Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Education, education, education. Excess inappropriate demand is the problem.
- F. Fausto Palazzo, Orlando J. Warner (11 August 2002)
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Alternatives for cases that are neither life threatening nor serious
- Andrew M Jones, Newport, Isle of Wight, PO30 5TS (12 August 2002)
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The ambulance service is the weakest link
- charles essex (17 August 2002)
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Alternatives to the emergency 999 response
- Bernard A Foëx, Darren Walter (5 September 2002)
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In defence of the Ambulance Service
- Darren Walter, Bernard Foex (11 September 2002)
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Emergency response to 999 calls.
- Keith Walker, (working part time in various practices in district) (10 December 2002)
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F. Fausto Palazzo, SpR Surgery Whittington Hospital, London N19 5NF, Orlando J. Warner
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Sir, We read with interest the article by Snooks et al. (BMJ 2002;325:330-3) concerning the alternatives to the current management of the emergency ambulance system. The inappropriate use of ambulances is operationally one of the biggest problems within metropolitan areas and the consequences are given wide press coverage. Review of the current literature confirms that no graduated or triaged system has proved itself worthy of implementation outside a trial in the UK. At the root of our inability to implement an alternative system of ambulance provision based on evidence lay two problems which have been overlooked. Firstly, studies on ambulance misuse are flawed by a fundamental problem – the definition of an "inappropriate" call. Secondly and most importantly why are more and more people calling an ambulance? The first problem is almost insurmountable. One-doctor retrospective analysis (Gardner GJ. Arch Emerg Med 1990;7:81-9) is laden with subjectivity and analysis by outcome (Morris DL, Cross AB. BMJ 1980;281:121-3) does not necessarily guarantee that the indications were not present at the time of calling the ambulance. Our attempt to overcome these problems (Palazzo FF, Warner OJ, Harron M, Sadana A. J Accid Emerg Med 1998;15:368-370) provided a significantly lower estimate of ambulance misuse (16%) but still suggests that 75,000 of ambulance calls to the London Ambulance Service may be unnecessary. More people are calling an ambulance because this is a reflection of the increased use of the accident and emergency departments. This in turn is explained by research into the provision and utilisation of out of hours services that shows a trend towards decreasing personal commitment among general practitioners and rising demand from patients for primary and hospital accident and emergency department care (Hallam L. BMJ 1994;308:249-253). The 40% rise in emergency ambulance requests is therefore the extrapolation of this demand onto the means of arrival to the accident and emergency department. This is supported by the fact that we found that 60% of patients that were deemed to have inappropriately called an ambulance by a blinded three tiered paramedic/A&E SHO/A&E consultant study provided as their reason for calling an ambulance that they thought that they had a serious or life threatening condition (Palazzo FF, Warner OJ, Harron M, Sadana A. J Accid Emerg Med 1998;15:368-370). Hence the solution lays in the education of the public as to what are the indications for a blue light ambulance. Public education programmes and triage combined may improve the balance between supply and demand of emergency ambulances. However perhaps it is time that we accepted that a small inappropriate ambulance callout rate constitutes good practice since rather like a negative appendicectomy rate it reduces the risk of overlooking ill patients. Mr F.F. Palazzo MS FRCS
Dr O.J. Warner FRCA
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Andrew M Jones, Paramedic Officer Isle of Wight Healthcare NHS Trust, Ambulance Service, St. Mary's Hospital,, Newport, Isle of Wight, PO30 5TS
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Sir, It is refreshing to see that a debate has begun on the issue of non- life threatening 999 calls, and ways that ambulance services have begun to deal with this. This category of patients represents a significant proportion of calls recieved by ambulance control centres, and with the notable increase in demand for emergency ambulances, safe and reliable alternatives have to be adopted. How should the ambulance service respond to a male who has has non- traumatic back pain for 36 hours, or to the patient who has run out of their regular prescribed medication over the weekend? The call prioritisation systems, such as Advanced Medical Priority Despatch System (AMPDS), are tools that were designed initially to reduce risk to ambulance crews and the public. Historically, AMPDS was designed to allow the emergency control room call taker to prioritise the patient into the category of 'life threatening', 'serious' or non-life threatening, thus allowing the despatcher to send a crew to the incident using lights and sirens (if life threatening) or dispatch an ambulance to attend under normal driving conditions (if non-life threatening). There are many benefits of adopting such a system. Telephone advice on airway or haemorrhage control are just two areas where this has been shown to deliver live-saving first aid long before an emergency crew arrive at the scene. Additionally, categorising patients this way opened up alternative avenues for response or referral. What is seen however, is the nationwide installation of AMPDS into control rooms but the use of only 'elements' of the system. Generally, AMPDS is reliable at identification of patients most in need of an emergency response by the ambulance service. Where there is little information, or the call taker has been unable to establish specifically what is happening at a scene the dispatcher has to send a maximal response with lights and sirens. However, where a patient is categorised as non- life threatening, dispatchers will still send an emergency ambulance using lights and sirens. This 'just-in-case' mentality is flawed, especially in the light of increasing demand and dwindling resources. By sending all ambulances on lights and sirens, not only do you increase the risk to crews and the public, but you limit the availability of resources to respond when the real emergency comes in. Only in extreme circumstances, usually when the despatcher has only 1 ambulance available, will the AMPDS be used in the way it was designed. I believe that this practice has in part been influenced by the focus on the 8 minute response standard for life threatening emergencies. Where alternative responses are available to the dispatcher, such as referring the patient to NHS Direct, or community care teams these should be used. Unfortunately, many ambulance services have no alternatives or links with other agenices and the idea of referring a caller back to NHS Direct or to their own GP fills many control room staff with dread. Clearly, more evidence on the reliability of priority despatch systems is needed and this may give confidence to dispatchers or control room managers when allocating resources. The ambulance service doesn't like risk. In fact, we would rather send all ambulances out on lights and sirens, chasing the 'cut finger' or the 'fall out of bed' than pursue other avenues of response to those not in need of immediate medical aid. It seems that ambulance services are waiting to see who will take the lead in using all elements of the medical priority despatch systems before allowing crews to 'cold call'. It is easy to justify a rapid response to a patient with chest pain, or who is having an acute asthma attack. Can we so easily justify a risky lights and sirens response to that patient with ongoing back problems? Andrew Jones
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charles essex, consultant neurodevelopmental paediatrician child development unit, gulson hospital, coventry CV1 2HR
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Snooks et al describe the inappropriate use of 999 calls by patients (or their relatives) for non-urgent conditions, which is a huge problem, both numerically and financially. Much rarer but with very severe consequences, at the other end of the severity of illness spectrum, is the response of the ambulance service to ‘do not resuscitate’ [DNR] instructions when 999 has been called. If 999 is called, this will override a DNR instruction even when this has been agreed with the parents (contrary to the popular view, including that held by Dame Justice Butler Sloss [1], decisions about resuscitation are not ‘doctor knows best’ but are discussed fully with the parents), and the paramedical crew will attempt resuscitation. Similarly if a patient is transferred from hospital to home to die with a DNR instruction signed by the appropriate consultant, if the patient deteriorates in the ambulance and a relative requests resuscitation, this is deemed to override the DNR instruction, even though this may be against the wishes of the patient or parent; what has been agreed with the medical attendants; and the instruction of the courts. I am not sure how the ambulance service would defend that action if a patient had given an advanced directive that he or she did not want resuscitation, or if a court had ruled that DNR was the correct course of action. Many ambulance services are now coordinated on a regional basis and claim that they cannot have local knowledge. However this is a specious argument even with current IT, and will become even less sustainable with technological advances. If, with the parents’ permission, I have written to the ambulance service giving details of a patient who is not for resuscitation, it cannot be beyond the wit of Man to devise a computer system such that when a 999 call is received at ambulance headquarters the operator is alerted to special instructions regarding that patient. Discussing (non) resuscitation with parents is difficult for parents, doctors, and others involved in the child’s care. It is often a slow process, over several months or even years, guiding parents to the inevitable truth about their child. And it can be destroyed in an instant. The ambulance service is the weakest link. Reference: 1. Sensky T. Withdrawal of life sustaining treatment. BMJ 2002;325:175-6 [27 July] |
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Bernard A Foëx, Acting consultant in emergency medicine South Manchester University Hospital, M23 9LT, Darren Walter
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Snooks et al rightly point out that the current 999 emergency response system has problems: increasing demand from the public and ever shorter response time targets. [1] They find a lack of evidence regarding alternative systems and responses in the English medical literature. By restricting their search, they overlook live examples only a few miles from these shores. France, since the mid 1960s, has had a system which incorporates many of the alternatives quoted by the authors: the SAMU (Service d’Aide Medical Urgente). [2] Calls to the control room are logged by trained telephone operators, and then passed on to a “medical dispatcher”: a physician, trained by the SAMU, in emergency medicine. The medical dispatcher may simply provide medical advice to the caller, or may decide to use one of a range of other responses to a call: 1) referral to, or the dispatch of, a primary care physician, 2) arranging non-urgent transport by a private ambulance, 3) urgent transport by the pompiers (emergency technicians working through the Fire Service), or 4) sending out a Mobile ICU with a physician trained in emergency medicine. The medical dispatcher also coordinates the deployment of additional resources and decides on the most appropriate destination for a patient. In 2001 the SAMU 75 (covering Paris) received 300,000 calls (approx 820 calls per day). Only 6% of the calls (50 per day) resulted in the dispatch of a Mobile ICU. In 16% of cases (130 per day) a primary care physician was called. 205 calls per day were managed by the pompiers, a private ambulance or simply by giving medical advice. The remainder were considered not to warrant an emergency medical response. In contrast, during the same period the Greater Manchester Ambulance Service (GMAS), which covers an equivalent urban population, received 256,000 calls (approx 700 calls per day), all of which received a standard emergency paramedic response. In GMAS calls are received by non-physician telephone operators using computer-based algorithms to determine the time priority of response. Compliance with the pre-set questions is audited as part of a risk management process. In contrast, the SAMU physician uses clinical training and experience, without computer support, to decide on the urgency and level of the response. We agree that alternatives to the current 999 system need to be explored. Aspects of the French SAMU, and other European models of emergency response, deserve to be considered in the list of examples. Bernard A Foëx
Darren Walter
South Manchester University Hospital, Manchester M23 9LT No competing interests 1. Snooks, N., et al., NHS emergency response to 999 calls: alternatives for cases that are neither life threatening nor serious. British Medical Journal, 2002. 325: p. 330-333. 2. Carli, P., Prehospital care in France, current status and international controversies. Acta Anaesthesiologica Scandinavica, 1997. Suppl. 110: p. 69-70. |
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Darren Walter, Consultant in Emergency Medicine South Manchester University Hospital, M23 9LT, Bernard Foex
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In his letter of 17th August, Essex moves from the subject of alternative forms of response to the 999 emergency call to discuss the issue of resuscitation orders. We agree that this is a difficult and sensitive area where a great deal of careful discussion over time may have lead to a decision on a "Do Not Resuscitate" (DNR) order. He draws attention to the legal base for a patient's right to self- determination. Inherent in this right is the option to change their mind at any stage. If an emergency ambulance has been called, then a decision has been made, by someone, to ask for assistance at the critical time. The ambulance crew, working in an uncontrolled environment and with limited resources, cannot be expected to consider the broader ethical, moral and legal aspects before beginning treatment. The wider implications of Advance Directives and DNR orders should be considered when there are senior medical personnel present who are able to stand back and take stock of the full picture and have the opportunity discuss the apparent "change of mind" with the involved parties. The information technology used by most ambulance services is perfectly capable of identifying patients for whom special circumstances apply, particularly if the call comes from the home address, but this does not alter the right to self-determination and the fact that an emergency call for help has been made. We would strongly contest the assertion that the Ambulance Service is "the weakest link". They are responding to a situation without adequate knowledge of the circumstances or how these may have changed. They are acting to prevent further deterioration and death and so in the "best interests" of the patient until the full circumstances are known. We believe that they would have little difficulty in defending their actions in a Court. Darren Walter
Bernard Foëx
No competing interests |
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Keith Walker, Locum GP Scarborough, (working part time in various practices in district)
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EDITOR--Charles Essex complains about ambulance crews agreeing to requests to resuscitate where a previous agreement has been made against this policy. Surely, when in doubt they have to do this, as a decision to do otherwise is irreversible. However my main point is to agree that dialling 999 will over-ride an instruction not to resuscitate, but the fault lies not with the team responding, but with the caller: it is not an appropriate 999 call. The problem must lie with education, communication, or disparate views within the caring team (both family and professional). Ideally the family should have one person to call, who can leave information with any deputy while off duty. The G.P. needs to be fully in the picture, and out-of-hours essentially all GP cooperatives and deputising services have computer systems which can hold appropriate information in case of a call-out. (letters BMJ 2002 325:1300 (30 Nov) From Keith Walker, General Medical Practitioner, Scarborough
Competing interests: None declared |
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