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Risks at the HSE National Ambulance Service

By Mindo - 01st Mar 2018

<p class=”p1″><span class=”s1″>The  HSE National Ambulance </span>Service (NAS) responds to more than 340,000 ambu<span class=”s2″>lance calls annually.</span>

<p class=”p1″><span class=”s2″>Its mission, according to its web</span>site, “is to serve the needs of patients and the public as part of an integrated health system, through the provision of high quality, safe <span class=”s2″>and patient-centred services”.</span>

<p class=”p1″>But like most State health services, it is under intense pressure to meet the needs of patients as it grapples with staff, hospital and safety challenges in a restricted <span class=”s2″>budgetary environment.</span>

<p class=”p1″><span class=”s2″>The NAS risk register, as of Octo</span>ber 2017, released to the <strong><em>Medical Independent </em></strong>(<strong><em>MI</em></strong>) via Freedom of Information legislation, high<span class=”s2″>lights the many risks facing the service and the actions underway to try and address and reduce these risks.</span>

<h3 class=”p1″><span class=”s3″>Hospital turnaround times </span></h3> <p class=”p1″>Reducing hospital turnaround times is an ongoing battle for the NAS, but the problem is particu- larly acute during periods of hospital overcrowding, which hit new records again this year with over 600 patients on trolleys in emer- <span class=”s2″>gency departments (EDs) awaiting admission during a number of days in January and February.</span>

<p class=”p1″>The NAS faces an “extreme” risk (the highest risk category based on NAS Risk Register matrix) due to <span class=”s2″>the negative impact of prolonged ED </span>turnaround times on the availability of NAS resources to respond to <span class=”s2″>emergency calls, the register reveals.</span>

<p class=”p1″>The register notes that this means, “NAS resources may not reach patients in a timely manner <span class=”s2″>resulting in negative outcomes for the patient and poor public perception of the NAS”.</span>

<p class=”p1″>This particular risk was added to the register in July 2014 and <span class=”s2″>remained on the register in October 2017.</span>

<p class=”p1″><span class=”s2″>Several control measures and actions are outlined in the register de</span>tailing how the NAS is responding <span class=”s2″>to and handling this risk, including </span>the deployment of IT solutions to <span class=”s2″>support ambulance arrival at EDs.</span>

<p class=”p1″>The target turnaround time is <span class=”s2″>30 minutes or less but in 2015 only 63 per cent of crews were available within the timeframe.</span>

<p class=”p1″>Currently, due to large numbers of patients waiting on trolleys in <span class=”s2″>hospital EDs, the NAS is under huge pressure to meet turnaround times, </span>as it is forced to wait to discharge <span class=”s2″>patients to overcrowded EDs.</span>

<p class=”p1″>This means, as the risk register outlines above, that the NAS is being delayed in attending other <span class=”s2″>emergency calls. Despite attempts </span>to address the problem it appears to be one that health officials have <span class=”s2″>yet to adequately address.</span>

<h3 class=”p2″>Staff safety</h3> <p class=”p1″><span class=”s2″>While patients are clearly at risk </span>because of inadequacies, it is also important to remember that NAS <span class=”s2″>staff are working in extremely challenging environments.</span>

<p class=”p1″><span class=”s2″>The register outlines a major risk to the health, safety and welfare of NAS </span>staff who can be exposed to “difficult and uncontrolled environments and <span class=”s2″>sometimes volatile situations”.</span>

<p class=”p1″><span class=”s2″>This is due to staff exposure to violence and aggression and can lead </span>to staff absences due to injury and <span class=”s2″>increased levels of stress on staff.</span>

<p class=”p1″><span class=”s2″>As part of a number of measures </span>to reduce staff exposure to volatile situations, an ongoing review by the National Emergency Oper<span class=”s2″>ations Centre (NEOC) of high-risk locations is underway.</span>

<p class=”p1″><span class=”s2″>Another major risk to the health </span>and welfare of staff and the safety of patients is staff fatigue, due to <span class=”s2″>prolonged on-call periods that may </span>see staff working additional hours before and/or after periods of du<span class=”s2″>ty. The risk was added to the register in 2012.</span>

<p class=”p1″><span class=”s2″>This can cause poor decision mak- ing by staff exhausted from working long hours. Control measures to mitigate risk include the “reduction and </span>elimination of on-call in the NAS W <span class=”s2″>NW [West North West] region”, the documents reveal.</span>

<p class=”p1″>A project management team is in place to develop a plan for the <span class=”s2″>service in the West North West region and an examination of out-of-hours availability for management grades is also listed.</span>

<h3 class=”p2″>Recruitment</h3> <p class=”p1″>Another major risk is the NAS’s ability to deliver services arising <span class=”s2″>from on-going recruitment difficul</span>ties resulting in an inability to cover shifts. The risk was added to the <span class=”s2″>register more than two years ago.</span>

<p class=”p1″>In a bid to tackle the problem, the register states that a review of the age profiles of current staff to <span class=”s2″>allow for future planning is underway, along with a capacity review.</span>

<p class=”p1″><span class=”s1″>The NAS also attended the Jobs Ex</span><span class=”s2″>po in Cork and Dublin last November as part of efforts to boost recruitment</span>

<p class=”p1″><span class=”s2″>Meanwhile, the NAS has a lack of station supervisors nationwide, the </span>register reveals. A major risk exists <span class=”s2″>to the NAS’s ability to deliver services because of “ongoing recruitment difficulties”, the register states.</span>

<p class=”p1″>The problem means there is a potential for adverse outcomes for patients, staff and the organisation as it struggles to cover shifts.

<p class=”p3″><span class=”s2″>This impacts on the NAS’s “ability to assure NAS internal control meas</span><span class=”s1″>ures are performed” and on its ability </span>to “assure patient safety and quality”.

<h3 class=”p2″>Dublin</h3> <p class=”p1″><span class=”s2″>A unique situation exists in Dub</span>lin where the allocation and dis- patch of ambulances are operat<span class=”s2″>ed by two control centres, the NAS and Dublin Fire Brigade (DFB).</span>

<p class=”p1″>A process is in place whereby when Dublin Fire Brigade is at capacity, calls are transferred from <span class=”s2″>the brigade to the NAS.</span>

<p class=”p1″><span class=”s2″>But this is presenting an extreme risk, resulting in possible “negative </span>outcomes for the patient and poor <span class=”s2″>public perception of the NAS”, the register outlines.</span>

<p class=”p1″><span class=”s2″>It is also impacting on patient care “due to being unable to respond in a timely manner”. The risk was added to the register in December 2016.</span>

<p class=”p1″>The register states that a report has been commissioned on the current management of emergen<span class=”s2″>cy calls within Dublin city and that </span>NAS has deployed additional re<span class=”s2″>sources in the Dublin area.</span>

<p class=”p1″><span class=”s1″>Proposed actions listed include the </span><span class=”s2″>development of one control centre with the ability to receive all emergency calls in Dublin city and with the ability to allocate and dispatch emergency ambulances directly.</span>

<p class=”p1″><span class=”s2″>Engagement with the fire brigade </span>on agreeing a common language and methodology for the transfer <span class=”s2″>of emergency calls is also proposed.</span>

<p class=”p1″><span class=”s2″>A less serious risk also exists in the capital regarding the capacity of </span><span class=”s1″>emergency resources to meet activity.</span>

<p class=”p1″>Overtime is being used to in- crease capacity while a Capacity Review has highlighted the need for more resources. Additional resources are being deployed in the <span class=”s2″>Dublin area, the register notes.</span>

<p class=”p1″>Last year, a HIQA review found that inadequate services are put<span class=”s2″>ting patients in Dublin at risk.</span>

<p class=”p1″>The report noted HIQA’s concern that “a detailed plan for the delivery of emergency ambulance <span class=”s2″>services in the greater Dublin area, still does not exist”.</span>

<p class=”p1″>In 2014 HIQA found that, “when <span class=”s2″>the National Ambulance Service were in a position to provide assistance, vi</span>tal minutes could be lost during the <span class=”s2″>process of call transfer from the Dub</span>lin Fire Brigade to the National Am<span class=”s2″>bulance Service” because of call handling and dispatch procedures.</span>

<h3 class=”p2″>Aeromedical service</h3> <p class=”p1″>According to the Organ Donation and Transplant Ireland (ODTI) Annual Report 2016 there were nine paediatric patients awaiting a UK <span class=”s2″>transplant [heart (three), lung (three) </span>or liver (three) transplant]. The report also states that 10 Irish paediatric transplants were performed in the UK in 2016, compared to seven <span class=”s2″>in 2015. The figures are based on data from four Hospital Groups.</span>

<p class=”p1″>However, since February 2017 there has been an extreme risk to the HSE’s ability to reliably and <span class=”s2″>consistently transfer ‘priority 1’ or</span>gan transplant patients, particu<span class=”s2″>larly cardiac patients, abroad within indicted time frames.</span>

<p class=”p1″><span class=”s2″>Priority 1 transfer involves the transport by air from Ireland to another country within eight hours of a </span><span class=”s1″>patient requiring emergency medical </span><span class=”s2″>or surgical treatment, without which the patient’s life or health is significantly endangered. To date, the ma</span><span class=”s1″>jority of patients fulfilling these crite</span><span class=”s2″>ria have been children who require transfer to the UK to undergo heart or liver transplant surgery.</span>

<p class=”p1″><span class=”s2″>Priority 1 transfers have primar</span>ily been provided by the Air Corps or Irish Coast Guard (IRCG). Due to staff capacity constraints and regulatory requirements these services have not been available to provide priority 1 transfers between the hours of 7pm and <span class=”s2″>7.30am since last November.</span>

<p class=”p1″>According to the risk register, the NAS had suggested families of severely ill children in need of organ transplants temporarily relocate to Dublin or London following a reduction in the availability <span class=”s2″>of aircraft transfers.</span>

<p class=”p1″>“The reduction in aircraft availa<span class=”s2″>bility effectively means that our ability to reliably and consistently trans</span>fer priority 1 organ transplant patients to the receiving UK hospitals within the indicated time frame is <span class=”s2″>not assured, particularly cardiac patients,” the register outlines.</span>

<p class=”p1″>It details a number of actions to <span class=”s2″>address the risk, with potential so</span>lutions such as the use of the private air ambulance provider contracted to the Northern Ireland healthcare system and noted that it awaited a HIQA health technol<span class=”s2″>ogy assessment on the issue.</span>

<p class=”p1″><span class=”s2″>Last November, HIQA published </span>its HTA and recommended, in the immediate-term, that the optimal <span class=”s2″>option was to engage a private pro</span>vider to deliver a dedicated night-<span class=”s2″>time air transport service.</span>

<p class=”p1″>In the short-term (to be implemented within six months), HIQA stated that the optimal solution may be to negotiate changes to the existing IRCG contract to allow

<p class=”p1″>for 12-hour rosters at one or more bases, thereby enabling the IRCG to undertake night-time Priority 1 transfers. The cost of this option should be compared to the cost associated with the ongoing use of a <span class=”s2″>commercial provider or of having a dedicated IRCG crew on standby at the Dublin base, the Authority said.</span>

<p class=”p3″><span class=”s1″>Additional short-term recommen</span><span class=”s2″>dations were that the Department of </span><span class=”s1″>Health explores both the use of an air ambulance service supported by philanthropy and examines whether the </span><span class=”s2″>IRCG can fly patients to the UK un</span><span class=”s1″>der a 24-hour shift following changes </span><span class=”s2″>to the regulatory framework.</span>

<p class=”p1″>HIQA said the preferred long-term alternatives are those provid<span class=”s2″>ed by the IRCG or the Air Corps. The </span>next contract to provide coastguard services in 2022 could provide for <span class=”s2″>an additional aircraft and aircrew to provide air ambulance services. The Air Corps options include the provi</span>sion of an air ambulance service on an “as available” basis or through a model similar to that used by the Garda Air Support Unit, where aircraft would be provided by the HSE <span class=”s2″>and dedicated aircrew would be provided by the Air Corps.</span>

<p class=”p1″>Following publication of HIQA’s report, Minister for Health Simon Harris confirmed that the HSE had put a private provider in place from 6 November 2017, thus ensuring that a 24-hour service continues to be available. “My Department will work with the HSE to consider the best option to address the service need in the short- to medium-term. <span class=”s2″>In the longer term, we will have discussions across a number of Government Departments in order to come to a considered position as to how air ambulance services are best provided in the future,” he said at the time.</span>

<h3 class=”p2″>Vision</h3> <p class=”p1″><span class=”s2″>The NAS is acutely aware of the risk </span>presented and has developed a stra<span class=”s2″>tegic plan, known as ‘Vision 2020’ to address these and other issues.</span>

<p class=”p1″><span class=”s2″>A SWOT (strengths, weaknesses, </span>opportunities and threats) analy<span class=”s2″>sis undertaken as part of this notes </span>that “funding is not keeping pace with demand”, and that a lack of resources may inhibit future ser<span class=”s2″>vice delivery and growth.</span>

<p class=”p1″><span class=”s2″>The analysis also points out that </span>the service must find recurring cost savings year on year despite <span class=”s2″>rising demand.</span>

<p class=”p1″><span class=”s2″>The HSE declined the opportunity to provide further comment to <strong><em>MI </em></strong>on the issues raised in the risk register.</span>

<p class=”p4″><strong>Additional reporting by Priscilla <span class=”s4″>Lynch</span></strong>

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