Emergency Medical Services & Emergency Medical Science - Where Now?
Prof. Gerard Bury MD, FRCPI, MRCGP, MICGP, Professor of General Practice, Director of the UCD Centre for Emergency Medical Science (CEMS)
A CASE STUDY
A small town in Ireland – in Sligo or Kerry, Wicklow or Donegal... Mr. Kelly, a man in his 70s complains of central chest pain and becomes very unwell. His distressed wife has called their daughter Emma to come and help; while they are talking, Mr. Kelly slumps to the floor, becomes unresponsive and appears to stop breathing.
What care will he receive? Situations like this arise every day and are managed by a well functioning emergency care system with volunteers and professionals working closely together.
Emma phones 999 and is connected to the National Ambulance Service (NAS) Control Centre, recently centralised to a high-tech site in Tallaght, County Dublin. A call-taker takes brief details before recognising that the situation she describes may well be a cardiac arrest, coded as ‘9Echo1’ (the highest priority) on the internationally standardised Advanced Medical Priority Dispatch System (AMPDS) used to manage all calls. As soon as the code appears on the computer system, a dispatcher at a nearby desk begins to allocate resources while the call-taker continues to talk to Emma.
The Computer Aided Dispatch system indicates available ambulances and Rapid Response Vehicles in the area and also automatically identifies and alerts volunteer Cardiac First Responders or nearby participating GPs who may be in a position to reach Mr. Kelly before an NAS crew. While the dispatcher juggles these assets, the call-taker asks Emma to re-check her father and then gives simple instructions on how to do compression-only CPR.
A local GP is making a housecall nearby when she receives the alert and goes to Mr. Kelly’s house immediately – Emma is doing CPR reasonably well and continues while the GP opens her Advisory External Defibrillator (AED) and attaches the adhesive pads to his chest. He is in Ventricular Fibrillation (VF) - she delivers the initial shock and immediately resumes CPR. At that point, a volunteer Cardiac First Responder from the local group arrives and they begin two-person CPR, using an airway adjunct. As they deliver a second shock, an ambulance arrives with an Advanced Paramedic crew member; the second shock produces a return of spontaneous circulation and soon afterwards, Mr. Kelly’s blood pressure is measured at 95/70, his heart rate is 68/min and regular and his SpO2 is 95%. A 12 lead ECG shows an anterior ST elevation myocardial infarction (STEMI).
There is excellent evidence that early Percutaneous Coronary Intervention (PCI), carried out within two hours of onset of a STEMI, is the best treatment in terms of survival and long term bene t. Since 2012, Ireland has had six hospitals providing round-the- clock PCI facilities in their interventional cardiology departments; the key challenge is to reach that centre within two hours of the first ECG to show STEMI changes. In many parts of Ireland, that time-critical deadline is met by the joint NAS / Irish Air Corps Emergency Aeromedical Service, introduced in 2012. If a land ambulance is unlikely to get Mr. Kelly to the nearest centre within those two hours, the Air Corps AW139 will be tasked to do so. With a crew that includes an NAS Advanced Paramedic, Mr. Kelly will receive ongoing monitoring and analgesia during his trip to hospital; the GAA pitches of most towns and villages around Ireland have been mapped and act as informal landing sites for the helicopter, which has successfully completed hundreds of such missions during its trial period in this role.
PERFORMANCE AND CHANGE
Mr. Kelly’s case study is a realistic narrative of high quality care delivered to many patients in recent years. However, it’s not the full story. As our country and health service struggle with painful financial restrictions and major structural changes, the NAS and the broader EMS community have faced many challenges. In recent months, the Health Information and Quality Authority (HIQA) has published two reports on aspects of our pre-hospital emergency care systems; key weaknesses were identified and recommendations for improvement set out [1,2]. Two further reports due early in 2015 will explore the capacity and capabilities of the NAS and its longterm relationship with Dublin Fire Brigade, which provides emergency ambulance services to most of Dublin City.
Our ambulance services comprise a key part of the emergency medical system but other components are also vital. Our hospital systems and particularly their Emergency Departments have experienced major changes in funding, organisation and roles which have significant implications for the communities they serve. Community services, including general practice and lay volunteers have also had clear recognition of their roles and potential.
KEY PERFORMANCE INDICATORS
So what has HIQA said in its analysis? Overall, HIQA says it has concerns about NAS performance. In all parts of our healthcare system, performance measurement should be an integral part of how we work and learn – it must be a tool to help us improve, not a stick with which to beat individuals.
Much therefore depends on how we measure performance.
HIQA highlights an Emergency Medical Services (EMS) system which relies on ‘legacy’ structures
and procedures and which has much work to do to become a uniformly high quality provider of care
to all of its patients, all of the time. HIQA expresses concern about the poor record of the NAS in meeting the time targets for emergency responses to 999 calls, reporting that in a 15 month period, only 58% of the most critical calls – Echo calls, – received a response within eight minutes and only 34% of the next most serious category – Delta calls, received a response in the same time period.
However, is HIQA itself part of the problem? During much of 2010 and 2011, the NAS, HIQA and the Pre- Hospital Emergency Care Council (PHECC) worked together on the development of Key Performance Indicators (KPIs) for EMS. There is general acceptance that KPIs have much to offer all health care services and the communities we serve – however, they should be valid (measure what it important) and reliable (offer consistent results). In 2011, HIQA formally required the NAS to introduce time-based targets, as the only measure of its clinical performance – essentially, to ensure that 75% of Echo calls received a response within eight minutes. A timely response is obviously critically important in cardiac or respiratory arrest but it is not the sole determinant of the quality of care provided. Paradoxically, a cardiac arrest patient who receives an EMS response at nine minutes and is resuscitated from VF (perhaps Mr. Kelly?) is counted as an inadequate performance issue by HIQA, whereas a similar patient who receives a response in seven or eight minutes but is not resuscitated, is a success story. Both NAS and PHECC strongly advised HIQA at the time that time- based targeting by itself is a poor measure of the performance of such a complex clinical service and that clinical KPIs should be introduced in parallel . HIQA chose to rely solely on time targets – its recent report is influenced heavily by performance against those targets but also accepts that clinical KPIs have a role in the future.
Many such clinical KPIs can be identified and are likely to be introduced by individual EMS services in Ireland and elsewhere in coming years (aspirin and ticagrelor for STEMI, control of seizures on scene, treated hypoglycaemia, adequate pain relief etc). However, if the public (and the statutory regulator of health service quality) continue to rely on surrogate measures of performance which have limited validity, then confidence in the EMS system may continue to fall.
Change to improve meaningful performance (clinical care) must be our goal. Much has changed in Irish EMS in the last decade and our systems are unrecognisable from those of two decades ago. But as the cliché says, much remains to be done. Appropriate change in systems and clinical practice will hopefully gather pace in the short term – some examples may illustrate the changes on the way:
1. SCOPE OF PRACTICE
Paramedics and Advanced Paramedics now deliver care that, until a few years ago, was the exclusive domain of registered medical practitioners and which required equipment and skills only available in specialist hospital units. Defibrillation, cardioversion and STEMI thrombolysis are among those skills; potent pain relief, reversal of hypoglycaemia and seizure control are among the pharmacological interventions available. Understandably, the rapid evolution of education, skills and Clinical Practice Guidelines has focused on ‘high acuity’ problems which threaten life or limb.
'Treat and Refer' or 'Treat and Discharge'
The next major shift in scope of practice may involve a re-focusing on those clinical problems dealt with by EMS which are ‘low acuity’ but very common. Some overseas ambulance services deal with up to 40% of their callers without sending an emergency ambulance - callers may receive advice, be referred to an alternative service (such as their GP or an out- of-hours service) with an appointment or be dealt with on a non-emergency basis.
‘Treat and Refer’ or ‘Treat and Discharge’ procedures carried out by Paramedics can safely and effectively deal with many problems. Those problems might include treated hypoglycaemia or seizures among patients where these are well established problems or certain types of minor injury or illness. Of course, most experienced clinicians will say that a problem is ‘minor’ only with hindsight and that every presentation has the capacity to be the start of a more serious illness. The skillsets needed are therefore complex and new for Paramedics and
in many ways, are reminiscent of those required by any good doctor – taking a careful history, establishing rapport, constructing differential and working diagnoses and formulating and negotiating a plan. The clinician also needs to be comfortable with taking responsibility for those decisions and needs to cope with the uncertainty (there’s always uncertainty...) of each clinical situation. The education of Paramedics is therefore likely to change considerably.
2. PARAMEDIC EDUCATION
Traditionally (certainly for the last 50 years), Paramedics in the UK and Ireland have been trained after they join the workforce, by the services which employ them. The inadequacies of this strategy have been well recognised, so that in the UK, by 2019, every Paramedic joining the workforce will be the graduate of a university programme (of three or four years' duration) which is closely aligned with the education of doctors, nurses and other healthcare professionals.
The introduction of third level education for future Paramedics in Ireland is less clear. UCD Centre for Emergency Medical Science (CEMS) has proposed the introduction of such pathways to government and UCD has accredited a four year Honours BSc Emergency Medical Science programme – however, its adoption as an option for those entering university is subject to government decisions on funding and how the NAS should adapt to such change. When introduced, these programmes will incorporate the care of high and low acuity illness and injury, the use of complex interventions and a closer integration of Paramedics into the education and Continuous Professional Development frameworks used by other healthcare professions.
3. COMMUNITY INTEGRATION
Since 2006, UCD CEMS has run the Medical Emergency Responders: Integration & Training (MERIT) Project which has equipped and trained more than 500 general practices around Ireland to deal with cardiac arrest in the community. The investment of more than €3 million by HSE, Department of Health and PHECC in this project represents one of the biggest research investments in general practice in Ireland in the last decade –
and has paid off handsomely. We recently reported almost 300 Cardiac Arrests with Resuscitation Attempts (CARAs) by GPs in the first five years of the project.4 Overall, 35% of practices reported a CARA in the study period and almost 19% of all these events resulted in a well patient being discharged from hospital. Most general practices in Ireland now have an AED and the most recent MERIT project is linking volunteer GPs all over the country to the NAS Control Centre, to be alerted in case of cardiac arrest in their locality.
Lay volunteers who join CFR groups around the country have made a great contribution to achieving rapid responses to cardiac arrests. CFR Ireland is the umbrella group for those local groups – their annual conference (Respond 2015) is becoming a highlight (www.cfr.ie).
The rapid development of a network of local volunteer responders is a key recommendation from HIQA, both in relation to the work of the NAS and in its Heath Technology Assessment of AED deployment in the community.
4. HOSPITAL GROUPS
In 2013, the government announced a major re-structuring of the country’s hospital system, by creating six networks each essentially centred on one of Ireland’s six medical schools . The intention
is to ultimately have a number of trusts which have a good deal of scope to address the needs of the populations they serve as efficiently as possible. It also implies that each trust may develop its own methods to address those needs, including the care of emergencies. It may therefore offer opportunities for emergency medical science to research new ways to offer such care.
‘Transport medicine’ has already been identified as a key innovation. With the reduction in the number of Emergency Departments which take emergency ambulances from more than 40 to around 20, patients with complex problems are being cared for for longer periods. Patients who are very unwell are also being transferred from smaller hospital to a small number of specialist national units. The science, logistics and training needed to deliver these diverse forms of emergency care are being brought together, under the auspices of the PHECC and will provide a novel expertise within the EMS family.
Both emergency medical science and emergency medical services are vibrant and central components of our health services. The challenges and opportunities they present make them increasingly central to academic medicine. Mr. Kelly’s case is an example of the high quality care we can deliver – we now need to make sure we deliver that standard of care to whoever needs it, whenever or wherever they are.
Much more to do...
About the UCD Centre for Emergency Medical Science
UCD CEMS was established in 2001 (under a different name) as a teaching, research and innovation centre. CEMS is a unit within Academic General Practice at School of Medicine & Medical Science (SMMS) and grew from our beginnings as the only unit in Ireland delivering Immediate Care training to Irish GPs – we continue to deliver about 400 training places for courses in cardiac, trauma and paediatric care each year. MERIT (Medical Emergency Responders: Integration & Training) a has greatly strengthened our Immediate Care teaching by linking teaching to the delivery of care in cardiac arrest and the collection of high quality research data. This is one key part of our research activities.
CEMS is the only unit in Ireland accredited to provide both Paramedic (DipEMS) and Advanced Paramedic (GradDipEMS) training, in association with our partners, the HSE National Ambulance Services College. More than 1,500 Paramedics and Advanced Paramedics have graduated from our programmes. The establishment of two MScEMS programmes (one for APs and one for Doctors, Nurses and Paramedics) has broadened our range of teaching opportunities.
CEMS also takes responsibility for components of the undergraduate medicine programme by accrediting all students in BLS and delivering an intense course in emergency care skills in the Professional Completion Module of final semester.
We work closely with partners in the HSE NAS, Dublin Fire Brigade, Defence Forces and many others; we look forward to working with colleagues and students throughout UCD to bring Emergency Medical Science to a wider audience.
- Review of pre-hospital emergency care services. HIQA, 2014.
- Health technology assessment of Public Access Defibrillation. HIQA, 2014.
- Price L. Treating the clock and not the patient: ambulance response times and risk. Qual Saf Health Care 2006;15(2):127-130.
- Bury G, Headon M, Egan M, Dowling J. Cardiac arrest management in general practice in Ireland: a 5-year cross sectional study. BMJ Open 2013;3(5):
- The Establishment of Hospital Groups as a Transition to Independent Trusts. Department of Health, 2013.
All photos were provided by UCD CEMS and portray Emergency First Responders in training