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The changing face of the ambulance service
David Sherwood, Head of Clinical Effectiveness, South Central Ambulance Service, reports on the effective Clinical Audit Reporting System (CARS) that will significantly improve the operational and clinical efficiency of the Trust…
With the increasing volumes of paperwork being handled by Ambulance Trusts throughout the UK, something had to be done sooner rather than later, to help ambulance healthcare professionals in managing the problem; especially with the delay in the introduction of the “mobile deployment” of the electronic patient record system that is at the heart of the £12bn national programme for NHS IT.
South Central generates more than 360,000 patient clinical records per annum. The Trust decided that a more proactive approach was needed to prevent the service grinding to a halt under the sheer pressure of paperwork. As a result, the decision was taken to move ahead and develop a solution that will deliver immediate benefits to South Central Ambulance Service.
There were several key drivers for developing the system and one of the first was to improve the access to, and the retrieval of, documents across the organisation. This was a time consuming and complicated process that could take up to two weeks depending on where the required documents were located. The Trust also wanted to reduce the high cost of document storage that amounted to more than £10.5k p.a. in Hampshire alone.
Crucially, this situation made it difficult to thoroughly investigate complaints within the twenty-day period required by the Healthcare Commission as part of the core standards for the annual health check, which also fulfil the requirements of the NHS Litigation Authority by being able to prove that a full record exists for each individual patient.
Another driver for the development was to create a cost-effective solution to make improvements to the way that ambulance staff currently maintained their skills portfolios used for annual re-certifications. The Trust wanted to move away from the manual methods used by individuals and provide a more efficient way for them to view their own performance for the different procedures and interventions that they have carried out.
The Trust also wanted to give clinical audit managers the ability to access all patient related paperwork to ensure that all decisions taken and clinical interventions provided fall within acceptable protocols. Audit managers need to be able to quickly identify any incidents where these protocols have not been followed as soon as they occur to ensure that patient care is delivered to prescribed standards at all times.
The fact that paramedics are now making decisions whether to treat a patient, deliver them to hospital or leave them where they are has only served to reinforce the critical importance of having a complete audit trail.
The challenges
After proving the concept of an effective Clinical Audit Reporting System (CARS) in an earlier trial in Hampshire, South Central partnered with e-Docs UK to translate the requirements into a cost effective and reliable solution.
Achieving a common data set across the organisation was a major undertaking. If CARS was to stand any chance of success, it was essential that a standard format be established. As a starting point, a template was developed and tested resulting in a single, unified patient clinical record form across the Trust.
Another challenge was to devise the most effective way of scanning the paperwork and loading it into CARS. Document safe post slots were deployed into every A&E department in Hampshire for daily collection and delivery to Hampshire Division HQ. Scanners were installed throughout the other divisions enabling images to be delivered via batch FTP transfers back to the Hampshire Division HQ.
CARS went ‘live’ in early May 2007 and the implementation process relied on the production of a ‘how to’ booklet which was made available for staff to download over the Intranet.
How CARS works
Every form is now scanned and all images are sent to Hampshire division HQ, where powerful data capture software is used to upload information into CARS. This data repository offers a range of reporting tools that provide important information on clinical performance indicators showing whether all protocols were followed. Any discrepancies are highlighted for further analysis and followed up by clinical supervisors.
CARS also provides the information required for a wide range of national reports and audits carried out by the Department of Health and JRCALC, the committee that produces clinical guidelines for the Ambulance Service. Information on the activities and performance of the ambulance service can also be easily provided to Primary Care Trusts.
CARS is also helping ambulance staff to maintain their skills portfolio. In addition, individual paramedics can add personal notes relating to the reasons why protocols were not followed and the contra indications that led the paramedic or technician to apply a different treatment. This gives a realistic picture of performance based on what staff are actually doing rather than what they perceive themselves to be doing – two very different things.
The next phase
Demand Management is an area that will be addressed during the second development phase of this project. Of particular interest will be the ‘frequent caller’ that makes regular requests for an ambulance to attend. CARS will be used to provide increased visibility for this category of patient, which typically includes falls, diabetics, asthmatics, and drink and drug users. This has proven to save the NHS money as well as in one case study a persistent faller was provided with walking aids which prevented her from falling and eventually suffering a fractured neck of femur, which would have required surgery and a long hospital stay.
Taking a more proactive approach to interact with other agencies will result in ‘alert lists’ that can be loaded onto CARS to highlight premises or individuals where special attention is required. This could be to inform the crew that a patient at that address could be on a special care plan, which requires a specific intervention or a direct admission to a specialist unit.
CARS will also be used to assist in the process of identifying ‘hot spots’ where regular accidents or injuries occur. While emergency operations centre’s computer aided dispatch systems can often identify the location of these incidents, what they cannot report on or predict accurately is the precise nature of the outcome of the emergency. The objective here will be to ensure that suitably qualified staff are on the vehicle that is sent to the incident to deliver the fastest possible access to treatment.
The Ambulance Service is now beginning to take a far more proactive approach towards working with other agencies particularly relating to the increasing incidence of drink and drug related injuries that are occurring.
Anything that can be done to reduce unnecessary usage of the Ambulance Service will result in significant cost savings that can then be refocused on improving the level of care to patients that really need it. There are standard costs used by Strategic Health Authorities throughout the UK for using the Ambulance Service - £220 to despatch an ambulance including patient treatments, any patient admitted into a hospital ward from the A&E department costs around £1100. Anecdotally, around 60% of South Central’s 2500 calls per day are transported to hospital. However, up to 30-40% of these trips are unnecessary because of a lack of an appropriate patient care pathway.
What next?
Future developments might include using the powerful audit functionality that is inherent in the CARS system to assist with the optimisation of the procurement tendering process.
CARS is a ground breaking development that will significantly improve the operational and clinical efficiency of the Trust enabling the provision of a more holistic approach to delivering patient care. It delivers the required level of reporting, gives a greater understanding of the true workload and provides a complete audit trail for every patient treated. What is more, it will provide a robust and reliable backup for the electronic records system when it is finally operational. Improving the way that the ambulance service interacts with other agencies will be a key factor towards ensuring that the most appropriate care is made available to individual patients as well as delivering significant cost savings.
