Clinical Assessment and Referral (CARE) Program

Ambulance Service of NSW

Abstract

The CARE program, by supporting paramedics in the provision of appropriate care to low acuity, low risk patients for whom transport to an Emergency Department (ED) is not the best option, has improved work satisfaction for an average of 44% of paramedics participating in the program, with the level of satisfaction increasing over time as positive patient outcomes are observed.

CARE education and training provides paramedics with a safe and systematic approach to the management of non-transport situations. An improvement in confidence around transport and non-transport decisions was expressed by 60% of paramedics and was mostly due to the increased level of Ambulance Service support felt by paramedics when providing non-ED care options to patients under the CARE program.

Aim

CARE aims to improve work satisfaction by providing education and training to support the provision of non-ED care to low risk patients in response to a changing health care environment.

Nature of the Problem

Ambulance Service disposition options (transport or patient refusal/decline of transport) were limiting the capacity to provide organisationally supported safe, appropriate care for some patients and impacting negatively on work satisfaction.

Root cause analyses related to non-transport identified a need for improved patient assessment, clinical decision making, and risk management skills and the provision of non-ED care alternatives for some low risk, low acuity patients.

Extent of the Problem

The pre-hospital landscape has changed considerably with increasing representation of elderly patients with chronic conditions and patients with sub-acute minor injury and illness. Paramedics have been poorly equipped to manage these patients and not provided with organisationally supported disposition options other than transport to an ED or patient refusal.

A number of root cause analyses since 2006 identified significant issues around the management of non-transport cases that resulted in adverse patient outcomes. Whilst it was recognised that for some patients transport to an ED was not appropriate and contributed to ED congestion, paramedics reported a lack of structure and organisational support around non-transport situations. Anecdotally, the imbalance between patient needs, Health Service pressures and Service limitations resulted in reduced work satisfaction for paramedics.

High-lighted was a need for training and education in non-transport principles including clinical decision making, risk management and medico-legal issues including documentation and patient consent.

Strategic Importance

Improved work satisfaction may increase staff retention rates.

Provision of non-ED care options to patients for whom ED care is not the most appropriate option has the potential to significantly ease congestion and trolley block and contribute to Health’s demand management, ED avoidance and sustainable access strategies.

Transport of inappropriate patients also ties up ambulance vehicles and staff, increases cycle times, reduces resource availability and adds to service costs.

Improved resource availability (higher non-transport rate and reduced cycle times observed under CARE pathways) will help achieve operational KPIs.

Improved risk management including better documentation may assist clinical KPIs.

Planning and Implementing Solutions

The CARE program was implemented as part of NSW Health Redesign to equip paramedics with the skills to identify and, with Service support, manage non-transport situations to provide low acuity, low clinical risk patients with treatment and care options other than transport to an ED.

The CARE project team was set up within the Advanced Care Unit. Local committees including representatives from allied health, Divisions of GP, hospitals and community stakeholders were established in proof-of-concept areas. Local committees were fundamental in formulating non-ED care alternatives and the CARE approach to low risk patients. Overseas experience (particularly in the UK) as well as Ambulance, area health and ED data was used to identify appropriate clinical pathways. Extensive literature searches were performed to collect evidence around which the pathways were built.

A risk plan, communication strategy and clinical governance were established to support the program. A steering committee of senior executives oversees the project.

The CARE education and training course was developed, reviewed and, in response to feedback, improved to address identified issues and provide paramedics with a safe and systematic approach to the management of non-transport situations through a structured risk identification, management and mitigation process.

Paramedics who participate in the CARE program complete a three day education and training course focussing on patient safety, patient assessment and history taking, consent, risk identification and management, risk mitigation and documentation. Experienced paramedics were recruited to participate in the program through expression of interest. An initial undertaking to train 80 paramedics per year (for the life of the project) has been exceeded with approximately 260 paramedics completing the CARE course in the first two years.

A CARE protocol, standard operating procedure, as well as program related pharmacologies and skills were developed to formally support paramedics from a Service perspective.

Outcomes and Evaluation

During the current proof-of-concept phase CARE is subject to rigorous monitoring and evaluation. As part of the evaluation process paramedic work satisfaction and perception of the program and its implementation were gauged through individual (random) interviews and a focus workshop.

Work satisfaction has improved for an average of 44% of CARE paramedics. An increase over time was noted and attributed to seeing positive outcomes as case numbers climbed. Further improvements in work satisfaction may occur therefore in line with continued implementation of CARE pathways.

Most respondents (93%) feel extremely or very confident in making the decision between transport and non-transport. An increase in confidence was expressed by 60% of paramedics and was mostly due to the increased level of support felt from the Ambulance Service in non-transport cases.

Four out of five respondents feel either extremely or very confident in the clinical pathways and tools provided to them by the CARE program to assist in clinical decision making. Most respondents feel some improvement in their service to the patient since participating in the CARE program.

The CARE training program received very positive feedback with 75% of respondents extremely or very likely to recommend CARE training to their colleagues.

Sustaining Change

Improving work satisfaction of paramedics by increasing their skills and equipping them to provide organisationally supported non-ED care alternatives to suitable patients will be extended to additional qualified paramedics consistent with the project plan.

Clinical risk management components of CARE are likely to be incorporated into core Ambulance education. Embedding the entire CARE course into core education is under consideration.

An improved communication strategy has been developed and implemented in response to program evaluation to reinforce current practice, to sustain and optimise program implementation and to further provide support to those paramedics involved in the program.

Future Scope

CARE is currently operating in several metropolitan and two regional areas. Based on experience to date, expansion and implementation of the program in additional areas throughout NSW will further provide organisational support for paramedics faced with non-transport situations, increase the provision of appropriate care to those patients for whom the ED is not the best alternative, help manage ever-growing demands on ambulance and ED resources and contribute to improving paramedic work satisfaction.

Continued reference to local needs and resources will optimise efficacy of the program and maximise potential synergies with, and utilisation of, alternative (non-ED) health care provision.

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