EMS World

SEP 2018

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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EMSWORLD.com | SEPTEMBER 2018 15 called "Miller training," which included more in-depth knowledge of anatomy/physiology, medicine, and even light rescue (every ambu- lance station of the era had at least two Neil Robertson stretchers). Concurrently, and especially during the 1970s, the Institute of Certi- fied Ambulance Personnel offered voluntary additional training to a higher level, and talking to veteran EMS staff, it's clear that building professional pride was important in an era when "ambulance drivers" were still classified as manual workers by their own union. Paramedics arrived in the U.K. in the mid-1980s. At this point Miller training morphed into a new national technician training program. Paramedic training was also standardized on a U.K. level, but the actual implementation of this training (and drugs that were carried) varied between services and was determined locally. Today WAST is a largely paramedic-delivered service, supported by technicians, with clinical capability comparable to other NHS ambulance services and equipment arguably ahead of the pack. The default clinical guidelines are those of the Joint Royal College Ambulance Liaison Committee (JRCALC), and according to WAST's assistant medical director, Dr. Jon Whelan, "Our crews are expected to adhere to them unless we say otherwise." Wales also has a higher tier of EMS capability in the form of its HEMS service, EMRTS Cymru (the Welsh Emergency Medical Retrieval and Transfer Service). EMRTS has full mobile critical care capability, with onboard physicians and critical care practitioners (mostly from a paramedic background or possibly nurses). The clini- cal staff are NHS personnel, but the aircraft on which they operate are provided by a charity, the Welsh Air Ambulance, and once again the service is free. There are three first-response EMRTS bases, each with an Airbus H145 T2 aircraft, plus a transfer aircraft. Call Responses Call-handling and dispatch for WAST take place in three control rooms. MPDS v13.1 (which will be familiar to many U.S. readers) is the call-handling interface, with a dispatch cross-reference table that converts MPDS codes into call priorities. The U.K. has had an eight-minute target for ambulance response time to highest-priority calls for more than 40 years. In Wales 65% of such calls should have an asset on scene within that interval. Histori- cally, chasing this target has skewed how U.K. ambulance services configured their operations, with fast-response cars being used to "stop the clock" and hit the eight-minute target. Unfortunately, cars can't convey stretcher patients, so an emergency ambulance was required as well, tying up two assets per call. A few years ago WAST was one of the first U.K. ambulance services to reconfigure its model to one more suited to a modern urgent- care service, recognizing that a very small proportion (around 5%) of 9-9-9 calls represent immediately life-threatening complaints. "We wanted a clinically honest model," says Whelan, "that stopped focusing on clock-stopping and instead aimed to get a 9-9-9 patient the right asset the first time, in a clinically appropriate time." Hence, since 2015 WAST's call prioritization system has differed from the rest of the U.K.'s. There are still five priority levels, but by reducing the number of jobs requiring two assets, asset availability has improved, and crews are reaching the highest-priority calls more quickly. "Prior to 2015, an average of 1.4 assets were tasked to each 9-9-9 call," Whelan says. "This has now fallen to 1.2, which makes a big difference when we are answering around 450,000 emergency or urgent calls each year." Like all ambulance services in the developed world, WAST is wres- tling with increased demand in terms of call volumes, the effects of demographic change, and ever-rising patient expectations. The same factors are affecting hospitals: ED crowding results in delayed handovers as ambulances queue at the front door (familiar to those in the U.S. as "ramping") waiting to offload. WAST loses many thou- sands of ambulance hours from the road in this way. There are political influences too. Healthcare in Wales is the responsibility of the devolved Welsh government, not the (U.K.'s) Westminster government. However, the Welsh government currently has no tax-raising powers and relies on a block grant from Westmin - ster. Hence, austerity policies of the Westminster Tory government have resulted in large cuts in both NHS and social care budgets in Wales as well as England, exacerbating service challenges. On the other hand, when it comes to actually spending money on the NHS, the close and direct links between the health minister and senior NHS clinicians in Wales (including within WAST) facili- tate service development enormously. The wholesale change in WAST's call prioritization categories in 2015 was introduced in only For More Information Circle 16 on Reader Service Card

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