South East Coast Ambulance Service NHS Foundation Trust. Trust Board Report

Transcription

1 South East Coast Ambulance Service NHS Foundation Trust Trust Board Report NHS Pathways Triage System Post Implementation Report 1 year on December Background 1.1. NHS Pathways was implemented as the Trust s telephone triage system during May Since implementation, the triage system has handled 1.2 million calls through the three Trust Emergency Operations Centres Following the implementation project, there was a post implementation project review This report sets out to summarise the current position, to apprise the Trust board of the current performance of the triage system, across a range of markers, in order to provide the necessary assurance. The report will reveal that, in these markers, NHS Pathways is operating successfully within the Trust, and that the Trust is operating the system successfully, as compared to other ambulance Trusts utilising the system. 2. Operational issues 2.1. Call Length The September 2012 Clinical Quality Improvement (CQI) data, validated by NHS Pathways, shows an average call length of seconds spent on NHS Pathways triage, with a further 39.3 seconds, on average, spent collecting the demographic information (address/location). This provides an overall average call length of seconds This is slightly longer than the average call length from September 2011, where the overall average time for calls was seconds It is likely that the additional length of call is due to two factors: An influx of new call-takers and An increased call handling through increased rates of Hear and Treat dispositions Category A and Hear & Treat rates The same data sets reveal that the rates of category A dispositions have fallen from 34.8% to 30.3% (which is understood to be the lowest category A rate of the ambulance services using NHS Pathways) Trust data shows Hear & Treat rates, similarly, have increased considerably from 5% at the end of March 2011 to 11% at the end of December 2012, which again is understood to be amongst the highest performance in the UK Ambulance Services using NHS Pathways. Page 1 of 6

2 2.3. Specialist Taking and Module 0 Development As a key member of the NHS Pathways 999 User group, SECAmb has influenced the current on-going review of the NHS Pathways Module 0. It has been recognised that the system needed to have a review of the components which related to the most time critical situations, especially pertinent to the 999 environment On the back of this work, consideration is being given to working with NHS Pathways to map symptom groups, which result in ambulance dispositions, to match these to both critical care and paramedic practitioner (PP) responses Operational use of PPs has increased as a result of introducing PPs into the Emergency Operational Centres (EOCs), which provide an alternative disposition. It is likely that the work mapping the symptoms groups will drive the use of PPs and Critical Care Paramedic (CCPs) in This, as well as adding PPs into the Directory of Services, is likely to improve Hear & Treat rates and improve patient care Operational Staff s Perspective of NHS Pathways Staff have not been formally surveyed or consulted on regarding NHS Pathways since the post implementation survey. As a result, opinion reflected within this report is based upon feedback from events such as the CTL/COM development days and other anecdotal evidence collected by the author In general, it is felt that the EOC staff are comfortable with the use of NHS Pathways particularly for new staff who have not previously been used to another triage system. The confidence in the use of the system can be measured by the decreasing rates of category A calls and the increasing Hear & Treat rates. However, they remain concerned over the perception of the audit process and work is currently being undertaken, in partnership with staff and their representatives, to develop a great emphasis on supportive development and positive perception of the audit and quality assurances systems and processes For operational crews, the NHS Pathways system was sold as a panacea that would reduce the numbers of calls that crews would be attending, especially low-acuity calls and those patients presenting with minor injuries or illnesses. Some staff had interpreted this as a likely decrease in workloads. This has not transpired to be the case, nor was it planned to, as the Trust s Cost Improvement Programme (CIP) has dictated a continued increase in Unit Hour Utilisation (UHU). Thus, any improvements in Hear & Treat rates have not translated less busy working lives for staff, work-loads have increased. Staff have noticed the increase in the low proportion of high acuity calls due to increased Hear & Treat Another key issue facing operational crews has been misunderstanding and misinterpretation around emergency responding. Despite a number of efforts to communicate that the default position for responding to Green 2 (30 minute) calls as an emergency (as this is the type of response dictated by the triage system), staff in many areas continue to respond routinely to these cases. Page 2 of 6

3 Staff have suggested re-introducing the AMBER categorisation to support easy understanding of different grades of emergencies In general, the Trust s NHS Pathways management team have taken a proactive approach to respond to issues raised by EOC and field operations staff, and these issues have resulted in a number of changes to the triage system, having been escalated through the national process to the National Clinical Governance Group. 3. Training and recruitment issues staff have been trained which includes recruitment of 120 fixed term Emergency Medical Advisors (EMAs) and 28 Clinicians Presently the establishment of EMAs is 130, and there are presently seven vacancies which are being recruited to. Recognising the drop-outs and natural attrition associated with the post, we are currently undertaking recruitment above establishment with a course of 12 planned for quarter The number of whole time equivalent Clinical Supervisors is 36 with 28 in post, two on secondment to NHS 111 and 6 being recruited to which is proving difficult. The EOC Management Team have highlighted the issues with the recruitment services team and have requested wider advertising, scoping the use of recruitment agencies We have successfully appointed 3 Clinical Advice Managers (CAM) to manage the Clinical Supervisor teams in each EOC. The Lewes CAMs started in post in December 2012, and the Banstead and Coxheath CAMs will be fully operational in post by March Clinical issues 4.1. There have been two SIRIs resulting from triage references 2011/14780 and 2012/30366, however neither investigation attributed the route cause to be as a result of a the triage system itself, but as a result of user error There have been 78 complaints and PALS enquiries since go-live, a large number of these relating to non-ambulance dispositions. Whilst a number were upheld due to failing by the EMAs involved, a number of cases identified that public expectation to always receive an ambulance when dialing 999 was not now met, especially through the enhanced dispositions available through NHS Pathways A number of underlying causes have been identified: Staff conversion to the new system by EMA s used to the previous system who struggled to embrace the different working practices and additional workload involved Staff given new information failing to follow the system correctly down to a new direction All grades of staff failing to take account of callers/patients concerns Staff failing to listen actively to what they were being advised. Page 3 of 6

4 Clinicians failing to appreciate the possible differential diagnose of some symptoms that patients were presenting with after a Hear & Treat disposition Inappropriate referral advice being given due to poor management of the calls. 5. NHS Pathways Call Closure 5.1. Closure of most Hear & Treat dispositions by EMAs is permitted under the terms of the NHS Pathways license. However, following initial concerns raised at implementation, the Trust has employed a system which requires all Hear & Treat dispositions to be reviewed by Clinical Supervisors Now that CQI and Audit information is available, an audit of call outcome has been undertaken, taking into account the complaints and PALS enquiries and including data from Clinical Supervisors where calls have had to be upgraded, in partnership with the Medical Directorate. This data has informed an agreement for EMA closure of calls in line with the NHS Pathways license. 6. Lessons Learned 6.1. As a result of investigations into Complaints and SIRIs, new working practices evolved which focused on supported 1 to 1 feedback sessions with either Trainers or Team Leaders. Peer reviews for Clinicians were held in year 1, and we have now rolled these out to include both the EMA and clinician in a joint Peer Review of their incident Lessons identified are also now being included in ongoing training courses, Version update days and also Clinician Training days. Calls are being anonymised and used as part of training. We are also starting to share calls with NHSP for review into whether these can be used in National training. 7. Patient perspective 7.1. There have been some informal small scale satisfaction exercises by the PALS department but no formal patient survey undertaken The view of patients has been mixed Many callers have also been pleased with the advice or assistance they have been given on calling 999. The Out of Hours/Community Health Services access pathway is very complex and often confuses patients or just presents them with what they perceive as a brick wall. NHS Pathways has provided information to the patient or allowed direct access to services they did not know existed, or allowed them to be managed in their own homes. Often their care has been speeded up or even improved on Some callers perceive the triage questioning as being prolonged. Where a Community referral was appropriate patient expectation of an ambulance response has been very high. This has generated complaints or dissatisfaction amongst callers and patients. This is due to lack of understanding by the public about the changing NHS systems with an increased emphasis at commissioner and governmental level at care within the community setting where possible. Page 4 of 6

5 NHS Pathways has also changed the way the Trust respond to some classes of incident with many more groups being advised to take responsibility for their own care or are referred to community services. This has created a problem with some institutions like Schools who have always received an ambulance and so have never planned procedures to manage unwell or injured children. Therefore when a child is unwell, the only policy the school has is to call an ambulance. Whereas there is no clinical reason that would make it inappropriate for a staff member from the school or a parent to be called in to take the child to where is appropriate. From a Health & Safety and legal responsibility scope, schools wish to discharge their care quickly to the Ambulance Service. Therefore these institutions have been amongst some of the most vocal when making PALS enquiries. 8. Audit & Quality Assurance Issues 8.1. There have been considerable difficulties with implementing the audit and CQI process required by the NHS Pathways license The required numbers of auditors to undertake the statutory requirement of 4 audits by non-clinical auditors and 1 by a clinical auditor per EMA per month have not been achieved since implementation. However, some regular audits are now being undertaken and this is supported by the development of the info.secamb based audit system specified by the EOC Management Team and developed by the Trusts info team Following completion of beta testing of this tool in January 2013, it is planned to commence regional auditing of calls and that this will increase the volumes of audits than can be undertaken. Additionally, the increasing capacity of Clinical Supervisors on discounting their role associated with closing Hear & Treat dispositions will support the audit process and provide the 1 clinician audit per EMA per month. It will also provide time for mentoring and support as part of the process The CQI data has been extremely challenging to access both because of problems with accessing the data from our CAD, despite it being part of the contract of our CAD supplier and also with accessing the support and information required from the NHS Pathways team. However, in the recent weeks, this information has become available and it is anticipated that CQI will become available, which is used side by side with the audit process to ensure safety and quality assurance of the call handling process. Page 5 of 6

6 October 2012 Audit Compliance Banstead 96.84% Lewes 91.95% Coxheath 90.25% SECAmb 93.01% November 2012 Audit Compliance Banstead 93.02% Lewes 92.63% Coxheath 90.29% SECAmb 91.89% December 2012 Audit Compliance Banstead 96.00% Lewes 91.54% Coxheath 94.31% SECAmb 93.95% 8.5. There has been feedback from staff that the audit and quality assurance process is viewed with anxiety as a punitive process, and the management team are working with the Clinical Supervisors to ensure that the process is used as a tool to support the development of staff. The emphasis and focus is on a no-blame, supportive framework which will develop staff. 9. Summary 9.1. In summary, whilst there are number of areas which require on-going development, particularly around recruitment and quality assurance and development areas, the Trust is operating well with NHS Pathways. It is clear that SECAmb has been able to deliver a sustainable increase in Hear & Treat in the context of increasing demand There is no doubt that investment in the EOC environment to support the effective use of this tool will provide saving both across field operations, but also in the context of the wider health economy Future developments will include: Developing specialist practice in the EOC environment including learning from the GP pilot in Coxheath as well as role development for SECAmb staff Developing the DOS further to ensure alternative pathways are in place. Sue Skelton Head of Emergency Control Centres Page 6 of 6