Agenda item

Will Legge, EMAS Director of Strategy and Transformation and Richard Lyne, EMAS LLR Service Delivery Manager will attend the meeting to present a briefing paper on the Ambulance Response Programme and Handovers to the Emergency Department at Leicester Royal Infirmary.     

Will Legge, EMAS Director of Strategy and Transformation and Richard Lyne, EMAS LLR Service Delivery Manager, attended the meeting to present a briefing paper on the Ambulance Response Programme and Handovers to the Emergency Department at Leicester Royal Infirmary.

It was noted during the presentation of the report that:-

a)         The presentation to the East Midlands Health Scrutiny Network, appended to the report, gave details of the improvement journey that the Trust had undertaken since CQC published its last Inspection Report in May 2016.

b)         The CQC had carried out a follow-up inspection February 2017 when significant improvements had been recognised. This had resulted in the ‘safe’ element of the inspection process moving from the previous rating of ‘inadequate’ to ‘requires improvement’.  The CQC commented upon a number of good examples of best practice; such as the procedures for dealing with sepsis.  No new areas of concern had been identified.  Both staff and patients had made positive comments about changes which already been made under the Quality Improvement Plan.

c)         A new Quality Improvement Plan had been produced in response to the February 2017 inspection and this was being monitored by an internal Improvement Board and the EMAS Board.

d)         Handovers had improved since the new Emergency Department had opened as a result of joint work between EMAS and UHL to address the known issues.  There had been some initial teething issues in the first month as the new arrangements had bedded down.  Since September 2016 to September this year there had been a 77% reduction in waiting hours by EMAS crews.  There had also been a bigger reduction in instances where the handover of the patient from arrival to being offloaded to the ED took more than an hour.  In 2016 more than third of arrivals at the ED had waited more than an hour and now this had been reduced to 7%. 

e)         EMAS had worked with UHL on many aspects to see if the improvements were sustainable; especially in relation to the winter plan. EMAS felt that they had a strong relationship with UHL which enabled robust discussions to take place when needed.

f)          EMAS staff had been involved in the design of the new ambulance fleet and the new fleet had made a difference to the clinical care and environment for staff.  The design of the new fleet had been highlighted as an example of good ambulance design and a number of Trusts are trialing the new EMAS fleet design.   The new design allowed crews to have quicker access to lifesaving and key equipment coupled with a more accessible treatment area that allowed crews to treat a patient more effectively en-route to a hospital rather than at the scene. 

g)         The ambulance response targets, which had been used since 1994, were felt to be somewhat outdated as they did not reflect the huge changes in the social care system or the increased levels of demand that had occurred since then.  In addition, they were based upon the relationship between time and the clinical outcomes/survival of patients.  This meant that in relation to an ambulance response to an incidence involving a cardiac arrest or myocardial infarction, an ambulance could arrive on scene in less than 8 minutes and this would be regarded as a success in relation to the target even if the patient died.  Alternatively, if an ambulance arrived on scene in more than 8 minutes and the patient survived, then this was regarded as a failure to meet the target.      

h)        In response to these target anomalies, NHS England commissioned the Ambulance Response Programme which replaced the previous Red/Green categories with new codes which aligned clinical and resource requirements.  The first operator response to a 999 call was now “is patient breathing and is the patient conscious?”  This enabled an immediate assessment of a life threatening conditions and whether an ambulance should be despatched immediately.   It was estimated that this simple change in answering the call could save an additional 250 lives a year in the EMAS area.

i)          The new response rates were now:-

·         Category 1 (8% of calls) An ambulance despatched within 30 seconds of call being answered and a 7 minute mean response time and a 15 minute 90^th percentile response time.

·         Category 2 (48% of calls) An ambulance despatched within 240 seconds of call being answered and an 18 minute mean response time and a 40 minute 90th percentile response time.

·         Category 3 (34% of calls) An ambulance despatched within 240 seconds of call being answered and a 240 minute 90th percentile response time.

·         Category 4 (10% of calls) An ambulance despatched within 240 seconds of call being answered and 180 minute 90th percentile response time.

In response to Members’ questions the following responses were received:-

a)         It was too early to assess the public reaction to the new ARP.  The vast majority of patients calling 999 for an ambulance do so for the first time so they have no expectation other than an ambulance would arrive in response to their call.  There had, however, been some positive comments from patients who had expected an ambulance car to arrive and were pleasantly surprised when the ambulance arrived.

b)         EMAS had bid for the Patient Transfer Service and had been disappointed not to have won the contract.

c)         EMAS responded to a number of incidents involving a person who posed a possible threat to for staff safety, which require a Police presence before staff could attend to the person.  Regular liaison took place with the Police in instances where an ambulance crew were waiting for the Police to arrive before entering a property. No such issues had been raised in recent months. 

d)         EMAS had close partnership working with LPT and UHL and had an integrated approach to addressing issues with patients with a mental health issue, who featured in a significant proportion of responses.       

e)         Measures had been introduced to make it easier to re-kit supplies on the ambulance between responses by having a replacement box of supplies available to replace the box used in response to the incident.  The average post-turnaround was now 12-13 minutes. 

f)          Crew breaks were monitored by operations staff and crews would be stood down and returned to base to take breaks where appropriate.

g)         There was duty of candour within EMAS and when issues needed to be raised, it was done in an open, transparent and candid manner.   All NHS services had embedded this cultural change in recent years in response to a national direction.  EMAS encouraged staff to report incidents and these were then reviewed and considered in formal meetings.  These issues were scrutinised by both internal and external processes.

John Adler, Chief Executive UHL NHS Trust, commented that the reduction in the number of delays in the handover of patients was encouraging and had been sustained over a period of months.   It was important that comparisons were made with the corresponding periods in the last year.  He believed that working arrangements with EMAS should now be sustainable. In August, the clinical average for handover was 15mins.  UHL were averaging a 17-18 minutes handover time where the average in the EMAS area was about 20 minutes.  UHL were now performing better than average; whereas before the new Emergency Department had opened, they had consistently been one of the worst performing Trusts.  The new facility was better equipped to cope with large surges of ambulance arrivals as it had more space and better links to admission wards for children and the elderly and frail.

AGREED:

(1)       That the EMAS representatives be thanked for their attendance and clear presentation of the improvement that had been made to the service.

(2)       That the Commission receive an update in 6 months’ time on the response to the current Quality Improvement Plan.