On Scene?

A quick recap for those who haven't yet seen me write about ORCON. ORCON is the government target that tells all ambulance services that they have to keep the time between the phone ringing up in Control and the ambulance arriving on scene to under eight minutes for our highest priority calls. There is also a nineteen minute target for not-so-serious calls. For the low priority calls, like grannies with broken hips, we can leave them on the floor for up to four hours.

This eight-minute target is based around outdated research and has little clinical significance for the majority of our patients, something admitted by our own chief executive as 90% of our calls come from people who do not need an emergency ambulance. This 90% figure is based on the London Ambulance Service's own research1.

It's easy to tell when to 'start the clock', as soon as the BT operator connects the 999 call to our Control, but when do you 'stop the clock'?

The target states that the ambulance should be on scene. Does this mean when the ambulance pulls up outside your house and I hit the big 'At Scene' button? Does it mean when the keys are out of the ignition of the ambulance (because we track that)? Does it mean when I poke my ugly mug around the bedroom door to find you on your bed with bellyache (and if you live in a block of flats with no working lift it might take me over a minute to actually reach you)?

All these are reasonable ways of measuring the time. When we pull up, or when the keys are out the ignition are easily measured due to the tracking devices in our ambulances. Being face-to-face with a patient would need us to have an accurate watch and to note the time ourselves, so accuracy would be a problem but it would better match the 'patient experience'.

How about marking us as 'on scene' when we are within 200 meters of the address? This is what many of us on the road suspect of happening – when we get within 200 meters or so of the address our MDT 'updates'.

It doesn't matter if you have crashed your car on one side of the dual carriageway and we have to drive an extra five miles to get on the correct side. It doesn't matter if we have to creep around tiny winding estate roads, wary of knocking off the wing mirrors of parked cars. It doesn't matter if the address is a bit wrong, if we are where the computer says we should be then we are 'on scene'.

As the time arrives when we have to finally collate our ORCON success rate approaches (appropriately enough April the 1st), so we find the percentage of calls that we make on target start creeping up towards the magic 75% mark.

Why is this? Well, in the words of our own Chief Executive,

…our Management Information team check all our records to ensure we capture everything correctly. [The] team are checking every missed call, and with over one million calls, inevitably they are finding some that can be legitimately included.”

Which makes me think that they go over every call, and if we were within 200 meters of the address when the eight minutes are up, they then count us as being 'On scene' and therefore the job can be seen as a 'success', regardless of patient outcome.

As always, the LAS and LAS management have the full right to reply to anything that I write here. It would be nice if they could confirm, or deny, us being within 200 meters as being part of hitting our targets, and to what 'legitimately included' means.

1Taking healthcare to the patient: Transforming NHS ambulance services (Page 8)

25 thoughts on “On Scene?”

  1. Every Ambulance man should have the latest Pedometer that is WiFi connected to HQ via the truck Transmitter, sending heart pulses issued by stressed out driver and watcher, for how long the body was stationary, for how long body was speeding, the elevation changes to nearest cm, a copy of the engine revs, speed, turns, no of braking movements, the number of times the gas pedal hit the floor, the number of nee naws issued.If Aviation can do this for a pilot and plane, why not for that clearly dangerous vehicle that be scaring nice little old ladies.Oh! 'wot' fun for those that need a thesis to study the mad streets of the town, then maybe they create jobs to put all sidewalks and pedestrian 'vias' one shop level high.The Romans had towns folk safety in mind when the young Centurions had competition with their chariots so supplied the pedestrian ways one level higher than the street..???

  2. I don't know how the powers that be are doing it, but in Control we have a list of “misses” and the area controller has to write a reason for each one. I'm think that list comes from the time that a crew presses their red at scene button (because I'm sure I remember calls appearing on the list because they've forgotten to press it). I can double check this tomorrow and get back to you.

  3. I think this is total bull, the target that is.You cannot bend time, you can only get there as fast as humanly possible.There should be a guideline to try and get there within a set period, but from the connecting of a call is plain daft.it should be from when you get the alert to go and let you do the job with a little less stress, when its a stressful job in the first place

  4. It's reasonable as long as it's a management / resourcing target: if ambulances aren't getting there on time it's because you need more ambulances, it's not the crews' fault.

  5. Wow, drive by ambulancing. I never knew you could help people merely by being within 200 metres. I'm very impressed. Mind you probably most of your “patients” don't actually need anything more than that in fact!I wonder what planet the people who come up with these targets come from. I can't help thinking it would be much better to simply record the number of “successful outcomes”. Ie the number of times where you attend, where an intervention is required, and where that intervention succeeds. Those three numbers would be more meaningful I'd have thought. Clearly you'd never get 100%, but it would be a more useful thing to minimise the number of trips where no intervention was needed, and maximise the number where the intervention is successful.I'm frustrated by the stupidity on your behalf!

  6. http://www.harrowobserver.co.uk/west-london-news/local-harrow-news/2009/03/19/harrow-volunteers-could-save-lives-116451-23184306/I thought this was somewhat relevant. Harrow are looking for volunteers to train up with basic first aid so they can be sent to 999 calls not deemed an emergency. One wonders how you would triage these calls (as I've read many times on your blog, the call comes in as not breathing and you arrive and they're sat up, chatting in bed) and if the calltaker is making a judgement call in sending a volunteer rather than an ambulance, why not cut out the middle man and get the call taker to tell the caller to get in their car and visit their GP/A&E while the ambulance service deals with people who actually need them? And who are these volunteers accountable to? What if something goes wrong or the call is triaged wrong and the patient dies. Is the volunteer then responsible? Can the family sue because the calltaker sent a volunteer and not an ambulance?This appears to be a logistical nightmare and something that doesn't stand up to the current procedures.

  7. Let's not confuse the meaning of a statistic with a performance measure for the individual team. If an automated clock is used that stops at a time that correlates well (over thousands of cases!) with the patient experience, then that is good enough for the statistic. That's because the purpose of the statistic is to measure and improve the patient experience. If you reduce the mean driving time, then the mean “at patient” time goes down as well.Every statistic can be improved. You say that the “time to scene” has no clinical significance, i.e. little correlation with outcome. That's an excellent argument. Often, it is what we call an extrinsic measurement, that provides a more “real-life” assessment of overall performance. For example, you can look at survival of heart attacks. However, when you do that, there will be a lot of factors that influence the outcome, not just how fast and how well-trained you guys are, but also, I'm guessing, whether there's a cath lab nearby and stuff like that. So, plenty of room for “finger-pointing”.

    Now, as for a measure of an individual EMT's performance, or even the performance of a group of ambulances, such a measure is ill-suited for the reasons you have repeatedly stated in your blog. It is an abuse of statistics to apply the measure designed to contribute to a mean to an individual or a local team, especially if you compare the measure to a grand mean, as is done in your case. (e.g., you might have more public housing and more congested streets).

    So, while you're very right about criticising unsuitable measures, it's important for one's mental health to not abuse such a measure to assess performance during an individual call.

  8. Oh, just wait until I post about my 'individual performance review', based on sampling 1.2% of my work over eighteen months. As well as how I drive slower than other people.Trust me, I tend to ignore a lot of the stress about such things…

  9. “There are three kinds of lies: lies, damned lies and statistics” -As Mark Twain said over a hundred years ago…

  10. Claire 14:57 refers to the “Harrow” scheme – this seems to be based on the existing Community First Responder system operated by NHS & St John Ambulance – http://tinyurl.com/chw75h.The volunteer is only expected to “provide care until the ambulance arrives.”

  11. We too in A&E have targets. We have to have 98% of patients out of the department in 4 hours or less. We too have “End of Year Madness.” We are currently at 97.94. That doesn't round up to 98. No, that would be too easy. So the Management go round with clipboards, making sure that every time a patient nears the 4 hours everyone knows, and everything possible is done to move them on. Patients are admitted to a busy ward, just so that they don't breach the 4 hours, only to be discharged an hour or so later. Don't get me wrong; I remember how awful A&E Departments were, for patients and staff alike, pre target. It's just when the target becomes an all consuming god that I despair.Oh, and by the way, Tom, thanks for mentioning my blog – one word from you and my hits go through the roof!!!

  12. What are you moaning about ? This is the perfect opportunity for you to shine at your next review.Just look up “big dart gun riffle things used for administering drugs to wild animals” on eBay and suggest to your bosses that you could treat people without stopping the ambulance. How great would that be for efficiency ? And how satisfying for the staff called out to people with a mild cold, “Just dangle the patient over the balcony and we'll treat them as we pass”…

  13. I think you msiunderstood the role of community responders. They will be sent on certain CAT A's ie Cardiac Arrests in addition to any LAS resource..

  14. Rumours were abound round our way not so long ago that the 200m target had been 's-t-r-e-t-c-h-e-d' a little, some suggesting upto 500m!

  15. Okay, I checked with an area controller and I was wrong and you were right. It is the automatic on scene time that counts.

  16. Thank god I'm not reviewing the 1M calls however I have been reviewing the IPR figures for my guys so I've got a fiar idea what they're talking about when they speak of reviewing calls. The first, and biggest group of calls, will be button press errors. Namely, you arrive on scene, you hit the MDT button, jump out and treat the patient only to return and find the button press didn't register. Hence the PRF needs to be checked and that figure used for the figures (this leads to about a 1.5% bump in figures). Others will show clear MDT errors (think how many times you've been asked to reboot the MDT because it's frozen). Oddly enough the 10+ staff on my complex who have now qualified for their bonuses as a result of “rechecking” the figures didn't feel it was a problem, was it different on your complex?

  17. Oh, our bonus (if you are talking about the activation/wheels rolling time) seemed to be pretty random to be honest.Especially as the accuracy of the button push is apparent;y 24 seconds.

    I think most people on our complex tended to ignore it to be honest.

    Anyhow – I agree that times like 'key out of ignition' can be used, but I feel somewhat icky when it's the 200 meter time, an example would be the extra minute it took us to get to a suspended weaving through several estate roads from '200 meters away'.

  18. Agreed – but then again think of the delays you get after pressing on scene finding a patient in a tower block or a care home. What about RVPs? It's a grey area at best. Should the service define what is “on scene”? Well it would certainly help in terms of transparancy and honesty.

  19. Here in the South West it's about 200m where we are 'logged' on scene regardless as to whether 'TerribleFix' has it right or not. Also regardless as to whether the scene is 'safe' or not.We are constantly questioned as to why it took us more than 8 minutes. The latest cunning stunt is constant phone calls from control once we have reached hospital requiring a reason if we are more than 1 second over 20 minutes…. I have had the phone ringing in my pocket while assisting in resus with CPR. My stock reply is “assisting with patient, and yes the patient is fine (or the patient is now deceased), but thanks for asking!”

    A previous reply is absolutely correct. Lets have a system whereby we audit by patient outcome and not bl**dy times! A system whereby if I reach a patient who is in cardiac arrest in 9 minutes and resus that patient is considered a failure, but if I reach the patient within 8 minutes and can unfortunately do nothing but it is still considered a success is an absolute farce!

  20. The best (and perhaps only) solution to this would be a web-based system, interlinking all elements of the NHS.Imagine filling out the PRF on the MDT, and this automatically being Xreferenced with any documentation that the A+E use, so we can plot the outcome of the patient from crew arriving to (hopefully) discharge.

    Another use is incident reporting. If there is an incident you can then fill in an LA52/277 on the screen in the vehicle at the time, which will then go to the DSO. As it is all one big system, it will automatically know what incident you are reporting from linking the 52/277 to the prf AND the cad number. Any subsequent investigation will then have an easily traceable route.

    Combining all this would make it easy to create patient-oriented targets and also drastically improve the efficiency of the service.

    Am I being an idealist? Or should we enter the 21st century?

  21. Whenever I read about ORCON, I wonder how ambulance services covering large rural areas manage to achieve their targets.The nearest ambulance station to us is a 20-minute drive in good weather during the day. (Add snow and ice to the equation and it can be impossible to get through.)On top of that, there's only one ambulance, so if it's on another call you either wait or they divert one from the next town, 25 minutes away.And on top of that, they have a rotating shift system whereby the ambulance goes “on-call” for 10 hours overnight. A technician takes it home and gets bleeped as needed, after doing the day shift. (It can result in staff doing a 106-hour work period!)Curiously, the service is still able to meet its targets, I suppose because quick response times in the towns and cities make up for the slower ones out here in the boonies.

  22. In NWAS we do use the 200 metre rule and is readily and openly admitted by Control. Often when querying location of ambulances as you get the reply they have booked on scene but it “must be the auto-arrive it they are not there”.

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