I’m writing this week’s blog about a recent news article in our area. It featured some community first responders (CFRs) speaking out to a news team. They were expressing various concerns among which were that CFRs were spending a long time on scene waiting for the ambulance staff to arrive and another concern that CFRs were being asked by the ambulance service to ‘discharge’ patients without the need for an ambulance to attend.
The tone of the article was quite negative. It implied that the ambulance service were being quite negligent and trying to do things ‘on the cheap’. The general public may have their confidence knocked in the ambulance service. Some of our excellent (and very competent) volunteer CFRs and ECFRs feel de-motivated by the article.
As always, these are my own opinions and do not necessarily represent my employing ambulance service, my union or any of my colleagues. It is all just my own humble opinion. I also only speak about my own area, other areas may and probably do have different procedures and guidelines.
Community First Responders are volunteers who undertake training in their own time and at their own expense. They are then provided with a uniform, pager and some equipment. In their spare time they log on duty with the emergency operational control centre (EOC). Then when certain categories of jobs come in details are passed to the CFR by pager and they set off (in their own car, no emergency lights or sirens) to the address to assess and provide initial first aid until the ambulance or response car arrive and then lend a hand to the paramedic or technician. Some CFRs have undertaken extra training to become Enhanced CFRs (eCFRs). ECFRs are trained to the same level as Emergency Medical Technician level 1 (EMT1). ECFRs respond in the same way as CFRs and use their extended skills to assess the patient and provide certain treatment while waiting for the ambulance or response car. I’ve already blogged about them here.
Getting back to the article:
CFRs (and eCFRs) waiting on scene for long periods with no ambulance response.
It’s true that people are waiting long times for an ambulance response. At the time of writing it is winter and the well known ‘winter pressures’ are putting a seasonal strain on all aspects of healthcare. Phenomenal demand for services means that a high volume of 999 calls are coming in. Added to this, hospitals are pretty full with very few spare beds. This means that patients in the Emergency Departments (EDs) are waiting for beds on wards with no beds available so they have to wait on trolleys (gurneys) in the ED. This in turn means that the EDs become full so ambulances have to wait longer to hand over our patients meaning that ambulances are tied up at EDs and not out responding to emergencies.
I know it’s difficult for the CFR/eCFRs on scene for ages but I know that the members of the public are relieved and grateful to have you there, every one generally understands the current political climate and know that you (and us) on the ‘front line’ of emergency care are not to blame.
This is an emotive point. The word ‘discharge’ in this context means to provide a safe, appropriate plan for a patient without the need to attend the ED. This can mean a visit to or from a doctor (General Practitioner (GP)), either the patient’s own GP or the Out of Hours GP service (OOHGP). It may also mean a visit from a nurse, or it may mean that after assessing a patient reassuring them that they don’t need to do anything now, just wait for natural healing to occur and see their own GP in a few days if needed. The minimum level of education needed to discharge a patient is nurse, paramedic or EMT2 (the cover-all term for medical staff is clinician). Some cases the clinician can discharge with no further referral, some cases the clinician has to consult a doctor (usually one of the OOHGPs) by phone to affect the discharge. The emphasis with any discharge is always safety. Advice is always given about what to look out for which may show that the patient is deteriorating and what to do in that case after the clinician has left the patient. This is called ‘escalation advice’.
The point of the article seems to be that CFRs are being expected to discharge without the patient seeing a trained clinician.
Discharges have already for many years been safely made by phone without a clinician actually visiting the patient.
If a patient rings the OOHGP or their own GP for a consultation the patient will speak to a call taker or receptionist who will take basic details. The patient will then speak to a clinician who will ask detailed questions about the symptoms experienced by the patient and their detailed medical history. From this, sometimes the patient is then safely discharged with a safe, appropriate care plan without seeing the clinician.
When someone rings 999 for an ambulance the call taker asks lots of computer generated questions. Based on the answer to these the job is categorised in terms of seriousness. Certain of the lower category jobs are then passed on to a group of clinicians in the EOC who ring the caller back. In the same way as the clinician at the GP service they will assess over the phone and may be able to safely discharge the patient without an ambulance or any clinician visiting the patient.
The CFR or eCFR would never be expected (or allowed) to make a discharge decision alone. The CFRs have access by phone to clinicians in EOC who with the benefit of the clinical observations measured by the CFR (pulse rate, respiration rate, blood pressure, blood sugar level) in addition to the signs and symptoms experienced can safely make a discharge decision if appropriate before the ambulance or response car arrives.
I guess my messages from all this are:
- Although far from ideal response times are currently being experienced, if a discharge decision is made it is by a fully educated and trained clinician to national guidelines. Safety of the patient is always foremost in a discharge decision and escalation advice is always given.
- CFRs and eCFRs should be proud to serve their communities and I know from talking with many of my patients that they are admired for their unselfish contribution to the local community.