to the patient‟s GP

98.9% satisfied or very satisfied with ECP care

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Frequent Callers

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Frequent Callers

2009/10 we identified 938 frequent callers who made >5 calls/yr ~14,578 calls resulting in: ~11,428 transports to EDs (09-10 financial year)

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Identified a resource to developed project to: Provide clarity of the criteria for identification of a patient as a „frequent user‟ Develop a clear referral and management process Three months into the project

Frequent Caller Project

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Chronic disease

Nursing homes

Police

Schools

Socio-

economic

Mental health

Transport

Carers

Treat and refer

Telephone triage

Endstage disease

Behavioural Interagency

Care plans

Frequent callers - factors, settings

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Types of Frequent Caller Patients

Acute Frequent Callers:

Callers who make a high volume of calls to Ambulance over a relatively short-time frame i.e twelve months

Enduring Frequent Callers:

Callers who repeatedly make a high volume of calls over a period of years

Specific Patient Groups e.g Mental Health

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Total Number of Calls from Patients making >10 calls per/Yr

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Ambulance FC cost >10 calls per/yr

$5,674M

$5,689M

$5,810M

2009-2010 2010-2011 2011-2012

(using Health Economics 2010 Data of $582 per call out)

Ambulance FC cost >10 calls per/Yr

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Brief Overview of Model

FC identified following review of Patient Data

Designated Ambulance resource notified of FC patient

Clinical Review of presentations to Ambulance .

Determine type of intervention

Review effectiveness of interventions / frequency of presentations

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Intervention Type

1) Notification to LHD only

2) Notification to Patient only.

3) Notification to Patient, LHD and development of multi-agency plan

4) Designated Case Management

5) Notification to police.

Interventions

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Patient Reason for

Referral

Length of

Intervention

to date

Number of calls

prior to

intervention

(time frame)

Number of

calls since

intervention

commenced

Reduction

in number

of calls

Average

cost saving

Patient

A

Enduring

high end

frequent

caller for

past 3

years.

2 months 55 calls in the 5

months prior to

intervention.

Median 11,

Range 10-14

12

10

(45%)

$5820

Patient

B

Enduring

mid-range

frequent

caller for

past 2

years.

2 months 26 calls in the 5

months prior to

intervention.

Median 5.2

Range 4-7

6 5

(45%)

$2910

Patient

C

Enduring

high mid-

range

frequent

caller for

past 2

years.

1 month 35 calls in the 4

months prior to

intervention.

Median 8.75

Range 6-13

2 6

(75%)

$3492

Patient

D

Enduring

high mid-

range

frequent

caller for

past 2

years.

1 month 7 calls in a two

week period

prior to

intervention

0 7

(100%)

$4074

Patient

E

Emerging

Frequent

Caller –

High use in

the past 2

months

1 month 13 calls in a two

month period

prior to

intervention

6 7

(46%)

$4074

TOTAL $20,370

Interventions are in development or have recently commenced with a further 15 patients

There has been an average 50% reduction in calls from these patients Similar interventions could be targeted at approximately 80 patients per year In 2011/2012, 80 patients were responsible for 3773 calls A 50% reduction (1886 calls) would result in a cost saving of $1,097,652 (1886 calls x $582 per call* = $1,097,652)

FC Initial analysis of data post-intervention

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Authorised Care Plans

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Reduce the number of avoidable transports to ED for patients with specific medical conditions requiring pre-authorised medications or procedures To reduce unnecessary use of Ambulance resources in these circumstances Improve the patient‟s experience by providing tailored care and a better understanding of EOL issues for palliative patients To develop a system for the effective management of patients requiring specific treatment and management

Program objective

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There are three aspects to the program for patients identified through their treating clinicians:

Authorised Paediatric Palliative Care Plan under the care of the Children‟s Hospital Network or their treating clinician

Authorised Adult Palliative Care Plan for adult patients under the care of their treating clinician

Authorised Care Plans: administration of pre-authorised medications and procedures outside of Ambulance practice

Authorised Care Plans

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43% of the occasions when paramedics attended a location where a patient had a current Ambulance Palliative or Authorised Care Plan did not require transportation to the Emergency Department or treating facility. YTD Registered Care Plans – Paediatric Palliative Care n= 58; Adult Palliative Care n=11; Authorised Care n= 233

Outcome

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More options

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Innovative practice models

The right care

Allocate the right resources

Use Ambulance and other health resources well

Provide the right care in the right

setting

Provide the right care for the

patient’s condition

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Potential future Emergency patient care pathways

Before 000 call Before

dispatch Treatment at scene

. Transport

Hospital

ED

Mental Health

Other clinical

specialty areas or

care providers

Preventive

health

improvement

strategies

Phone

advice &

referral

Patient

withdraws

request -

programed

review of need

Increased

LAP

ECP

Patient decides no transport

in line with care plan

Patient remains in

residential facility

Promote

alternate

provider

organisations