Response Times

I’ve just come from a management meeting about changes and suggestions for the Rapid Response Car.  Given that I now want to stab things, I think I’ll wait until tomorrow before letting you know what was discussed…It is, in part about this report.

Loads of people have asked me about the recent UK news items about the response times of various ambulances.  Essentially the BBC investigation suggests that ambulances that should respond to “Category A” (high priority) calls within 8 minutes, are only doing so because trusts fiddle the numbers.

Note: I am not a Dispatcher, and have only spent a few hours up there – if anyone in Control wants to correct anything I write below, just let me know.

I’ve mentioned this before, but for any new readers…

“Cat A” calls are the highest priority calls, and from the time of activation we have 8 minutes to get to the patient.  There is absolutely no medical reason why it is 8 minutes, and although it is often mentioned as he maximum time that someone can survive with a stopped heart, the actual number is actually closer to 6 minutes.

The story is that different ambulance trusts start the clock a different times, so that they have more time to get to a call.  You can read more about it here, and listen (for the next couple of days) to a radio discussion about it here (MP3).

What has amazed many in the ambulance services is that the Staffordshire trust is being held up as the ‘golden child’, when it has been widely believed that they fiddle the figures more than anyone else…  (Just a rumour, I’m not suggesting that it’s true, please don’t sue/sack me)

The government, whose bright idea this is, tells us that the clock should start when the calltaker has,

a) The name of the patient (or caller).

b) The complaint or injury (enough detail to know how serious it is)

c) The location the ambulance needs to go to.

Rather reasonable I think.

The problem is that some trusts have been starting the clock later (apparently).

There is a crazy idea that the London Ambulance Service has a delay of minutes when dealing with calls.  Well I can only see the times when the phone is picked up, and when the clock starts.  The times are often around a minute apart.  Sometimes it is longer, and that is because of the problems that the LAS has due to the size and makeup of our patient population.  One of our calltakers has posted a comment, and it’s pretty much as I expected. 

The problems are…

a) Only 1 in 6 callers has English as a primary language.

b) People dial 999 shout “I want an ambulance” down the phone and hang up.

c) People with mental health problems will ring up for a chat, and calltakers can’t hang up the phone on them.

d) People don’t know the address that they want the ambulance sent to.  Our computer mapping system isn’t brilliant and pretty much requires a postcode.

e) People who keep talking, but don’t answer the questions the calltaker asks.

When I spent a couple of hours up there once, none of the calls I listened to were easy to understand…

Do I think that we ‘fiddle’ the numbers?  Well – back in the good old days before we had the computer dispatch and all the times were taken from your paperwork, then we could use the ‘magic pen’ to knock a minute or two off the times.  Now we can’t fiddle the times, as they are all collected, to the nearest second, by the computer system.

Does getting to 75% of all calls within 8 minutes help patient outcome?  Well no, except in a very few cases.  Remember, if I get to a dead body in 7 minutes that is a ‘success’, while If I get to someone and save their life in 9 minutes, then its a ‘failure’.

Do Trusts ‘fiddle’ the numbers?  Possibly.  Do they wait four or five minutes before starting the clock?  Probably not, and almost certainly not in London.

Was the radio piece biased?  Oh yes…

Maybe more later, check on the comments – but I desperately need some sleep.

22 thoughts on “Response Times”

  1. I heard in my ACLS (Advance Cardiac Life Support) course of studies done in Las Vegas with MI's and the AEDs (Defibrillators). They could watch the times because of so many security cameras. And the time needed was more like three minutes. No way an ambulance could get there in that time, so they trained the security guards to use the civilian friendly automatic defib. machines. All very cool and scary, and I would love to hear about this from other sources.

  2. If you can't measure what you should be doing (or if it's too difficult) then change what you measure!So, 7 minutes and dead = Success, 9 minutes and alive = Failure

    Stupid, isn't it!

  3. I've had to call ambulances out a couple of times in my life, and in both cases it's been somewhere where I know the postcode, or street name and so can give precise information about how to get there. In fact on one occasion control asked for directions for the last couple of hundred yards, which I was fortunately able to give.Most people (I would hope, but could be wildly wrong) rarely call an ambulance, and often are likely to be in some distress when they do, and one thing I've heard about people in that state is that they basically lose all reason! That's why we have fire drills, rather than just relying on telling people what to do. It means people can practice while they're calm. Then in a panic they just repeat what they did in the drill which they can just about cope with!

    So I wonder if you think it would be helpful for people to be educated on what they need to tell control when they call for an ambulance – or any of the emergency services for that matter. Should kids be taught how to call for an ambulance in school? Should there be ads of TV every now and again reminding people?

    Also, I can't help thinking that the only piece of information you need before dispatching would be the seriousness of the incident and the location. Couldn't details like a name be collected while the ambulance is on its way? I'm probably being hopelessly naive here, and you're probably just happy to get the details in whatever order you can get them!

  4. Hmm, not really relevant to the subject of this post, but the BBC article you link to in the first paragraph saysThe proposals…will enable a million 999 calls to be dealt with in the community rather than in hospital, saving the NHS money as it costs 14,000 to send an ambulance out.

    Just where do they get a figure of 14,000 from?

  5. Can't speak for other areas, but in London we don't ask for the patient's name at all. The dispatch desks will send out an ambulance if possible/appropriate after getting the address and what is wrong.As for your fire drill idea… yes please!! Children actually tend to be rather good at calling for ambulances, they don't shout or tell you to hurry up like adults do, although admittedly they aren't great at providing medical details. If you taught them what to do in school, I'd bet they would go home and teach it to their parents. Also, any foreign person who moves to England should immediately be sent to Ambulance School since these people are responsible for 90% of the frustrating/inappropriate calls/requests for pizza, presumably through a lack of understanding exactly what 999 and ambulances are for.

  6. I read the story on the Beeb before you raised it here and as I perused it, I wondered what your response would be. I'd be intrigued to find out what their stats for saved call-outs are based on. Are they based on the information given or on what the problem subsequently turns out to be? All your “stopped breathing” call-outs are presumably emergencies when you get the info, but not when you arrive on the scene.I too wondered about the 14,000 per call-out. I presume that's the cost of the ambulance and staff, etc. for the whole year divided by the number of times it's used. But if you halved the number of call-outs, you wouldn't be saving much as you still have to pay for the ambulance, staff, etc. You might save a bit on cleaning and equipment used.

    The whole notion, and the article, seems very simplistic.

  7. On the LAS website, its around 120 pounds to send an amublance out, one of hte main reasons why I dont call unless its absolutly nessessary (NHS Direct the other day told me to call an ambulance, I ignored thier advice and went to the hospital by myself – a 25min walk, the doctor at the hospital said I didnt need an amublance – do NHS Direct just ditch people onto the Ambulance service because its easier, or what?)

  8. haha yes… once I was providing first aid cover to an event in a university building. We needed an ambulance (but for a non-life threatening condition) and in line with the rules we sent someone to the building's reception to summon one. The guy working there was obviously new night-staff with a fairly basic grasp of English…when we told him we needed to call an ambulance he rooted around for a yellow pages to find the phone number.He was rather startled when we took the phone off him and made the call ourselves.

  9. The most worrying sentence in your post, to me at least, was:“Our computer mapping system isnt brilliant and pretty much requires a postcode.”

    That's scary, particularly if you fall ill or have an accident somewhere unfamiliar. Surely the ambulance service deserves the very best computer mapping system, and not something reliant on sick people knowing or remembering a six figure locational code.

  10. The dispatch operator in his description of working conditions at dispatch mentioned that their computer system does not even support locating the names of pubs and shops in the general area of the emergency unlike one that the police uses.I just checked out Yell.com and on the first attempt managed to get a full address as well as a map and driving directions to a pub in Nottingham called “The Slug and Lettuce”.

    If what you need is the ability to search for shop and pub names couldn't you at least use that one as an interim remedy until you are granted the XX million pounds needed to develop the same capability in your in-house computer system?

  11. Many London boroughs run 'Junior Citizens' courses that teach children in year 6 at school (10 or 11 years old) how call an ambulance. The senario is run by the LAS in conjunction with the local authority.

  12. Funnily enough, some London schoolkids at least DO get taught how to call an ambulance, and that teaching almost certainly saved my friend's life when we were both 13. Anna had what I now know was an anaphylactic reaction to a bee sting when we were alone in her house. God bless that cantankerous Citizenship 'tutor' from – I guess – the ambulance service because I actually knew what to do. We must have been in one of the pilots or something for the scheme cause I think the Citizenship training I got was in Year Six – 1994 or 1995, I reckon.Worth doing for everyone, definately.

  13. Actually, it doesn't (and indeed cannot) use full postcodes at all — what it requires is the first part of the postcode (W1, E17 etc) plus a road name (or name of a station or sometimes a famous building like Big Ben). It's a shame it can't use postcodes because a lot of people know their postcode but not how to spell the name of their road. On the other hand, lots of people, especially those involved in car accidents have no idea which postcode area they are in and it is a nightmare trying to work it out for them.

  14. I found a entry in my livejournal from a while back which is an example of a call with a long delay before dispatch (address details changed for patient confidentiality wotnots, obviously):One of my pet hates has always been people who live in England but can't speak English. One step worse than this are people who live in England, can't speak English, but refuse to admit it. Like the man who rang me last night. In fact, this guy didn't even seem to speak his native language very well…

    Me: Nee Naw Service, what is the address of the emergency?

    Him: Chest pain! Uuurgh!! Argh!

    Me: No, no, the address first, please!

    Him: Chest pain! Uuurgh!! Argh!

    Repeat the last few lines five hundred times.

    Me: WHERE DO YOU LIVE?

    Him: (in extremely thick accent) 7, Rosevalley Road. Chest pain! Uuurgh!! Argh!

    Me: Rosevalley Road in which area??

    Him: Chest pain! Uuurgh!! Argh!

    Me: Okay, that's it. I am getting the interpreter. Which language do you speak?

    Him: Engleeeesh!

    Eventually I establish the man speaks Punjabi. I call the Punjabi interpreter and tell the man to hold the line and not hang up. He hangs up. I put the Punjabi interpreter on hold and ring him back. The Punjabi interpreter talks to him in Punjabi. He answers her in English.

    Me: (via interpreter) First of all, there's no Rosevalley Road in London… could you spell the name of the road?

    Him: I cannot spell it! Rosevalley Road!

    Me: And which area is it in?

    Him: By Tescos! By Queen Pub!

    Me: We cover the whole of London. What is the name of the area? Or the postcode?

    Him: I do not know postcode. I do not know name. ROSEVALLEY ROAD!!!

    Me: You need to spell it or tell me which area it is in. If you can't, find a neighbour or someone who does. Or call me from your landline and we will trace the call.

    Him: Okay, you not help me. I die! *click*

    So I ask the operator to trace the call (if he had called from a landline or an Orange or Vodaphone mobile, this would be done automatically) and we establish that he is somewhere in Bromley, Kent. Then I call the police, who have better software for finding addresses and try to find an address in Hayes that sounds like Rosevalley or Roseberry or Rosemary Road. Eventually the police stumble across Roseville Road, Bromley. The man obviously doesn't even know how to pronounce the name of his road, let alone spell it.

    Anyway, the man got an ambulance, which was dispatched a good fifteen minutes after the start of the call. I hope he wasn't having a heart attack!

  15. I used to have (until I moved) an 'Ambulance Card' by my phone with the Address, Postcode, National Grid Reference and the Page and Grid from the local county atlas. It also had instructions on how to find the flat – access was somewhat convoluted – worked out to be clear and concise.The point was, I live alone. So if I call an ambulance I'm likely to not to be a state to think clearly. That info was there so I didn't have to think.

    I had better make up another one for this address – although I have neighbours now who can do the call for me, if I can contact them.

    Actually, we have such bad access here that the Residents Association organises a visit by the Fire Brigade every few years to check and review the access plan. It involves breaking down fences but the route is a lot quicker than the 'obvious' one – and they can get the appliance to a position where the hoses will reach!

    Unfortunately this is the result of a fatal fire where the Fire Service _couldn't_ get rapid access and the hoses didn't reach.

    We had probably best work out an ambulance access plan as there are parts of the area where parking up in a non-obvious place and using a few yards of path not marked on the map would be a lot quicker than the several hundred yards to the normal access point.

  16. We got 911 emergency service in something like 2001 where I grew up in upstate (rural) New York. At the time, we had somewhat strange addresses, from living on what were essentially parceled-out farms. (Mine was actually 386-I on my road name.) Nothing as hopelessly bizarre as your UK adresses (Strompwiffle under Wardrobe, Whingeing, Pancake, W601-!!) , but still a little off.So they simply gave us new addresses. That was it, you just didn't live at 386-I anymore, you lived at 249. Bam. Done.

    Though currently, in our fairly well-funded fire-EMS response station, we still rely on giant metal binders full of hand-drawn and indexed maps, drawn by each fire station of their own area. In all honesty, these are quite good and usable, in the passenger seat of a speeding ambulance or engine. (We don't do one-person responses, though, unless you are a Battalion Chief or similar…)

  17. Just a thought but could it be that our good friend Roger 'Response Times' Thayne is jostling for position? ie: trying to look like the best man for the job when the government give up on Agenda for Change (once we've all been on strike for a year) and decide to make the ambulance service national??

  18. As I understand it, New York City handles fire/EMS dispatching on a borough-by-borough basis, so that the city is broken up into five separate districts. Call-taking dispatchers are thus somewhat more familiar with their territory than they would be if they covered the entire city.Of course, New York's geographic divisions are enforced by huge rivers.

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