Optimising ambulance management: the heart of the emergency care system

As one of the three main emergency services in the UK, the ambulance service plays a unique, critical role. Ambulance trusts operate as the mobile arm of the NHS, an extension of our country’s wider healthcare system.

What is the ambulance service responsible for?

Ambulances perform two main functions in the interests of public health:

• an accident and emergency paramedical response service
• a Patient Transport Service to assist specific patients with getting to and from hospital appointments.

All emergency calls to 999 that request an ambulance are received by a call handler who will decide whether it is an immediate, life-threatening emergency or an emergency that is not life-threatening – depending on the specifics of the patient’s condition and situation. An example of the former would be cardiac arrest; the latter, minor injuries. If urgent medical care is required, an ambulance response crew – typically comprising a paramedic and an emergency care assistant – will attend the scene. All ambulance crews are highly trained, enabling them to handle any aspect of pre-hospital trauma assessment and emergency medical care. Equipment carried by an emergency ambulance includes oxygen, heart defibrillators, intravenous drips and drugs.

What are ambulance quality indicators?

The NHS states that ambulances are at ‘the heart of the urgent and emergency care system’, and that their aim is that ambulance services:

• meet all targets and deliver patient outcomes
• are efficient and effective
• have a satisfied, happy and productive workforce
• are integrated into the wider urgent and emergency care system
• are digitally fit for the future.

Ambulance quality indicators (AQIs) are the service’s version of key performance indicators (KPIs), used to assess and benchmark how well they are performing and how they compare to other services across the country.

In England, for example, all ambulance trusts are measured against the latest iteration of the 11 AQIs. These performance measures are divided into two categories: ambulance systems, which focuses on and clinical outcomes.

Ambulance quality indicators

Clinical outcomes

1. Outcome from acute ST-elevation myocardial infarction (STEMI – a type of heart attack)
2. Outcome from cardiac arrest – return of spontaneous circulation
3. Outcome from cardiac arrest – survival to discharge
4. Outcome following stroke for ambulance patients

Ambulance systems

5. Proportion of calls closed with telephone advice or managed without transport to A&E (where clinically appropriate)
6. Re-contact rate following discharge of care (i.e. closure with telephone advice or following treatment at the scene
7. Call abandonment rate
8. Time to answer calls
9. Service experience
10. Category A 8-minute average response time
11. Time to treatment by an ambulance-dispatched professional

What are the challenges facing ambulance trusts?

Increases in demand, large-scale workforce shortages and a lack of funding are systemic challenges currently facing the ambulance service and the rest of the health service.

These issues, whilst acute and difficult for ambulance operations management to balance, are felt across the service. However, according to NHS Providers, there are a wide variety of factors and variations – outside of their control – that frequently impact management and performance:

• population count
• population demographics, such as age
• size of geographical locations, as well as whether they consist of more urban or more rural areas
• distribution and number of emergency departments
• distribution, number and type of other healthcare services and providers, such as specialist clinics and performance of local acute care hospitals
• number of ambulances and ambulation locations
• quality of local primary care facilities and facility locations, together with care home and community networks and services
• other emergency medical services, the police service and the fire service.

Many of the difficulties are rooted in the individual characteristics and demographics of the regions that ambulance trusts serve.

Another challenge is that ambulance fleets experience higher levels of sickness absence than other emergency response services. Additionally, their workforce suffers an increased likelihood of verbal and physical assault from members of the public.

Recently, there have been critical issues regarding ambulances queuing outside hospitals, unable to hand over patients due to a lack of beds and general care capacity. These handover delays make it incredibly difficult to plan ambulance allocation and deployment and put patients with medical dependencies at greater risk.

Many are attempting to address the critical challenges facing the ambulance service.  For example, the ambulance location optimisation model – also called the ambulance optimisation model – is a linear programming model that proposes a methodology to provide as much ambulance demand as possible, in the shortest time possible, using available fleets. Research in this field includes Ingolfsson, Budge and Erkut (2008) and Brotcorne, Laporte and Semet (2003). Such relocation models rely on algorithms, machine learning, real-time datasets, emergency medical systems (EMS) and event simulation models to support ambulance station forecasting and operations related to optimal locations and travel time. In this way, data-driven, location model-based decisions can replace heuristic assumptions regarding ambulance allocation.

What are the next steps for ambulance management?

Ambulance services have already made vast gains in meeting the targets around ambulance quality standards. To further optimise the maximal quality, safety and coverage of ambulance trusts – and to help them continue to support the wider health service – adequate investment is required.

Funds can be used to increase the workforce, broaden the scale of emergency response services, undertake more operations research, and upgrade ambulance fleets with the help of industrial engineering, further enabling trusts to make progress in key areas. Alongside this, improving workforce morale, engagement and retention is an important step in optimising the overall performance of the ambulance service, as is integrating ambulance services more fully within local healthcare systems and related services.

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