Different Destinations

   A rising tide lifts all boats, as they say, and so it is with increasing demand for EMS. The climbing call numbers faced by many systems include both direly ill and injured citizens in true extremis, but also numbers of less-sick and not-so-terribly-hurt callers whose needs can be appropriately met through other avenues.

   Recognizing and redirecting the latter helps you better serve the former, and those twin benefits underlie the Clinical Assessment Units (CAU) conceived by the London Ambulance Service in England.

   LAS knows a bit about demand: It gets around 4,000 calls a day, nearly a quarter of them for immediate life threats. Cumulatively it tallies more than a million incidents a year across a service population that can swell as high as 9.5 million.

   Many of those callers, service leaders believe, can have their needs safely met through the CAUs: solo paramedics in nontransport vehicles sent to calls to assess patients and determine suitable care pathways for them.

   If, upon assessment, their patients are found to need ambulances, the CAU medics can call them. Alternatively, they can treat and release those patients, if they deem it sufficient, or direct them to primary care, walk-in clinics or other facilities that can meet their needs without transport to an emergency department.

   "It's partly about managing rising demand," says LAS Medical Director Fionna Moore, MD, "but also because there's a strong feeling that some patients who currently go to emergency departments could be managed quite properly by referral to a primary care physician or general practitioner, or perhaps by going to a minor-injuries unit or urgent care center. Many times patients can be seen there more quickly than they would be in an emergency department."

   The idea arose in part from the work of the U.K. Department of Health, whose 2005 publication Taking Healthcare to the Patient: Transforming NHS Ambulance Services promoted empowering providers in their care delivery and working with other healthcare organizations to share the burden of urgent care; and an English healthcare/emergency services consultant, ORH Ltd., which envisioned a "New Front End Model" built on using rapid-response vehicles to answer low-priority calls and thus reduce ambulance demand and hospital transports.

   Putting those ideas into practice required some groundwork. LAS leaders first had to collaborate with potential local destination facilities that had differing hours, capabilities and levels of medical expertise, so as to know which were feasible for which patients. Jointly they developed a list of minor injuries and illnesses that could safely be directed to these destinations. "Basically it's minor conditions like coughs, colds and minor rashes," says Moore, "and then minor injuries that won't need an x-ray and generally won't need suturing."

   Paramedics manning the CAUs also needed expanded training. This included enhanced patient assessment: taking more detailed histories on presenting complaints, drugs and medical backgrounds; and performing more detailed physical evaluations, with good, supportive documentation.

   The CAUs were first trialed last year in Barnehurst, southeast of London. In 24 hours, they resulted in a 36% reduction in ED transports. The program was expanded to Greenwich before being temporarily stalled, but is hoped to resume in Bromley later this year.

Appropriate Pathways

   Beyond the extra training and collaboration with local healthcare facilities, there are a few other important considerations to the CAU program.

   One is the overall mixture of vehicles on the road. LAS has historically used cars to help meet demand, backed up by ambulances, but ended up averaging around 1.6 resources sent to every call.

   "Clearly that's pretty wasteful," Moore says, "but you do need to decide what your safe level of service is. Because what you don't want is to use your cars to assess patients who turn out to be quite unwell, and then there'll be a long interval between first arrival on scene and the ambulance turning up."

   LAS used its CAUs on most calls, with specific exclusions. During the trial, red 1 (imminent death likely) and 2 (imminent death possible) category calls got CAUs plus ambulances; red 3 (breathing and conscious but at high risk), amber and green level calls got just the solo response, with response allocation prioritized by skill level to optimize use of clinical assessment pathways.

   Medics determining where patients need to go and with what urgency also need ample clinical support to back them up. LAS medics have 24/7 access to online medical control (doctors or senior paramedics), and the service is looking at enhancing the skills of its "team leaders" in the field (it has approximately 180 around London), and ultimately introducing advanced paramedic practitioners and paramedic consultants. This will have the dual benefit of bringing more clinical expertise to the field and expanding career opportunities for ambitious personnel.

   Finally there's an educational component. For the public, when people call 9-9-9 (the U.K. equivalent to 9-1-1), they expect an ambulance and transport, not a medic who steers them to urgent care. They need to know their needs are being met fully and safely. And for LAS medics, Moore wants to emphasize this isn't just a way to leave more people at home.

   "We have to get the message across that this is about referring patients to appropriate care pathways," she says. "There may be more people you can leave at home, but you can only do that safely, and that means a lot of additional training, sometimes additional clinical support, and always being aware of the potential significance of the decision not to transport someone."

Figure 1: Call Categorization

   RED 1: Actual death imminent (e.g., unconscious not breathing)

   RED 2: Possible death imminent (e.g., unconsciousness/not alert with other signs like mechanism of injury)

   RED 3: Risk of imminent death (breathing and conscious but at high risk)

   AMBER1: Definitely serious (not immediately life threatening but require urgent on-scene assessment, treatment and conveyance) 

   AMBER 2: Possibly serious (not immediately life threatening and no specific gain from immediate treatment on scene or in A&E)

   GREEN 1: Requiring assessment and/or transport (not life threatening or serious, but needs assistance)

   GREEN 2: Suitable for telephone triage and/or advice (probably no need for transport—telephone consultation can be used to determine need)