How an Ambulance Service can contribute to the health care continuum

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The rationale

The primary role of all ambulance services is emergency pre-hospital medical care, although they generally provide both emergency response and patient transfer on behalf of the health sector. They provide easy access to health services, particularly out of hours, and contribute significantly to telephone triage and telephone health services through sophisticated communications infrastructure. In recent times it has become apparent that increasing health system pressures cannot be resolved only by adding resources, but must also be addressed with new methods of service delivery.

The ambulance service is ideally placed to be part of the first line in the continuum of health care, and can significantly contribute to ‘treat and transfer’ or ‘treat and leave’ programs. If ambulance services can develop towards an out-of-hospital, clinical care service rather than merely pre-hospital clinical care, they could substantially add to functionality of the health system. This could be through more efficient transfer of patient information; more efficient movement of patients; an ambulance service with a public service – rather than profit driven – philosophy; and patient treatment regimes consistent with the broader health system.

By integrating ambulance services into the health system generally, their respective strategic agenda are aligned, increasing efficiency, and providing an opportunity for an ambulance service, with its relevant expertise, to influence the outcome of ‘health’ initiatives.

The service

Ambulance services are the primary providers of a 24/7 response to medical and trauma related emergencies. They provide a disciplined and organised system, allowing a timely response of appropriately qualified health care workers – often to potential or confirmed medical emergencies. Although medical retrieval teams are provided by the major trauma centres, coordination of the team and rescue helicopter is provided by the ambulance communications centre, and also crewed in most instances with intensive care paramedics.

Ambulance services provide the equipment, expertise and experience in the emergency intervention, assessment, management and transport of patients in a variety of controlled, uncontrolled, and disaster environments. Whilst a wide variety of both professional and non-professional people can provide individual aspects of this service to varying levels, ambulance services are in the best position to deliver these services on the whole. In addition, modern ambulance services operate state of the art, 24/7 communication centres with experienced and highly trained telephonists, call takers, despatchers and clinicians. This makes them ideally suited to co-ordinate the ad-hoc crew requests being placed on the health system. In doing so, they can co-ordinate the response of the health system to ensure the right clinical/medical resources are provided to the right patient within the right timeframe for their medical needs.

Given the pre-hospital clinical environment of ambulance operations, being part of the health system ensures consistent patient care from the home or event to the hospital, i.e. a “system” approach to health care rather than individual health units working in isolation from – and sometimes opposition to – one another. An ambulance service provides the first point of contact with an incident, as well as a patient, therefore it provides early warning to the health system of its operating environment as a whole. This enables a degree of flexibility in the health system response to an event, allowing flows of patients to be adjusted or anticipated according to system performance. This provides a more efficient model in terms of resources and cost and can enable the redeployment of resources to other areas of the system, e.g. lower on-site staffing levels and higher on-call capacity. Continuous, seamless patient management from an initial incident to definitive care and recovery work well when all components are part of one system.

Currently, ambulance services make a huge range of unmeasured contributions to patient outcomes. These include the minimisation of clinical harm; the early reduction of myocardial workload and hyoidea in myocardia infarction; the early defibrillation in sudden cardia arrest; the early restoration of vital organ perfusion in major trauma, the rapid transportation of the time critical patient, to definitive care, and so on. Anecdotal opinion is that the activity of interventions, length of stay, and morbidity all decrease with the early intervention of paramedic care. To consider ambulance as anything other than integral to a health system is wrong.

The profession

An ambulance service provides paramedics who operate in an autonomous environment, remote from the backup and support of a full hospital. Long gone are the days when “ambo’s” were simply “stretcher bearers”.

Today’s paramedic is a highly trained clinician, and a fundamental link in the delivery and continuity of patient care. Defining the place of paramedics within health and the health service continuum, establishes them as professionals operating within a professional entity.

Paramedics are able to provide appropriate treatment to patients in their own and immediate locality, taking the treatment to the patient rather than patient to treatment. This is regardless of whether the patient is suffering a minor wound or illness, chronic illness or major trauma. Paramedics will become increasingly well placed to provide out of hospital care, thanks to advances in Intensive Care education and training, and the introduction of practitioners or extended care paramedics.

The integration of ambulance services within health has not reduced its responsibilities for emergency response, nor its role in the State Disaster Response plan. Paramedics often respond with and work alongside emergency service organisations and play a vital role within the emergency management framework. However, the prime reason that they are involved is the potential for a patient to require clinical care. Consequently ambulance services maintain and enhance the relationships between other emergency service agencies and the health system as a whole.

Whilst ‘paramedic’ is a unique specialist area of health care provision, so is podiatry, chiropractic, nursing, etc. All are accepted as part of this health continuum, and therefore it appears there is no functional reason why paramedics should not be part of this model. Paramedics ultimately deliver patients to other health providers who then take over their care, and this suggests the requirement of an integrated approach.

The community

Recently, the role of ambulance services has evolved from the traditional ‘treat and always transport’ to many programs that encourage ambulance services to ‘treat and leave’ or – more likely – refer the patient to health services more appropriate than the hospital emergency department.

In rural areas, new health care models with flexible workforce roles are emerging to meet the community needs. The view amongst ambulance services is that the introduction of extended care practices for paramedics benefits health care, especially in rural and remote communities. To better understand this issue, a study was commissioned to review and analyse this expanded role of the ambulance paramedic in rural and regional Australia.

The study examined information evolving pre-hospital practices in the United Kingdom, Canada and the United States, health workforce issues and projections in rural and remote Australia, and the current issues affecting health systems. The findings confirm that paramedics are becoming the first line of primary health care providers – particularly in small rural communities – because of stretched hospital emergency departments and the diminishing capacity of medical practitioners to attend patients outside their surgeries. Thus the provision of integrated pre-hospital clinical care by ambulance services, local health care providers and other stakeholders has high potential to enhance health services for rural communities. There is an obvious national benefit of fully evolving and integrating these expanded-scope paramedic models into the health care system, in terms of health resource efficiency, continuity of care and quality of patient outcomes.

The health continuum

The transition of a patient from ambulance care into the hospital or other health facility needs to be seamless. Treatment regimes should be complimentary across health providers. The patient should experience a smooth transition whereby the care of the paramedic does not differ from the care of the receiving or referred facility.

By being part of the care continuum, a patient’s personal, event and treatment histories can be transferred from one health professional to another, in a smooth, efficient process. This is vital for appropriate patient care and can avoid repetitious, wasteful diagnostic procedures. It allows the receiving facility to gain a complete history of the patient’s event from the home or first contact, ensuring the transfer of significant information that may seem irrelevant to the patient. In time-critical circumstances, this can speed the patient’s movement through the system.

Of course, a patient is involved in the delivery of health care from the moment they are first sick (and recognise it) or injured, until they are restored to stable health. They have no time for cross portfolio/inter-professional pettiness, and have the expectation that the entire health system will work toward making them better. The patient journey from home or event into the receiving facility must be seamless. Anything else indicates system inefficiency and deficient patient care.

Another contribution to the “continuum” is the movement or flow of patients through and from the health system. Ambulance and hospitals are now working together to provide solutions to patient flow blocks. As ambulance delivers and removes patients from facilities, it is now understood that they can play an integral role in creating efficient patient movements.

There have been significant improvements in efficiencies of patient flow within the health system, with initiatives such as electronic booking systems, web based patient transfer status boards, prioritising patient discharge movements and altering timings of patient movement events (pre discharge examinations, etc.). In an environment of critical bed block issues, this reaffirms the need for health and ambulance to be on a continuum.

Following the care provided to patients, ambulance services are ideally placed to co-ordinate their most efficient and effective movement when required. A whole of Health approach means that paramedics are now emerging as major players in the continuum of care and systems.

Ambulance services will continue to identify and explore opportunities to contribute to the health care continuum and optimise patient outcomes. The focus will be to build organisational capacity for rapid and appropriate emergency response; (the far more prevalent) provision of urgent advice or treatment, and treating or moving those otherwise unable to access health care services.

Conclusion

The ambulance service is the natural extension of the health system to inaccessible and/or traumatised members of the community, whether through ‘treat and transfer’ or ‘treat and leave’ programs. Given the site-based limitations of General Practitioners and the untenable burden on hospitals, ambulances can substantially add to the mobility and capacity of the health system. Through integration, strategic agendas, resource allocation and treatment regimes can all be aligned. For patients, timeliness, continuity of care and consequent health outcomes can all be enhanced.

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