National Ambulance Service Martin Dunne

Director NAS

Ireland

Capital: Dublin

Population: 4,761,865

Currency: Euro

Official Languages: Irish/ English

Area: 26,592 square miles (68,890 square kilometers)

The primary & secondary road network in Ireland

is some 5,306km long & is made up of motorways,

dual carriageways & single lane roads

Vision of the National Ambulance Service

(NAS)

The health and wellbeing of our community is

supported and preserved by the NAS providing

clinical care and transport to our patients in a

professional and compassionate manner in close

partnership with the wider health and social care

services.

NAS AREA WEST

NAS AREA NORTH

LEINSTER

NAS AREA SOUTH

NAS Operational Area’s

NAS Station

Locations (102)

HISTORICAL PERSPECTIVE

Yesterday

1900 Horse Drawn Ambulance

in Dublin

1950 Ambulance Midlands

1999 Ford Transit Lunar

Ambulance Service National Ambulance Service

2006 2017

Basic Life Support Basic and Advanced Life Support

11 Individual Control Centres Single National Emergency Operations Centre across 2 sites

Emergency Medical Technician- 2 drugs

• Emergency Medical Technician -13 meds

• Paramedic - 24 meds

• Advanced Paramedic - 48 meds

• Community Paramedic -48 plus

Limited medications and interventions

Limited equipment

• Expanded range of patient monitoring devices

• Expanded range of patient management devices

• Expanded range of medications

• Equipment List for each vehicle type

• Emergency Ambulance Service

• Patient Transport Service

• Emergency Ambulance Service

• Intermediate Care Service

• Aero Medical Service

• Response Vehicle, MRU , Decontamination Units etc

• Critical Care Retrieval Service

• Aged Profile varied

• Varied Specifications

• No replacement plans

• Best Practice Procurement & Replacement Policy

• Standard Specification

• Modern Fleet

• Overcrowded due to increased staffing

• Requires significant development

• Major estate upgrade commenced

• New bases

• Deployment Points been developed in line with New Primary Care

Centre Builds

• Limited ICT

• Limited connectivity to control

• Varied Specifications

• Modern integrated CAS system

• Modern Digital Communications System

Patient Intervention

Service

People Competency

Patient Care Equipment

Operations

Fleet

Estate

Technology

NAS Service Evolution 2006 to 2017

Patient

Centred Care

Major Service

Reviews

International Practice DoH Strategy

HSE Corporate Plan

HIQA National

Standards

Consultation

Process

13

Requirement to embed effective clinical and corporate risk management

structures in the NAS

Increasing emergency ambulance capacity in order to meet HIQA

standards

Move to a new model of care

Movement of paramedic training to an undergraduate programme

HR practices and need to improve staff development

Age and roadworthiness of the NAS Fleet and Equipment

Investment and integration of technology

HIQA Review Recommendations

Confidential Briefing ©Lightfoot Solutions 2016

Baseline Capacity Review

Recommendations

14

• This review has created a platform for NAS to develop a high

quality, clinically-led service that delivers excellent pre-hospital

care across the state.

• 15 key recommendations

– Could not possibly achieve the HIQA prescribed targets

– Could make some improvements and efficiencies without

extra resources

– Would require extra resources to achieve full potential

• Turning the review into actions to deliver change

– Identify and prioritise recommendations with immediate gains

– Discuss a strategy to deliver the recommendations

• Develop an implementation and improvement plan

Martin Dunne

Director NAS 14

“The purpose of this strategy is to support

our goal to be a high quality clinically led

service”. Myhill & Giannasi (2015)

NAS has 2 Separate Statutory Regulators

1. Health Information and Quality

Authority

2.Pre Hospital Emergency Care Council

NAS Vision 2020 Document.

17

A single cohesive five year plan, based on all the recommendations of the various

reviews, consideration of international best practice and the strategic plans of

hospital groups.

New National Emergency Operations Centre (purpose built)

National CAD system

National Unified I.C.C.S.

National Digital Communications Platform

National A.V.L.S.

Eircode enable, AML enable

National Digital Recording Solution

National Horizontal Dispatch

Funding (big bucks)

IR/ HR (Mistrust, job losses)

Political (Not in my local electoral area)

Media (State funded health services always wrong)

Business Continuity

- Switch from Analogue to Digital platform,

- Switch from MIS A2K CAD to C3, with all interfaces.

- Switch emergency call routing to new centre, as live calls were occurring

- Protect historical data gathered

- Training for all

Step 1 - Patient Centred Reform

Opportunities Challenges

Consolidate 9 Call Taking and Dispatch Centres to operate as 1

Centre across 2 sites.

OUTCOME

Introduced Intermediate Care

Services

In Parallel – Step 2

Targeted at low acuity inter-facility transfers

Specific build – two stretchers + 4 sitting

Allows EAs to focus on emergency response

In Parallel – Step 2

Develop Community First Responders schemes

Introduction of Fleet Replacement Programme

and enhanced Green Technology

In Parallel – Step 2

Replacement policy in place to address

HSA requirements

Multi-year capital funding planning in place

Governance process in place

Fleet and Equipment Team structure

agreed and priority posts being filled

NAS

Vehicle Profile 51%

12%

10%

15%

12% EA's

ICV

RRV

ORV

Other

Development of Solar Powered EAs

National Singular Standard Specification for all Resources

Eliminate Shoreline Charging

Improve battery longevity

Reduce fuel consumption

Touchscreens

In Gas Monitoring

In Command

Intelligent Camera Monitoring

National Singular Standard Specification for all Resources

Driver ID Wi-Fi Hub

Relocated NAS Training College to purpose built premises

In Parallel – Step 2 Education and Competency Assurance

Low and Medium Fidelity

Simulation Training

Where We Are Now

Live Performance Management (SFN)

Minor capital programme established

to address immediate high risk H&S

issues

Station upgrade/replacement

prioritisation completed

Standard specification agreed for

Primary Care Dynamic Deployment

Point

Standard Station Specification agreed

for station types

1843 Staff (2017)

NAS Five Year Workforce

Plan in place

NAS Organisation Design

Report

HR Action plan drafted in

line with HSE People

Strategy

NAS Digital Plan will

ensure alignment with the

Wider eHealth programme

Digital Identity programme

ongoing

Replacement policy in place to

address

Multi-year capital funding planning

in place

Governance process in place

Fleet and Equipment Team

structure review

The future………………………

33

Our new clinical model will introduce new ways in which callers to 112 / 999

are triaged to ensure they receive the most appropriate care and response to

suit their needs.

The changes will clearly identify those patients who require an immediate

life-saving response – ‘Emergency Care’ (these patients will receive the

highest priority response in the fastest time), and those ‘Urgent Care’

patients who can be managed more appropriately in a care setting other than

an Emergency Department.

Future Model of Care

SEE AND TREAT Focused clinical assessment by paramedics at the patient’s location, followed by

appropriate immediate treatment, discharge and/or referral to other services - more

appropriate to needs

ALTERNATIVE DESTINATIONS Aim to ensure patients are treated in the right place first time and in doing so reduce

the number of patients unnecessarily taken to an ED.

- Local injuries unit or an appropriately resourced primary care centre

- Specialist Centre – PCI; Stroke; Fracture; Trauma

DYNAMIC DEPLOYMENT Where Emergency Response Resources will be strategically positioned at various

predetermined locations, in order to provide a more rapid response to patient needs.

35

CLINICAL HUB – HEAR AND TREAT Telephone Triage - providing advice on self care, discharge or referral to other appropriate local treatment pathway (GP and primary care, local based urgent care service, specialist services – such as mental health service, social care services, dental services)

COMMUNITY FIRST RESPONDERS Groups of volunteers who, within the community in which they live or work, are tasked by the NAS to respond to emergencies appropriate to their skill set Three Community Engagement Officers appointed for each area.

COMMUNITY PARAMEDIC Paramedics will function outside their customary emergency response and transport roles, in ways that facilitate more appropriate use of emergency care resources and enhance access for patients in rural and minor urban areas – take advantage of locally developing collaborations

36

Key Benefits of a New Model of Care

Ambulance

Service

Key

Be

nef

its

Wider

Health Service

The Patient

• Reduction in dispatches

• Incidents dealt with more promptly

• Most appropriate pathway chosen

• System capacity better utilised

• Reduction in ED attendances

• Appropriate and immediate resolution

• Care closer to home

• Reduction in call cycle as no journey undertaken

• More effective use of crew clinical skills

• Reduction in ED attendances

• Reduction in hospital admissions

• Immediate access to clinical treatment

• Directed to most appropriate setting

• Care closer to home

Resolution of calls using telephone triage without

the need to dispatch crews

Resolution of incident at scene without need to

convey to another provider

Hear and Treat See and Treat / Refer / Transfer

Non – Conveyance

Operational Performance Management

Conclusion

Heifetz and Linsky 2002

“People do not resist change per se.

People resist Loss”

Different Viewpoint – One Team

High Quality Safe Patient Centred Care

NAS Developments 2014 - 2017

Finance Fleet 2014 2015 2016 2017 2018 2014 2015 2016 2017 2018

Allocation €m 137.7 144.3 151.4 156.5 164.6** ELS ELS ELS New ELS New ELS New

Increase €m 6.6 7.1 5.1 9.6 EA's 1 42 0 50 50 5

Increase % 4.6% 4.7% 2.4% 6.2% EA Remounts 36 22 35 0 25

Capital €m 7.5 13.0 18.0 19.87* ICV's 0 0 7 0 6

* incl. Fleet, Minor Capital, ICT, Funded Projects RRV's 0 0 20 0

** includes €2.8m New Developments Motor Cycles 0 0 0 0

Cars 20 11

Critical Care 2 0 0 2 2

Driver Training 0 0 0 2 2

Specialised 0 0 0 3

Sub Total 62 57 95 26

Employment Levels by Grade Groups Total Units 39 64 119 121 0

2014 2015 2016 2017 Fleet and Equipment Allocation €m 7.50 13.00 18.00 14.53

Patient & Client Care 1,558 1,611 1,650 1,755 Includes 5 DFB EA's

Medical 1 1

1 1

Nursing - - - 2 Equipment (major) Purchase

Management / Adm 46 63 67 71 2014 2015 2016 2017

Support Staff 18 18 16 14 Lifepak 15 160 55 50 6

Total 1,623 1,694 1,734 1,843 Lucas 10 35 200 6

Community First Responder Fleet Running Costs

2014 2015 2016 2017 2014 2015 2016 2017

Linked

Schemes 105 134 145 168 Fuel €m 3.520 3.425 3.830

Calls Engagements 135 146 236 2,649 Maintenance 5.372 5.096 5.509

2014 2015 2016 2017 Mileage (Km) #########

## #########

## #########

## #########

##

AS1 & AS2 Total 293,095 303,502 313,735 321,379

Increase

12,092

10,407

10,233

7,644 NAS Call Volume Annual Data

Increase % 4% 3.4% 3.3% 2.4% 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

AS3 Completed 48,552 35,822 29,262 30,396 AS1

197,046

208,039

210,986

205,388

206,042

198,459

209,685

230,528

249,153

271,485

289,275

296,694

Completed by ICS 37,009 29,045 25,973 27,073 AS2

63,196

62,039

62,156

59,025

59,127

58,044

57,300

50,248

43,942

32,017

24,463

24,685

% Completed by ICS 76% 81% 89% 89% AS3

177,306

209,421

185,979

166,041

237,499

82,906

62,747

50,000

48,552

35,822

29,262

30,396

Total Calls 341,647 339,324 342,997 351,775 Total

437,548

479,499

459,121

430,454

502,668

339,409

329,732

330,776

341,647

339,324

343,000

351,775

Thank You Go Raibh Maith Agat