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SUBMISSION TO EXPERT ADVISORY COMMITTEE “Healthy Hospitals Come From Healthy Debates.” April 2004 Authors Adrian L Abel, BEd, DipTeach, AssocDipAppSc (Ambulance), MACAP - Chairman, Tasmania Branch. Peter D Morgan, BHSc(Pre-hospital), AdvDipEmergMgt, AssocDipMgt(HRM) AssocDipSocSc, FACAP -Secretary Treasurer, Tasmania Branch. Timothy A Rider, MHSc, BSocSc(Emerg Mgt), AssocDipAppSc(Ambulance), MACAP - Vice Chairman, Tasmania Branch. 1-5 Melville St Hobart TAS 7000 Ph 0418 1264362 Table of Contents The Australian College of Ambulance Professionals The Current Position Relating to Ambulance Practice Comments on Issues Paper OFD1.1 Reduce Waiting Times through the adoption of Clinical Service Frameworks OFD 2.2 Targeting Education Campaigns OFD 2.3 Increased specialisation through dedicated service centres. OFD 2.4 Increase Home and Regional Treatment Options OFD 2.5 Emphasising the Role of Primary Health and Community Care OFD 2.6 Palliative Care at Home FD 2.7 Role of the Tasmanian Ambulance Service OFD 3.5 Improve Health Care Support in Residential Aged Care Facilities OFD 3.6 Increase Capacity for Alternatives for Acute Care OFD 3.8 Greater Involvement for Rural Public Hospitals OFD 4.1 Develop a Australian/State Government Technology Partnership Agreement OFD 4.2 Ease Pressures on Acute Care Hospitals by the Expansion of Quality Assurance Technologies OFD 4.3 Ease Pressures on Acute Care Hospitals by Expansion of Home Technology Options. OFD 5.1 The Development of a Workforce Strategic Plan . OFD 5.4 That the Tasmanian and Australian Governments, and the University of Tasmania Work Together to Encourage and Actively Facilitate the Health Research Capacity of the Sector OFD 5.5 Extending Public/Private Cooperation In Tasmania OFD 5.7 The Development of a Workplace Recruitment Plan OFD 5.9 Workforce Retention Plan OFD 6.1 Education Strategic Plan OFD 6.2 Funding Teaching Activities OFD 6.3 Increasing the Training Opportunities for Health Professionals OFD 6.4 Nurturing Our New Graduates OFD 6.5 Strengthen the Links between Clinical Education and Research OFD 6.7 Extension of Current Arrangements for the Financial Support for Health Students. OFD 7.1 Increase preparedness OFD 7.2 Consider Scale OFD 7.3 Ensure a Consistent Response OFD 7.4 refine financial arrangements Recommendations for improvements to the provision of Pre Hospital Care services in Tasmania. Recommendations for changes to supporting systems to the provision of out of hospital care of Tasmanian Residents. Glossary of terms Bibliography
The Australian College of Ambulance Professionals (ACAP) is an interested party in the process of review and reform of the Health system within Tasmania. The interests of the pre-hospital care industry do not appear to have been fully considered so far in the issues examination process apart from moving patients from hospitals. In this paper the College will suggest a number of mechanisms whereby the provision of primary healthcare can be better managed through change. The Australian College of Ambulance Professionals ACAP was established in 1973 as the Institute of Ambulance Officers (Australia) and is the peak national body representing ambulance professionals. ACAP is the leading representative association for professionals engaged in the delivery of pre-hospital emergency medical systems. The Current Position Relating to Ambulance Practice Ambulance practice is currently regulated in each State and Territory by Acts of Parliament. Ambulance professionals are licensed to practice by their employing agency. This agency establishes and governs the skills and knowledge required of the paramedic and also establishes the limits to which they will practice. Ambulance paramedics are not enabled to practice outside the bounds of a State authorised agency. These agencies are also tasked with the provision of training and education as well as professional discipline of practitioners. The Convention of Ambulance Authorities (CAA) intent is to establish common practices amongst ambulance authorities. There is a standard education curriculum set out in the “Health Services Training Package”. However this package allows sufficient leeway for there to be considerable variances in agreed practice between agencies to provide for geographic and demographic demand profiles. ACAP’s View for the Future of Pre-hospital Health Care. Ambulance Professionals in their daily practice identify the need for change to the current system of Pre -hospital care provision in the state of Tasmania. It is ACAP’s position that a change to the scope of practice for the Tasmanian Ambulance Officer/Paramedic can offer overall savings to the Tasmanian system of health provision and provide significant improvement in morbidity and mortality for Tasmanians. In this document we will offer suggestions for improvement in both ambulance practice and affiliated practices. The College asserts that Ambulance practice within Tasmania has not kept abreast of international best practice when compared with Europe and North America. We recommend that the Tasmanian Government move to develop an Emergency Medical System (EMS) comparable with contemporary international practice. The United States National Highway Traffic Safety Administrators “Agenda for the future” which has set the framework for direction of EMS in the in the USA , foresees EMS agencies, undertaking a community based health management role that is fully integrated with the overall health system.1 The College would welcome the opportunity to expand the issues identified in this paper during any public consultation. Comments on Issues Paper OFD1.1 Reduce Waiting Times through the adoption of Clinical Service Frameworks The College contends that whilst the objective of this OFD is aimed at reducing waiting times, there is the opportunity for this to be extended to the pre-hospital environment. By doing this it will ensure that current and evidence based guidelines are used by pre-hospital personnel and enable the continuum of care. This will has the potential to offer the Tasmanian community significantly improved outcomes by developing an improved scope of practice for its existing paramedics. If these recommendations are to be adopted, we contend that we can provide a significant improvement in mortality and morbidity amongst the Tasmanian community. The current scope of practice for Tasmanian paramedics is pedestrian compared with international best practice. The English system in particular has seen groundbreaking improvement in the past decade. ACAP contends that the Tasmanian public would be better served if the TAS was to be refocused into an Emergency Medical Service (EMS) in the context of international systems. ACAP foresees that by improving service delivery so that paramedics are able to provide such procedures as pre-hospital thrombolysis to patients, especially those from outer metropolitan and rural areas, a significant reduction in the morbidity and mortality of Tasmanians suffering from heart attacks may be achieved. This technology and practice is already available to pre-hospital care providers in a number of centres throughout the world and many studies have shown the benefits of such programs.2,3,4,5,6,7,8,9,10 Other pre-hospital interventions can have the potential to improve outcomes in patients by reducing length of stay (LOS) in hospital and thus savings in both monetary and resource usage. A recent review of the use of pre-hospital steroids in moderate to severe asthma has shown a reduced LOS when compared to patients that received steroids in the hospital environment.11 This study shows that there is the potential for early pre-hospital interventions having a significant impact on the whole of health system. The use of intravenous steroids is already a standard of care used by TAS paramedics. Other perceived improvements are in the area of the management of brain trauma. There are comprehensive pre-hospital and hospital guidelines on the management of traumatic brain injury that have been developed by the Brain Trauma Foundation to ensure that there is a continuum of care in this patient group.12 The English NHS systems have identified that significant improvement in patient mortality and morbidity can be shown if Ambulance response times can be improved so that 90% of emergency cases are responded to within 8 minutes. Similarly the Canadian OPALS study identified similar results in their review of defibrillation and cardiac arrest13. The OPALS study is ongoing and is looking at aspects of pre-hospital interventions in respiratory, cardiac and trauma patients. Results of these should be released soon. Some two decades ago Professor Ron Stewart of Pittsburgh first described the concept of the “Golden Hour”. This concept suggests that trauma patients have the greatest chance of good recovery if they are able to be in surgery within one hour of the incident insult. The experience of Tasmanian members of ACAP is that our ability to manage patients within this timeframes is often compromised. ACAP believe that better systems of response and immediate retrieval to an appropriate centre, particularly in rural areas are required as a matter of some urgency. ACAP has a clear view that to improve rural outcomes we as part of the Tasmanian community need to provide improved response times both from paramedics and rapid transport to a facility of adequate care. Often the solution to this problem is aviation, either from rotary or fixed wing aircraft. The College sees the provision of paramedics in the rural communities as imperative. It proposes that the scope of practice of these people be improved and expanded into the role of a Paramedic Practitioner14. This is a concept similar to that of the proposed Nurse Practitioner. The College argues that the up-skilling of ambulance paramedics in some rural areas would be beneficial to providing an integrated health care system with existing healthcare professionals. Paramedic practitioners will be able to provide a high level emergency medical response system as well as provide additional health services. The College remains concerned that there are still members of DHHS who think that nurses are a panacea for out of hospital emergency care systems. The College identifies that broadening the skills of the isolated paramedic and change of work design can have the potential to provide support to the provision of rural health services. Conceptually the paramedic practitioner, in whatever form finally chosen, can manage such things as (but not limited to) emergency medical response, minor suturing, catheter management, minor prescribing, vaccinations in the community, wound management, chronic illness management and triage services. The College also has some concerns about the lack of informality of skills sets amongst paramedics. In most EMS systems, paramedics provide endotracheal intubation as a part of their skills set. In some parts of Tasmania, this is not the case with only a proportion of paramedics being able to utilise this procedure. The College contends that all paramedics are trained in this procedure with consideration to using an alternative airway system for ambulance officers. OFD 2.2 Targeting Education Campaigns ACAP identifies potential benefit in the expansion of this criterion to support its actions in pre-hospital care. Compared with international best practice we have been lacking in this area. Certainly in the United Kingdom and North America, EMS systems play a significant role in education programs. Members identify that amongst other health promotions, campaigns promoting the appropriate use of ambulance, warning the public about the use of violence against ambulance officers, etc would offer the potential for cost savings over time. OFD 2.3 Increased specialisation through dedicated service centres. The College acknowledges the value of such proposals and the benefits it can have for Tasmanians as a whole, however, we ask that in preparing these proposals that ambulance be properly consulted about the impact upon it and that they are provided with the appropriate support/staffing required to allow it to happen in a timely fashion.8 Other considerations to this model include the concept of medical retrievals around the state. With the increase in dedicated service centres, there is a real potential for increase in demand on the current retrieval system. The current practice uses doctors as retrieval specialists in some patient groups. It may mean that there will be a strain on the ability to supply appropriately trained medical officers to fulfil this retrieval role. As part of the process, we need to examine whether we need to “up skill” our flight paramedics to manage some of these patient groups and then be able to provide specialist retrieval doctors when the need arises. We may also need to consider specially trained road transport teams. We suggest that other models in regards to this issue be reviewed such as those in USA and Canada (Ontario). In resolving this, the DHHS may need to consider tasking helicopters for medical retrieval such as that used in most mainland hospitals. We foresee that there may also be a need in the near future to provide a second fixed wing aircraft for aero medical transport The College identifies that DHHS needs to establish transport protocols so that paramedics can “by pass” some rural and regional hospitals when the patient’s condition dictates that they need to go immediately to a dedicated service centre. For example, head injuries from the West Coast are taken straight to Hobart and not to Burnie and then have a secondary transport with its associated risks and costs. There was a review of the Victorian trauma system several years ago and there are some recommendations in that review that would have some impact on trauma systems in Tasmania. OFD 2.4 Increase Home and Regional Treatment Options Improvements in this area suggest probable impact upon all ambulance services including PTS and voluntary ambulance units that requires careful consideration. It is likely that many volunteer centres would refuse or be reluctant to participate in the routine transport of patients between health facilities. Volunteers are usually recruited in rural areas to provide an emergency ambulance first response to the local community. Many need to leave work when paged or contacted to attend an ambulance call. We are fortunate that many employers still support their staff to attend emergencies. It is not reasonable, however, to expect that these good offices will continue to cover routine medical transport. TAS already experiences these phenomena. The impact of this experience is that we may need to develop regional transport mechanisms outside of that of the traditional Ambulance Services. Alternatively, we may need to upscale the existing PTS or private contractor transport options. 9 We do highlight that with the increased use of home and community treatment there needs to sufficient resources to provide appropriate after hours support. There is often increased workload on the ambulance service and emergency departments as a result of lack of support services. If it deemed that the ambulance service is to undertake this after hours support role then there must be appropriate resources and training supplied. One area is that of mental health services. After hours there is a crisis intervention service that is operating up to 2300hrs. After that there is very little support and the ambulance service often becomes the first point of contact. The ambulance service personnel need appropriate training and guidelines if they are to effectively deal with these patients. This may require a revision of the Mental Health Act 1996 to make TAS personnel authorised officers. Previous reviews have look at the difficulties of General Practitioners and other health workers in dealing with mental health patients but ambulance have largely been ignored. OFD 2.5 Emphasising the Role of Primary Health and Community Care The College members already provide a significant primary health and community care solution to the community on an after hours basis as part of our routine ambulance response. Many community members feel isolated due to their inability to access “after hours” support, falling back on ambulance service for this support. The answer to this conundrum is not an easy one however we suggest that there are community options in use around the world that could be considered for the Tasmanian community. One option recently trailed in Sussex UK, has been the contracting of the Sussex Ambulance NHS Trust to create an integrated out of hours service. This model sees the Ambulance Service employing Nurses and GP’s in addition to paramedics to support the community. TAS already operates a state of the art communications centre, 24 hrs a day that could with the appropriate funding be expanded into a community telephone medical advice centre with appropriately qualified staff. OFD 2.6 Palliative Care at Home The College encourages the support of home palliative care. In doing so we acknowledge a potential small increase in ambulance demand to support these patients and families. We encourage the provision of good family education processes particularly in developing expectations of the ambulance service when patients become unwell.10 An issue affecting ambulance staff with patients wishing to die at home includes the concept of “living wills”. Occasionally Ambulance staff have the conundrum of family members insisting that their loved one be resuscitated when that may not be the patient’s wish. Mechanisms exist through the Guardianship Board for people to specify their wishes in respect to whether or not they wish to be resuscitated or not however these wishes need to be clearly transmitted to ambulance officers and paramedics. The College encourages clarification of living wills and the provision of clear direction and protection for Ambulance officers in these cases. OFD 2.7 Role of the Tasmanian Ambulance Service Throughout this document the College has promoted changes in the manner in which the government and DHHS operate the Tasmanian Ambulance Service. With a proactive approach the Government can provide its people with a world class EMS system that offers the potential to improve the mortality and morbidity of Tasmanians. The College encourages debate about the future role of ambulance paramedics within the health system. We acknowledge that some of the concepts we have provided will not sit well with some parts of the health community but in the context of an integrated health system offer plenty of benefit for Tasmanians. In suggesting change, we do of course expect that any change would occur as a result of evidence based medicine and that the TAS Clinical Council would monitor the impact of these changes on the community. One of the greatest concerns that College members have at the current time is that of “response times.” Current best practice indicates that 90% of emergency cases in “urban” areas should be attended in less than eight minutes; this should not be confused with 90% of cases being attended in less than an “average” of eight minutes. As can be seen this concept can easily become unclear and sound definitions and guidelines need to be established to report against. The College asks that it be provided with membership of the Tasmanian Ambulance Service Clinical Council. It is inappropriate that a professional College not be offered membership of the governing Board that determines practice within its profession. The College would like to be involved in discussion about mechanisms for the ambulance service to expand its income generation activities such as training, first aid provision, advice etc to the public.11 The College urges DHHS to integrate and restructure its patient transport service (PTS) into a state-wide organisation controlled from the TAS State Communications Centre, in order to reduce some of the inefficiencies currently experienced by having different command and control systems. Further our members would like to see the system expanded further and have its hours of operation expanded into the early evening and weekends. By doing this we should reduce the number of incidences of emergency ambulances in metropolitan and rural areas being tasked with routine patient transport due to the unavailability of PTS. The College does not have a position on the use of Private Contractors, other than to identify that they require (like the TAS PTS system) to be licensed and their actions held against their licence conditions. The licence must detail the qualifications of the staff and ensure that regular skill updates are undertaken. At this stage, the College does not support their use for anything other than routine transport of patients. The College has some concerns about the skills provided by contractors at sporting and recreational activities. The College recommends that a proper risk analysis be performed by the DHHS to determine appropriate skill levels of the officers who attend these activities. These include high speed motorboat racing, horse racing of all descriptions, motor cycle demonstration racing, motor cycle racing and others. OFD 3.5 Improve Health Care Support in Residential Aged Care Facilities The health care support system that is currently available to aged care facilities after hours is limited with the ambulance service and the hospital emergency departments filling a large portion of the void. Often patients are transferred from these facilities for conditions that should be able to managed in these facilities by appropriately trained staff. Catheter changes and routine nursing procedures are frequently directed other facilities due to lack of trained staff or time available for these personnel to undertake these procedures. Conditions such as minor suturing are also transferred due to lack of after hours GPs. This increases the workload on both the ambulance service with emergency vehicles tasked to do these transports and at the moment is not an efficient model.12 OFD 3.6 Increase Capacity for Alternatives for Acute Care The College welcomes improved, alternative models of acute care but is concerned that the demand on ambulance may increase and without additional resources may compromise emergency operations. The College has outlined above some alternatives such as the paramedic practitioner, after hours response system and expanded scope of practice. Other models could include rapid response vehicles. OFD 3.8 Greater Involvement for Rural Public Hospitals The College reiterates it concerns about increasing workload with transfer between health facilities and possible impact on volunteer officers. The College identifies the potential for the use of paramedic practitioners in emergency departments of rural hospitals. For more detail see OFD 5.1. OFD 4.1 Develop a Australian/State Government Technology Partnership Agreement The College supports any technological innovation that improves excellence of outcomes in the health care system. Such innovations could include computer based patient care reports that can be integrated into the patient’s medical record and also provide the basis for a comprehensive quality improvement/assurance program. OFD 4.2 Ease Pressures on Acute Care Hospitals by the Expansion of Quality Assurance Technologies. As mentioned in OFD 4.1, the provision of quality assurance technologies would assist the TAS in providing best practice in pre-hospital care whilst providing a system and culture of quality assurance and improvement excellence. OFD 4.3 Ease Pressures on Acute Care Hospitals by Expansion of Home Technology Options. The TAS already deals with patients of home alarms and alerts systems and the various companies that market these services. In addition to these services, there may be an increase of more technical equipment such as home dialysis machines. The College is supportive of these types of equipment as long as training and resources are provided. OFD 5.1 The Development of a Workforce Strategic Plan In considering a workplace strategic plan the College raises a number of industry relevant issues for consideration. The provision of pre-hospital care is essentially a profession best suited to younger people. Historically it has been rare for Tasmanian Ambulance Officers to attain a retirement age of 65. The issues are complex and include critical incident stress and the effects of shift work, particularly continued night shift. Other physical aspects include the lifting and movement of patients. It is not possible to have “no lift” policies as most hospitals do. Because of the difficulties in replacing ambulance staff the department has been historically reluctant to let staff move sideways to undertake acting positions elsewhere in government or industry. In the Colleges opinion, the Whole of Government would be better served if it recognised the realities of its staff limitations and actively worked to allow ambulance officers to use their expert skills elsewhere in the community. There is also room for the TAS to take on such things as first aid training and move people sideways, if required. Further benefits to consider in developing a workplace strategic plan include extending and developing the qualification regime for medical/health professionals aligned with that of a basic paramedic degree. We could consider combining ambulance/nursing and other allied health professionals degrees using core competencies/syllabus and then undertaking specialist add ons. This would enable us to have the economies and efficiencies of being able to train Tasmanians mostly in Tasmania. We identify that there is a fair shrinkage of nursing professionals nationally into the ambulance services. Cross skilling employees in both these professions offers a number of possibilities that could be of benefit to the Tasmanian community and to the health system on a whole. It would allow those professionals who seek the thrust and cut of the paramedic profession but allow them to move back into the nursing sector once it no longer suited their aims. This concept further extended offers some solutions in rural areas with cross trained personnel such as a combined nurse/paramedic who could work in the emergency section of a rural hospital such as Queenstown, responding to ambulance cases as required. In the United States some models have paramedics working in Emergency Departments (ED) performing the triage component, others have them working in the ED whilst waiting for calls. OFD 5.4 That the Tasmanian and Australian Governments, and the University of Tasmania Work Together to Encourage and Actively Facilitate the Health Research Capacity of the Sector. The College strongly recommend the establishment of a Pre-hospital Research Unit either attached to the Tasmanian Ambulance service or linked into the University. 14 The preferred model is attachment to TAS with links to the University and the College. OFD 5.5 Extending Public/Private Cooperation in Tasmania The College has no position on the use of service contracts for the provision of government/private non urgent transport services. We would expect any service contractor to adhere to strict patient care and performance criterion that is actively managed. The College is opposed to the outsourcing of emergency ambulance response. OFD 5.7 The Development of a Workplace Recruitment Plan The College recommends the development of a proper workplace recruitment plan. This includes the recruitment and training of Student Ambulance Officers before the actual vacancies occur. The College abhors the proposal by DHHS to employ medical and nursing students as ambulance officers when there are staff shortages. A proper workplace recruitment plan would employ student ambulance officers on the basis of projected demand. The rationale for this proposal is the length of time taken to train a qualified ambulance officer to be able to practice independently. I the future it may be an option for TAS to recruitment some of its student ambulance officers directly from universities offering pre-employment paramedic degrees. The College is happy to provide advice as appropriate. OFD 5.9 Workforce Retention Plan The College recognises that there are a number of issues that impact on the retention of staff. In the rural areas in particular the College would like to see employment strategies that encourage the employment of local residents, rather than the current system which sees a large number of staff transferring from interstate and then leaving again at a later stage. In looking at retention strategies we recommend that the TAS look at working with its staff, especially those with long experience and possibly on selling their services for specified periods of time eg to work on ships, working with Antarctic division etc to give them a spell from the norm of ambulance practice. OFD 6.1 Education Strategic Plan The College supports the adoption of a strategic education plan and agrees with the general position that this issue addresses. The flexible approach to health professional education is further expanded in OFD 6.3.15 OFD 6.2 Funding Teaching Activities The College supports the push to adequately fund clinical teaching positions and the need to raise the importance of this role within the TAS. To this point TAS should review the role and staffing of its Clinical Practice and Education Unit to assess if it is adequately staffed to effectively and efficiently undertake this clinical teaching role. OFD 6.3 Increasing the Training Opportunities for Health Professionals Training in Tasmania for the ambulance profession is restricted to TAS and its student intakes where student ambulance offers undertake a diploma level course through Charles Sturt University. Pre-employment training (in the VET or tertiary sectors) is not available in Tasmania for those wishing to gain this qualification then apply for vacancies. Tasmanians who wish to pursue this option need to attend universities in other states. This has the potential to lose these people to other state service or employers. The College advocates the revisitation of the proposal to create a generic health sciences degree with a core first year syllabus and then allow for specialisation in the second and third years. This may the potential to overcome the lack of training in other health professions. OFD 6.4 Nurturing Our New Graduates The College concedes that if pre-employment training of ambulance professionals’ takes place then there must be provision for opportunities for employment in Tasmania otherwise these trained personnel could be lost to other states and employers. With proper human resource management systems, predictions on staff requirements could be forecasted. The College has concerns about the current training focus of student ambulance officers. These officers are not given the opportunity to have a suitable mentor/preceptor during their studentship with operational rostering requirements often dictating their placement. The College suggests that these students should be with dedicated mentors/preceptors so that their development can be monitored on a continuous basis and not on an intermittent basis as happens now. OFD 6.5 Strengthen the Links between Clinical Education and Research Research in the pre-hospital field is evolving and the College contend that to ensure the application of best practice and evidence based medicine, there needs to be a strong focus in this area. The College strongly supports the focus of this item. 16 OFD 6.7 Extension of Current Arrangements for the Financial Support for Health Students ACAP encourages the improvement of the financial arrangements supporting student health professionals including student ambulance officers. The College proposes that financial incentive schemes be considered to attract and retain staff such as paying of HECS (either full or partial). We would encourage the provision of financial support through scholarships, grants and expansion of the current loan scheme to encourage professional development. ACAP notes that many of the health professions have access to specific funding to assist them in their professional development. We encourage the department to identify mechanisms whereby some of that funding can be applied to paramedic professional development. OFD 7.1 Increase preparedness The College contends that it has a strong role to play in the management and preparedness of emergency management plans for the DHHS. Interstate and internationally, the Ambulance Services are the lead health agency with practical experience in the management of multi casualty incidents. In current planning there appears to have been little interoperability designed and planned. The College recommends that the Department establish a proper emergency management Unit and that senior ambulance practitioners be seconded to that unit, the model proposed is similar to that currently being used by the NSW Health Department. The College identifies the need for the operational management of TAS to undertake the ICS system of incident management similar to that of other Australian ambulance services. That training needs to be further extended to senior ambulance practitioners who may be required to manage an incident at the scene. The interoperability of the health system requires working up in the very short time. The College identifies that there is a clear lack of understanding of roles between the hospital and ambulance services that have emerged following recent anti terrorism exercises. OFD 7.2 Consider Scale The College supports the creation of formal intrastate arrangements to bring interstate ambulance Officers into the state to help us manage our operations during and following a major incident. 17 OFD 7.3 Ensure a Consistent Response The College encourages the DHHS to undertake immediate measures within the department and TAS to address this issue. Recent exercises demonstrate a significant shortfall in knowledge across the system. Some areas of concern include CBR response and protection, cross training of managers, exercising staff, regional medical coordination, the ambulance service and medical team roles in a multi casualty situation. OFD 7.4 refine financial arrangements We believe our role understated and that we need to move more towards a system of the Ambulance becoming and Emergency Medical system. Recommendations As part of ACAP’s internal review arising out of the issues paper we have developed the following series of recommendations, which we believe would improve the provision of pre hospital care in Tasmania as well as improve the morbidity and mortality of Tasmanians. The College is happy to talk to the Expert Committee and argue our case. Recommendations for improvements to the provision of Pre-hospital Care services in Tasmania. Recommendation 1 That the DHHS establish a Pre Hospital Care Research unit within the TAS. The unit would have the responsibility of examining current and future pre hospital care with the task of continually updating ambulance practice throughout Tasmania on an ongoing basis. Recommendation 2 That the Tasmanian Government change the focus of the Tasmanian Ambulance Service from that of an historic “Ambulance Service” to that of an “Emergency Medical Service” (EMS System). That the TAS receive contemporary operational and support funding commensurate with that being provided to the major Australian Ambulance Services to allow it to better service the Tasmanian community. 18 Recommendation 4 That the Tasmanian Ambulance Service / DHHS immediately implement a program of Pre Hospital Anti Thrombolytic therapy, commencing in the rural areas ASAP progressing into the outer urban areas within 12 months. Recommendation 5 That the Tasmanian Government immediately accept an urban response time target of 90% of Emergency responses provided within 8 minutes and 90% of non urban response within 19 minutes in accordance with English and Canadian best practice standards and that they provide appropriate pre Hospital systems to achieve this model. It further recommends that the TAS be funded to achieve this target within 3 years. Recommendation 6 That the Department encourage the professional development of Ambulance Personnel in similar manner to that provided to other Health Professionals through the provision of appropriate funding to allow them to attend Seminars and in Service experience elsewhere in Australia. We note that similar funding is currently available to members of the Tasmania Fire Service and the Tasmania Police Service. Recommendation 7 That the Government immediately provide a seat on the Tasmanian Ambulance Service Clinical Council to the Australian College of Ambulance Professionals, so that the College may proactively work with the other professional Colleges to improve Pre Hospital practice. The College identifies that it is ironic that other health professions are directing the future of ambulance practice, yet Ambulance professionals as such have not been provided with this opportunity. Recommendation 8 That the DHHS immediately establish a working party with strong representation from the pre hospital care industry to examine and introduce advanced pre Hospital practice for ambulance professionals. Recommendation 9 That the DHHS give its staff the opportunity to sit on committees examining Multi Casualty / CBR issues so that practitioners have the opportunity to direct the future of their practice in this important area. The TAS should have a professional ambulance 19 practitioner working on a permanent basis within the Departments Emergency Management unit. Recommendation 10 That all Tasmanian ambulance managers and those who relieve in these positions be immediately trained in the “ICS” incident management system to better prepare them with the skills they require in major incident management Recommendation 11 That the Tasmanian Ambulance Service immediately rejuvenate its Clinical Practice and Education Unit (CPEU) with the necessary additional staff they require to ensure that quality mechanisms exist within the TAS and Patient Transport (private and Government). They should also be provided with separate and appropriate training facilities for their role. Recommendation 12 That The Tasmanian Ambulance Service CPEU be tasked with updating and upskilling the current practitioners. They need to expand their training to include such important areas such as management training, professional development, rescue training and research. Recommendation 13 That the Tasmanian Ambulance Service be authorised and funded to employ Tasmanian Student Ambulance Officers on the basis of projected losses rather than acting retrospectively. Recommendation 14 That the Tasmanian Ambulance Services role in the provision of Road rescue be confirmed by government and supported with training and resources that are supportive of this role. Recommendation 15 That the role of the Tasmanian Rescue Helicopter be restructured to that of an EMS Helicopter and that the Helicopter be resourced adequately so that it can provide a five minute turnout to rural areas and that the funding be such that it can be dispatched on the basis of best available information rather than the current system of turnout only after confirmation of need is established. 20 Recommendation 16 That the Tasmanian Government fund within the next three years the establishment of an EMS helicopter landing zone on the roof top of the Royal Hobart Hospital. Recommendation 17 That DHHS refine their system of Community Volunteer Ambulance Officers so that they are trained to a high level as first responders and that they receive high quality / timely support from qualified paramedics. Recommendation 18 That the Tasmanian Government gives consideration to the establishment of a new “Ambulance Act” that encourages the development of contemporary EMS practices. Recommendation 19 That the current Training for Student Ambulance Officers be upgraded from Diploma level to Degree level and that the training be better designed to reflect the current practice of ambulance officers or higher. Recommendation 20 That the terminology used to describe ambulance officers be modified to that being used by Ambulance services throughout Australia. Recommendation 21 That the Government renumerate its Pre-hospital care providers at a rate commensurate to the knowledge, skills and support provided to the community. Recommendation 22 That the DHHS integrate issues of health education identified by the Tasmanian Ambulance Service within the health promotions budget. Issues to be included are such things as, appropriate use of ambulance service, non-acceptance of violence against ambulance officers etc. Recommendations for changes to supporting systems to the provision of out of hospital care of Tasmanian Residents. Recommendation 1 That the mental health outreach system has its hours of operation extended to a 24 Hr basis and that its operation be further extended so that it compliments the Ambulance officer / Paramedic and allows adequate support for all mentally ill residents. This may negate the need for transport to an emergency receiving facility. Recommendation 2 Mechanisms are provided to nurses, to reduce the number of ambulance calls and transports to a Hospital. Alternatively the DHHS should consider extending the scope of practice for ambulance officers/paramedics and adequately resource the service accordingly so that they can provide out of hospital support in this area. Further possible solutions include the formation of a mutual aid system amongst the aged care community to provide something like a “nurse flying team” to support their members. Tasking of the Ambulance Service to provide such a service is another potential solution. (Similar to that provided by the Sussex Ambulance Service in Britain. This system also sees the Ambulance Service employing a GP to support out of hospital care). Recommendation 3 Create greater connectivity between the TAS and aged care services so that problem clients in the community can be better offered crisis care. Recommendation 4 Further extend the provision of After Hours GP services in the community so that community members can access the services of a GP and do not need to attend Emergency Departments as a “last choice”. The College believes that care should be available at a minimal personal cost to the community where they do not have the capacity to pay, thus reducing the presentations of these patients to the emergency departments.22 Glossary of terms Terms used in this document mean: Ambulance Officer; A person who has completed a three year Diploma of Clinical Practice or similar, and who holds qualifications accepted by the Director of Ambulance Services as being appropriate for employment. This term is no longer used to describe this level of practice in most states of Australia. Emergency Medical Service (EMS) system; An emergency medical services system is "a coordinated arrangement of resources (including personnel, equipment, and facilities) which are organised to respond to medical emergencies, regardless of cause." Paramedic; in this context (Tasmania) means a n Ambulance Officer who has undertaken extra studies beyond the Diploma Course and is permitted to administer a greater range of drugs and perform more advanced practices. In other States a person with these qualifications is called an “Intensive care Paramedic” or Mobile intensive Care Paramedic. A Number of States are offering this qualification at Graduate Diploma level. Ambulance Practitioner is a person who is authorised to Perform a higher level of skills that the IC Paramedic. In the Australian context they are new, however experimentation has begun in rural Victoria to develop their scope of practice. Tasmanian Ambulance Service (TAS); Created under an Act of Parliament, TAS is the Governments Pre Hospital Care Provider and Licensor of Ambulance Services and Ambulance Officers. Australian College of Ambulance Professionals (Tasmania Branch Inc) (ACAP) is the peak body representing Ambulance Professionals in Australia / Tasmania. NHS Trust; In England the system of Pre-hospital care is managed through a system of National Health Service Trusts. The Trusts are aggressively managed and are penalised if their response time performance is below the required standard Volunteer Ambulance Officer; In the Tasmanian context volunteer ambulance Officers are taken from the General community and a re provided with basic training by TAS in the field of pre Hospital Emergency care. At the time of writing they study a certificate 11 in Ambulance Studies although most volunteers are not provided the training to allow them to complete the qualification. The Volunteers provide significant support to the TAS and the Tasmanian public in rural areas. Their tasking with salaried staff in the outer urban areas is contentious and problematical. The College takes the view that this model does not provide the Tasmanian public with the best service model possible. It does not reject the usage of volunteers in remote low caseload areas. Pre Hospital Care: Medical care provided in the community prior to admission or treatment in Hospital. Bibliography 1 United States National Highway Traffic Safety Administrator. Emergency medical services: Agenda for the future. Unknown: Author. Downloaded 4 April, 2004 from the World Wide Web. http://www.nhtsa.dot.gov/people/injury/ems/agenda/emsman.html#INDEXF 2 Arntz, H. Z. pre-hospital thrombolysis in acute myocardial infarction. Thrombosis Research; 2001;103:Suppl. 1: 91-96. 3 Stern, R, Arntz, H. R. pre-hospital thrombolysis in acute myocardial infarction. European Journal of Emergency medicine; 1998; 5: 471-479. 4 Morrow, D. A., Antman, E. M., Sayah, A., Schuhwerk, K. C., Giugliano, P. P., deLemos, J. A., Cohen, S. A., Rosenberg, D. G., Culter, S. S., McCabe, C. H., Walls, R. M. & Braunwald, E. Evaluation of time saved by pre-hospital initiation of reteplase for ST-elevation myocardial infarction: Results of the early retavase-thrombolysis in myocardial infarction (ER-TIMI) 19 trial. Journal of the American College of Cardiology; 2002; 3 (40): 71 –77. 5 Lamfer, E. J., Hooghoudt, T. E., Uppelschoten, A., Stolwijk, P. W. & Verheugt, F. W. Benefit of pre-hospital thrombolysis in the treatment of acute myocardial infarction. American Journal of Cardiology; 2000; 84: 928-930. 6 Morrison, L. J., Verdeek, P. R., McDonald, A. C., Sawardsky, B. V. & Cook, D. J. Mortality and pre-hospital thrombolysis for acute myocardial infarction: A meta-analysis. Journal of American Medical Association; 2000; 283: 2686-2692. 7 Steg, P.G., Bonnefoy, E., Chabaud, S., Lapostolle, F., Dubien, P., Cristofini, P., Leizorovicz., Touboul, P. Impact of the time to treatment on mortality after pre-hospital fibrinolysis or primary angioplasty: Data from the CAPTIM randomized clinical trial. Circulation; 2003; 108: 2851-2856. 8 Welsh, R.C., Ornato, J., Armstrong, P.W. pre-hospital management of acute ST-elevation myocardial infarction: A time for reappraisal in North America. American Heart Journal; 2003; 145: 1-8. 9 Keeling, P., Hughes, D., Price, L., Shaw, S., Barton, A. Safety and feasibility of pre-hospital thrombolysis carried out by paramedics. British Medical Journal; 2003; 327: 27-28. 10 Pedley, D.K., Bissett, K., Connolly, E.M., Goodman, C.G., Golding, I., Pringle, T.H., McNeill, G.P., Pringle, S.D., Jones, M.C. Prospective observational cohort study of time saved by pre-hospital thrombolysis for ST elevation myocardial infarction delivered by paramedics. British Medical Journal; 2003; 327: 22-26. 11 Knapp B, Wood C. The pre-hospital administration of intravenous methylprednisolone lowers hospital admission rates for moderate to severe asthma. pre-hospital Emergency Care: 2003; 7: 423-426. 12 Brain Trauma Foundation. (1995). Guidelines for the pre-hospital management of traumatic brain injury. New York: Author. Downloaded 5 July, 2002 from the World Wide Web. http://www.braintrauma.org/guideems.nsf 13 Stiell, I.G., Wells, G.A., DeMaio, V.J., Spaite, D.W., Field, B.J., Munkley, D.P., Lyver, M.B., Luinstra, L.G., Ward, R: For OPALS study group. Modifiable factors associated with improved cardiac arrest survival in a multicenter basic life support/defibrillation system: OPALS study phase 1 results. Annals of Emergency Medicine; 1999; 33: 44-50. 14 O’Meara, P. Would a pre-hospital practitioner model improve patient care in rural Australia? Emergency Medicine Journal; 2003; 20: 199-203.
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