BCEHS Clinical Response Model Neil Lilley Senior Provincial - - PowerPoint PPT Presentation

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February 13, 2019

Neil Lilley

Senior Provincial Executive Director

Patient Care Communications & Planning

BCEHS Clinical Response Model

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BCEHS Action Plan

3 The BCEHS Action Plan was developed to ensure the right care is provided with the right resource to the right patient at the right time. The plan calls for:

• Adjustments to our clinical responses – not all patients need to go to ED;
• Implementation of strategies that better match our service when and where our

patients need us; and

• The development of opportunities for sustainable careers

2020 Action Plan

Additional Resources Community Paramedicine HealthLink BC & Secondary Triage Future Initiatives Clinical Response Model

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Clinical Response Model and the Action Plan

Background

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• BCEHS can utilize alternative clinical responses to

▫ Provide the most appropriate care for each patient ▫ Ensure timely care for high acuity patients ▫ Provide alternative care options for low acuity patients ▫ Relieve pressure on emergency departments and BCEHS by reducing transports to hospital

• Ministerial Orders M146 and M147 extend the mandate of BCEHS under the Emergency Health

Services Act to conduct secondary triage and to develop protocols for treatment at scene or transport to a non-ED destination

• Need to build a foundation and baseline before launching new protocols

▫ Standardized approach for call prioritization and decisions on alternative care ▫ Coordinated approach to introducing protocols (alternative destination, alternative transport, treat & refer)

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2013 Resource Allocation Plan

HLA -3

• Highest Level Available
• Code 3 (lights and sirens)
• Highest priority events

BLS-3

• Basic Life Support
• Code 3 (lights and sirens)
• Medium priority

BLS-2

• Basic Life Support
• Code 2 (routine)
• Low priority

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• Previous allocation system used three levels
• f prioritization. CRM allows for six
• Diversions can only be made from Code 2

to Code 3 events

• No capability to support low acuity

pathways (Secondary Triage, Treat and Refer, etc.)

• Focus is on response times, less of a clinical

focus

Clinical Response Model – Initial Rollout

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Clinical Response Model – Descriptions

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Purple

• Highest level of acuity
• Immediately life threatening
• Takes precedence over all other

events

• Response: HLA Code 3
• MPDS Codes: Deltas & Echos
• Example: 09E02 Cardiac Arrest –

UNCERTAIN BREATHING 10

• Immediately life threatening or

time-critical

• Divert from Red to Purple
• Response: HLA Code 3
• Mostly Deltas and Echos
• Example: 19D04 Heart Problems /

A.C.I.D. – Clammy or cold sweats

High Acuity Events

Red

• Urgent / potentially serious but

not immediately life threatening

• Divert from Orange to Red or

Purple

• Response: PCP / EMR Code 3
• Example: 23C02c Stroke (CVA/TIA)

– Abnormal breathing – PARTIAL evidence stroke < 6 hrs 11

• Non-urgent (not serious or life

threatening)

• Divert from Yellow to Orange, Red
• r Purple
• Response: PCP / EMR Code 2
• Example: 02A10 Sick Person –

Unwell/Ill

Orange

Mid-Low Acuity Events

• Non-urgent (not serious or life

threatening)

• Used for scheduled Community

Paramedic visits

• Future Uses:
• Low acuity patients in need of

advanced skills

• Assess, See, Treat & Refer

capabilities

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• Non-urgent (not serious or life

threatening). Further telephone triage appropriate

• Response: HealthLink BC
• Example: 18O01 Headache –

Breathing normally with 1st party verification

• Will be re-coded if an ambulance

response is required

Blue

Green

Low Acuity Events

Clinical Response Model Objectives

• 1. Align with global practice to shift from a time-based response model to a

clinically based model

• 2. Ensure the highest acuity patients are better prioritized
• 3. Build the foundation for future changes to low acuity responses
• 4. Align requests for First Responders and Fire Agencies to provide patients with the

most appropriate care and utilize resources effectively 13

Foundations for Improvements in Care

Clinical Response Model Colours Prioritization Reviews

Secondary Triage

Assess, See, Treat, Refer Mental Health Services Referrals to Other Health Providers Virtual Care Palliative Care Alternative Care Pathways Alternative Transport Alternative Destination

• The Clinical Response Model is the foundation for organizational improvements and required changes to

clinical responses

• This enables future initiatives for alternative types of care (other than treat and transport) which will

become Blue and Green responses

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2% 25% 29% 44%

911 Events with Ambulance Response

Purple Events Red Events Orange Events Yellow Events

BCEHS Event Volumes

• Highest acuity (Red & Purple) events

make up 27% of events with an ambulance response

• Code 3 (lights and sirens) response for

56% of all pre-hospital events

• Low acuity Yellow events (44%) make

up the highest volumes

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What this means for First Responders

17 First Responders play a critical role in responding to our most urgent calls, and their quick arrival can mean the difference between life and death. The Clinical Response Model provides the following benefits for First Responders: ▫ Less time on scene for FRs ▫ Fewer calls FRs will need to attend and wait for an ambulance to be freed up ▫ More effective use of municipal and provincial resources, with time freed up to address other responsibilities ▫ Improved patients/residents experience and outcomes ▫ Reduction in call volume related to low acuity events

Criteria for Requests for Fire FRs

• Co-response with the Clinical Response Model is focused on high acuity time critical

calls

• BCEHS will request First Responders for all calls that meet any of the following

criteria:

• Any call triaged as a Purple or Red event
• Any Orange calls where ambulance response is likely to take >10 minutes to arrive
• Any call involving a motor vehicle accident, hazmat, drowning / near drowning or fire
• Any other call with a clinical or operational need for First Responder expertise, such as an

environmental or safety risk, or in the case where the Paramedic Crew requests First Responder backup

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19 Response Type: Co-Response First Response Tactical Support

Clinical Response Model Call Type:

Purple and Red FR appropriate Orange Calls (as per 2013 RAP review) Any

Description:

Fire will be requested to all Purple and Red calls to provide medical support in addition to BCEHS resources Fire will be requested to Orange calls to provide medical attention when BCEHS is expected to take 10 mins or longer to arrive Fire will be requested when a crew or dispatcher identifies that an event requires fire services support for tactical reasons

Method of Notification:

Automatic through InterCAD or by phone if n/a Manually send via InterCAD

• r phone if n/a

Automatic through InterCAD

• r by phone for MPDS codes

7, 8, 14, 15 and 29. By phone for any other code

Types of responses for Fire FRs

20 1. BCEHS response times are from time of call received from 911 through to the time BCEHS resource on scene 2. Before FR receives an event there is an average of 3 mins of call processing time at BCEHS 3. FR response time is from time they received the call from BCEHS to time FR arrived

• n scene (avg 7mins as per ORH report)

4. Average FR response in total would equate to 10 mins 5. Reduces unnecessary double dispatching of resources when not required and ensures resources are available for high acuity calls when they present to BCEHS

Why the 10 minutes?

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Why the change in response for Fire FRs?

BCEHS is changing the way in which it dispatches all resources and not just FR

• responses. This is to ensure that resources are more readily available for those

events where time is critical. How?:

• Reduce the number of resources being dispatched to low acuity calls
• Reduce sending any resources to the lowest acuity calls that do not need a

response and alternative treatment is best for the patient

• Reduction in responses for BCEHS and FR
• Increased availability for most critical calls

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Situation: Pre-CRM

Friday night at 8:00 pm Friday night at 8:10 pm

MPDS 10C02 – Chest pain/Chest discomfort/cocaine MPDS 9E01 – Suspected workable arrest/Not breathing

Situation: Post-CRM

Friday night at 8:00 pm Friday night at 8:10 pm

MPDS 10C02 – Chest pain/Chest discomfort/cocaine MPDS 9E01 – Suspected workable arrest/Not breathing

What does medical evidence tell us?

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Why use evidence based medicine?

• Evidence based medicine (EBM) is an approach to medical practice intended to
• ptimize decision making by emphasizing the use of evidence from well-designed

and well-conducted research.

• EBM advocates that to the greatest extent possible, decisions and policies should

be based on evidence, not just the beliefs of practitioners, experts, or administrators 26

What is the harm with over response?

▪ Increased traffic incidents and harm to public ▪ Increased patient handover ▫ Chance of medical error increases significantly with patient handover ▪ Decreased resources available to attend to critically ill patients ▫ Survival probability significantly decreases each minute without medical aid ▪ Patient privacy concerns ▫ Access to patient health information to providers who are not ultimately involved in patient care 27

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BCEHS Response Times

Median Response time format: mm:ss Pre CRM data is for 2017 Calendar year Post CRM data is from May 30, 2018 to November 30, 2018 (first six months of CRM in operations)

Community Purple Red Orange Yellow

Pre CRM Post CRM Pre CRM Post CRM Pre CRM Post CRM Pre CRM Post CRM

Metro / Urban 07:43 07:38 09:01 08:28 10:36 10:18 15:28 15:44 Rural 08:43 08:04 09:00 08:38 09:12 09:04 10:41 10:44 Remote 17:19 17:09 19:35 18:35 20:03 19:17 23:22 22:34

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Secondary Triage Trial

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• Date Range: June 18 – December 31, 2018
• Total Number of Working Days: 95
• One nurse
• Parameters: Channel 1, 2, 3; Alpha calls only; Age >= 16

Total Outbound Calls Total unsuccessful attempts Total successful connections # Secondary Triage Call attempts 751 81 670 Average on phone call time 4.05 min Call Time Range 1 – 22 min Average # calls per hour 1 # Events reviewed and excluded 1961

Secondary Triage Trial

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Secondary Triage Result Total Purple Red 7 Orange 94 Yellow 460 Resolved over the phone 109 Total connections 670 Outcomes:

• 15% of calls were upgraded to a Red or

Orange response (primarily due to pain)

• 16% of calls resolved without an ambulance

Next Steps:

• Complete hiring in 2019 of additional

nurses

• Expand channel coverage
• Identify other initiatives nurses can support

What’s Next for BCEHS Secondary Triage Expansion Assess, See, Treat and Refer Palliative Care Data Sharing with FR Dispatch Centres LifeGuard OD

Thank you

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Neil.Lilley@bcehs.ca