1. Norma Lane Director of Clinical Operations St John
111 Clinical Hub
Norma Lane
Director of Clinical Operations
St John

2. Background
The Clinical Hub undertakes clinical triage of low acuity 111 calls in the Ambulance Comms Centre using nurses and paramedics.
Partnership initiative between St John and Homecare Medical
Piloted in the 3 Auckland DHBs in 2014 and extended to Northland and Waikato in 2015
Funding for a full national rollout confirmed by the MoH in late 2016
Rollout completed in partnership with DHBs (on a DHB-by-DHB basis) in 2017

3. What gets triaged by the Clinical Hub?
Approximately 200 types of clinical problems are eligible to be triaged by the Clinical Hub. Examples:
Mild abdo pain
Sore throat
Earache
Blocked catheter
Soft tissue injuries
Influenza-like illnesses
Generally unwell
Approx. 78K calls triaged by the Clinical Hub per annum (approx. 15% of all 111 calls)
Total number of 111 calls in NZ is now 500K per annum

4. How does the Clinical Hub work?
If safe to manage in the community:
111 call
Referral to GP
Referral to urgent care
Referral to other services
Self care advice
Ambulance response required
Call triaged using ProQA by St John Call Handler
Clinical triage is undertaken using Odyssey / Manchester Triage Tool
Purple, red or orange call?
Ambulance resource dispatched
Nurse or paramedic phones patient back
Eligible for clinical triage (grey call)? No
Call enters ‘triage’ queue and is reviewed by nurse or paramedic
Yes

5. National Clinical Hub – percentage of calls managed in the community
The Clinical Hub now clinically manages approx. 3.8% of 111 calls without an ambulance response.

6. National Clinical Hub – number of patients managed in the community
This equates to approx patients/month being clinically managed without an ambulance response.

7. Typical dispositions for patients triaged by the Clinical Hub
Outcome
Percentage
Referral to general practice or urgent clinic
20%
Self care advice or patient care plans
10%
See and treat (non transport):
15%
Transport to non-ED (GP / urgent care): 3%
Transported to ED:
43%
Other (cancelled, not required, etc): 9%
Triaged without an ambulance response 30%
Ambulance dispatched
70%

8. Overall percentage of incidents transported to ED in NZ
Approx 64% of patients who contact 111 are transported to an ED (versus 74% in 2010)

9. Bay of Plenty Clinical Hub impact - percentage
Since going live in the BoP, the Clinical Hub has clinically managed approx. 2.6% of 111 calls without an ambulance response (2018 average is 2.9%).

10. Bay of Plenty Clinical Hub impact – number of patients
Since going live in the BoP, the Clinical Hub has clinically managed approx calls/month without an ambulance response average is 88 calls/month

11. Differences between the Western and Eastern Bay
Eastern Bay: average triage rate of 2.2%
Western Bay: average triage rate of 2.6%
Demonstrates differences between urban and rural

12. Overall percentage of calls transported to ED in the Bay of Plenty
8-9% reduction in ambulance transports to ED in the Bay of Plenty from
Currently approx. 67% of 111 calls result in a transport to ED.
National average 63%.

13. Right Care, Right Time Bay of Plenty Non-ED transport
Lianne Pepperell RN, PG Dip Nurs, EMT
Right Care, Right Time

14. Background
Patients receiving the Right Care in the Right Place at the Right Time through…
Clinical Hub – Telephone triage
Hear and Advise, Patient Care Plans, clinical triage of health professional calls
High Acuity:
National Destination policies such as STEMI, spinal cord injury, Stroke
Low Acuity:
Safe and well referral pathways e.g. falls prevention, smoking cessation, healthy homes, vulnerable children, vulnerable older adults, COPD, diabetes etc.
Non ED Transport e.g. POAC, Acute Demand
Referrals – GP, Nurse led clinics, Pharmacists etc
It is our belief that our patients should be receiving the right care in the right place at the right time. For this reason we have been developing and we continue to develop pathways that support this. We have the clinical hub which by passes the road staff completely and includes telephone triage followed by advice as Norma has discussed. Our high acuity pathways which are national policies for immediately life threatening/urgent cases and are the same no matter which DHB we are under. Our low acuity pathways, which is where most of our work lies. This comes from face to face contact with the patient. It allows us to modify the pathway for each region or DHB based on the current programmes or funding available in the area. These include: read from slide the development of a care plan for frequent or complex patients or a referral to another provider.

15. Background cont. Historically St John was only an emergency service.
81% of ambulance incidents are status 3 and 4 (minor-moderate).
Goal of 100k ED diversions by 2023 nationally (includes see & treat, clinical triage in the Ambulance Comms Centre, the use of allied health teams, referral pathways and GP care).
By working in collaboration with primary health organisations and counterparts we can make sure that patients receive the right care at the right time
Supports the NZ Health Strategy – closer to home, smart system, one team
As stated we were only known as an emergency service but with barriers of access to healthcare, increasing population and overloaded health systems, the public are starting to reach out. This may be because they don’t know who else to contact for help, advice or it can be because they are simply lonely.
We are going to increasing numbers of low acuity call outs, in fact 81% of our ambulance call outs are for minor to moderate injuries or sickness.
Read slide

16. Leading referral area and type 1st October – 31st October 2018

17. YTD figures

18. Transports to GP/A&M clinics over a 12month period
A total of 16,641 patients were transported to EDs within the Western Bay of Plenty area
285 patients were transported to primary GP services in the last 12 months
Accident and Healthcare received the greatest number, with 120 patients
The number of patients received by primary GP services ranged between 1 – 42, the majority of GPs receiving 1-10 patients per annum
Count of Case Type MED and ACC records: WBOP by Primary GP Services  (Last 12 Months)
Primary GP Services
Count
Accident and Healthcare
120
Katikati Medical Centre 42
Bayfair Doctors 24
Te Puke Medical Centre 17
Centralmed Medical Centre 14
Otumoetai Doctors 9
Bethlehem Doctors 5
Chadwick Health
Farm St Family Health Centre
Fifth Ave Family Practice
Matamata Medical Centre
Mount Medical Centre
Papamoa Pines Medical Centre
Dee St Medical Centre 4
Girven Rd Medical Centre
Omokoroa Medical Centre
Papamoa Health Centre 3
South City Medical Centre 2
Avenue 14 Medical Centre 1
Gate Pa Medical Centre
Hairini Family Health Centre
Palm Springs Medical Centre
Tauranga Moana City Clinic
Te Puke Family Health
Waterloo Surgery
Total
285
Prior to the Acute Demand pathway being introduced there were a total…

19. Types of Clinical Impressions Transported to GP Clinics/Other cont.
There is a wide range of low-acuity clinical impressions transported to GP Clinics
The top 5 clinical impressions are:
-Falls (ACC)
-Generally unwell
-Laceration
-Syncope
-Pain

20. Acute Demand – Local initiative
Does the patient need further medical care?
Yes
Do they need to see a Dr today? No
Reassurance and advice for delayed treatment including pharmacy, physio and chiropractic treatment
If not high acuity and able to be managed in primary care arrange to see GP via Acute Demand
If urgent or not manageable in primary care, transport to ED
Reassurance and advice for self care and delayed treatment including pharmacy, physio and chiropractic treatment
Local to the Bay and in conjunction with the Western Bay of Plenty PHO we have developed the Acute Demand Pathway. This is a flow chart to make sense of our acute demand responsibilities. We follow this basic algorhythm to assist our decision making on the road and to allow patients access to the right care at the right time.

21. Audit and projections
An audit of cases with only those identified as suitable for primary care was completed
26% of status 3 & 4 transfers eligible for primary care management in Autumn
41% of status 3 & 4 transfers eligible in Summer
Estimated potential diversions from ED to primary care per annum = 500
To manage the effectiveness and potential volume of redirects we chose to audit previous ambulance call outs. The audit: Conducted by Dr Luke Bradford, GP owner and co-chair WBoP PHO in collaboration with two senior nurses Philippa Jones, and Ruth McChesney and three St john staff including a Clinical Support Officer, Territory Manager and myself. The rationale for category selection was to support future St John decision making. These categories were believed to be those most likely able to be managed by General Practice, as opposed to chest pain, for example, which would generally be managed through ED.  Other categories are diverse and multiple. The overall audit findings are significant given that at a conservative estimate 26% percentage of status 3/4 transfers could have been managed by primary care in Autumn increasing to 41% in summer. It is likely therefore that at least 500 admissions to Tauranga hospital each year could be managed by Primary Care (based on at least 10 St John transfers to General Practice per week) and assuming the ED admission percentage of St John transfers remains constant at 77%.

22. Beyond the test of change – PHO report and stats
Staff are readily utilising the pathway
Transport to non-ED destinations has increased by 0.7%
Combined percentage increase of redirects risen by 3.6%
612 patients per annum redirected
As per the WBoP PHO report - Funding for St John referrals to General Practice has continued beyond the test of change as many St John staff are now more readily trying to access care from the patients General Practice as appropriate, rather than transfer the patient to Tauranga ED.  Since commencement of the project, St John patient attendances which have resulted in ambulance transport to non-ED destinations has increased by 0.7%, as has their percentage of patients who are seen and treated (often with a referral to the PHO) and not transported to ED.  The combined percentage increase of redirects has risen from 40.3% to 43.9% - across all ambulance calls in the WBOP.  This translates to 612 patients per annum whom are being redirected away from hospital to the Right Care, First Time goal that St John has.

23. Ambulance statistics Non-ED transports business hours
Non-ED transports during business hours of 8am to 5pm shows an overall increase over the past 3 years with October sitting around 3.4%

24. ED transports during business hours
In comparison - Transports to ED shows a general decline during business hours to around 68% last month

25. Non-ED transports including weekends
Looking at the data for transports to non-ED including weekends there is still a steady increase although the past two months has seen a fall back to around 2.6%

26. ED transports including weekends
However transports to ED during business hours including weekends has shown a significant drop from 74% in 2015 to 68% last month.

27. Non-ED transports 24/7
And looking at data overall covering 24/7 we see a steady increase again of transfers to non-ED facilities

28. ED transports 24/7
And a steady decline of transports to ED

29. Questions?
Thank you