Hiqa: Ambulances being used inefficiently

Many people who call an ambulance should be treated on the phone or by paramedics rather than being taken to hospital, according to a major report on the ambulance services.

The report criticises the lack of coordination between the National Ambulance Service (NAS) and the Dublin Fire Brigade (DFB) and says they could do more to work with hospitals to address ambulance delays.

However, delays are a complex problem requiring a multi-faceted approach, states the review of pre-hospital emergency care services by the Health Information and Quality Authority (Hiqa).

Over recent years, the ambulance services have been at the centre of repeated controversy over delays in getting seriously ill patients to hospital. There has also been friction between the national service and the DFB over responsibility for services in greater Dublin.

The Hiqa review says “it is possible” more ambulances and response vehicles may be needed, but there is also significant scope to improve services with existing resources. This can be achieved by improving the efficiency of control-centre call-handling, dispatch and resource mobilisation.

In addition, the NAS and DFB could improve response times by better matching of their resources to demand and redeploying resources away from ambulance stations based on a predictive analysis of ambulance need.

The report calls for “better ownership of performance amongst staff and managers” and suggests there is no longer a need to bring almost all patients to hospital emergency departments, as happens now.

“This model of care is not in keeping with international best practice which, when it is safe to do so, now looks to treat patients with certain conditions via telephone consultation; treat patients at the scene and then discharge them; or treat patients at the scene and then refer them to an alternate healthcare provider.”

In other countries, almost half of all patients are successfully treated by paramedics without bringing them to hospital, the report says. “Transporting what is an annually increasing number of patients to the emergency department is not sustainable for the two ambulance services or acute hospitals.”

Efforts to explore alternative treatment paths have been limited, it notes, and needs to be addressed. However, it will require more paramedics. There is scope too to bring some patients to local injuries units rather than emergency departments.

Hiqa chief executive Phelim Quinn called on the two ambulance services to publish a joint action-plan setting out how they will improve performance. “It is of serious concern to Hiqa that current governance arrangements between the NAS and DFS are disjointed, with inadequate quality assurance and accountability controls.”

The problem of ambulance delays, which occur at emergency departments when patients are being handed over, is a complex one that requires a multi-faceted approach. The NAS and DFB could do more to work in partnership with hospitals to address the issue.

The public also has an important role to play in ensuring ambulances are used appropriately, and need to be aware of alternatives to emergency departments.

The report says the DFB and the NAS are not integrated and there are “poor levels of cooperation” between both entities which is not in the best interest of patients, especially in the use of pooled ambulances. It recommends the creation of a fully integrated ambulance service in greater Dublin.

Despite progress in clinical care capability, other aspects of the services provided to patients have not progressed as well as they could have, Hiqa’s report states.

This is the result of “legacy issues” dating to the “fragmented nature” of the original nine providers of ambulances services across the State, with the NAS struggling to fully integrate services.

"To overcome this problem, ambulance services in Ireland must continue to undergo significant change. Such change is ongoing, with the NAS moving from six ambulance control centres to one national ambulance control centre over two sites."

It calls for effective leadership, clear strategic planning and constructive cooperation between management and staff to best serve patients relying on the service.

“Better performance could also be achieved through an ongoing investment in management support and training. Using alternative models of treatment, better pooling and use of existing resources, further development of community-first responders, and public engagement on appropriate use of services.”