London Ambulance Service Appropriate care pathways LAS NHS Trust

Major trauma London Ambulance Service NHS Trust LAS involvement in development of the proposals. Continual engagement with HfL Pan-London pre-hospital care group LAS clinical staff on each network board FM = London trauma director Public consultation: all stakeholder organisations asked to submit response. LAS response. London Ambulance Service NHS Trust

Stroke Hyper-acute stroke unit (HASU) 24/7 access to consultants, CT scans, thrombolysis 30 minute blue light travel time 72 hour ave length of stay Stroke Units (SUs) Treatment of TIA Rehab for stroke patients London Ambulance Service NHS Trust

Cardiac Care Heart attack centres High Risk Acute Coronary Syndrome Emergency arrhythmia centres The following patients may now be conveyed 24-7 as a ‘HIGH RISK ACS’ to area heart attack centres: • Patients with ST depression of >1mm in at least two ECG leads and/or T wave inversion AND • Ongoing ischaemic chest pain on presentation (i.e. pain still present while crews are with them) of < 12 hours duration Exclusion criteria: • ≤ 18 years of age • Pain lasting >12 hours • Previous coronary artery bypass surgery • Left bundle branch block • STEMI (these patients would go through the existing STEMI pathway) • Functioning pacemaker Please remember to place a pre- alert call on PD09 and refer to it as a ‘HIGH RISK ACS’. Receiving hospitals: Harefield Hammersmith Royal Brompton via Sydney St main entrance Royal free Northwick Park via A & E London Chest Patients north of the River Thames are conveyed 24/7 as an ‘Emergency Arrhythmia’ patient in these circumstances: • Patients with the 12-lead ECG diagnosis of ‘complete heart block’ • Patients with the 12-lead ECG diagnosis of ‘ventricular tachycardia’ • Patients whose internal cardioverter defibrillator (ICD) has discharged two or more times within a 24-hour period This group of patients should be taken directly to the nearest of these emergency arrhythmia centres, placing a pre-alert first via PD09 (directions below, or click on the link for a map): • The Royal Brompton Hospital (access via Sydney Street, will be met at main entrance) • Hammersmith Hospital (access via A&E) • The Heart Hospital (will be met at main entrance in Westmoreland Street) • Bart’s Hospital (access to cardiac block via Little Britain, will be met unit located on fourth floor Harvey Ward/CCU)

GP / Referral Support Team Elderly Faller referrals Crews are asked not to regard emergency departments as the best destination for all patients. Consideration is given to whether the best management of the patient could be in the community (GP/district nurse/palliative care team) or at a minor injuries unit or urgent care centre. Crews refer non-conveyed falls patients over the age of 65 to their GP; either directly or to the referral support team Elderly fallers • The Service attends approximately 6,500 fallers aged 65yrs and over (excluding falls from heights) per month, and 29% of these are assessed, treated and left at home without any onward referral, i.e. no‐one within the local healthcare economy is informed of our attendance. It has been recognised that this situation constitutes a clinical risk for both the patients and the organisation – something that we needed to address. • To aid in the assessment and clinical decision‐making regarding elderly fallers, a decision tree (similar to that used for major trauma cases) and an accompanying training package was developed by our Medical Directorate and a consultant in elderly care. This training was rolled out in conjunction with that for minor injuries In summary, we are simply looking to refer all non‐conveyed patients back to their own GP In the Airwave handset, there are three numbers in the address book identified as the referral support team (RST) which is located within the Emergency Bed Service at HQ. When an elderly faller needs to be referred on, this should be done via the RST, they will locate the call details and obtain further information from the crew on scene before passing on the referral to the patient’s GP. There are two levels of referrals to be made; ‘information only’ when the patient has a good care package and support system in place, or for an ‘active referral’ when this is not the case and there is a clearly identifiable cause for concern. In addition to this, the Service is involved in – the ‘SAFER2’ study. This investigation is looking into paramedic referrals directly to falls teams, and staff at the Islington, Newham, Tower Hamlets and City & Hackney complexes have volunteered to be involved over the coming year. On completion, the study will be written up and the recommendations identified will be used to influence national ambulance strategy.

LAS Falls Decision Tree Using the Falls Decision Tree Steps 1 & 2 – patient conveyed to ED Step 3 – patient referred to GP/out-of-hours service for referral to appropriate service (via EBS) Step 4 – patient left at home to self-care., GP to be informed patient has fallen (via EBS) Using the falls decision tree Many tools across the NHS for falls/risk assessment – need a pan-London approach. Similar to trauma tree so structure is familiar. Follow structure to assist in identifying appropriate outcome for each patient. All referrals to go via EBS for governance & audit issues. Options for patient disposal: ED. or GP/OOH. or Falls ACP – to specific falls team or other named service (e.g. Intermediate Care Team/rapid response team) as appropriate to each PCT.

‘Top 10’ lists for Minor Injury Units / Urgent Care Centres & Walk-In Centres Minor Injury Units (MIUs) Walk-in Centres (WiCs) Ankle injury – no deformity; able to weight bear with assistance of one person. Wrist injury – no gross deformity; good distal perfusion. Minor head injury – no history of loss of consciousness, GCS 15/15; no intoxicating substances; no facial injury and no current anti-coagulant therapy. Elbow injury – must be non-displaced and have good distal pulse. Burns & scalds – less than 3%in adults, less than 1% in paediatrics; no facial burns; no inhalation injury. Bites & stings – no human bites, no systemic reaction. Wounds & lacerations – minor injuries only; scalp and facial wounds, excluding the hands, feet & triangle of the face. Rib injury – if no primary survey problems, must be due to trauma/injury not non-traumatic presentation. Digit injury – no open injuries; no infection; no diabetic problems; discussion with clinician is highly recommended prior to transfer. Eye conditions – no penetrating injury; no peri-orbital cellulitis. Upper respiratory tract infection – uncomplicated infections; version 8 of the flu algorithm should be used to assess these patients. Skin complaints (incl. rashes) – incl. impetigo, minor cellulitis & wound infections; patient must be apyrexial, no non-blanching rashes. Minor allergic reactions Earache Lower back pain – no ‘red flags.’ Vomiting – if less than 4hrs. Urinary tract infection – uncomplicated infections in females aged 16yrs and over only. Sore throat – patient must be able to swallow; no drooling; no indications of quinsy; no trismus. Note: An Urgent Care Centre (UCCs) will be able to manage any patient presenting with any one of the above conditions (both lists). Any queries should be addressed to the Clinical Support Desk (CSD) – this includes any feedback or issues arising from conveying a patient with an appropriate condition to a MIU/UCC/WIC. This card will be provided for all staff to assist in when to convey a patient to a MIU/UUCC or WIC. Note that the UCC will see patients off both lists and 10+10 = 18 as a couple of conditions occur on both lists. Any queries regarding these lists should be addressed to the Clinical Support Desk. Any issues arising after conveying a patient with a presenting complaint on the above list to a WIC?MIU should be brought to the attention of the local complex management teams and/or the CCD. It is important to note that MIU/UCC/WIC will clearly take additional groups of patients above and beyond those listed, but this work is about having a consistent approach with recognised standards across London. If you get to know your local centres well and are confident taking other patient types there, this too is fine – we are not trying to stop good practice that has already developed, simply to ensure basic consistency across the LAS.

Appropriate Care Pathways The personal issue Enhanced Pre-Hospital Practice booklet [issued 2012/13] describes the appropriate referral pathways for a range of different patient groups

Appropriate Care Pathways The personal issue Alcohol and Diabetes Aide for Operational Staff [issued 2012/13] describes the appropriate referral pathways for these specific patient groups

Appropriate Care Pathways; example Diabetes Hypoglycaemia If after patient-staff discussion the final outcome is for non-conveyance, we ensure the patient has recovered and that they are well enough and safe to be left at home We then request consent for the service to call the patient back within 2 hours; we explain that a referral will be made to the patient’s own GP to support the patient’s on-going welfare Contact the Referral Support team to enable the referral to be made; insert destination code 9500 on the PRF Patient consent – Patients should be told ‘It is our policy to refer you to your GP’ – record that consent was obtained To prevent the patient’s blood glucose levels dropping again, they may need a follow-on snack (10g–20g of a longer-acting carbohydrate). Diabetes UK offer the following suggestions: half a sandwich fruit a small bowl of cereal biscuits and milk the next meal if due. The exact quantity will vary from person to person.

Appropriate Care Pathways; example Diabetes Hyperglycaemia We continue to measure blood glucose levels for all patients over 40 years of age regardless of their presenting complaint If the reading is significantly raised (13Mmol/L to 25Mmol/L) and the patient declines conveyance we contact the Referral Support team indicating the raised reading is the reason for the referral In additiona reading greater or equal to 25 Mmol/L requires attendance at ED, even if the presenting complaint may not require attendance

Clinical Hub: for crews to discuss difficult decisions or complex cases End of Life Care: Over 7,000 records are now held by the Clinical Hub and detail important information about plans for preferred places of care and death. Thank you. We endeavour not to transport end of life care patients unnecessarily to emergency departments LAS NHS Trust