Analysis of Tomaree Community Hospital's (TCH) Ambulance Service NSW (ASNSW) expenditure and activity resulted in the relocation of an existing Newcastle Health Transport Unit (HTU) vehicle and staff to a base at TCH. This project has seen a reduction of over $100,000 in (ASNSW) expenditure in its initial six month, during a period of increasing numbers of patient transfers for both diagnostic examinations and transfers to tertiary hospitals in Newcastle for continuum of care.

Wait times for patient transfers have also been reduced, and the reduction in ASNSW bookings for lower acuity patient transfers has freed up time for ASNSW to attend to emergency (000) transport.

To reduce ASNSW expenditure for the TCH, whilst providing an appropriate, safe, effective, timely and cost efficient means of transferring patients.

The ASNSW fee structure is moving towards full cost recovery by 2008/09. TCH is a small rural hospital with a coastal location that is experiencing an increasing population. Emergency Department (ED) presentations have risen from an average of 662 per month in 2005/06 to 976 per month in 2007/08 (peaking at 1488 in January), with fluctuations as the peninsula's population increases by up to 50,000 during the summer months.

The hospital's lack of diagnostic resources requires patient transfers to both external private imaging facilities and tertiary hospitals. With the limited transport options available, monthly ASNSW expenditure was increasing significantly.

Data from the ASNSW accounts was used to show the actual number of road transfers from January 2005 to March 2008 (Figure 1).

In 2005/06 an average of 60 patients per month were transferred by ASNSW. Since this project started an average of 87 patients per month are being transferred by ASNSW and HTU. The potential number of ASNSW road transfers if this project was not in place are shown in Figure 1.

Figure 1. Number of ASNSW Road Transfers 

The cost of ASNSW Road Transfers from TCH has risen significantly since July 2006. Figure 2 shows actual and potential ASNSW expenditure until 30/6/2009.

Patient transfers using ASNSW were not always timely due to limited resources. This often resulted in long delays for transferring patients, especially for diagnostic examinations

The increasing number of presentations at TCH; the higher number of patients needing to be transferred for diagnostic examinations or ongoing care; and the increased cost of transfers provided by ASNSW were the key drivers towards finding an appropriate and cost effective solution to reduce ASNSW expenditure by TCH.

Saving money and saving time, firmly fits into the strategic direction of Category 5, Making smart choices about the costs and benefits of health services. The relocation of an existing Newcastle HTU vehicle and staff to a base at TCH has reduced ASNSW expenditure and ensured safe and appropriate transport of patients, while at the same time maximising service delivery from a community hospital.

A fact finding exercise identified the following issues at TCH:

1. Escalating ASNSW costs for road transfers.
2. High costs of transferring patients for diagnostic examinations.
3. Reduced ability of ASNSW for routine transfers due to lack of resources and the priority of emergency transport.
4. Increasing population in the area, many of whom were elderly.
5. Holiday population fluctuation resulting in increased ED presentations.

Discussions took place between senior management of the TCH and HTU regarding the significant ambulance expenditure and activity with a view to determining a more cost effective way of managing patient transfers.

It was decided to relocate a HTU vehicle and staff to TCH for inpatient and ED transfers on a trial basis between the hours of 10:00 and 18:00.

Patients being transferred were reviewed and found to be:

• elderly, and whilst able to sit in a seat for transfer, they were unable to climb into the vehicle due to steps.
• were often suitable to travel together but due to vehicle access issues were unable to do so in a conventional HTU vehicle.

It was also decided to utilise a dual-purpose vehicle that enabled patients to enter the vehicle via a wheelchair lifter and transfer into a seat and therefore enabled another patient to be transferred on the stretcher. Vehicle staffing was established as a Patient Transport Officer and Transit Nurse to allow the transfer of the widest range of patients.

Monitoring of the ASNSW Account showed that despite an increase in the overall number of transfers from TCH (Figure 1) and the increase in the ASNSW fee structure, that the introduction of the HTU service significantly decreased ASNSW expenditure for TCH.

Timely patient transfer to diagnostic facilities was an enormous benefit from the implementation of the HTU vehicle. A secondary benefit achieved was that in escorting the patient, the HTU Transit Nurse relieved TCH nurses of this duty and therefore reduced staff ratio impact to the facility. The choice of a dual-purpose vehicle has been effective, as it allows patients to be transferred simultaneously on many occasions The cost of the HTU service for this period has been

The overall number of transfers from TCH is steadily increasing, with 719 in 2005/06, 781 in 2006/07, and 744 from July 07 to March 08. The number of transfers for diagnostic procedures has increased dramatically, averaging 7.5 per month in 2006/07 and 22 in 2007/08.  The HTU now performs 94 per cent of these transfers. Minimal patients are now transferred via ASNSW during the hours of operation of the HTU vehicle.

After the initial three-month period, managers from HTU and TCH agreed to continue basing the vehicle at TCH, with three monthly reviews to assess the ongoing benefits.

Transit Nurse escort down times have been considered and a range of tasks allocated for these periods. When no transfers are pending, the vehicle is utilised by being returned to the HTU vehicle pool. The impact of the vehicle and staff placement at TCH is being monitored, with expenditure of $81,798 in 2007/2008 resulting in a saving of $261,244. Potential expenditure of $109,064 is projected to save $380,000 ASNSW costs in 2008/2009.

The process of HTU monitoring trends and being willing to trial the relocation of resources within a service can be applied to other HNE Health facilities. The coordination of HTU resources to respond to demand at HNE Health facilities maximises the opportunities to reduce external expenditure and to provide an appropriate, timely and cost efficient means of transferring patients.

The HTU will continually review ASNSW expenditure across HNE Health. Financial savings will be reinvested in additional frontline and Health Transport resources, to enhance the provision of clinical care to our patients.

• Health Transport Unit and Tomaree Community Hospital

Co-Authors

• Michelle Carmody, Registered Nurse, Health Transport Unit and Margo Roland, Manager, Health Transport Unit

Team Members

• Julie Palmer, Manager, Health Transport Unit, Southern
• David Boyd, Service Manager/Director of Nursing, Tomaree Community Hospital
• Warren Jennings, Patient Transport Officer, Health Transport Unit
• Julie Willett, Scheduler, Health Transport Unit
• Rebecca Collins, Transitional Nurse Practitioner, Tomaree Community Hospital

Acting Area Quality Manager, Clinical Governance
Hunter New England Area Health Service
Phone: 02 6767 7233