Handing Off

The London Ambulance Service today announced a new initiative designed to improve their response to emergency calls. The new scheme named ' Complimentary Rapid Access for Patients' will enable ambulances to turn around much quicker at hospital.

Instead of the traditional handing over of a patient to the A&E department, which takes valuable time, the patient will instead be placed into a sturdy plastic shell. All paperwork will be affixed to the outside of the shell; then as the ambulance passes the hospital the patient will simply be slid out of the back of the vehicle. There will be no need for the ambulance to actually stop moving.

Experts estimate that this new proceedure will enable ambulance crews to reach more patients within the allotted eight minute target. Ambulance staff will be discouraged from stopping at the hospital for a cup of tea or a toilet break, as the government considers ambulance crews as being able to work twelve hour shifts without such luxuries.

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Of course this isn't true; but it wouldn't surprise me if some bright spark hasn't suggested something similar.

It's 'silly season'; April approaches and with it the cut-off point for us to hit our government mandated eight minute ORCON target. Normally around this time of year certain management types in ambulance trusts across the country start sweating.

Some trusts have already had inaccurate figures, I couldn't possibly comment on whether other trusts have similar problems; lets just say that it wouldn't surprise me in the least if we hear more accounts like this whether it's due to computer error, human error or someone purposefully 'massaging' the numbers.

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From Monday, in order to try and improve our ORCON, the London Ambulance Service is going to stop us from doing any 'administrative' hand-over.

How we book patients into hospital in the past has gone something like this. We arrive at the hospital. We show the nurse the patient and let them know what is wrong with them. The nurse tells us where they want us to put the patient. The nurse gets on with looking after the patient. The ambulance crew heads to the reception area and 'books the patient in' by giving the receptionist all the relevant details. Paperwork is generated by the reception staff that enables the clinical staff to perform such tasks as sending off blood for tests and arranging x-rays.

From Monday we will no longer be talking to the receptionists – instead the nursing staff, as well as looking after the patient, will have to book in the patient. Or send a relative to book the patient in for them.

No possibility for anything to go wrong there then…

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In my memory this has been tried twice before; at least once when I was myself an A&E nurse. Neither time has it worked in the patient's favour. The ambulance crews would hand over to us nurses, then we'd have to make sure that the patient was booked in. Sometimes (because A&E nurses are occasionally busy) paperwork would be forgotten, or lost, and the patient would disappear off the system.

This obviously can have serious effects on the safety of the patient, especially patients who are sat out in the waiting room.

This is why we book our patients in at reception – it's because then we can be sure that the hospital has responsibility for the patient. That the patient shouldn't get lost in the system.

It's that bit more work for us, but we do it because it gives us peace of mind.

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I'm not sure how this is going to be enforced. I suspect that for a few weeks we'll have some Team Leaders or Duty Officers sitting at the hospitals making sure that we follow the protocols. I leave it to the imagination of the reader as to the effect such staff could have on ORCON if they were working on ambulances instead.

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I also suspect that this initiative will only last for around a month. April brings in the new year of ORCON targets, and so a rapid turn-around at hospital won't be so important after April 1st.

Until this time next year.

What I do hope is that no-one dies because of this. If someone does die, sitting in the waiting room, or in the toilets I know that the hospital will do all they can to shift blame on someone else. That blame will doubtless be on the ambulance service; and it won't be the manager who thought up this idea, it'll be the poor bloody road crew who get the short end of the stick.

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Part of our Visions and Values is –

Clinical Excellence

We will demonstrate total commitment to the provision of the highest standard of patient care. Our services and activities will be ethical, kind, compassionate, considerate and appropriate to the patients’ needs.

Could someone please explain how not bedding our patients securely down in hospital fits this value? The last time this was tried patients disappeared and spent hours waiting for treatment while the hospitals didn't know they were there.

All this is to fit in with the clinically irrelevant ORCON standard (do click on this link – it makes interesting reading when the BMJ agree with us. Particularly “The strategies introduced to meet the targets can be detrimental to patient care and also have adverse effects on the health, safety, wellbeing, and morale of paramedics.“).

It is just another way that the ORCON standard is having a negative impact on the effective and humane treatment of our patients. Anyone who wants to disagree should take a look at my proposed solution, and then tell me that ORCON is the ideal measurement.

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If we really want to be living up to our Visions and Values I think we should be kicking and screaming at the government to get ORCON measurement off the table, or at least made vastly less important. It's not evidence based and it's having a detrimental effect on patient care – and this latest initiative is just one more example of this.

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I want my management to take this in the manner that it is meant. As a call to realise that bending over backwards to fulfil the inappropriate targets set by the government is no way to lead a service, and that we need to start pushing back against these diktats. That we, as ambulance trusts, need to start fighting for our patients, so that they get the service that they deserve, not what the government finds easy to measure.

No sooner than I hit publish for this post than I note that Mousethinks has written about the problems caused by slavishly following the A&E targets.

(And if I do get sent my P45, anyone got a job for a jumped up first aider who is experienced in all sorts of internety stuff?)

29 thoughts on “Handing Off”

  1. Silly Reynolds, “Visions and Values” aren't for sticking to, or for aspiring to, or for paying any attention whatsoever.They are for writing down in a massive folder which is then submitted to a bunch of people in suits who've never done any frontline work so that the organisation can say it has Matrix Accreditation or similar.It's the sort of thing where the person compiling the massive folder gets a colleague to throw a bit of water on the kitchen floor, then get the yellow 'slippery floor' hazard sign, then mop up the water in the approved manner, while the compiler watches. The compiler can then confirm that the organisation has correct procedures for dealing with spillages despite the fact that the next person to spill something is simply going to ignore it or at best chuck a towel over it.It's stuff for saying, not doing.

  2. Just when you think the decisions have reached the pinnacle of stupidity someone climbs that little bit higher.Could we not build the sturdy plastic pods and put the managers in them? I'm seeing brightly coloured ManagerPods floating down the Thames with members of the public throwing apples at them. If it's a success we could introduce it at the Olympics.

  3. Add to this the new 'standard' for ORCON where the clock starts at the moment that a caller dials 999 and the next year will be worse I think. The people on my station think its a matter of weathering the storm, but I cant see it ending any time before the next election..As a student paramedic I have been quite frankly shocked at the ways that hitting this ridiculous target is affecting the care provided to the patient. In my trust its INCREASING the amount of stay and play as they are sending RRVs to jobs, that need to load and go, to hit targets.

    Keep up the campaigning Tom hopefully they will listen to the qualified professionals on the front line eventually!

  4. Reynolds,I know we've been round the houses on this before, just to point out that the BMJ piece appears to be merely a focus group of paramedics saying that 8 mins depresses them, whilst I agree the 8 min bit of the target isn't science, neither is taping a bunch of moaning ambo staff (we all do it all the time with no encouragement).

    Your piece about the “administrative handover” fails to point out that about 30 mins of a 70 minute job cycle is spent at hospital, you're right the NHS should ensure that all patients are properly cared for and not lost to the system, my only question is, since we're just as busy as the nursing staff why should we be doing it? After all the patient is now the hospitals patient and I can't help feeling that by booking in all we are doing is re-inforcing the idea that you get special treatment in A&E if you go there by ambulance.

  5. You beat me too it!!As for trusts hitting targets, me thinks that FRVs / RRVs / PRUs which ever they are called in the different trusts will be deployed a lot more in the coming weeks so that they can hit that button within the time limit….. not cynical me….

  6. “…since we're just as busy as the nursing staff why should we be doing it? After all the patient is now the hospitals patient…”Maybe because the patient has deteriorated en route, and/or doesn't want to have to list every last symptom again because they feel, well, VERY ILL?

    “…and I can't help feeling that by booking in all we are doing is re-inforcing the idea that you get special treatment in A&E if you go there by ambulance.”

    Well, SHOULDN'T you?

    I mean, if I can walk or otherwise move myself into A&E, that is generally going to mean I'm in better shape than some poor bugger who can just about manage to dial 999 from home, or whose family are freaking out so much they dial an ambulance.

    I'm not trying to have a go, but with respect, I don't follow your logic here, at all.

  7. “…and I can't help feeling that by booking in all we are doing is re-inforcing the idea that you get special treatment in A&E if you go there by ambulance.”I think what he was trying to say was that many people still think that because you have arrived at hospital in an Ambulance you will receive preferential treatment over those who have got themselves there under their own steam….. I still have to explain to people on a daily basis that just because you arrive in a big white taxi doesn't mean you will be seen straight away, or get a bed even….. but no-one seems to understand this no matter how many times you tell them

  8. Surely that should be down to the patient's needs though? I mean, a broken toe arriving in an ambulance shouldn't get faster care than someone with a heart attack who got driven in by their spouse, but on the other hand they don't deserve to get lost in the system, which is what I'm (perhaps wrongly) reading is a worst-case scenario for the new system.

  9. “as the government considers ambulance crews as being able to work twelve hour shifts without such luxuries. “If you have experience of 'retaining' fluid for long periods, are a good communicator and can work a computer then why not become a Mobile Librarian? Oh, wait a minute, I am forgetting that you like to drive fast and that you might actually expect to work with a computer on the Mobile Library (you do get about an hour and a half, a fortnight, to access a computer unless you want to work lunchtimes, in violation of the legal requirement for drivers to take breaks) and the pay is only 16k. However, if anyone else does wish to try this challenging job then contact your local Library service and pray it is not the one I work for. Annual Information Day soon and we will be discussing Charter Mark… the fun just never ends!

  10. But the general public don't see it that way. I can remember a bloke with “back pain” post RTA – 6 months post! – who represented at A&E basically looking for evidence to beef up a compensation claim (happens lots in NI) but unluckily got the same Dr… After he had been waiting 4hours + (no 4 hr rule in NI) he said “I'm going home and calling an Ambulance, then I'll get seen”, only to be sadly dissapointed by the Dr who told him what would really happen.I worked as a receptionist in A&E for nearly 3 years and sometimes the Ambulance crews booked the patients in, but usually the nurses just thrust the yellow forms at us and left us to it. Not very helpful when you are tryng to find the details on PAS/Symphony. Our triage system was arse about tit to, so you booked in at reception and then waited to be called for triage in the order that you arrived (unless you went straight to cubicles). It wasn't unheard of to be waiting 40mins for triage on a busy day, or longer if the receptionist forgot to click “awaiting triage” on the computer system…. oopsie!

    A few times some of our frequent flyers were not put on the system for an hour or more as the forms from the crews would be left at the nurses station and no one would pass them on to us. We'd only realise when we saw them wandering up and down and would ask “why is so and so not on the ssytem” and then go and investigate.

  11. Hi DSO! I was hoping you'd comment.I agree with the BMJ bit – I'd like to read the whole thing. But I'd disagree that it isn't science; it's sociology (or some such).

    The 30 minutes at hospital thing, sure it's too long – but do you really think that the people who sit at hospital for 30 minutes are going to become available 5-10 minutes sooner? Being realistic, I'd say that 'at hospital' times are going to remain the same.

    The reason why we should do it is because it's our responsibility to ensure our patient's safety. We do one job at a time, and that's our strength. And yes, it's partly because I can't always trust the nurses to do what I think is the right thing.

    We all know that we should leave another medical professional between us and the patient, by booking the patient in we *prove* that we have taken them to hospital.

    (And yes, that's horribly legal-cover-your-arse, but there you go).

    What next? Do away with the clinical handover – I mean, nurses are able to do that, and it'll be as if the patient just rolled up under their own steam – so they won't get that 'special treatment'.

    I don't like it because it puts the patient, and us at risk. It's why I don't walk 'regular drunk #3' of the night straight into the waiting room because I know that that one patient will be the one that dies.

    And then what? Pressure to try and reduce the time on scene?

    All because the government won't pay for the service that is needed.

  12. Absolutely! How very true that is Batsgirl.I've had an afternoon-full of this crap today and 15 of us wasted lots of money on a hired room and 4 hours coming up with ideas that will never be possible or acceptable in relation to such statements…4 hours and s that would have been much better spent with patients.

  13. Could be worse – They've just replaced ORCON in N Yorks with a 6 minute target, with a big article in the paper about how its going to help patient care. Personally, I just think its going to increase the rate of heart attacks amongst ambulance staff – especially as N Yorks is a big county with a lot of sparesly populated areas. Oh, and I guess the 6 minute target'll move to being from the moment the caller dials 999 when that change comes in too!Anyone work up there?

  14. Hi Tom. I was unfortunate enough to be in a A&E department saturday night just gone, until a little past 2 in the morning. I was just a little surprised by what I seen over the course of those few hours.I don't know if this new handover system is also coming into place in Dorset (anyone?), but one young man was brought in by ambulance, quite obviously worse for wear. He was wheeled in on a chair and left to his own devices in the waiting area, where he slumped over and fell into a drunken sleep.

    He stayed there for a good hour before anyone realised they didn't actually know who he was. I don't know if there was any sort of handover in the background, but the information didn't seem to get to the people who needed it if there was.

    It was around this time that one of the security guards there decided he needed to sit up, and manhandled him up in the chair, the mans stomach didn't approve and within a few moments he found himself on the floor in a heap covered in vomit.

    It took myself and my wife to put the guy in a safe position, as where he was he was in a real danger of choking on the streams of vomit he was bringing up. Both the receptionists and the security guys stood by, waiting for a nurse to come and deal with the situation.

    The only comment we got from one of the receptionists was “Now I have to clean that up, because the cleaners won't do it, they are not qualified”, to which I quipped “And you are…!”, which got me a funny look…

    I don't really know where i'm going wih this post, other than to say I sort of understand where your coming from with regards to the patient safety aspect. Anything that potentially upsets the chain between ambulance and hospital is only going to foster errors, and possibly cause some serious harm to come to some patients. My example (if this is an example, I don't know the system in place here) is a bad one anyway, he was simply a drunk, but of course that wont be the case everytime.

    I must say I left that place with a little less trust in the NHS.

  15. They really didn't think through their cunning plan very well, did they? This is a cheap journalist's wet dream: “New government targets are CRAP”.

  16. I know it's a liitle of topic, but with regards to ORCON can i quote from the IHCD driving manual? (capitals theirs) “REMEMBER THAT NO EMERGENCY IS SO GREAT THAT IT JUSTIFIES AN ACCIDENT – IT IS FAR BETTER TO ARRIVE LATE THAN NOT AT ALL.” How mant FRU drivers have had to quote that in the last couple of weeks when you get a “friendly” phone call asking why you missed ORCON on that last job?

  17. I've used it 3 times, that and ….. well I was in the road within ORCON but without someone sitting next to me helping me find the address it takes a little longer….. I am happy to drive fast on the main roads leading up to the job, but once I am in the street there is little point in me flying up and down the road at 60mph in the hope that someone will have had the forethought toa) illuminate their house to make it stand out amongst the others

    b) have the number of their house in a position that can be seen from the road

    c) have a house number at all

    I could go on but http://www.999whereareyou.org/ does a much better job of it than I will. Not that the public seem to pay much attention to that or what the HEOC (Health and Emergency Operations Centres or what everyone else calls control) guys tell them.

  18. What the public (sorry some of the….) don't seem to grasp is the triage system. It doesn't matter how you arrive at hospital, you will receive your treatment in order of its seriousness. I was booking in something trivial and non-life threatening just the other day only to find a guy who has just arrived by bus, the colour of this background, clutching his chest and patiently standing in a queue suffering from chest pain that was radiating into his left arm and jaw that he has had for the last hour. He was spotted at the same time as me by the receptionist, who politely asked everyone to wait while she fast bleeped the chest pain nurse, once they had got him stable he was told off (in a nice way obviously the guy was having a raging MI) for not calling an ambulance! He still got some nasty looks from some people that saw him only as jumping the queue, but that is how triage is meant to work. Incidentally he is fine now after I ended up transferring him for an angiogram/plasty and as for those that thought he was queue jumping, I don't really care, two of them could have gone to their GP, but thought it would be quicker coming to A&E as they couldn't get an appointment till the next day (which in my experience is extremely fast!)

  19. DSO – isn't there a risk that a 'them and us' attitude might arise because of this new diktat – our department prides itself on friendly relations with LAS crews, but I've already heard petty rumours (from managers I hasten to add) about changing the code on the kitchen.Limiting access to cups of tea expedites turnaround time, these diabolical quislings claim.

    What a miserable state of affairs, eh ?

  20. Hi Tom, the C R A P thing could work (not) however if left in the road they may be run over by theF A R T (s) fast action response team, the orininal rapid resonse car or single responder as it is now known. Lets hope the plan back fires, in an unsuspecting way , not booking patients in = attending more patients per shift = clogging up the A & E dept = crews standing in line in said A & E dept twidddling their thumbs making small talk with patients and relatives = fewer crews now on the road = worstening response times for the few crews not standing in line in A & E = patients not being treated by overwhelmed A & E dept = whist crews are waiting in line, one of said crew may as well go and book patient in etc etc. So any apparent imprvement in orcon we will assume be the result of surepticious massaging of figures. Lets hope the WRVS have mobile tea making facilities and a port loo in tow, would be a shame not to make good use of the waiting time whilst standing in the NOT booking the patient in que!!!!

  21. Tom,I think, as usual there's more that unites us than divides us, however to answer some of the points…

    It's called a clinical handover for a reason, we've handed over the patient, they're not our patient any more. I take the point about ensuring their safety but I guess I'd ask, where do you draw the line, after all we don't do an administrative handover for warded patients, or those who are left in care of the police (and I think the risk of further damage is far greater there).

    Finally to answer the 30 minute question, I guess the truth is that those staff who are having their coffee and reading their red top whilst waiting for the time to tick over won't change their ways, but for people like me (who for obvious reasons need to keep their hospital time to a minimum) this will propbably save 5-10 minutes, believe it or not your local isn't the worst wait to book a paitent in!

    All the best

  22. I agree that there is more that unites us.I guess that I just feel that the admin handover is the other half of getting the patient bedded down. You know road crews – lazy buggers the lot of us, so why do we do the admin handover at all? And why are people unhappy about not doing the admin handover?

    (And it's not just because the reception staff might be the only 'normal' people we talk to all shift…)

    And I agree, 585 is really good for booking in, as is 892 – some of those a bit further East *are* a nightmare though. But that's why one person books in while the other does the clinical handover.

    Anyway – the proof is in the pudding, lets see what happens first; times at hospital drop or a patient drops dead in the waiting room (or complaints about being 'forgotten' rise).

    And we'll see if 'I was only following orders' saves a paramedic from a HPC grilling…

    (In the long run I agree that we shouldn't be spending so long at hospital – but with the pressures of handing over to a nurse, and making sure that our paperwork is up to scratch I can't see it decreasing much at all).

  23. I would rather book-in my patient. If we've a delay and are parked up in the corridor… sorry… ambulance waiting… then we take the opportunity to get our patinet into the computer system. So begins the countodwn to 4 hours. If we're shown straight to a cubicle then, following hand-over to the nurse i am then released. The nurse stays with her charge and i will take the Form to reception. This means the nurse does not have to leave her/his patient in the early stages following hand-over.Sometimes, due to writing in a moving vehicle, reception are unsure of something we have written and we are the best people to advise upon our own scrawl.

    To me, it makes sense that this continuity be… well… continued 🙂

  24. Hi Tom,I just found this on the news RSS feed I get:

    http://news.bbc.co.uk/1/hi/england/7309621.stm

    Whilst I understand they are only being prepared what makes me smile is the rationale behind it which is to “ensure all 999 calls can still be responded to in time” – now is that in time for the patient or in time for the 8 minute rule….? It certainly doesn't mention patient's best interests….

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