by Tom Lynch
London Ambulance Service, London, England
The London Ambulance Service (LAS) deals with over 3,500 calls per day, with central London being one of the busiest areas. Faced with the challenge of meeting government-mandated targets for response time, the LAS began exploring alternative methods for reaching patients. The result of this effort to reduce response time and keep ambulances free for serious calls was the London Ambulance Service Cycle Response Unit (CRU).
Why I Undertook the Project
The project brought together:
1. My commitment to easing the pressure on the ambulance workload in an area in which it is difficult to reach patients quickly (and thereby achieve government-set targets for response times) due to:
- traffic congestion
- high 999-call demand
- high non-conveyance rate
2. My personal interest in cycling as a:
- World class champion competitor
- Cycle coach for Team Great Britain
How I Set it Up
The idea was raised initially in 1998. I delivered my Feasibility Proposal to the Accident and Emergency Development Team, who then led the research on the idea and brought together a Cycle Response Unit Working Group. A pilot scheme staffed by myself was set up in the summer of 2000 with full evaluation of qualitative and quantitative data. This was the first Technician Responder and was monitored closely. Criteria were set for the operational use of the CRU.
Following successful evaluation of this innovative idea, a London Ambulance Service organisational decision was made to fund a team of Cycle Responders.
The implementation of the team involved:
- recruitment of co-ordinator and riders (who underwent occupational health and cycle-specific fitness and skill tests)
- further training - Category C, Cycle Response Riding and Health Promotion
- set up of a dispatch system in CAC
- designation of an Operational Management liaison
- set up of a system for ongoing management information data gathering for evaluation
- set up of ongoing risk assessment
- operational cycle rider supervision
- developing a public relations campaign
- developing (design/trial) and purchasing appropriate clothing and equipment
- liaising with external organisations, such as the National Treatment Agency for the Department of Health, Primary Care Trust NHS Walk-in Centre, Department of Transport, Metropolitan Police, City of London Police, Soho Community Group, Westminster Crime and Disorder Reduction Team, City of Westminster Community Protection Department, International Cycle Show and Transport for London Cycling Centre of Excellence.
What the New Service Looks Like
A team of four riders (Paramedics and Technicians) cover a ten-hour day, seven-day-a-week shift pattern, dynamically deployed in a five-kilometer area in the heart of the Capital.
Cycle Response Unit uses custom-built mountain bikes with London Ambulance Service livery. The cycle and medical kit is lightweight and includes:
- Medical Kit: Defibrillator, one litre Oxygen/Entonox, Pulse Oximeter Monitor, Automatic Blood Pressure Monitor, Adult/Child Bag & Mask Resuscitators, Nasal/Oropharangeal Airways, Maternity Kit, Adult/Child Oxygen Masks, Adrenaline, Aspirin, Glucagen, GTN, Hypostop, Salbutamol, Watergel, Bandages, Dressings, Clinical Waste Sharps Bin/Yellow Bags, Rubber Gloves and Cleanser. The Paramedic carries an additional Extended Skills Pack.
- Cycle Unit: Blue Lights, Siren, Puncture-Proof Tyres, Pannier Bags & Rack, Tool Kit, Water Bottles, Cycle Computer, Sensor & StandLight Technology Lighting.
The rider is clothed in LAS insignia cycle clothing and protective equipment which consists of helmet, gloves, glasses, reflective jacket/jerseys, shorts, trousers, waterproofs, cycle shoes, base layers, socks/padded undershorts, scarf/ear warmers, anti-pollution mask, stab vest, utility belt with pouches, and radio with earpiece and mobile phone.
The unit is activated (primarily) by CAC to Category C calls but will respond to any call and can self-activate. Using the additional Category C skills on scene, the rider can assess the patient's condition and decide to cancel the ambulance and appropriately advise on other facilities, e.g., NHS Walk-in Centre, or offer self care advice.
The Results of the Change
The main areas supported by the results of the team implementation over a six months period are on average:
Workload and Performance
- 999 calls: 46 calls answered per week - 35% of all CRU area calls
- Ambulance Cancellations: 22 per week by the CRU or not sent by CAC - 50%
- Not Conveyed: 22 once the CRU attended - 50%
- Response Time: 6 mins
- Running Time: 4 mins
- Job Cycle: 25 mins
- Cat A Performance: Calls attended to within eight minutes: 100%
- Clinical Performance Indicators: 98% compliance
- Utilisation Rate: 35%
- Category of Call: Seven calls a day (two red, three amber, two green).
- Ambulance availability: Saved over 250 hours of front line ambulance time.
- Tasking: Identified difficulties in communications and dispatch.
- Sole Response: No ambulance was dispatched to Category C Calls.
- Call Demand: Greater understanding of the times of day/year when the CRU could be used more efficiently to ease the pressure on 999 vehicles.
- Cat C Referral: Reforming emergency care, protocol for NHS Walk-in Centre developed.
- Shelter & Stock Reserves: No ambulance premises led to arrangements with other local organisations.
- Community "Ambulancing": Health information and advice possibly prevents 999 calls and has now given us a more community-based role.
- Popularity: With patients, staff, local health/social care agencies, police, fire service and increased our cross organisational partnerships.
- World Media: Successful and positive international press, television, radio and internet coverage.
- Awards: '999 EMS Research Forum' at AMBEX, 'London Hero' at City Hall presented by the Mayor and HRH Queen Elizabeth, ASI licentiate and nominated for the ASA awards.
- Rider Fatigue: Identified possible health issues.
- Cycle Mileage: 170 miles per week, approx 4,500 over six months.
- Savings: Approx £80,000 in ambulance non-dispatch/attendance and £2000 in fuel.
- Fitness: Increased level of fitness.
- Sickness: None.
How We Measured Our Success
The collection of routine Management Information data on a weekly basis helped measure our success. This was supported by ongoing feedback with the CRU riders, operational staff, managers and external partners. The CRU riders also kept reflective journals and were closely supervised by the Cycle Co-ordinator and the Clinical Team Leader for safety and quality assurance purposes.
Keys to Success
- Listen to staff who have good ideas and support them in developing solid proposals. Your staff are your key asset and can be innovative, determined and resourceful if given the opportunity.
- Involve departments that are likely to be affected by any new systems required or by the results early in the planning process.
- Leave enough time for planning and run a pilot scheme; this could pave the way for change and will also tell you what will work.
- Evaluate the program constantly.
- Create an image for your scheme that you want to portray to the public and media.
- Select suitable staff who will be committed as you are.
- Ensure that new developments fit with your service's aspirations e.g., London Ambulance Service Improvement Plan aims to improve alternative responses such as the CRU for lower priority calls.
© 2003 IPMBA.. This article first appeared in the Fall 2003 issue of IPMBA News.