The policy of ambulances in Ireland to automatically bring all patients to hospital emergency departments (EDs) is unsustainable and contributes to delays in these EDs, a major new review has found.

The review of pre-hospital emergency care services, published by the Health Information and Quality Authority (HIQA), also highlighted that staffing levels in some ambulance control centres are unsafe, some vehicles are too old and are at risk of breaking down, and services provided by Dublin Fire Brigade and the National Ambulance Service ‘are not integrated'.

In fact, HIQA identified ‘poor levels of cooperation between both entities, which was not in the best interest of patients'.

"It is of serious concern to HIQA that current governance arrangements between the National Ambulance Service and Dublin Fire Brigade are disjointed, with inadequate quality assurance and accountability controls. As a matter of urgency, both services must act to ensure that there is a fully integrated ambulance service in the greater Dublin area," commented HIQA chief executive, Phelim Quinn.

The report pointed out that the Dublin Fire Brigade ‘regularly' does not have adequate capacity to meet demand, so it asks the National Ambulance Service over the phone for assistance in responding to calls, which can take up ‘valuable time'.

"This can lead to delays in resource deployment and ultimately prolongs response times for patients. On some days, up to 50% of all emergency calls received by Dublin Fire Brigade may be delayed for various periods of time," the report said.

Last year, Dublin Fire Brigade requested assistance from the National Ambulance Service in relation to almost 27,000 calls out of a total of more than 81,000 calls. However of these, the national service could only help with just over 8,000. The remaining calls either had to wait for a Dublin Fire Brigade ambulance ‘from a relatively long distance away from the incident' or the call had to be queued until an ambulance from either service became available.

"Dublin Fire Brigade explained that it estimates that calls need to be queued until a resource becomes available approximately 14,000 times per annum," the report pointed out.

Rural areas also present a number of challenges, it said.

"Staff interviewed highlighted a particular challenge on some occasions in
finding the correct locations for calls in rural areas using current systems. The long distances that crews need to travel to patients, coupled with the pattern of one-off housing in rural areas also makes the universal attainment of rapid response times difficult," it stated.

HIQA also emphasised that it was very concerned about the fact that the ‘well
known ambulance black spot areas of Tuam Co Galway, Mulranny Co Mayo and Loughglynn Co Roscommon remain without a dedicated ambulance resource'.

Meanwhile, the policy of bringing all patients to an ED ‘needs to be modernised'.

"At present, an emergency vehicle is dispatched to all calls, and patients are automatically transferred to hospital EDs. This is unsustainable and contributes to delayed patient handovers at EDs.

"The model of care which requires 100% transporting of patients to EDs in all cases needs to be modernised, to include the potential for treatment or triage over the phone and also to provide for direct access to alternative care pathways, such as local injuries units," Mr Quinn noted.

Also commenting on this issue, Health Minister, Leo Varadkar, said that the ‘inefficiency' of taking everyone to an ED needs to end.

"In some cases, the best thing for a patient is to provide paramedic treatment on the scene, or give advice over the phone, or see the patient in a clinic the next day instead of taking them to a hospital, or take them to a minor injury unit or specialist centre instead of the local ED. Clearly these are big changes, and will require new training, protocols and a public education campaign, but it can be done," he insisted.

Meanwhile, the report also noted that some control centres ‘remained challenged due to staff shortages'. In fact, when staffing levels were reviewed by HIQA, some ‘fell below the required safe level'.

Furthermore, the HIQA review team also noted that the National Ambulance Service ‘has failed to maintain recruitment of paramedics at a rate sufficient to replace those staff that leave the service'.

"Declining paramedic numbers has resulted in a reliance on the payment of overtime to staff ambulance rosters, or in some cases the dropping of ambulance shifts. Both immediate and sufficient paramedic recruitment, and more effective ongoing workforce planning is required to address this problem," the report said.

It also expressed concern about the ageing profile of the national service's fleet of ambulances. According to its fleet programme, ambulances should be replaced when they are seven years old and have mileage greater than 500,000km. However at the time of the review, almost one in five of the ambulances were eight years old or more. This increases the risk of breakdown.

"Staff repeatedly identified an increase in emergency ambulance breakdowns which they perceived to be due to a reduction in fleet investment, while senior staff highlighted lack of real-time fleet management information. The National Ambulance Service needs to act to mitigate this risk in the short term," the report said.

HIQA stated that it is ‘vital' that the HSE, the National Ambulance Service and the Dublin Fire Brigade ‘use this report as a catalyst for improvement'. The report contains 12 specific recommendations which HIQA believes will increase the safety and quality of ambulance services nationwide.

The full report can be viewed here