End of Shift Trial FAQs

End of Shift Trial Phase 2  - Frequently Asked Questions

The trial aims to reduce late finished for DSA and RRVs

If the trial was successful, why not roll out now across the whole trust. 

We have demonstrated on a locality level that the trial is successful against the main key indicators. We now need to test it on a larger scale to ensure that we can manage anticipated possible issues (eg pressure on clinical oversight) but also to check for unanticipated issues that might only become apparent when ‘upscaling’. 

How many DSA or RRV shifts avoided a ‘late job’ because of the trial. 

 There were 21 instances in the five weeks up to 6 September where a trial resource was the nearest to a C1 but was not dispatched due to the trial. There are only two instances that we are aware of where a trial resource was dispatched in their last 30 minutes: one to a ‘Echo code’, the other on Clinical Coordinator oversight. 

Only 21 resources avoided being dispatched? 

Yes. This illustrates that the risk of getting a C1 in the last half-hour is already quite low (approx. 1 in 100 shifts) without the trial. With the trial criteria the likelihood – on an admittedly crude analysis – becomes 1 in 1000. 

Why expand first to Norfolk and Waveney and Hertfordshire and West Essex? 

The two phase one localities were in these STPs. Expanding to the whole STP makes sense by building on the knowledge and experience that has already been accrued both in these STPs and on the relevant dispatch desks in Norwich and Bedford AOCs. During phase one we also noticed some expected cross-border anomalies caused by the trial, e.g. when a non-trial resource from a neighbouring locality in their last 30 minutes is dispatched instead of a trial resource. Expanding to the whole STP rather than into single localities in a new STP will help minimise these anomalies.  

What are the plans for further expansion? 

As in the Need to Know article, the plans are to expand the trial as follows 

Phase 3Mon 11 Oct – Mon 8 Nov (4 weeks) 

  • Mid and South Essex STP 
  • Suffolk and North Essex STP 
  • Chelmsford AOC 

Phase 4: Mon 8 Nov – Mon 29 Nov (3 weeks) 

  • Cambridgeshire and Peterborough STP 
  • Milton Keynes, Bedfordshire and Luton STP 

Might this timescale change? 

Yes, the timescale might change. It is possible that the timescale might be extended, should we feel that more data is required to be able to come to reliable conclusions. Conversely, should evidence indicate, it is possible that the timescale may be shortened. 

Where did the idea for this trial come from?

The trial is based one conducted successfully and then implemented by London Ambulance Service in 2018. The working group was alerted to the LAS trial by an EMT who responded to a request for examples of problems experienced with the various operational processes (e.g. end of shift, cross-border working) and ideas for possible solutions.

How will we ensure patient safety throughout the trial?

Patient-safety remains of prime importance. Staff safety and well-being is also of prime importance and this trial is an attempt to facilitate an appropriate balance between the two. Results from the LAS trial suggest that there should be no significant impact on patient safety related to response times. However, fatigued staff are vulnerable to accidents and errors as well as the well-being issues that arise from these.

There is a comprehensive escalation and ‘stop the line’ process which includes some automatic responses (e.g. an automatic suspension if an internal critical incident is declared), a daily review of data by the trial team and the patient safety team to monitor for patient safety issues,  and a daily presence/input at the Tactical Meeting to raise/discuss any concerns regarding the trial. 

What about LOMs and their response to scene management in the last 30 mins?

LOMs will be included in the trial. They will remain expected to respond as manager for scene management and/or staff welfare but only in accordance with ESOP02 (i.e. not tasked as an RRV) or to confirmed cardiac arrests if they are the closest resource, including deployment of a Lucas Device where appropriate.

What can DSAs or RRVs be dispatched to in their last 30 minutes 

Phase 1 of the trial started with DSAs and RRVs in their last 30 minutes only being dispatched to confirmed cardiac arrests. Part way into the trial a review concluded that a limited set of additional codes needed to be added to ensure that we still responded adequately to our sickest patients. 

So, from part way through Phase 1, and continuing into Phase 2, DSAs and RRVs be dispatched to: 

  • Confirmed cardiac arrests. 
  • Echo codes 
  • Five obstetric C1 codes. 

A Clinical Co-ordinator can also, in rare circumstances where they feel an immediate life-saving intervention may be needed, override the criteria to dispatch a resource in their last 30 minutes. This happened only once in Phase 1 of the trial.  

What are ‘Echo codes’? 

Echo codes are subdivision of code sets (e.g. 17 Falls) and relate to the sickest patients within code sets, an example being electrocution/lightning (Code 15) where an ‘Echo’ will be added if the patient has ineffective breathing, which would show as 15E01 on a MDT message. These are the types of call where an immediate intervention could save a patient’s life”. 

The specific Echo codes are 

  1. Allergies (Reactions) /Envenomations(Stings, Bites) 

Ineffective breathing 

02E01 

  1. Breathing Problems

Ineffective breathing 

06E01 

  1. Burns (Scalds) / Explosion (Blast)

Person on fire 

07E01 

  1. Choking

Complete obstruction/ineffective breathing 

11E01 

  1. Drowning / Near Drowning / Diving / SCUBA Accident

Arrest (out of water) 

14E01 

Underwater (non-specialised rescue) 

14E02 

  1. Electrocution / Lightning

Not breathing/ineffective breathing 

15E01 

  1. Overdose / Poisoning (Ingestion)

Narcotic/Opioid arrest (obvious) 

23E01 

  1. Unconscious / Fainting (Near)

Ineffective breathing 

31E01 

 

What are the five C1 obstetric codes? 

These are: 

  1. Pregnancy / Childbirth / Miscarriage

Breech delivery or cord prolapse 

24D01 

Head visible/out 

24D02 

3rd trimester haemorrhage 

24D04 

Baby born (complications with baby) 

24D06 

Baby born (complications with mother) 

24D07 

 

Why were the Echo codes and obstetric codes added? 

These are codes for calls which are truly time critical – the types of call where an immediate intervention could save a patient’s life. This change was recommended by the clinical directorate to ensure that our most unwell patients’ safety is not impacted. Despite this addition there is still almost an 80% reduction in the number of calls which you could be dispatched to in the final 30 minutes of your shift. These are also calls which may recode when more information is known and, as such, you would be stood down.  

Is this not a slippery slope that will lead to even more codes being added? 

This is not expected to be the case. The added codes are the result of an analysis of the types of call where an immediate intervention may save a life, an analysis that has been completed thoroughly enough to need doing only once. 

How many resources were dispatched to these codes in the first phase of the trial? 

We are only aware of one instance during the five weeks that the trial has run in West Norfolk and West Hertfordshire where a resource has been dispatched on an Echo or obstetric C1 call in their last 30 minutes, although there may be examples that we have missed. Our data capture strategy was more tuned to identifying the times when a resource was not dispatched as a consequence the trial rather than the times that they were, something we have corrected for the next phases of the trial. 

How does the oversight by clinical co-ordinators work? 

A call handler, dispatcher or dispatcher can escalate a call to a Clinical Co-ordinator if they have concerns that an immediate response may be needed despite the call not being coded as per the trial criteria. The Clinical Co-ordinator will then review the call, which should include speaking with the caller, to determine whether overriding the trial criteria is justified. 

This has happened only once over the five weeks that the trial has been running. 

Do we have enough clinical co-ordinators to do this? 

The trust is short staffed with regard to Clinical Coordinators and part of the rationale of the trial expansion is to test the level of pressure it might put on clinical oversight. An advantage of the added Echo and obstetric C1 codes is that dispatch to these calls will be based on MPDS coding by the call handler, easing the pressure on clinical oversight. 

Are PTS included in the trial?

No. PTS staff work under a different system with workload generally being able to be planned unlike emergency operations, equally late finishes are less frequent and elongated as such PTS are excluded from this trial.

What will happen when we go up surge levels?

At Surge Black the Strategic Commander will have the discretion to deploy resources outside of the trial guidelines, but this should only be in exceptional circumstances.

Should the Trust declare an Internal Critical Incident then the trial will be temporarily suspended.

What about major incidents? Will these affect the trial? 

Should a major incident be declared then it is also possible that resources geographically local to the incident may be withdrawn from the trial. However, major incidents are few and far between and as most crews would probably offer up to a GB for a major incident, the impact of this is likely to be low. 

Will the trial still go ahead if we are in REAP 4? Updated

REAP 4 actions do not involve any additional end-of-shift processes that are not already considered under REAP 3. Thus, the continuation of the trial will not be affected by the REAP level unless an internal critical incident is declared, which is a possible action under REAP 4 and which would temporarily suspend the trial under the pre-planned trial escalation and ‘stop the line’ process. The first phase of the trial was not affected by EEAST being at REAP 4 for the duration.  

Will this result in uncovered or delayed response to C1s? Updated

The trial by LAS showed no significant reduction in response to C1s. It is anticipated that the reduced availability of off-going crews will be mitigated by the increased availability of on-coming crews. Data shows that in July, the C1 response time in the trial areas was 08:55 with an average response time of 09:26 in August. This increase is on a smaller scale when compared with last year: we were 58 seconds slower responding to C1s in August 2020 than in the preceding month, whereas in 2021 we were 31 seconds slower. 

What criteria does EOC use to categorise a call as ‘confirmed cardiac arrest’?

Confirmed cardiac arrest will normally produce a coding on 09E01 through AMPDS and there will be active CPR instructions given by the call handler until the resources arrive at scene, this will be the case for cardiac arrests at point of call.  There will be exceptions to codings if the patient is not in cardiac arrest at point of call but later deteriorates into cardiac arrest during the call-taking phase.   AOC has escalation plans in place should this occur outside of the 09E01 coding.


DSA/RRV oriented

Are Urgent Tier Vehicles included in the trial?

Yes.

Can we respond to GBs in the last 30 minutes?

Yes.

Will we still be deployed as normal to C1/2 and Hot 1/2 in the 60-30 minutes before end of shift

For now, yes. If this trial is successful, changing deployment criteria for the last 60-30 minutes might be the next iteration in the PDSA (plan, do, study, act) process.

What do we do if we are at our base station in the last 30 mins? Can we go home?

No, you should not be leaving until the end of your shift. You can, of course, have everything ready to leave (e.g. restocked/refueled, PPE off the ambulance, drugs put away) ready to sign off as your shift ends. If you decide to respond to a GB but have already offloaded your PPE etc, then you can still offer but book a delay to allow for putting kit back on.

What if I am out of area? Will the dispatch desk know that I’ll be unavailable for the last 30 mins?

Your locality dispatcher will normally know when you have been taken by another dispatch desk and they will have been able to communicate your status as part of a trial. Should this not happen, and you get dispatched contrary to the trial criteria, call control and you will be stood down.

Does this affect IX?

IX will still be calculated on allowing you to return to station on time and you will be unavailable in the last 30 minutes. When calculating your journey time for liaising with AOC do not forget to factor in that when on single and dual carriageway roads you will be travelling 10mph slower than the speeds Google Maps will be using to calculate.

How does this relate to application of missed meal-break policy at end of shift?

Normal meal break arrangements apply: if you have to return to station for a late meal break in your last hour you will be unavailable for any calls.

Will there be other changes to end of shift procedures trialled? - New 

Yes, this trial is anticipated to be just the first stage in a ‘Plan-Do-Study-Act’ (PDSA) improvement process. 

AOC oriented

Is there an ESOP for this?

Yes, ESOP 01a covers this trial.

So, even if a crew in their last 30 minutes are the closest resource to a C1, they can only be dispatched if it is a confirmed cardiac arrest.

Yes, that is correct. However, response statistics suggest that this will be a rare occurrence. You can still general broadcast and the crew, if they wish, can respond.

Can trial crews respond to general broadcasts in the last 30 minutes?

Yes.

If crews are on station in their last 30 minutes, what are they expected to do?

They should be ensuring that the vehicle is ready for the next crew i.e. refueled, restocked, clean. If they are not handing over to another crew, they can garage the ambulance and offload personal kit (e.g. PPE) and drugs just before shift finish time. Thus, if dispatched to a confirmed cardiac arrest or responding to a delay in the last minutes of the shift they may need to book a delay while they put PPE and drugs back on the ambulance.

What if crews I dispatch go out of area?

Please inform the relevant dispatch desk that the resource they have taken is part of a trial and will be unavailable in the last 30 minutes except for confirmed cardiac arrests.

How does this relate to application of missed meal-break policy at end of shift?

Normal meal break arrangements apply: if a crew has to return to station for a late meal break in their last hour, they will be unavailable for any calls.

Will a major incident affect the trial?

The Strategic Commander can authorise an area-specific suspension of the trial in the event of a major incident, particularly towards the end-of-shift.

 

Published 15th July 2021