Jillian Skinner MP Member for North Shore Deputy NSW Coalition Leader Shadow Minister for Health Shadow Minister for Science & Medical Research Shadow Minister for the Arts

Ambulance Service of NSW ...

Major problems exist in the transportation and delivery of patients to hospital Emergency Departments despite Labor Health Ministers adopting a variety of management and reporting strategies over the last ten years.

This site provides information about those changes and about how an ambulance is activated, the steps in getting patients to treatment, the ways that this is reported and measured. You can jump to various sections using the following links:

• The NSW Ambulance Service - Struggling to respond
• Calling '000' …
• Response times based on percentiles …
• Emergency Departments closed to all but 'life threatened only' (LTO) patients...
• Discredited by the Auditor General …
• Introducing the 'traffic light system' …
• The Auditor General still critical …
• The new Matrix Communication System ….
• Dealing with blockages at the hospital …
• Ambulance officers helping with patient flow ...
• Non-Emergency Patient Transport Service (PTS) …
• Meeting benchmarks - latest results …

The NSW Ambulance Service - Struggling to respond

At the opening of the Sydney Ambulance Centre in January 1999, then Health Minister Craig Knowles said: 'Ambulatory care is a vital part of the health care system and the Carr Government is committed to ensuring the community is provided with the most appropriate, quality care and the quickest response times.'

The trouble is that, despite the commitment and skill of ambulance officers and despite spending more than $50million to set up a Computer Aided Dispatch system, ambulances are tied up at choked hospital Emergency Departments, response times have improved very little, if at all, and the Labor Government is in denial.

Table 1 uses response times reported in Government Budget Estimates papers. It shows the worsening situation from 1993-94 until 2000-01 when new benchmarks were introduced.

Table 1

The Auditor General, has reported Ambulance Service response times each years since, noting in his 2003 Report to Government that: 'The Department of Health and the Service had initially agreed on a 2002-03 target for Sydney, of achieving 61 per cent of responses within 10 minutes. The Service told us that this target was based on strategies scheduled for implementation in future years. Because of this the target was revised to 55 per cent.'

Table 2 comprises data published in NSW Budget Estimates Papers and the Annual Auditor's Reports to Government, it can be seen that the 61% target has never been met and even the lower 55% target has only been reached twice.

Table 2

Table 3 showing state-wide response times over the last three years indicates a deteriorating situation.

Table 4 from the latest report shows very little change given the response times have been increased. The Auditor notes that: 'The Service told us that delays in hospital emergency departments and higher activity levels continued to affect the Service's efforts to improve operational efficiency'. But he also notes that: 'The Service's patient health care record system shows that 763,360 patients were assessed, treated or transported 2004-05, a 1.4 per cent increase over the previous year.'

Table 4

Calling '000'

'The [NSW Ambulance] Service considers the number of incidents and road responses to be its primary measures of activity.'

65.5% of ambulance calls in NSW are emergency events , and calls to '000' are the most frequent medium used to activate ambulance attendance at such events.

Health Minister Craig Knowles, opening the Sydney Ambulance Centre in January 1999, announced that $10million would be allocated to introduce a Computer Aided Dispatch (CAD) system to help call-taking and dispatch operations. However it was beset with problems in early days with ambulance officers complaining about black-spots and difficulty finding patients.

And it was revealed in February 2001 that the government would have to allocate further funds to make the system work, doubling to total cost of the project with an allocation of $30 million to build a new radio network. The Auditor General had warned of this in his 1999 Report to Parliament, reporting that the Government Radio Network (GRN) 'is (and has always been) unable to provide' what was needed '.... there appears to be an expectation gap between what the Service wanted and the service able to be provided by the GRN.'

The $50million CAD Medical Priority Dispatch Systems (MPDS) system involves '000' call centre operators at Dubbo, Sydney, Charlestown (Newcastle) and Warilla (Wollongong) asking questions according to a computer program and then prioritising ambulance dispatch based on the answers.

It has been claimed that the non-medical operators have to rely entirely on key phrases in the computer instructions and callers have worked out answers that will trigger urgent dispatch. '000' callers are essentially in the hands of a computer, not a medical expert.

Response times based on percentiles ...

The NSW Health Website advises that the Ambulance Service has now adopted 'a standard measure for response times, which are measured at the 50th and 90th percentiles, in minutes.'

Table5

Chart 1, from the NSW Health Website and updated monthly, relates to the time within which 50% of ambulances first arrive at the scene of an emergency call.

Chart 1

However there are numerous problems with the chart - there is no raw data so real analysis cannot be done; it is misleading as the scale starts at 3.0 and jumps from 3.8 to 10.0; and comparisons cannot be made between the 2004-05 and 2005-06 results because they are reporting different activity.

The Website notes that: 'from May 2005 emergency response performance is reported for "000" cases determined as "emergency" (immediate response under lights and sirens - incident is potentially life threatening) under the Medical Prioritised Dispatch System. Prior to May 2005, response performance was reported for all "000" calls.'

The Productivity Commission's 2005 Report on Government Services illustrates various steps in an ambulance retrieval that are used as performance indicators including activation time, response time, treatment time, transport time, hospital turn around time and total case time.

Emergency Departments closed to all but 'life threatened only' (LTO) patients...

In early years Emergency Departments that were at capacity could advise ambulance officers that they could not deliver any patients except those in Life Threatening Only (LTO) condition.

However figures reported on the NSW Health website at the time revealed a worsening situation and by 2001-2002 Emergency Departments were closed for over 10,566 hours compared to 2,277 in 1994-1995 when the Coalition was last in government.

Table 6

Source: 95 data from Auditor General's Report to Parliament, 01-02 figure from NSW Health website.

And in its 'NSW Metropolitan Trauma System Monitoring Report 1995-2000', the Department of Health acknowledged 'The percentage of trauma cases where the ambulance arrives at the accident scene within 10 minutes from the call for assistance had declined by 7% between 1994/95 and 1998/99.'

Table 7, taken from the report, also shows a reduction in the number of cases and fewer of those meeting benchmarks.

Table7

Discredited by the Auditor General …

On March 7th, 2001 at the release of his performance audit 'Ambulance Service of NSW Readiness to Respond', the Auditor General said that never before had he brought down a report with so many 'adverse findings'. Some of the Auditor General's key findings included:

• NSW ambulance response times are worse now than they were in 1997 with an average response time in Southern NSW being the worst at 11.46 minutes compared to 9.96 minutes;

• response times are among the worst in Australia, despite $34 million spent on new communications and dispatching technology;

• Extensive waiting at hospital emergency departments lead to 'trolley block' which ties up crews and ambulances, with evidence of 10 or 11 ambulances queued at Gosford Hospital;

• Diversion from blocked hospital emergency departments reduces availability of crews for other emergency work with 'possible adverse patient outcomes;

• Whilst funding has increased, NSW spends less per person than nearly all other States.

Health Minister Craig Knowles responded to the Auditor's report in March 2001: 'My agenda is a simple one. I want a public sector ambulance service delivering better response times and providing a decent return for the taxpayers' investment'.

Introducing the 'traffic light system' …

Immediately dubbed the 'traffic light system' by the media because it relied on codes green, red and orange, Mr Knowles introduced the Emergency Department Network Access system in July 2002 to flag the capacity of hospitals to cope with patients being transported by ambulance. According to the NSW Health website as at January 25 2006 , the codes indicate:

• GREEN - the hospital is managing its patient workload comfortably within its capacity

• ORANGE - the hospital is approaching capacity of its Emergency Department and the Ambulance Service is considering networking patients to nearby hospitals

• RED - the hospital has reached capacity and ambulances have to access other hospitals in the network for less serious patients.

The Auditor General still critical …

Despite the new system, the Auditor General still found considerable problems with the system in two reports. His 2003 performance audit 'Code Red Hospital Emergency Departments' found that:

• The frequency of hospitals going red is on the rise. On some days, nearly all metropolitan hospitals can be red at the same time.

• It is difficult to measure the effect of EDNA as there is no data on the number of ambulance diversions that occur in response to changes in status.

And in his 2004 audit 'Transporting and Treating Emergency Patients', the Auditor General found:

'Ambulances have to queue at emergency departments because crews cannot unload their patients, and the time taken to assess patients in most metropolitan emergency departments has not shown any improvement despite significant increases in expenditure.'

'The reduction in bed numbers and high occupancy levels has led to a long term increase in access block. This contributes to congestion in emergency departments which can affect assessment and treatment of patients. Ambulances, unable to unload patients, then have to wait at emergency departments or are diverted to other hospitals.'

'The response time of the Ambulance Service improved following the reforms and additional funding and staff after the Audit Office report of 2001. However more recently, response time performance in Sydney has declined to below the Service's own target levels.

'Ambulance Service management mainly attributes this to the increasing time which ambulances lose in queues at emergency departments. Data show that turnaround times at many metropolitan hospitals are well in excess of the time allowed.

'At times of peak workload, it is clear that hospitals are transferring to the Ambulance Service some of the responsibility for emergency patient nursing care. When emergency departments are congested they may leave patients in the care of ambulance crews, which reduces the ability of the Ambulance Service to respond to new calls.

'The introduction of Ambulance Liaison Officers has produced worthwhile benefits in teamwork and coordination between the Service and hospitals.

'The reduction in bed numbers and high occupancy levels has led to a long term increase in access block. This contributes to congestion in emergency departments which can affect assessment and treatment of patients. Ambulances, unable to unload patients, then have to wait at emergency departments or are diverted to other hospitals.'

The new Matrix Communication System ….

So once again the government changed the system dropping Codes Green, Yellow and Red and Emergency Department Network Access (EDNA) after an investigation found that EDNA resulted in:

• Ambulance car crews being told to wait at hospitals to look after ill patients outside emergency departments because of no available beds in hospitals.

• Many patients with minor injuries unnecessarily being taken to busy emergency departments.

• Many hospitals unnecessarily registering as code red because too many ambulances were queued up outside Emergency Departments.

Health Minister John Hatzistergos advised Parliament in September 2005 that: 'The Emergency Department Network Access system has been refined and as a result Emergency Departments no longer call a "Code Red" and divert ambulances. The refined system involves a multidimensional approach, including the use of a hospital clinical services matrix, hospital diversion thresholds and an Ambulance status board. These assist in managing both the patient as well as positively impacting on Ambulance and Emergency Department capacity.'

The Matrix Communication System designates a quota of patients that a hospital Emergency Department must see before medical staff can claim they are at capacity. The hourly quota is based on the size of the hospital and the services it offers.

Table 8

Hospitals and the Thresholds each rolling hour

Hospital staff and the Ambulance Service communications centre use an online booking system to determine whether a hospital's threshold has been reached.

Ambulances are equipped with CAD screens which how many out of the hourly quota of patients have been taken to a particular hospital. For example, if 3/5 RNS shows on the screen it will mean Royal North Shore Hospital can only take two more patients in that rolling hour. If a hospital has reached its quota then it is not shown on the screen as an option.

Ambulance Officers are given a choice of hospitals that the patient can be transported to depending on their assessment of the patient's injury, the time it will take to get to the hospital and whether the patient needs to go to a specialist hospital. The Ambulance officer advises the hospital that a patient is on approach through the CAD system. (These may need updating to version 2 or 3)

Table 9 shows for example that, within the South Eastern Sydney Area Health Service boundaries, St Vincent's Hospital is not suitable for obstetric or paediatric patients;

Table10 shows that within Northern Sydney Area Health Service paediatric patients cannot be taken to Ryde or Manly;

Table 11 shows that within Sydney South West Area Health Service boundary, Concord Hospital is not be an option for patients needing obstetric, paediatric or psychiatric care, and

Table 12 shows that within Sydney West Area Health Service boundaries, Mt Druitt would not be a suitable hospital for patients who had suffered a stroke, or who needed obstetric or orthopaedic attention.

· P4- Patients Treated Transported under Protocol 4 Pre hospital triage trauma

Ambulance officers may override the system, but only according to the following guidelines:

Area Health Service Matrix Version 2- 30 May, 2005

1 Patient Requests:

• Patient Requests a specific hospital and a more appropriate alternative is not provided as a recommended transport option;
• Patient requests a private hospital;
• Peripheral areas such as Bowral where most patients will be transported to the local facility.

2 Traffic Conditions: during peak travel times and periods of interruptions to traffic flows (eg motor vehicle accidents, a HAZMAT incident ect) it maybe clinically more appropriate to transport the patient to a hospital that has not been provided as a recommended transport option.

3 Patients Clinical Condition:

• Patients who require minimal transport time;
• Patients being treated within a clinical trial protocol;
• Obstetric patients who are booked into a specific facility.

  4 Major Incident- Transport Destination provided by medical commander.

  5 Trauma P4- Patients treated and transported according to Ambulance protocol 4 - Pre Hospital Trauma Triage.

  6 Paediatric- This clinical speciality overrides all others with the exception of Trauma P4.

Asked what they think of the Matrix plan of matching up the injury with the specialty hospital, ambulance officers have replied that: 'It only works about 60 to 70 % of the time. The problem is that it makes more sense if you are a crew working in the western suburbs to take a patient with a serious hand injury to the nearest hospital which is Westmead. That way the patient gets immediate care and the crew get straight back out on the road but it means that we have to double up on work later when we transfer the patient to Sydney Hospital for specialist treatment.'

They say that the Matrix system is a long way from achieving its primary objective of substantially reducing Access and Trolley Block. Problems still occurring include:

• Trolley block which occurs because there are not enough beds,
• Car crews are stuck at hospitals looking after patients inside their ambulance because they haven't been triaged within the agreed 10 minutes because emergency departments are full, and
• Queues of ambulances are still tied up at hospitals because when a car crew overrides and goes to a full hospital it overloads the emergency wards again.

Dealing with blockages at the hospital …

The best delivery system in the world with much improved response times from ambulance dispatch to arrival at hospital does nothing to address the real problems in getting optimum patient care.

Much of the criticism of ambulance delays relate to the time they are forced to wait at hospitals. Ambulance officers are responsible for patients until hospital medical staff take over their care and they will not do that until sufficient space is made for their treatment in the Emergency Department.

Ambulance officers themselves have regularly spoken of their frustration at the delays in hospital turn around time, for not being able to respond more quickly and for bearing the brunt of criticism for delays when it is the lack of hospital beds causing delays in Emergency Department treatment that is mostly to blame.

'Access Block' is the term used to describe the situation where patients are choking hospital Emergency Departments because of a lack of ward beds staffed and ready to admit patients.

It has been identified as the major contributor to patient delays in every review into Emergency Departments and the Ambulance Service including the government's own Emergency Department Services Plan developed by the Emergency Department Clinical Implementation Group in 2001 which stated: 'Inpatient bed access block, where a patient who has completed Emergency Department care waits for an inpatient bed, continues to be the most significant problem for urban (and some rural) Emergency Departments.This also creates flow-on problems for other services - particularly the ambulance service.'

'Trolley Block' is the term ambulance officers use to indicate they are stuck at a hospital Emergency Department with patients occupying their trolleys because there are no beds available and no staff free to handle the patient's needs.

These problems (sometimes now termed 'offload delays') have been identified in many reviews and reports and demonstrated in data published in government documents - some only coming to light when the Coalition has used Freedom of Information to get the information.

Ambulance officers helping with patient flow …

Off duty ambulance officers are being employed in hospital Emergency Departments in Sydney and regional centres to assist the triage nurse, doctors and bed managers to help prioritise patients coming in by ambulance.

They may be employed as Patient Flow Officers and as Ambulance Relief Teams (ART) working in shifts from 10am until 10pm seven days a week.

While some good work has been done in some hospitals (with Patient Flow Units established as the single point of authority for bed management and patient flow activity) ambulance officers report that too often the seven ARTs rostered on duty everyday at Sydney Hospitals are merely babysitting patients offloaded by ambulances at the Emergency Department. They say that they have been used successfully to cover-up the real waiting times in the Emergency Department.

Non-Emergency Patient Transport Service (PTS) …

Patient Transport Officers (PTO) are employed by the Ambulance Service to provide non-emergency transport for patients whose condition is not life threatening, who don't need to be monitored but who are not well enough to travel by private or public transport.
Available from 6am to 10pm Monday to Friday, the service must be approved by a medical authority. Examples of non-emergency stretcher ambulance transport include:

• Admission to hospital from home
• Discharges from hospital to home
• Inter hospital transfers
• Transports to and from nursing homes
• Transports to and from specialist and diagnostic centres
• Transfer of patients to and from Air Ambulance / airports
• Patients requiring day treatment

Meeting benchmarks - latest results …

Besides waiting for data to be reported in annual reports and Auditor General's reports, the Coalition regularly uses Freedom of Information to ascertain how hospitals and ambulances are coping.

Visit again soon for latest information.