A&E attendances

We needed to determine who was making the calls and the reason for them prior to looking at ways to reduce the numbers of calls. Until this point there had not been any collaborative work between the two groups to address the issue.

A vital component to the community matron role is cross boundary working and case management; this enables a truly holistic service to be provided co-ordinating, patient centred care.

Following early discussions it was found that many ambulance staff were unaware of the role of the community matron and how they play a part in case managing patients to reduce number of admissions, improve management of long term conditions and improve co-ordination of care.  

The ambulance service frequently attend patients that are being managed by a matron but they are not aware at the time of the call or there was no robust or simple system in place at the house before the ambulance crew attended to be made aware of the ongoing care plans and normal medical state of the patient. Ambulance staff  were not aware of the clinical observations that may be normal for a patient, for example a patient with COPD may have abnormal oxygen saturations, or a patient with heart failure may have a low blood pressure; this could be the ‘normal’ state for the patient.

Ambulance staff were not familiar with care plans and paperwork which is held at the patients home- this varies greatly according to which area of Yorkshire they work. In an emergency situation it can be difficult to find appropriate information about a patient in terms of medication, current illness, and clinical observations, care plan etc and the patient may have difficulty in explaining their condition especially if breathless and ill.

Methods

Areas of work identified were:

1. Develop and pilot an emergency care plan that would be clearly visible, recognisable and accessible for ambulance crews and other health care professionals attending a patient managed by a community matron.
2. Organise awareness sessions between community matrons and Yorkshire Ambulance staff to highlight each others roles and discuss emergency care plans
3. Development of other possible means to quickly identify, alongside the care plan, that community matrons were involved with the patients. Once agreed, raise awareness of yellow key rings and fridge stickers for easy identification of patients being managed by community matrons
4. Development of referral pathway for ambulance clinicians to refer patients direct to community matrons
5. Work with YAS  frequent caller case manager to develop frequent caller information in a usable format in order to ensure timely information  received and acted upon   
6. Community matrons to review frequent caller list and devise systems to reduce number of calls and attendances to local emergency departments.

Actions to date

• Emergency care plans, developed with input from Yorkshire Ambulance staff were devised to be easily recognisable, being produced on bright yellow, double sided paper and containing clear information including the patients normal clinical parameters.
• Emergency care plans have been introduced across Kirklees to more than 200+ patients.
• Staff awareness sessions (road shows) were held; Pinderfields, Huddersfield Royal Infirmary and Dewsbury District hospital
• Regular liaison / communication between Community Matrons and Yorkshire Ambulance crews when in the A&E departments and also liaison with the operational supervisors advising them of the Community Matron role.
• Direct contact from Yorkshire Ambulance staff to community matrons asking specific advice.

Additional work took place looking specifically at frequent callers of 999 that were having high numbers of A&E attendances. This identified specific patients who were accessing both the emergency departments and Yorkshire Ambulance Service.

Conclusion

• Much of this work is still ongoing but so far a number of patients have benefited from a much improved liaison between the ambulance service and the community matrons.
• Many patients have been managed at home rather than be taken to hospital.
• Better communication between health professionals is now taking place and there is a greater appreciation of each others roles in improving the care to patients. 
• Frequent callers work ongoing, community matrons playing a vital role in many patients.

Recommendations

Community matrons at Kirklees CHS in share the results of this work with all other PCT’s in the Yorkshire area with a view to introducing the emergency care plans, using a similar style and format.

This will enable ambulance staff to use the same recognisable system, for community matrons to follow a generic process with the overall aim of reducing inappropriate hospital admissions and improving the care of patients by joint working.

Acknowledgements

Helen Frain

Long term conditions team Kirklees CHS