Emergency response: smart systems, from Kabul to Brisbane

New initiatives in the Queensland Ambulance Service and silo-breaking collaboration with hospitals have paid service delivery dividends in recent years. It’s helped having a leadership team that stays in touch with front-line staff.

The QAS was brought under the umbrella of the state’s health department in 2012 and, according to its medical director Dr Stephen Rashford, that’s helped smooth out the continuum of care that starts as soon as paramedics are called. “It’s not just about getting them to hospital alive, it’s actually making sure that when they recover, they’re in a better state,” he told The Mandarin.

The service keeps an eye on its performance metrics against other jurisdictions, but the main reason behind the success of its continuous improvement efforts is the way the organisation works, says Rashford.

“I think it starts from having good leadership, so we have an excellent commissioner, and an excellent senior leadership team, so you surround yourself with the best people and then let them innovate,” he said. “And also there’s some ground-up solutions, so we’re big on getting information from our officers and having feedback.

“One of the innovations for the ambulance service in the last couple of years is that we changed the structure; we cut out a lot of levels so there’s only four levels, technically, between the officer on the road and the commissioner of the ambulance service. And this is in one of the largest ambulance services in the world, by both size and geography.”

Rashford says some long-standing challenges will likely remain for the foreseeable future — like having the perfect roster — but that a culture of innovation and a good flow of information makes for a well-oiled machine that can keep getting better.

“I think that all our officers know that they can get ideas through to the highest levels of the ambulance service and it’s not seen as a bad thing,” he said. And it goes both ways; he adds that one advantage of joining the officers out in the field on a regular basis is he can see for himself how the work practices he devises actually work in real life.

Heart attacks and strokes

According to Rashford, advancements in cardiac care are “probably the biggest example” of the way ambulance officers are now more integrated in the health system’s continuum of care than in years gone by. Heart attacks are caused when blood flow to the heart is restricted and do not always result in cardiac arrest. To improve the eventual outcomes for patients, Queensland paramedics now have two options when they get to the patient before their heart stops.

“We can give them clot-busting drugs to eat away the clot in the artery, open the artery up, and that’s really more in rural areas,” he said. “And in the urban areas, we have very big hospitals [which] have very big cardiac catheter laboratories, and we will take them directly from their home into the cardiac cath labs … So, if it’s an area where we can’t get you to a cardiac laboratory in less than 60 minutes, we’ll give you the drugs to eat the clot away, and when we can, we’ll get you into the cath lab. There’s probably a small advantage to getting to the cath lab [straight away], but you can’t have them in every town.”

Making a quick diagnosis via roadside electrocardiogram as made a core skill for every Queensland ambulance team. As a result of the up skilling, more patients survive heart attacks, with less long-term damage.

“[They] then don’t have chronic heart failure, don’t need medications, don’t need [regular] admissions to hospital, so it’s actually a win-win for society and the individuals concerned,” said Rashford, who believes it’s important for paramedics to understand their role in the wider health system. It’s an approach pioneered in New South Wales, which Queensland decided to roll out state-wide.

“And we’re doing the same thing with stroke,” he explained. “Stroke’s the same sort of field; there’s a little bit of conjecture about whether people should have clot-busting drugs with strokes, and there probably is a role, but there’s probably a variance in how much that role is. Certainly what we do know is if you can diagnose a stroke and go into a hospital with a stroke unit, no matter what therapy they give you, it improves the outcome.

“So we’ve increased the skills of paramedics to diagnose stroke … and we’re about to let our paramedics talk to the stroke physician directly from the scene, which is a bit new for this country. It’s the same thing we’ve done with the cardiologists, so it’s streamlined; it’s taking out all the middlemen.”

While they’re always on the lookout for new ideas interstate and overseas, continuous improvement in the heart-pumping world of emergency medicine is not just about finding new drugs and interventions and teaching them to paramedics. “We wanted a system in place which would benefit the maximum number of patients,” he explained.

“There’s a lot of things we could get paramedics to do but it has to be evidence-based, it truly has to change outcomes, and it’s got to be worth training for and the costs of that.”

From Afghanistan to Brisbane

Based on medical findings from the wars in Iraq and Afghanistan conflicts, the QAS has also won plaudits for developing a highly trained Trauma Response Team in Brisbane. The team intercepts a regular ambulance in serious cases where it can help, giving blood transfusions and anaesthesia on the fly, performing some surgical procedures, and using ultrasound to identify the source of the bleeding so there’s minimal time lost between unloading the patient and getting them into an operating theatre.

Part of the justification for starting the TRT was finding that the team would be able to get trauma patients to hospital quicker than a helicopter within an area up to 40 minutes from the hospitals they need to get to. And based on the unique geography of the South East Queensland area and its past statistics, QAS could predict there would be enough cases to make having the TRT worthwhile.

“If they ring ahead and say ‘this person’s bleeding to death, we’re giving them blood and we’ve got an ultrasound which shows they’re bleeding from the abdomen’, they will open up the operating theatre and we will go directly from the roadside into the operating theatre,” said Rashford.

“We’ve had a number of people recently stabbed in the heart and so our paramedics have made the diagnosis, not just suspected it, and within minutes of arriving in hospital, they’ve got knife to skin in the operating room. And that’s how you save lives.”

Another innovation in the service is the unique and world-leading iRoam system, which combines huge amounts of data — including locations of ambulances — into a useful, real-time format.

“Ultimately,” said Rashford, “it’s not just the adrenalin you give, it’s the uniforms you wear, it’s having cars available, it’s having people on who aren’t fatigued, it’s rostering. All of that all goes into improving someone’s outcome.”

Depending on their roles, the system gives different staff throughout the service the real-time information most relevant to the decisions they need to make, on mobile devices or desktops. It also displays some information on a public website, a level of transparency the good doctor welcomes as all part of working for the government.

“We want to make QAS as good as it can be,” he said. “I think people who concentrate on saying they’re the best never are, but we run a pretty good ship and we’re led very well, and we’ll continue to innovate.”