*BLEEP!*

*BEEP!*

We are spending too long at hospital.

*BEEP!*

In order to have ambulances that can reach calls in under eight minutes, we need to have ambulances 'Green up' (be available for another call) at hospital faster than they do at the moment.

*BEEP!*

There is a policy in place that if we spend longer than twenty minutes at hospital we are supposed to book in with Control and explain that there is a delay. Unfortunately It's nearly impossible to get your patient booked in at the hospital in under twenty minutes. So we don't do it – we only book a delay if we spend longer than forty minutes at hospital.

Otherwise we'll make our controllers go mental with our calling up after every job.

*BEEP!*

You see, you have to get the patient off the back of the ambulance – this sometimes involves hunting around for the increasingly rare 'Hospitalis Wheelchairus', the common hospital wheelchair. Then you wheel them into the department where you need to wait for a nurse to take a handover of the patient off of you.

*BEEP!*

It's in the interest of the hospital to delay this handover for as long as possible, so as to make it easier to make their four hour breach target. Sometimes there are three ambulance crews in front of you waiting to handover their patients.

*BEEP!*

Sometimes the hospital just has a culture of not taking ambulance handovers until they have been waiting for twenty minutes in any case.

*BEEP!*

Then you have to get the patient onto the trolley (or more likely wheel them out to the waiting room while trying to explain exactly why the nurse doesn't believe that they are going to die).

*BEEP!*

Then one of us heads to the reception area to book in the patient, while the other returns the trolley/wheelchair and makes the ambulance ready for the next patient. It is rare that the ambulance trolley gets a clean – it takes too long to dry.

We do try and wash our hands between patients though.

*BEEP!*

The crew in the reception then books the patient into the hospital – sometimes there is a queue of walking wounded waiting to book in – sometimes they are more ill than the patient you have just brought in, so you let them book in first.

*BEEP!*

Then you head back to the ambulance where you fill in your documentation in a way that will cover your arse should the patient suddenly drop dead and you find yourself up before the Coroner's Court. There are boxes to tick and findings to write. Times to be entered and obs to be recorded.

*BEEP!*

Then you hit the 'Ready for another call' button and get sent somewhere else for some fool with a poorly elbow.

*BEEP!*

This takes as a minimum around thirty minutes – note that I haven't included going to the toilet, grabbing a cup of tea or eating a bag of crisps. With an uncomplicated walking patient, with no delays on handover and a reception that is poised ready to take your handover this takes a minimum of around eighteen minutes.

I know, I've timed it.

*BEEP!*

In an effort to 'speed us up', and to remind us that we should be making Control's life more difficult by booking a delay after every job, some bright spark has installed a new programme on our vehicle based computer terminals.

*BEEP!*

After two minutes at hospital a big friendly black screen appears on the terminal. Then a big friendly timer appears that says…

RED AT HOSPITAL FOR 4 MINUTES

If you are, god forbid, at hospital for longer than twenty minutes it goes

RED AT HOSPITAL FOR 26 MINUTES (IF DELAYED PLEASE ADVISE CONTROL)

Also after you have been at hospital for more than twenty minutes it starts going…

*BEEP!*

Every minute it goes…

*BEEP!*

While you are trying to do your paperwork, in the manner that is expected of you.

*BEEP!*

It's like Chinese water torture.

*BEEP!*

Oh, and the number starts flashing in a friendly red and white manner.

All in an effort to get you to make available those few minutes quicker.


Now, I understand that there are ambulance crews out there who take way too long at hospital. These cause more work for those of us who get on with the job. But surely if you are concerned about those people (and management know who they are because everything we do is logged) then you pull them into the office and have a quiet word with them.

What you don't do, at least if you want a happy workforce, is to force them to endure psychological torture. Or to punish everyone for the crimes of the few (although it seems that this is the tactic that Nazis in war films use…)

It's all in a bid for increasing the calls we get to in eight minutes (and I've moaned enough about how it is clinically unimportant for such a target).

There is a rumour that in the new year we will be banned from booking our patients in at reception. The nursing staff will have to do this (because, you know, they have so much free time). This surprises me as I can remember when it was tried about six years ago and was a horrible failure as paperwork kept going missing and patients were left for hours without seeing anyone.

I'll still be booking my patients in because of a little thing called 'duty of care'.

But, you know, eight minutes is all that matters.

Anyway, 'nerd determinism' has won out and there is a simple way to stop the *BLEEP!* from sounding that isn't in the slightest bit damaging to the equipment on the ambulance.

I'll continue to have two mouthfuls of coke between jobs, and will make available as soon as I can (if only because I find it really dull to sit at hospital). My patients come first, not the eight minute target.

(It's a shame, for once, that only Mozilla browsers still support the *blink* tag…)

26 thoughts on “*BLEEP!*”

  1. My point is that ORCON is clinically pointless – if you want to count targets then count the survival rate of cardiac arrests. Count the asthmatics that don't need to go to ITU. Count overall survival rates.The 'Be there now' is for your cardiac arrests, by eight minutes you have suffered so much hypoxic damage (especially without bystander CPR) that your chances of recovery are next to nil.

    You agree with my point that ORCON is clinically useless – even though it was part of a clinical paper over twenty years ago. So why are we changing the service to serve this made-up number at the detriment of patient care?

    We take people off of ambulances to man FRUs, only to leave the FRU sitting at scene for 45 minutes because there are no proper ambulances to take the patient to hospital. It's the reason why I came off the FRU – I came too close to watching people die in front of me to be happy doing it anymore.

    I agree completely that the telephone triage that we use is awful (but that it has to be) and that call takers should be clinically trained – but it would cost too much money not only in training, but also in AfC wages.

    I've been shouting that first aid should be part of the national curriculum ever since it came in (I was training to be a teacher at the time…) So should education – but unfortunately I think that it would be countered by the 'me first' culture that seems to have taken over in the UK.

    The vast majority of crews on the road will tell you that ORCON is a pointless target. One that the government uses so that it can 'tick box' ambulance trusts as failing, or not failing (and therefore cut the budget of failing trusts).

  2. What is wrong is this -(an example)

    Eight minutes is the target you need to hit.

    You spend resources on hitting the eight minute target.

    So you have community responders, or FRUs instead of ambulances (because resources are limited).

    Responder goes to patient who needs urgent hospital treatment (let's say a AAA).

    There are no ambulances available because half the staff are on FRUs.

    You've 'succeeded' in the job because you got there in eight. The next free ambulance is sent to a different call because *that* needs to get there in eight.

    All the time the patient isn't getting any better because there is no-one available to take them to hospital.

    So the concentration on something that isn't clinically important has an effect on how the care is provided. This is my problem with it.

  3. Ride-outs – It may just be that they don't know how to behave – realistically though a ride-out would be a chance to better tailor a 'chat in the office'.For targets, and I really should do a blogpost on it, there needs to be a better determinant than 'it was classified as a Red, we got there in eight, Huzzah!'.

    How about condition specific targets.

    Rate of MI diagnosis and speed from call to needle/angioplasty?

    Stroke recognition and transport to stroke centre.

    Asthma treatment and keeping people out of ITU.

    Sickle Cell Crisis – adequate use of pain relief.

    Cardiac arrest survival rates (something that I'll be posting about when I get my hands on this months 'pulse')?

    Time until a 'proper' ambulance arrives?

    How about ratio of paramedic cover?

    Number of vehicles off the road?

    Even better – amount of time that there is spare capacity?

    All these things are recorded already – why aren't *they* the 'gold standard' target? By improving these we improve patient care, and isn't that what targets are for?

    These are the targets we should be chasing, and the eight minute ORCON takes resources away from this.

    I also think that cardiac arrest survival rates have more to do with the new resus guidelines (and perhaps dispatcher instruction trial) than with an ORCON rate that has remained pretty much unchanged from year to year.

    (Thanks for the comments DSO.)

  4. I, for one, am enjoying the blinking. So much that I stared at it for a good minute seeing if it seemed faster when I looked at it out my peripheral vision and all sorts.Of course, this is instead of doing a respiration lab report…

  5. Some of the crews on our sector have taken to booking delays in minute detail (sat in queue, spent half an hour getting patient to remember their name, waited for bored looking nurse to finish reading book and talk to us, waited for cubicle, filled paperwork, helped old lady into reception, found K301 were blocking us in, argued with K301, cleaned vomit from trolley bed, had glass of water, went to toilet…) and I always write what they have said word for word on the log. If management are actually reading this it might convey the idea that 20 minutes isn't really a long time to be at hospital and crews resent having to justify themselves for taking longer.

  6. Hey, why not just screech to an (almost) halt at the hospital and throw the patients out the back doors of the ambulance with a quick note safetypinned to their clothes.I'm sure that would speed things up a treat and and please the Government target setters no end…

  7. Oh man… that would get really irritating. However, I think dispatch calling asking what your status is 5 minutes after you arrive at the hospital is probably more irritating. When I'm not on a 911 truck, I end up doing a lot of transfers and can do the bulk of the paperwork enroute, but still… if they're that short of trucks, they should think about hiring and pay more. Yeah, like that'll happen.

  8. No, you could have a chute like for laundry, pop 'em down that (compound fractures and all)…Coming from the people who brought us today's headline, the loss of discs containing the personal details of every family in the UK with a child under 16, nothing would suprise me….

  9. I feel sorry for all the road crews that have to put up with targets etc.And as for the warnings on the terminals in the vehicle, it seems like the powers that be dont trust our ambulance service.

    Stick the minister for Health in an ambulance on a friday night or stick them in the control room to see what we have to put up with.

  10. Funny thing about that 8 minute target, its completely meaningless… unless you need an ambulance of course.Oh yeah, and it has no clinical relevance, except that the longer you wait for an ambulance the worse your prognosis is!

    Yes the screen indicator is the work of an idiot, but equally it is very difficult to manage staff who intentionally take longer at hospital,

    There is a culture of acceptance of such behaviour that is hard to breach.

    There is, as ever, another side to most arguements!

  11. …Which is why I suggest the other way to handle such situations – calling people into the office rather than 'punishing' us all.How about DSO/TL ride-alongs? So as to better educate crews and suggest how they might improve.

    The 8 minute time has no clinical relevance in anything other than perhaps in cardiac arrest (and that may be shorter at four minutes). ORCON is terribly out of date, hardly the evidence based practice we like to use.

    (Actually, perhaps research into a more reasonable ORCON time should be one of our priorities?)

    Maybe in a few other rare occasions like brittle asthma minutes matter. But surely you see what chasing this target has done to the ambulance service – it's seldom done anything for the betterment of the patient, or of the ambulance workers.

    There are, as I see it, three times that need to be met.

    (1) Be there NOW.

    (2) Be there within 15-20 minutes.

    (3) Be there some time today.

  12. Your first category (Be there now) is of course impossible to achieve unless you have an ambulance parked outside every house, office, shop etc. in the UK. The 8 minute target was designed to allow for this fact, in that it is the maximum allowable time that we should be aiming for in life & death emergencies.Imagine you have brittle asthma, have been in a serious car accident, or are performing CPR on your wife. You want (and need) an ambulance straight away, and 8 minutes is probably the very most you're willing (or indeed able) to wait. Ideally you want it in 3-4 minutes.

    Of course, 3-4 minutes is completely unachievable in all but the most unusual of circumstances, and if this had been set as the target you'd be complaining about how “stupid targets” make you rush around in a dangerous frenzy. Hence 8 minutes as a compromise. If you aren't able to get to a life-threatening emergency within 8 minutes (particularly in a built up area such as London) you damn well should be ashamed of your service, whether the target is there or not.

    What we absolutely must do better is classify “life-threatening” more appropriately. Currently a lot of calls classified as such are really not. This is in part due to the inevitable problems of telephone triage and the somewhat necessary over-caution that is required because of these. Better use of clinical judgement by call-takers is perhaps one mechanism by which this can be achieved, although that does throw up problems as, by and large, these people are not clinically-qualified. Another attack route is better education of the public – this is already being done with advertising campaigns, but also more widespread first aid training (perhaps by tieing it to the national curriculum a bit more tightly than it currently is, or offering free courses to community members).

  13. But surely someone who works for the ambulance service is doing it because they want to work for the ambulance service, dealing with emergencies, helping people, etc… they're certainly not doing it for the money.In which case, when a 'red call' comes through, the person driving the ambulance is, one would imagine, going to be thinking “I must get there As Soon As Physically Possible in order to save a life.”

    It therefore doesn't matter if ORCON is 2 minutes or 8 minutes or 20 minutes. The person driving the ambulance has a rather more pressing reason than “targets” to get there fast.

    This is an assumption, and may be incorrect. Perhaps in the days before the 8-minute target, paramedics and EMTs sauntered about going “yeah, it's a red call, but let's go get some chips first” or something.

    I can understand why the bosses would want to know how fast ambulances get to emergencies, but I can't quite grasp the idea that a target will make front-liners respond any faster.

  14. Most of us 'drive to arrive', that is we get there as quickly and as *safely* as we can. We don't check the clock while whizzing around time.We don't want to have an accident, we don't want to kill anyone, and we also don't want people to die while waiting for us.

    If someone was to tell us to 'drive faster' we would all refuse – and quite rightly. The alternative is to have ambulances crashing all over the place because we are driving too fast for the conditions.

    ORCON is designed to make trusts 'think smarter', unfortunately this chasing of the targets results in less ambulances on the road and the problems of solo responders.

    (Solo responders are fine in small amounts – but not at the expense of proper ambulances).

  15. Tom,I'll take your points from both your replies if I may…

    Rideouts: These only deal with situations where staff don't know the “right” way to behave. Do you believe those that “hang-out” their jobs do so because they don't realise there's a quicker way of doing it!

    8 minute response: Yes its an arbitary figure but then it doesn't suggest that you should respond in 8 minutes it suggests “less than 8 mins”, bottom line “asap”.

    Outcome targets: These are great in cardiac arrest where clearly “life” is a good outcome, however in all other cases setting a benchmark of “not death” is setting the bar pretty low and if you chose “life quality” then it is incredibly difficult to define at all and open to even more abuse than the ORCON is at the moment.

    You suggets that the 8 minute response is, in effect 20 years out of date, while in fact 14 minutes was the measured standard within the LAS up until about 8 years ago.

    Bottom line, standards, and we don't just use ORCON, show you whether you (the trust) are performing and they focus the minds and purse strings of all involved.

    Cardiac arrest survival is now superb within London, do you think this would have been possible without an 8 minute target?

    Truth is, we all, within the service agree on so many things, sadly we focus too much on the areas we don't agree on.

    As ever, just my two pence worth!

  16. Sometimes the hospital just has a culture of not taking ambulance handovers until they have been waiting for twenty minutes in any case.I would hope and trust that this practice is confined to the walking wounded – I would hate to think that someone in acute need isn't left waiting for 1/3 hour on principle?!

  17. If it was me needing the ambulance, I'd be happy if it got there within 13 minutes, so long as that was quickly enough to save me from death/serious problems.Equally, if I died/suffered irreperable damage because it got there within SIX minutes, but I needed it to arrive within four, then ORCON's targets are not going to console me!

    I can see the point for having targets etc, but given that clinically 8 minutes is no magic figure, we need to ensure that those targets only work to improve service, and that surely has to include not making quality of life worse for ambulance service staff in any way.

  18. Absolutely. The 8 minute target is not there because ambulance crews are driving slowly!The target's purpose is to improve the organisational process as a whole – if you have an 8 minute response time target which absolutely must be met, then organisational change will ensue in order to create a system whereby it is possible for a call to be answered within this time, whether this be by means of a community first responder, first response unit, ambulance, or whoever. If there is an organisational culture in which it is unacceptable to delay your down time inbetween jobs, and thus make yourself available for more emergency calls, then this is all for the better. It may be irritating, but if it is then it's doing its job – if someone had just told you that you need to be quicker leaving the hospital it wouldn't really register in your conscience. If you are given a reasonable amount of time on each job then nagged, then it encourages you to speed up. I don't work in the LAS, but I'm sure the idea is not to rush you into providing bad care, but just to keep you on your toes a little. I agree it's annoying, but if it's brought the issue into your consciousness then it may just be doing its job.

    I'm by and large a sceptic of targets in healthcare as I believe they tend to measure meaningless things and are usually met by shortcuts rather than actually improving care, but this is one which absolutely does improve clinical outcomes and is extremely important. I'm sure you'd all agree that time is of the essence in these life & death emergencies, and anything which speeds up the response is a good thing.

    A figure of 8 minutes doesn't mean that someone who's reached at 7:30 is going to live and someone at 8:30 is going to die. It means that, in general, people do better if they are responded to quicker, and for these types of patients 8 minutes should be regarded as the minimum acceptable timeframe in which to respond. What on earth is wrong with this?

  19. Tom,Check out the work being done in South-East Coast with Douglas Chamberlain's Protocol C. Amongst other things, his research proves that hypoxia during the early stages of an arrest is a myth and demonstrates the value of compressions over pretty much everything else.

    They're getting some really stunning results and showing that its not about getting there in less than 8 minutes but what you do when you arrive.

  20. Where I work, the 8 minute target isn't an issue. I don't mean that we always make it, or that it doesn't apply. What I mean is that it doesn't affect the way we go about our job.When I am driving to a job, how long it takes me to get there doesn't matter. It will be more than 8 minutes on many occasions, it will be less on many others. What matters is that we get there as quickly and safely as we can.

    In fact, in many cases it would be impossible to achieve the 8 minute target, such as a job I had two nights ago. Very little traffic and we took 22 minutes to reach the address as it was on the other side of the city. Nothing – other than a set of wings – could have cut that to 8 minutes! On the other hand, I once reached a call in 42 seconds, it's just luck where you are at the time! (Incidentally, the patient that had the 22 minute wait was in far worse condition than the patient with the 42 second wait, but that's life, isn't it?)

    Control have never asked why we have taken more than 8 minutes, nor have they ever congratulated us on taking less than 8 minutes.

    In short, I don't hear from control or management about the 8 minute target from the start of my shift to the end of it, and that's the way I like it.

    It's quite concerning that crews in other services seem to have this target impressed upon them on a daily basis, why can't management leave them alone to do their jobs?

    And on the point of crews taking too long to clear at the hospital, Tom is quite right. The known culprits (and they are known – it's hardly a secret that control can track our every move) should be pulled in and asked to explain themselves!

  21. Except for “true” category A calls, having someone on-scene, even if they can't transport, is of utmost importance. In the peri-arrest situation there is nothing that can be done in hospital or an ambulance that can't be done on scene by someone appropriately trained – CPR, defibrillation, airway management, ventilation, fluid resuscitation, nebuliser/o2 therapy etc. can all be initiated by an FRU, and patients in cardiac/respiratory arrest, hypovolaemia, respiratory crisis and so on are all managed just as effectively at the scene.The issue is inappropriate categorisation of calls and appropriate staffing. These seem to me, as an outsider admittedly, far from ideal, and should be looked at. But none of that is directly the fault of the 8 minute target.

  22. There's a line in an 80's movie “commander, are you telling me a 10 year old boy just disabled 24 million dollars of military hardware with a stick of gum?!”Somewhere on the case there should be a small hole to allow the sound to escape from the case – bit of chewing gum over hole, job done! It might not silence it completely but it'll certainly muffle it enough to stop it annoying you.

  23. It's not as effective when there is only one person providing the CPr/Ventilation/drugs/etc…And *that* is the problem I have with us chasing the 8 minute target – that patient care suffers.

    Anyway – I'll have a bigger post on the subject after I wake up…

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