East Midlands Ambulance Service
NHS / Health Body
Action Taken
East Midlands Ambulance Service (EMAS) has discussed the concerns within the Coroners Working Group and developed an action plan, reintroduced monthly meetings with hospitals and commissioners to improve ambulance turnaround, and increased available hours for ambulances and fast response vehicles by recruiting staff and realigning rosters. (AI summary)
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Dear Ms Connor Re: Report to Prevent Future Deaths: Peter Scott (DECEASED) Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 11" May 2016, bringing to my attention the Coroner's concerns arising from the inquest into the death of Peter Scott would like to assure you that within the East Midlands Ambulance Service (EMAS) all matters related to patient safety are taken extremely seriously: In particular, any matters arising from Coroners Inquests from which lessons can be learnt, and this includes any Prevention of Future Deaths notices, are discussed within the Coroners Working Group. The Coroners Working Group having considered all the relevant issues of concern relating to the particular inquest will develop an appropriate action plan with specified timelines and identified individuals to deliver the actions specified. This process has been applied to the Prevention of Future Death notice pertaining to the inquest into the death of Peter Scott. The MATTERS OF CONCERN are as follows: consider) that there is risk of future deaths as set out above unless an urgent review of resources is undertaken. Consideration should be given to strategies to improve handover times at hospitals Taking the concerns in turn, set out the actions we have taken and our response to HM Coroner's concerns in the PFD notice. The Care Quality Commission report recognised that EMAS has been working really hard to improve response times to emergency calls. However there are concerns that ultimately relate to the lack of resource (staff and vehicles) made worse by the numbers often kept waiting at hospital; and lack of capacity to do things as quickly or as well as should be. they
East Midlands Ambulance Service [NHS NHS Trust Emergency Care | Urgent Care We Care EMAS has taken the CQC seriously and value the additional support from other NHS organisations following the CQC Quality Summit: With their input EMAS can progress areas that cannot be fixed quickly, or that are not within EMAS' immediate control. Following extensive negotiations an agreement has been reached with all commissioners for the EMAS 2016/17 Accident and Emergency 999 contract: The final position is for a one year block contract with a value of E152.5 million: key part of this year's contract is the agreement to carry out a independent strategic demand, capacity and price review to look at the level of staff and vehicles needed, along with finance, to respond to increasing demand on the service_ EMAS and clinical commissioning groups have agreed to implement the outcomes of the review, and this should ensure EMAS is able to meet demand. Despite funding challenges during 2015/16, EMAS proactively recruited and educated 350 whole time equivalent (wte) frontline posts against recruitment plan target of 342- However, higher level of turnover was experienced compared to that forecast (11% against target of 8%). EMAS continues to recruit to the frontline again this year: Through exit interviews, EMAS monitors the reason for staff leaving: From those interviews the top reasons are (in order of priority): Lack of opportunitylcareer progression/further 2 Work life balance 3_ Better pay To address this, EMAS has produced a new People Strategy to develop and support our staff to be highly skilled, motivated, caring and compassionate professionals_ Hospital handover is the time it takes Emergency Department staff to accept clinical handover from ambulance crews, thereby releasing them to respond to other 999 calls (Note: national target for this is 15 minutes). Hospitals are not able to accept prompt clinical handover when are experiencing high demand or a large influx of patients arriving at the same time. The Care Quality Commission inspection at EMAS in November 2015 and findings published in May 2016 brought focus to the seriousness of the hospital handover delays experienced over the last year: Delays result in patients waiting on the back of ambulances, or in hospital corridors whilst their care is supervised by ambulance crews. While the ambulance supervision is being provided it prevents crews being able to respond to new 999 calls that have been received: This means patients in the community experience in response and this is of concern The delays impact on staff wellbeing and morale because can increase shift length and increase anxiety levels when crews know calls are waiting to be responded to, or when know will be first on scene having to explain lengthy delay: also impact on ambulance resourcing across the region, as vehicles and crews move across county boundaries to assist where there are delaysThis takes crews away from their usual operating area and has corresponding impact on the ability for the ambulance service to use resources efficiently. That is why EMAS continues to escalate the problem and work with regulators, commissioners and acute hospitals, as well as and the wider health and social care system to try to improve the situation. Actions taken by EMAS in particular at the LRI includes: findings the training they from delay they they they They
East Midlands Ambulance Service [NHST NHS Trust Emergency Care Urgent Care We Care Daily contact and working with hospital teams and clinical commissioning groups to improve patient experience and reduce Increased number of paramedics based at hospitals to support their teams with the triage of patients and through the department A new booking system has been introduced with priority patient assessment to ensure the most ill patients are seen promptly when are being experienced These measures have allowed progress and improvements to the average handover times; however there is still more work to do to ensure the improvements continue on a sustainable basis, and that there is a continued reduction in long waits_ would also like to make a comment with particular regard to the work that EMAS has undertaken with the acute hospitals in Nottinghamshire_ Prior to March 2016 EMAS used Radio Frequency Identity (RFID) system to record the hospital handover time cycle. The system required a small tag to be attached to the ambulance stretcher and the electronic patient report form Toughbook: When either device passed through the doors at Queens Medical Centre (QMC), Nottingham a record was generated which allowed for monthly statistics to be produced: RFID proved difficult to manage as the device had to be matched to vehicle, should the stretcher or Toughbook be swapped onto another vehicle, the produced data could be erroneous. The data provided was not real time therefore delays could not be challenged at the time. Since March 2016 the QMC has engaged with EMAS t0 install Ambulance arrival screens_ Unlike RFID which used electronic the ambulance arrivals screen uses a simple touchscreen interface based on webpage. This new process provides real time data to both QMC and EMAS which allows both to see as happen, thus ensuring mitigating plans can be actioned rapidly. Ambulance arrival screens display the number of vehicles inbound to QMC, those that have arrived, awaiting handover and where the handover is complete_ The handover requires both the handing over and receiving clinician to input an individual PIN which ensures an accurate time stamp enabling the delays within the ambulance turnaround process to be identified and acted upon: Illustration of QMC Arrival Screen chormange Notify Handover Curent Current Curreni East Midlands Ambulance Service Arrived t0 Handover Usage Usage Mumarou Ambulance Arrivals (Today) (Tocay) Hendover to Clear Averagt Averace Averace Queens Medical Centre Campus Hospital
73.33 % 97 7006 13 mins 10 mins
22.25 mi Total Resources Awalting Handover Creuss Anved cers Inbcund-; creus Expecteds us UpdJted: 15 2 Arrived call Number Callsign Type Call ReccNel As Stats TmevETA| Elpsd Pals Ratlllty Ashi 8375429 8411 EMG 21003 Dangerous Haemorrhage Notified
15.20 Emergency Dept 8375274 8916 EMG 30B01 Traumatic Injures to Possibly Dangerous Body Area Notified
15.06 Emergency Dept 8375239 8420 EMG DXO162 Transport t0 ED wlin Handover
15.07 Emergency Dept Inbound Call Number ' Callsigh TyPe call Recenved As Status Time/ETA Elpsd Pals Raclllty Ashif 8375407 8913 EMG 33[FT Priority IFT transfer Inbound 0 Mil Mins Emcrgency Dept 8375376 8419 EMG 31C01 Unconscious or Fainting Alertewith Abnoral Brea Inbound 3 Mil 6 mins Emergency Dept 8375425 2412 EMG 18C01 Headeche and Not Alert Inbound 3 Mi Mins Emergency Dept When are identified the Division will, where possible, allocate a Team Leader manager to act as a local Hospital Ambulance Liaison Officer (HALO): The role is to work with the hospital management team to ensure that ambulances are not delayed at hospital any more than necessary: delays flow delays tags delays they delays
East Midlands Ambulance Service NHS NHS Trust Emergency Care Urgent Care We Care The Division has reintroduced monthly meetings with both QMC and commissioners to identify improvements that can be made to further improve the ambulance turn round cycle time: Since April 2015 Nottinghamshire Division has increased available hours for both Double Crewed Ambulance (DCA) and solo Fast Response Vehicles (FRV): This is through the recruitment of staff and realignment of rosters to match increased demand_ Table Resourcing comparison April 2015 and April 2016 DCA Filled Hours FRV Filled Hours April 2015 34252 8606 April 2016 36487 9478 Increase 2235 872 Percentage Increase
6.52%
10.13% trust that this has answered all of the issues from your Prevention of Future Deaths Notice, but please do not hesitate to contact me if there is further information which is required
East Midlands Ambulance Service [NHS NHS Trust Emergency Care | Urgent Care We Care EMAS has taken the CQC seriously and value the additional support from other NHS organisations following the CQC Quality Summit: With their input EMAS can progress areas that cannot be fixed quickly, or that are not within EMAS' immediate control. Following extensive negotiations an agreement has been reached with all commissioners for the EMAS 2016/17 Accident and Emergency 999 contract: The final position is for a one year block contract with a value of E152.5 million: key part of this year's contract is the agreement to carry out a independent strategic demand, capacity and price review to look at the level of staff and vehicles needed, along with finance, to respond to increasing demand on the service_ EMAS and clinical commissioning groups have agreed to implement the outcomes of the review, and this should ensure EMAS is able to meet demand. Despite funding challenges during 2015/16, EMAS proactively recruited and educated 350 whole time equivalent (wte) frontline posts against recruitment plan target of 342- However, higher level of turnover was experienced compared to that forecast (11% against target of 8%). EMAS continues to recruit to the frontline again this year: Through exit interviews, EMAS monitors the reason for staff leaving: From those interviews the top reasons are (in order of priority): Lack of opportunitylcareer progression/further 2 Work life balance 3_ Better pay To address this, EMAS has produced a new People Strategy to develop and support our staff to be highly skilled, motivated, caring and compassionate professionals_ Hospital handover is the time it takes Emergency Department staff to accept clinical handover from ambulance crews, thereby releasing them to respond to other 999 calls (Note: national target for this is 15 minutes). Hospitals are not able to accept prompt clinical handover when are experiencing high demand or a large influx of patients arriving at the same time. The Care Quality Commission inspection at EMAS in November 2015 and findings published in May 2016 brought focus to the seriousness of the hospital handover delays experienced over the last year: Delays result in patients waiting on the back of ambulances, or in hospital corridors whilst their care is supervised by ambulance crews. While the ambulance supervision is being provided it prevents crews being able to respond to new 999 calls that have been received: This means patients in the community experience in response and this is of concern The delays impact on staff wellbeing and morale because can increase shift length and increase anxiety levels when crews know calls are waiting to be responded to, or when know will be first on scene having to explain lengthy delay: also impact on ambulance resourcing across the region, as vehicles and crews move across county boundaries to assist where there are delaysThis takes crews away from their usual operating area and has corresponding impact on the ability for the ambulance service to use resources efficiently. That is why EMAS continues to escalate the problem and work with regulators, commissioners and acute hospitals, as well as and the wider health and social care system to try to improve the situation. Actions taken by EMAS in particular at the LRI includes: findings the training they from delay they they they They
East Midlands Ambulance Service [NHST NHS Trust Emergency Care Urgent Care We Care Daily contact and working with hospital teams and clinical commissioning groups to improve patient experience and reduce Increased number of paramedics based at hospitals to support their teams with the triage of patients and through the department A new booking system has been introduced with priority patient assessment to ensure the most ill patients are seen promptly when are being experienced These measures have allowed progress and improvements to the average handover times; however there is still more work to do to ensure the improvements continue on a sustainable basis, and that there is a continued reduction in long waits_ would also like to make a comment with particular regard to the work that EMAS has undertaken with the acute hospitals in Nottinghamshire_ Prior to March 2016 EMAS used Radio Frequency Identity (RFID) system to record the hospital handover time cycle. The system required a small tag to be attached to the ambulance stretcher and the electronic patient report form Toughbook: When either device passed through the doors at Queens Medical Centre (QMC), Nottingham a record was generated which allowed for monthly statistics to be produced: RFID proved difficult to manage as the device had to be matched to vehicle, should the stretcher or Toughbook be swapped onto another vehicle, the produced data could be erroneous. The data provided was not real time therefore delays could not be challenged at the time. Since March 2016 the QMC has engaged with EMAS t0 install Ambulance arrival screens_ Unlike RFID which used electronic the ambulance arrivals screen uses a simple touchscreen interface based on webpage. This new process provides real time data to both QMC and EMAS which allows both to see as happen, thus ensuring mitigating plans can be actioned rapidly. Ambulance arrival screens display the number of vehicles inbound to QMC, those that have arrived, awaiting handover and where the handover is complete_ The handover requires both the handing over and receiving clinician to input an individual PIN which ensures an accurate time stamp enabling the delays within the ambulance turnaround process to be identified and acted upon: Illustration of QMC Arrival Screen chormange Notify Handover Curent Current Curreni East Midlands Ambulance Service Arrived t0 Handover Usage Usage Mumarou Ambulance Arrivals (Today) (Tocay) Hendover to Clear Averagt Averace Averace Queens Medical Centre Campus Hospital
73.33 % 97 7006 13 mins 10 mins
22.25 mi Total Resources Awalting Handover Creuss Anved cers Inbcund-; creus Expecteds us UpdJted: 15 2 Arrived call Number Callsign Type Call ReccNel As Stats TmevETA| Elpsd Pals Ratlllty Ashi 8375429 8411 EMG 21003 Dangerous Haemorrhage Notified
15.20 Emergency Dept 8375274 8916 EMG 30B01 Traumatic Injures to Possibly Dangerous Body Area Notified
15.06 Emergency Dept 8375239 8420 EMG DXO162 Transport t0 ED wlin Handover
15.07 Emergency Dept Inbound Call Number ' Callsigh TyPe call Recenved As Status Time/ETA Elpsd Pals Raclllty Ashif 8375407 8913 EMG 33[FT Priority IFT transfer Inbound 0 Mil Mins Emcrgency Dept 8375376 8419 EMG 31C01 Unconscious or Fainting Alertewith Abnoral Brea Inbound 3 Mil 6 mins Emergency Dept 8375425 2412 EMG 18C01 Headeche and Not Alert Inbound 3 Mi Mins Emergency Dept When are identified the Division will, where possible, allocate a Team Leader manager to act as a local Hospital Ambulance Liaison Officer (HALO): The role is to work with the hospital management team to ensure that ambulances are not delayed at hospital any more than necessary: delays flow delays tags delays they delays
East Midlands Ambulance Service NHS NHS Trust Emergency Care Urgent Care We Care The Division has reintroduced monthly meetings with both QMC and commissioners to identify improvements that can be made to further improve the ambulance turn round cycle time: Since April 2015 Nottinghamshire Division has increased available hours for both Double Crewed Ambulance (DCA) and solo Fast Response Vehicles (FRV): This is through the recruitment of staff and realignment of rosters to match increased demand_ Table Resourcing comparison April 2015 and April 2016 DCA Filled Hours FRV Filled Hours April 2015 34252 8606 April 2016 36487 9478 Increase 2235 872 Percentage Increase
6.52%
10.13% trust that this has answered all of the issues from your Prevention of Future Deaths Notice, but please do not hesitate to contact me if there is further information which is required