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The HSE National Ambulance Service (NAS) responds to more than 340,000 ambulance calls annually.
Its mission, according to its website, “is to serve the needs of patients and the public as part of an integrated health system, through the provision of high quality, safe and patient-centred services”.
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 budgetary environment.
The NAS risk register, as of October 2017, released to the Medical Independent (MI) via Freedom of Information legislation, highlights the many risks facing the service and the actions underway to try and address and reduce these risks.
Hospital turnaround times
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- gency departments (EDs) awaiting admission during a number of days in January and February.
The NAS faces an “extreme” risk (the highest risk category based on NAS Risk Register matrix) due to the negative impact of prolonged ED turnaround times on the availability of NAS resources to respond to emergency calls, the register reveals.
The register notes that this means, “NAS resources may not reach patients in a timely manner resulting in negative outcomes for the patient and poor public perception of the NAS”.
This particular risk was added to the register in July 2014 and remained on the register in October 2017.
Several control measures and actions are outlined in the register detailing how the NAS is responding to and handling this risk, including the deployment of IT solutions to support ambulance arrival at EDs.
The target turnaround time is 30 minutes or less but in 2015 only 63 per cent of crews were available within the timeframe.
Currently, due to large numbers of patients waiting on trolleys in hospital EDs, the NAS is under huge pressure to meet turnaround times, as it is forced to wait to discharge patients to overcrowded EDs.
This means, as the risk register outlines above, that the NAS is being delayed in attending other emergency calls. Despite attempts to address the problem it appears to be one that health officials have yet to adequately address.
While patients are clearly at risk because of inadequacies, it is also important to remember that NAS staff are working in extremely challenging environments.
The register outlines a major risk to the health, safety and welfare of NAS staff who can be exposed to “difficult and uncontrolled environments and sometimes volatile situations”.
This is due to staff exposure to violence and aggression and can lead to staff absences due to injury and increased levels of stress on staff.
As part of a number of measures to reduce staff exposure to volatile situations, an ongoing review by the National Emergency Operations Centre (NEOC) of high-risk locations is underway.
Another major risk to the health and welfare of staff and the safety of patients is staff fatigue, due to prolonged on-call periods that may see staff working additional hours before and/or after periods of duty. The risk was added to the register in 2012.
This can cause poor decision mak- ing by staff exhausted from working long hours. Control measures to mitigate risk include the “reduction and elimination of on-call in the NAS W NW [West North West] region”, the documents reveal.
A project management team is in place to develop a plan for the service in the West North West region and an examination of out-of-hours availability for management grades is also listed.
Another major risk is the NAS’s ability to deliver services arising from on-going recruitment difficulties resulting in an inability to cover shifts. The risk was added to the register more than two years ago.
In a bid to tackle the problem, the register states that a review of the age profiles of current staff to allow for future planning is underway, along with a capacity review.
The NAS also attended the Jobs Expo in Cork and Dublin last November as part of efforts to boost recruitment
Meanwhile, the NAS has a lack of station supervisors nationwide, the register reveals. A major risk exists to the NAS’s ability to deliver services because of “ongoing recruitment difficulties”, the register states.
The problem means there is a potential for adverse outcomes for patients, staff and the organisation as it struggles to cover shifts.
This impacts on the NAS’s “ability to assure NAS internal control measures are performed” and on its ability to “assure patient safety and quality”.
A unique situation exists in Dublin where the allocation and dis- patch of ambulances are operated by two control centres, the NAS and Dublin Fire Brigade (DFB).
A process is in place whereby when Dublin Fire Brigade is at capacity, calls are transferred from the brigade to the NAS.
But this is presenting an extreme risk, resulting in possible “negative outcomes for the patient and poor public perception of the NAS”, the register outlines.
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.
The register states that a report has been commissioned on the current management of emergency calls within Dublin city and that NAS has deployed additional resources in the Dublin area.
Proposed actions listed include the 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.
Engagement with the fire brigade on agreeing a common language and methodology for the transfer of emergency calls is also proposed.
A less serious risk also exists in the capital regarding the capacity of emergency resources to meet activity.
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 Dublin area, the register notes.
Last year, a HIQA review found that inadequate services are putting patients in Dublin at risk.
The report noted HIQA’s concern that “a detailed plan for the delivery of emergency ambulance services in the greater Dublin area, still does not exist”.
In 2014 HIQA found that, “when the National Ambulance Service were in a position to provide assistance, vital minutes could be lost during the process of call transfer from the Dublin Fire Brigade to the National Ambulance Service” because of call handling and dispatch procedures.
According to the Organ Donation and Transplant Ireland (ODTI) Annual Report 2016 there were nine paediatric patients awaiting a UK transplant [heart (three), lung (three) or liver (three) transplant]. The report also states that 10 Irish paediatric transplants were performed in the UK in 2016, compared to seven in 2015. The figures are based on data from four Hospital Groups.
However, since February 2017 there has been an extreme risk to the HSE’s ability to reliably and consistently transfer ‘priority 1’ organ transplant patients, particularly cardiac patients, abroad within indicted time frames.
Priority 1 transfer involves the transport by air from Ireland to another country within eight hours of a patient requiring emergency medical or surgical treatment, without which the patient’s life or health is significantly endangered. To date, the majority of patients fulfilling these criteria have been children who require transfer to the UK to undergo heart or liver transplant surgery.
Priority 1 transfers have primarily 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 7.30am since last November.
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 of aircraft transfers.
“The reduction in aircraft availability effectively means that our ability to reliably and consistently transfer priority 1 organ transplant patients to the receiving UK hospitals within the indicated time frame is not assured, particularly cardiac patients,” the register outlines.
It details a number of actions to address the risk, with potential solutions 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 technology assessment on the issue.
Last November, HIQA published its HTA and recommended, in the immediate-term, that the optimal option was to engage a private provider to deliver a dedicated night-time air transport service.
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
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 commercial provider or of having a dedicated IRCG crew on standby at the Dublin base, the Authority said.
Additional short-term recommendations were that the Department of Health explores both the use of an air ambulance service supported by philanthropy and examines whether the IRCG can fly patients to the UK under a 24-hour shift following changes to the regulatory framework.
HIQA said the preferred long-term alternatives are those provided by the IRCG or the Air Corps. The next contract to provide coastguard services in 2022 could provide for an additional aircraft and aircrew to provide air ambulance services. The Air Corps options include the provision 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 and dedicated aircrew would be provided by the Air Corps.
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. 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.
The NAS is acutely aware of the risk presented and has developed a strategic plan, known as ‘Vision 2020’ to address these and other issues.
A SWOT (strengths, weaknesses, opportunities and threats) analysis undertaken as part of this notes that “funding is not keeping pace with demand”, and that a lack of resources may inhibit future service delivery and growth.
The analysis also points out that the service must find recurring cost savings year on year despite rising demand.
The HSE declined the opportunity to provide further comment to MI on the issues raised in the risk register.
Additional reporting by Priscilla Lynch