8 Minutes More

 

Sorry folks, more on that 8 minute response time stuff. I keep coming across more ‘papers’. I ploughed through 2 of interest tonight. Firstly: Effect of reducing ambulance response times on deaths from out of hospital cardiac arrest: cohort study. Pell et al – available from BMJ June 2001.

This is the paper I remembered that had an analysis of how we got the ‘mythical’ 8 minutes. The study looked at “all out of hospital cardiopulmonary arrests due to cardiac disease attended by the Scottish Ambulance Service during May 1991 to March 1998″.

Results Of 13 822 arrests not witnessed by ambulance crews but attended by them within 15 minutes, complete data were available for 10 554 (76%). Of these patients, 653 (6%) survived to hospital discharge. After other significant covariates were adjusted for, shorter response time was significantly associated with increased probability of receiving defibrillation and survival to discharge among those defibrillated. Reducing the 90th centile for response time to 8 minutes increased the predicted survival to 8%, and reducing it to 5 minutes increased survival to 10 – ­11% (depending on the model used).
Conclusions Reducing ambulance response times to 5 minutes could almost double the survival rate for cardiac arrests not witnessed by ambulance crews.

In their discussion they note:

Survival of out of hospital cardiac arrest in the United Kingdom is up to three times lower than that in some other countries. The American Heart Association described the “chain of survival” concept in which survvival depends on several factors including public awareness of symptoms, early basic life support by bystanders, rapid access to emergency medical services, and prompt defibrillation. Survival from cardiac arrest can be increased sixfold by providing first line responders with defibrillators.

Hey, guess which parts of the ‘chain’ we don’t cover in the UK. How about BLS in schools? Ooohhh don’t get me started on something else!

So, on to paper 2: Measurement of Healthcare Output and Productivity – Ambulance Response Times for Patients with Cardiac Arrest – DoH December 2005. Get a PDF copy.

This paper mentions that elusive ORCON study group report, Review of Ambulance Performance Standards:

A DH report, Review of Ambulance Performance Standards, July 1996, examined the health benefits to be gained by improving response times. The report presented estimates of the benefits of moving from the existing 1996 standard of 50% of emergency calls responded to within 8 minutes, to the current target of 75% of Category A calls responded to within 8 minutes, and an intended longer term target of 90% of Category A calls responded to within 8 minutes. [my emphasis]

The authors quote extensively from the first and produce all sorts of ‘estimates’ of Lives Saved and Quality Adjusted Life Years (QALYs) saved, and manage to place a financial costing on these ‘improvements’. For me the real problem was that they never, ever seemed to consider whether it would be physically possible to improve response times. Perhaps, in one of those parallel universes I posted about on Monday the ambulance could actually charge out the yard the second the phone rang in Control, and assuming it could do 0-60mph instantaneously and there were no obstacles (traffic lights, roundabouts, idiotic motorists) and supposing we got straight to the address without faffing about trying to find the number. We could still only get to calls within an 8 mile radius of the ambulance station. How many stations and ‘hot spots’ do these guys thing there are. They no doubt live in the same ‘cloud cuckoo land world‘ as commissar Hewitt.

Anyway enough ranting. Hidden away in the conclusions –

These estimates are based on a DH report from 1996, which may be somewhat outdated.so that ORCON report is flawed???

However, the estimates presented are for cardiac arrest patients only and relate only to surviving the immediate event, rather than wider clinical outcomes for surviving patients. These patients represent less than 5% of the total number of Category A responses. [my emphasis]

So, once again we find that the 8 minute response time is based on survival for out-of-hospital cardiac arrests only – yet 95% of A category responses are for something else (usually rubbish) but we still have to respond in 8 minutes. Heaven knows what we’ll do if some nutter, sorry Health Secretary ever gets the crazy idea to make it 90% of A cat calls in 8 minutes.

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9 Responses to 8 Minutes More

  1. ecparamedic says:

    I understand the 90% target may not be far away………….

  2. Kingmagic says:

    Its in the pipe line. Yes we will be responding to Cat A red calls within 8 minutes 90% of the time. As you say it will be mostly to rubbish.

    Get rid of AMPDS and use a system solely for Acute Coronary Syndromes which identifies a cardiac arrest and so cuts out the unneccessary amount of RRV/RFU/Crews flying around to these jobs.

    By the law of averages if we increase the number of jobs classed as Cat As with a 90% response target then….someone is going to get killed trying to hit the time.
    (Heaven help us if the response time comes down to 5 minutes also!!!)

    More pressure will be put on managers to hit targets and they will in turn put pressure on the roadstaff.

    I,ve also read somewhere recently that crews will be required to respond to “urgent” details on “blues & twos” also!!! I think it mentioned bringing that in 2008.
    Happy times ahead!

  3. kevinmillhill says:

    I thought that I had directed you to the Pell et al paper during the last round of discussion of this subject. I find that I did not. My apologies.

    You will note that the second author credited on the paper is Andrew K Marsden. Since the firm’s decision to create the post of Medical Director and to appoint Mr Marsden to it, his pronouncements have been greeted by disbelief or hoots of derision from the green-clad riffraff. He was, after all, the man who said that we were either to switch the (expensive) fluid-heating cabinets off, or to discard the fluids every 3 months. (Bit of a bugger bulk-storing fluids in cupboards during the summer then.) He also decreed that technicians were no longer to do BM tests, then got umpty because of the effect , on the PRF audit ,of 2xtechnician crews’ not doing BM tests on query CVA victims! He has been trotting this kind of stuff out for years, to the ears of crews whose view has pretty well always been “If he was any good as an A&E Consultant, why is he working for an ambulance service?”

    We understand that he may soon be seeking alternative employment “You have been warned”; the scuttlebut story surrounding his demise includes the words “Clinical Standards Audit”, and, yes, “ORCON”!!

    Who said “There ain’t no justice in the world”?

  4. Kingmagic says:

    You have my deepest sympathy if your medical director is now A. Marsden!

  5. kevinmillhill says:

    To kingmagic,

    Re putting pressure on the road crews. See my remarks on the subject in the last round of discussions Remember, nobody is actually interested in reality – not us (because we know that we’re already doing the impossible), and not managers (because they’re only interested in on-paper ORCON compliance, which we all know is bean-counting nonsense)

    All that matters is that the buttons are pushed within the right time frame; not what you are doing when you push them. Patients will still get our best efforts, but ORCON compliance will be achieved, and there will be no pressure. Think like a politician – the end justifies the means.

  6. kevinmillhill says:

    To kingmagic, re AKM Not for much longer!!

  7. BananaHammock says:

    ORCON sucks. The sooner it is scrapped, the better. Improved training, skill levels, and clinical practice should be the benchmark for clinical excellence within the ambulance services of the UK.

    You know this. I know this. Everyone who reads your blog knows this.

    Sadly, in an attempt to meet and/or beat ORCON response times, certain areas of south-eastern England have churned out trainee technicians in such huge quantities that they have to work with people that have qualified only the day/week/month before.

    Now clinical excellence (or, dare I say it, proficiency?) and ORCON are going out of the window.

    Gaaaaa!!

  8. ecparamedic says:

    You know it’s funny really, we get a load of ex-LAS staff coming this way where they can afford to live.

    For years I’ve endured shift long rants about how brilliant LAS is and how shit all our systems/vehicles/ uniform/ managers/ training are, particularly our use of CBD compared to their shiny gold standard AMPDS.

    Looks like it wasn’t all that crap after all.

    I’m now being told that ‘the patient is going to hospital’ by Control (that’s their excuse for not sending me) and that this is based on information from AMPDS! WTF??????????

    This week I’ve been sent ‘Green’ to an arterial bleed and a diabetic collapse, clinical excellence in action……………

    SD
    😦

  9. kevinmillhill says:

    Re BananaHammock,

    From the viewpoint of what we actually do for a living, ORCON is nonsense. It is akin to awarding the prize in a distance race to the runner who took fewest steps. However, from the Bean Conter’s viewpoint, it has the virtue of being easy to understand (even if it IS nonsense) and easy to measure. (How would a Bean Counter measure and compare good clinical practice? You can’t buy it by the yard.)

    On the other hand, why not just look at the “A&E Upheld Complaints” rate? That would give a measure of how well we are doing – at no extra cost. It would embrace reponses, patient care, and clinical performance – because hospital staff complain as well as patients.

    I suspect that it has already been thought of; however, it is a fact that we receive very few complaints, with even fewer being upheld – because people generally think that we do OK. There would therefore be no stick to beat us with, and that would not suit our political masters!

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