ED @ HomeCost-effectiveness of EM middle grades working on land ambulances in rural North West Wales

Greg Cranston Ben Hall

Jake Hartford-Beynon Rhiannon Talbot

Jennifer DinsdaleRichard Griffiths

Linda Dykes

The Clinical Fellow project @ Ysbyty Gwynedd, Bangor

AMBIWLANS

Our Clinical Fellow Posts

Clinical fellows at Bangor are 6 to 12-month posts for post-ACCS EM (or anaesthetic) trainees wanting a fun year out, combining rural EM with an introduction to the pre-hospital world: the job plan includes 20% PHEM.

Perfect as “prep school” for those wishing to enter formal PHEM sub-specialty training later, PHEM time is mainly undertaken with Welsh Ambulances services both on land (ambulances and RRVs) and in the air (Welsh Air Ambulance).

Our Clinical Fellows also gain a unique insight into the challenges of Search & Rescue medicine in the mountains of Snowdonia - and spend a year living with mountains and beaches on the doorstep.

They are also expected to undertake CV-enhancing activities such as this poster for the 2013 CEM conference!

IntroductionOur ED in rural North Wales pioneered post-ACCS Clinical Fellow (CF) posts incorporating 20% PHEM.

Clinical Fellows work with all Ambulance assets (Helimed, RRVs and ambulances) seeing a full range of 999 cases, whereas most UK pre-hospital physicians attend only high-acuity calls.

We wondered whether the use of Clinical Fellows working pre-hospital is cost effective: although they reduce demand on the ED and Welsh Ambulance by treating/discharging from scene, they see far fewer patients during ambulance shifts than in the ED.

Method•Logbooks of six CFs were

scrutinised and data from 80 road ambulance shifts extracted. •Overall costs for ED visits

(£147) and ongoing cost of paramedic ambulances (£80/hour) were obtained from the relevant finance departments. •A CF PHEM shift (2 sessions)

costs ≈£245, including on-costs.•Time taken to convey to

hospital, handover and return to base was estimated very conservatively as 60 minutes: over winter 2012, delays at hospital meant the job cycle was often much more than this.

Results255 patients were seen by the Clinical Fellows over 80 shifts. 225 cases were analysed: transfers/GP referrals were excluded.

126/225 (56%) were conveyed to hospital. However, Clinical Fellows enabled the ED to be bypassed in 40/225.Transport to hospital was avoided in 99/225 (44%). 12 patients were diverted to GP, and one each to a Minor Injury Unit, directly to Plastics, and to a specialist nurse clinic.

84/225 (37.3%) were discharged from scene. The Fellows considered 20/84 suitable for paramedic discharge, and therefore the doctors enabled the discharge from scene of an additional 64/225 patients (28.4%) who would otherwise have been conveyed to the ED.

In total, 104/205 (50.7%) ED visits were averted, saving £15,288 in ED costs. 79 transports to hospital were averted, saving ≈£6,320 in ongoing ambulance costs.

Conclusion80 CF shifts (costing £19,600) produced estimated savings of £21,608.

The use of ST4-level Emergency Physicians working on land ambulances and RRVs improves availability of ambulance assets (particularly if there are handover delays at hospital) and is cost effective for the UK tax-payer. www.mountainmedicine.co.uk