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Immediate care: the
devil is in the details
The Scottish experience provides a useful example of how best to implement
a cohesive, well regulated and comprehensive immediate care service in
Ireland, writes Brian Carlin
Is the provision of immediate care in Ireland both underused and under-regulated? I ask this as someone who
believes that a well-governed immediate care system will
improve patient care delivery, complement existing and
evolving health systems and also have the potential to positively impact on definitive care decisions.
This may be the right time for Ireland to embrace this
concept, but we must not start with a system that is fragmented, disorganised and unregulated. One key factor to
achieve this is the relationship between the GP and the
ambulance service. There is a willingness among GPs to be
more involved in this area of care locally but with a feeling
that it must be set up properly, perhaps within a national
standardised framework.
We have to be realistic
In my previous role as assistant director of education for
BASICS Scotland, I was responsible for the development of
immediate care training for GPs and assisted in the implementation of immediate care systems at a local level.
More focus initially concentrated on those who practised
in remote and rural areas of Scotland, primarily where the
Scottish Ambulance Service had no or limited resources
and where ORCON (Operational Research Consultancy)
standards, which acted as key performance indicators (KPI)
as set by the government, could not be met. These standards were set around ensuring patients had care within a
specific timeframe (14 minutes) from the time of a 999
call, for both urban and rural populations.
The issue of a quick response by a GP is one area where
immediate care schemes can enhance patient care, but,
apart from targets, there are other benefits such as the GP
making definitive care decisions that can reduce ambulance
journeys and thus waiting times in emergency departments
where many minor cases will be discharged back home.
The evolution of immediate care in Scotland has gone
from local schemes run by GPs to regional schemes that are
recognised and part-funded by the local health boards and
managed and supported by the ambulance service. This
support may come in the form of training, personal pro-
tective equipment (PPE) and practice-based medical and
communication equipment.
The success of these schemes is mainly due to the enthusiasm, interest and willingness of the GP to attend incidents
that occur in the practice locality. There is also a sense that
GPs have a moral obligation to be available to attend immediate care incidents when requested. One way of limiting
disruption to the day-to-day activity of GPs who are part of
an immediate care scheme is to base calls against clear criteria that are agreed by the ambulance service and the GP.
This criteria is vital to ensure that time called away from
the practice is kept to a minimum and reflects an essential
attendance requirement.
One of the concerns when developing these schemes in
Scotland was that the GP may be called out to anything.
There has to be assurance that immediate care doctors are
not used inappropriately. It is unrealistic to assume that the
GP can attend all calls (unless that was a local agreement).
The GP should be called when they can complement,
support and add to the care of the patient that is already
provided by the paramedics and advanced paramedics.
An example of a call-out criteria developed for Scotland
is outlined in Table 1.
Co-ordinated service
Another key factor in establishing a successful immediate
care scheme is the way the ambulance service co-ordinates
and manages these schemes. In some of the well established schemes, working arrangements between the GP and
the ambulance service include:
• A named ambulance officer in charge of the coordination
and liaison of immediate care schemes
• A dedicated ambulance controller responsible for tasking
immediate care responders
• Regular meetings between all parties involved
• Audit of calls to identify what type of incidents the GPs
are attending. This will also shape training programmes
• I ntegration in training and education between both
parties.
These elements ensure that resources, deployment and
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Table 1
Scottish call out criteria
Primary response
Immediate care responders are prepared to respond to any
999 calls for trauma where information from the caller or
other emergency services already on the scene indicates
the possibility of anything more than a minor injury.
The three absolute categories include:
• Entrapment – all cases, not just those in which there is
serious injury
• Multiple casualties
• Possible fatality or fatalities at the scene
• No ambulance response immediately available
Secondary response
Immediate care responders will be prepared to respond to
requests for assistance from ambulance personnel already
at the scene
Local arrangements
Some immediate care schemes, particularly those in
remote areas where the doctor is likely to be on scene
significantly earlier than the ambulance, will have agreed
special arrangements with the ambulance service, possibly to include attendance at life-threatening medical
emergencies (such as chest pain, severe acute asthma,
unconsciousness, prolonged convulsions) and serious
obstetric emergencies
Major incidents
The role of immediate care practitioners in major incidents
will be to the predetermined local emergency plan, which
will have been agreed and exercised by local arrangement.
MIMMS trained staff should be identified and given a
command role
development are linked with the ambulance service’s
objectives of providing effective patient care. Thus, the
ambulance service must act as the hub for these types of
schemes.
Subspeciality
Recently in the UK there has been a push towards
Immediate care becoming a subspeciality in its own right,
although it will be impractical for many of those GPs currently providing some form of immediate care locally. More
realistic is the development of ‘General Practitioner with
Special Interests’ (GPwSI) project which has encouraged
primary care organisations to support GPs and allied health
professionals who wish to develop expertise in a particular
clinical area.
More commonly this has centred on improving access to
outpatient services such as ENT. However, the Department
of Health in the UK has commissioned the Royal College
of General Practitioners (RCGP) to develop a framework for
GPwSI roles in ‘Emergency and unscheduled care’. This
framework includes pre-hospital and scene-of-incident
care. It also states that a process of accreditation should
be undertaken by the employer of these GPwSIs, ie. the
ambulance service and/or primary care organisation. This
emphasises the importance of the relationship between the
immediate care GP and the ambulance service.
The RCGP has also reinforced that there must always
be a role for doctors in the provision of immediate and
unscheduled care, and that all GPs involved in such care
be appropriately trained to national standards.
The right training
In my view GPwSIs are, first and foremost, GPs and while
we shouldn’t expect a GP, working from a generalist position, to be an expert in this area or expect them to have the
time to be trained based on national standards to the level
of an advanced paramedic, we should expect that they have
attained and taken steps to maintain knowledge and skills
to work safely and effectively in this specific area.
So what training would be required to allow safe and
effective practice in a pre-hospital care environment?
Obviously experience as a GP will go a long way, but unfortunately, there was and still is a misconception that anyone
can simply and instantly adapt their practice to the out-ofhospital environment. In my view this is not the case, and
any training must concentrate on filling the gap between
these two environments.
Therefore, although the cardiac (ALS) and trauma (ATLS)
resuscitation courses that began in hospitals during the
late 1970s and early 1980s were adopted by immediate
care schemes, it was soon realised that specific courses
were required to suit pre-hospital care. These fit for purpose
courses addressed core themes within training that must be
covered, ie:
• The operational environment
• Cardiac emergencies
• Trauma emergencies
• Common medical emergencies
• Major incident management
• Paediatric emergencies.
There are many other topics that can be added to a list
of requirements, but the above will provide a solid basis to
practice in this area. The Scottish courses are attended by
GPs, nurses and paramedics who wish to be trained in existing or new pre-hospital care techniques. To ensure that the
learner’s needs are met, innovative formats are used, such
as a specially prepared vehicle that can be used to practise
extrication techniques based on the clinical aspect of care.
Development of these courses has continued throughout the
years, and approximately 350 course places per year are provided, through central funding from NHS Education Scotland.
Thus, there is no course cost to the students who attend.
Equipment
This type of training is fine, only if the skills taught are
used and it’s not just about the training. Those GPs who have
volunteered to be part of a scheme should be provided with
the appropriate kit. In Scotland the GPs were lucky enough
to have a ‘Sandpiper’ trauma bag (www.sandpipertrust.org)
provided after the course. A Vehicle Location System (VLS)
was also provided. This device plugs into the GP’s car and is
linked into the ambulance command and control centre and
allows the practitioner’s location to be identified and called
if any incident occurs nearby. As a result, many immediate
care-trained practitioners are the first on scene to incidents
in rural areas, ensuring potentially life-saving medical care
is given immediately.
This type of system could also link in or replace local
non-medical responder schemes, and through time the
development of an emergency medicine retrieval service
will further enhance the credibility of any immediate care
schemes.
Built-in support
It is important to remember that the approach to developing an immediate care scheme should be based on a
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multi-skilled, multidisciplinary team of clinicians – medical, nursing and paramedical – to provide care in this
setting. Thus the GP should not feel isolated if called to
any incidents, but rather supported by and supportive of the
emergency service personnel they are working with.
The regulation of these schemes is vital and must also
involve input from all relevant institutions and organisations
including the ICGP, FEM, RCSI, PHECC and the relevant
academic bodies associated with immediate care training.
This is the type of model I would like to see in Ireland.
Immediate care schemes must fit into the broader objectives of the HSE and rather than be viewed as a separate
entity, have to form part of wider healthcare plans. This can
only be achieved through working in collaboration with the
national ambulance service.
The targets and expectations for modern day ambulance
services require a complex approach to ensure these are
being met. This includes looking beyond providing a service using only the resources within its own organisation,
and includes developing partnerships with others. Therefore, for any immediate care scheme to be deemed a useful
resource, this must be based on various factors:
• Helps to meet ambulance time targets
• Criteria-based dispatch to prioritise the need
• Complements existing EMS and medical systems
• Standardised approach relevant to best evidence and current guidelines
• Recognition of roles and responsibilities by individuals
involved in the scheme.
SHERPA
My views are informed by my experience and involvement
on developing and implementing immediate care schemes
in rural Scotland. An example of one such scheme in Scotland is that of the Scottish Highland Emergency Response
Association (SHERPA) immediate care scheme, which
operates in the Highland and Island region. The geography
of this region is unique, as not only is the mainland deemed
one of the last true wildernesses, but it includes over 800
islands. Thus, for any ambulance service to provide cover in
these areas similar to an urban setting is unrealistic; thus
SHERPA is an integral part of the ambulance response.
At its inception there were four doctors selected initially
on an eagerness to be involved more formally in pre-hospital
care work. They were trained in immediate care, equipped
with a Sandpiper bag and had VLS units fitted to their vehicles. In year one, SHERPA attended 83 calls. It became
apparent that it may be more feasible to have these VLS
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units shared between the practice GPs rather than individually allocated. This would allow a share of the commitment
and ensure the best available response from these GPs.
This led to an increase to 148 calls in year two, and in year
three as the schemes increased in number and were recognised as a key resource, the number of calls rose to 223.
An audit enabled SHERPA to identify some key data, and
from this analysis further development can be planned in
line with patient needs and organisational needs/targets.
The above data obtained from the SHERPA scheme also
identifies and shapes training and education requirements
and also the time commitment that is required from the
immediate care doctors. Initially, immediate care training
was only open to GPs, but due to the limited resources in
rural parts of the highlands, practice nurses and off duty
paramedics also became and are a fundamental part of the
SHERPA scheme.
Another link in the chain of the immediate care schemes
in Scotland is the involvement at both the training and
operational level of the Emergency Medical Retrieval Service (EMRS). The inclusion of this consultant-led team and
critical care paramedics allows the SHERPA immediate
care doctor to liaise with the team to decide on interventions required and definitive care decisions.
Irish service?
So would an integrated immediate care system work in
Ireland. Why not? There are many similarities in the geography of Scotland and Ireland, and the challenges of providing
pre-hospital care are the same.
As with GPs in Scotland, there is a core group of GPs who
are frustrated that they are not being used as effectively
as they would like to be in the area of immediate care at a
local level, but yet have a willingness to be involved.
Immediate care schemes work, but work better, if they
are coordinated, regulated and supported by the HSE and
the ambulance service. Let’s not think short-term, but think
long-term. Patients get care earlier, there is integration of
care and decision-making between GPs, the ambulance service and emergency departments, definitive care decisions
are made in the community, reducing patient journeys and
hospital attendances that are not required. These are all the
benefits of a properly-managed and coordinated immediate
care scheme. So if we want to do it – let’s do it properly. Brian Carlin is a senior lecturer and programme director
of the MSc EMS (immediate care), Centre for Emergency
Medical Science at the School of Medicine, UCD
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