Emergency Ambulance

EMERGENCY AMBULANCE

SERVICES SURVEY

Re: MATERNITY CARE SERVICES

Prepared by:

Canterbury West Coast Emergency Care Co-ordination Team

2005 - 2006

INDEX

Introduction / 3
Recommendations / 4
Survey Results / A: Service Specifications / 5
B: Emergency Situations / 7
C: Specific Incidents / 17
Contributing Responses / SouthComm / 23
St John Operations / 24
St John Clinical Education Unit / 25
New ZealandCollege of Midwives Canterbury / West Coast Region / 26
Acknowledgements / 32

EMERGENCY AMBULANCE SERVICES SURVEY

FINAL REPORT

RE: MATERNITY CARE SERVICES

The Canterbury / West Coast is one of five ECCTs throughout New Zealand that is required to promote the implementation of the Ministry of Health’s Roadside to Bedside strategy. The requirements of this strategy which affect maternity care providers and emergency ambulance services include:

Promotion, assessment and improvement of services for the transport, reception and treatment of seriously ill maternal and newborn clients
Monitoring the provision of emergency services
Monitoring the provision of education and training in emergency care
Ensuring co-ordination in planning
Ensuring the effectiveness of PRIME (rural GPs and practice nurses trained in trauma management, who respond in support of the ambulance service)

This ECCT considers implications of the “Roadside to Bedside” strategy for South Canterbury, Canterbury and West Coast regions and also interfaces with the Nelson- Marlborough District Health Board, due to occasional variations in emergency responses in some bordering areas. In consideration of this, the ECCT initiated a survey in conjunction with the New Zealand College of Midwives and St John to all emergency ambulance providers in these regions.

AIM

Emergency ambulance service providers were surveyed on current maternal and neonatal emergency transport, particularly with regard to access and transfer to secondary services from the community and primary units.

Maternity care providers were also surveyed about their experiences relating to maternity cases in an aligned but separate survey.

The survey aimed to identify what is currently working well, any barriers to mothers and babies accessing safe, timely and effective care, and how often issues arise. Possible solutions to issues of concern have been reported and it is hoped that the results of this survey will lead to an improved service for women and babies and for all maternity care providers in the region.

METHODOLOGY

An introductory letter and questionnaire were sent to Team Leaders or Station Managers within St John and Marlborough Ambulance Service in late July 2005 with completed surveys due by 2 September 2005. Reminders were emailed through the St John network via senior management to encourage a greater response to the survey.

Out of a total of 305 surveys sent, 45 responses were returned, giving a total response rate of 14.75%.

Six surveys were returned uncompleted due to lack of relevant maternity situations experienced by staff at this rural St John station. (No data was recorded from these responses)

RECOMMENDATIONS

The survey findings and subsequent contributing reports are summarised with the following recommendations. Full contributing reports follow the main survey text.

Education regarding the use of RAPID Response numbers to women using maternity services

Standardisation of questions asked by SouthCommstaff on receipt of incoming calls

Clear understanding of protocols for making complaints or for giving praise regarding lead maternity carers

Clarification of legal issues regarding which practitioner assumes overall legal responsibility of the patient

Further education of ambulance staff regarding capabilities of lead maternity carers

Improved interaction and communication between ambulance staff and lead maternity carers

Involvement of midwifery educators into ambulance maternity-related training

Improved accessibility to training programmes for ambulance staff

Revision of ambulance charges in maternity cases to include these costs as part of overall maternity funding

It is suggested that areview of these recommendations is made after a period of 6 and 12 months following publication of this report to assess progress and any resulting outcomes.
SURVEYRESULTS

Results are listed in tabular form and by graphs where a question has a multiple or variable response.

Where the survey asked for comments regarding a particular situation, these comments have been added at the end of each group of responses. Comments made by respondents are reported verbatim.

SECTION A: SERVICE SPECIFICATIONS

You are responding for the following service:

Response / Number / Percentage
St John / 40 / 89%
PRIME response / 1 / 2%
St John/ Rescue Helicopter / 2 / 4%
Marlborough Ambulance / 2 / 4%
TOTAL: / 45 / 100%

How long have you worked in this capacity?

Response / Number / Percentage
< 5 years / 11 / 24%
5 – 10 years / 8 / 18%
10 years / 24 / 53%
Not answered / 1 / 2%
Not applicable / 1 / 2%
TOTAL: / 45 / 100%

What District Health Board does your district cover?

Response / Number / Percentage
CanterburyRural / 5 / 11%
Canterbury Urban / 1 / 2%
Canterbury Rural and Urban / 13 / 29%
South CanterburyRural / 1 / 2%
South Canterbury Rural and Urban / 6 / 13%
West CoastRural / 2 / 4%
West CoastUrban / 1 / 2%
West CoastRural and Urban / 8 / 18%
Nelson / Marlborough Rural and Urban / 8 / 18%
TOTAL: / 45 / 100%

What geographic area does your work cover?

Response / Number / Percentage
Main urban / 4 / 9%
Secondary urban / 4 / 9%
Minor urban / 3 / 7%
Rural centre / 4 / 9%
Rural area / 2 / 4%
Rural and urban / 16 / 36%
Secondary urban and rural / 3 / 7%
Main urban and rural centre / 1 / 2%
Main urban and rural area / 1 / 2%
Rural centre and rural area / 2 / 4%
Minor urban and rural area / 4 / 9%
Main secondary and minor urban / 1 / 2%
TOTAL: / 45 / 100%

The above regions are defined as follows:

Main Urban Areacities/towns with population over 30,000

Secondary Urban Areatowns with population between 10,000 – 29,999

Minor Urbantowns with population between 1,000 – 9,999

Rural Centretowns with population 300-999

Rural Areaall areas not specified as urban

Both Rural and Urbanas above

SECTION B:EMERGENCY SITUATIONS

If you cover a rural area, are you always notified of the woman’s/baby’s “Rapid Response” number for locating the home address?

Response / Number / Percentage
Yes / 23 / 51%
No / 5 / 11%
Often number not given / 3 / 7%
Not all have a number / 3 / 7%
Use cross streets/roads/house description / 2 / 4%
Most times when available / 2 / 4%
No - public do not know what Rapid Response number is and why it is used / 1 / 2%
No - correct number not always given / 1 / 2%
Not answered / 4 / 9%
Not applicable / 1 / 2%
TOTAL: / 45 / 100%

How many staff respond to a call?

Response / Number / Percentage
2 / 37 / 82%
3 / 3 / 7%
As many as required / 1 / 2%
Fire Service first aiders / 1 / 2%
Two staff plus PRIME Doctor / 2 / 4%
2-3 staff / 1 / 2%
TOTAL: / 45 / 100%

What information are you given prior to responding to a call?

Response / Number / Percentage
Location , condition , other services responding / 2 / 4%
Address, chief complaint. Follow up advice on radio / 3 / 7%
Condition of patient / 9 / 20%
As given by SouthComm / 14 / 31%
Address and if maternity case / 4 / 9%
Birth imminent, midwife present or not / 1 / 2%
Priority level, incident, address and name / 3 / 7%
Is birth imminent or baby born already / 1 / 2%
Priority, incident , address / 3 / 7%
Minimal information / 3 / 7%
Code and address / 1 / 2%
Not answered / 1 / 2%
TOTAL: / 45 / 100%

Is there any other information you would like to receive?

Response / Number / Percentage
The more information we receive, the better / 3 / 7%
More than just basic information / 1 / 2%
Name of patient / 1 / 2%
Specific type of emergency / 1 / 2%
Is Midwife and /or Doctor present? / 2 / 4%
Is closest hospital not receiving hospital? / 1 / 2%
Is it maternity or childbirth specifically? / 1 / 2%
What is status of baby? / 1 / 2%
Is this a first baby? / 1 / 2%
Whether PRIME doctor is attending with Midwife? / 1 / 2%
What equipment is required? / 1 / 2%
Is it a transfer and why? / 1 / 2%
None extra / 4 / 9%
Any maternity specialists at house, full labour details, inc contraction times / 1 / 2%
Location, distance, cross streets (intersections) / 1 / 2%
Not answered / 22 / 49%
Not applicable / 2 / 4%
TOTAL: / 45 / 100%

5.Do maternity care providers usually introduce themselves, indicating their role?

Response / Number / Percentage
Yes / 34 / 76%
No / 9 / 20%
Not answered / 2 / 4%
TOTAL: / 45 / 100%

6. Do you introduce yourself to maternity care providers, specifying your level of qualification?

Response / Number / Percentage
Yes / 33 / 73%
No / 10 / 22%
Yes – without stating qualification / 1 / 2%
Not answered / 1 / 2%
TOTAL: / 45 / 100%

7.Do you believe maternity care providers understand your level of skills/qualification?

Response / Number / Percentage
Yes / 3 / 7%
No / 38 / 84%
Don’t know / 3 / 7%
Not answered / 1 / 2%
TOTAL: / 45 / 100%

Do maternity care providers usually travel with you?

Response / Number / Percentage
Yes / 24 / 53%
No / 13 / 29%
Sometimes / 3 / 7%
As required / 1 / 2%
Not answered / 4 / 9%
TOTAL: / 45 / 100%

Are you able to take the family/whanau in the vehicle with you?

Response / Number / Percentage
Yes - 1 person / 19 / 42%
Yes - 2 people / 12 / 27%
Yes - 3 people / 3 / 7%
Yes - 4 people / 1 / 2%
Yes - 5 people / 3 / 7%
Yes - 6 people / 1 / 2%
Depends on patient condition / 2 / 4%
No / 2 / 4%
Sometimes – no number given / 1 / 2%
Not answered / 1 / 2%
TOTAL: / 45 / 100%

Have you ever responded to an emergency to find that circumstances had changed and the ambulance was no longer necessary? What was your response to this situation?

Response / Number / Percentage
Fine –part of job/ adapt to situation/ happy for good outcome / 14 / 31%
Return to station / 4 / 9%
No problem but are all volunteers who leave day job which can be difficult / 1 / 2%
Make sure all was alright / 1 / 2%
Return to station - advise patient to follow up with General Practitioner /Midwife / 1 / 2%
Part of job. Ensure woman doesn’t hesitate to call again / 21 / 47%
No / 1 / 2%
Not answered / 1 / 2%
Not applicable / 1 / 2%
TOTAL: / 45 / 100%

COMMENT: The results of this question are encouraging and show an understanding on the part of ambulance staff regarding the variable nature of maternity emergencies, where often a situation can change dramatically in a short period of time.

11a1. If you have had concerns about any aspect of service provided by a maternity care provider, did you notify anyone?

COMMENT: With regard to Questions 11a1 – 13b1, the correct procedure for expressing concerns and compliments regarding the ambulance service, including how this process is implemented and progressed, is outlined in the recommendations section.

Response / Number / Percentage
Yes – manager (?ambulance – not specified) / 4 / 9%
Yes – Supervisor/Team Leader St John / 2 / 4%
Yes - person concerned / 1 / 2%
Yes – not specified / 1 / 2%
Not answered / 18 / 40%
Not applicable / 19 / 42%
TOTAL: / 45 / 100%

11a2. If yes to Question 11a1, did you feel your concerns were acknowledged?

Response / Number / Percentage
Yes / 6 / 14%
No / 2 / 5%
Not answered / 16 / 36%
Not applicable / 20 / 45%
TOTAL: / 45 / 100%

11a3. If yes to Question 11a1, did you receive any feedback?

Response / Number / Percentage
Yes / 4 / 9%
No / 2 / 4%
Not answered / 19 / 42%
Not applicable / 20 / 44%
TOTAL: / 45 / 100%

11b. If no to Question 11a1, was it because you didn’t know who to address these concerns to?

Response / Number / Percentage
No –didn’t know who to address / 13 / 29%
Inappropriate to speak outside service / 1 / 2%
No- “because nothing ever gets done” / 2 / 4%
Not answered / 16 / 36%
Not applicable / 13 / 29%
TOTAL: / 45 / 100%

12.Are you aware of whom to address any concerns about a maternity care provider to?

Response / Number / Percentage
Hospital or Team manager / 1 / 2%
Maternity Unit manager / 2 / 4%
DHB / 3 / 7%
Team Leader / Station Manager/ St John / 3 / 7%
In service complaint via Ambulance District manager / 2 / 4%
WairauHospital Ward 1 / 1 / 2%
No / 23 / 51%
Team manager / 1 / 2%
Team manager and Maternity manager / 1 / 2%
Maternity Manager and MW organisation / 1 / 2%
DHB or private MW to MW board / 1 / 2%
Yes - unspecified / 1 / 2%
MW / GP / 1 / 2%
Not answered / 4 / 9%
TOTAL: / 45 / 100%

Are you aware of whom to pass on compliments and recognition for good teamwork/skills/service?

Response / Number / Percentage
Person concerned / 3 / 7%
Person concerned and their manager / 1 / 2%
Station /Team Manager/Ambulance / 2 / 4%
District Health Board / 1 / 2%
Local medical centre / 1 / 2%
WairauHospital Ward 1 / 1 / 2%
My crew / 1 / 2%
Yes - not specified / 5 / 11%
Maternity Manager / 1 / 2%
District Health Board or for private Midwife to Midwifery Board / 2 / 4%
District Manager / 1 / 2%
Not answered / 7 / 16%
Not applicable / 19 / 42%
TOTAL: / 45 / 100%

13a2.If yes to Question 13, did you receive any feedback?

Response / Number / Percentage
Yes / 4 / 9%
No / 5 / 11%
Not answered / 13 / 29%
Not applicable / 23 / 51%
TOTAL: / 45 / 100%

13b1.If no to Question 13, was this because you did not know who to address these compliments to?

Response / Number / Percentage
No –didn’t know who to / 20 / 44%
No - don’t think there is teamwork / 1 / 2%
Not answered / 6 / 13%
Not applicable / 18 / 40%
TOTAL: / 45 / 100%

How would you rate your need for an updating of skills in dealing with the following emergencies?

Emergency / 1 (low) / 2 / 3 (med) / 4 / 5 (high) / Not answered / Not applicable
Cord prolapse / 1 / 6 / 14 / 11 / 11 / 2
Shoulder dystocia / 1 / 3 / 12 / 12 / 15 / 2
Uterine inversion / 1 / 3 / 12 / 12 / 15 / 2
PPH management / 2 / 6 / 12 / 10 / 10 / 5
IV line insertion (adult) / 20 / 2 / 3 / 2 / 10 / 5 / 3
Neonatal resuscitation / 6 / 12 / 4 / 7 / 12 / 3 / 1
Adult CPR / 31 / 6 / 1 / 4 / 2 / 1
Undiagnosed breech / 2 / 3 / 14 / 11 / 13 / 2
Other / 34 / 10

Can you easily access skill updates/further training as required?

Response / Number / Percentage
Yes / 16 / 36%
No / 25 / 56%
Yes - if doing National Ambulance Certificate / 1 / 2%
Not answered / 3 / 7%
TOTAL: / 45 / 100%

WHAT IS THE BEST THING ABOUT THE SERVICE / SYSTEM AT PRESENT?

(Respondents were asked to express this in their own words - no suggestions were given)

Ambulance

Fixed wing neonate /obstetric retrieval service to West Coast appears to work very well
Opportunities to work in city for upskilling
Haast has a few people who endeavour to help others; we would be in a bad situation otherwise
Ambulance rarely required. 20 years ago many deliveries but system seems to be so much better now
Midwife does not travel or respond to a call with us -it would delay response
Do training every 2nd week. Can up skill if and when required
Christchurch Women’s is based at ChristchurchHospital (which saves transporting patients from other hospitals)
Dedication of volunteers as without them there would be no service

Maternity

Easily contactable independent midwives
Still based at local hospital, more convenient for patients
Midwife is usually present on scene with patient. She is a specialist in this field.
Good receiving hospital for urgent maternity care and premature baby resuscitation, covering a large rural area and some time from hospital

General

Things work well at present
Teamwork and satisfaction
Making a difference and putting something back into the community

17.WHAT WOULD YOU LIKE TO SEE IMPROVED OR CHANGED?

Ambulance

More staff support
Ambulance should be resuscitation experts – stand back and let us do our job
Access to training times; more training; training night 1 or 2 x per year
More across board training between ambulance and hospital
Rural staff to have better access to city shifts
Greater interaction between St John and West Coast DHB regarding services. There is a lack of current agreement/contract re Inter Hospital Transfers. Causes uncertainty and confusion re levels of service i.e.: vehicles, crew capabilities, response times etc and vehicles and crew being removed from emergency/ambulance cover to provide patient transfer services for DHB
Evaluation of degree of urgency for ambulance response
Communication updates
Employ staff (interpreted as: rather than using volunteers)
Would like to know what ward a patient needs to go to (at receiving hospital)
Level of volunteer reimbursement

Maternity

Fuller services at AshburtonPublicHospital
Attitude of midwives
We have no midwives in our area that we can call on
Midwives to acknowledge skills of paramedic registered nurse when travelling in ambulance
Earlier admission to hospital for first time mothers or mothers at risk
Midwife or maternity team at Emergency Department on arrival
More contact between midwife and PRIME responder

General

Staff who communicate effectively

18.WHAT IS THE WORST ASPECT OF THE CURRENT SYSTEM?

Ambulance

Urgent transfers needed due to lack of services at AshburtonPublicHospital
Poor management of service
Current level of ambulance staff – volunteer training not fully inclusive and experience only gained on exposure to cases
Often feel we are just a taxi service as working in an area very protected by existing staff
Expectations made of the volunteers
Lack of experience in rural areas due to low population. Need to work in city regularly
Insufficient updates. St John is a large organisation and updates and up skilling take time to filter through
Our distance from training areas as we still need to keep our skills up
Having to go urgently to St George’s (Christchurch) and long waits. Because there is no loading bay at St Georges, they expect us to behave like Titan cranes and lift heavy women into ambulances
Too many shifts/calls/on call duties - due to volunteer shortages
Lack of staff and mismanagement of funding

Maternity

Midwives don’t have identification. Is this person really qualified to be in charge of the delivery?
Nil maternity support at hospital as staff consider ambulance at lower end of patient care scale
Mix of independent and District Health Board midwives and conflict between staff
Nearly every maternity transfer comes through as urgent. Ambulance staff are recalled then wait 30 -60 mins for midwife and/or doctor to be ready / organised for patient to depart hospital
Midwives unwillingness to seek help early
Don’t feel midwives are aware of ambulance staff abilities and they feel we are just taxi drivers
No midwives in our area that we can call on

General

PRIME covers each others areas on time off. Don’t know patients history and can be difficult tracking down when midwife is 3 hours drive away
Staff lacking communication skills
Adoption of home births in rural areas means unacceptable delays when things go wrong
Not being informed of patients infectious level before having contact with patient
Time spent waiting for retrieval team to put premature babies in incubator is too long – often 5 hours

ADDITIONAL GENERAL COMMENTS

Ambulance

PRIME appear to want to run Rural Ambulance rather than be of support role

Most times we are used in transportation with sick babies or parents to Christchurch or helicopter

Little information from SouthComm on patient condition

Information given by SouthComm is often incorrect or misleading

SouthComm do a very good job providing information

Strictly, we shouldn’t take any extra passengers due to loading certificates, especially in vehicles with Stolenwerk stretchers. We are not a bus

Maternity

Due to patient privacy, if the midwife travels with us we are told very little. If no midwife with ambulance, getting info sometimes requires interrogation

I am a qualified ambulance officer and have never had a maternity call. Would aim to assist midwife or doctor with thorough knowledge of ambulance familiarisation

Maternity staff have generally not taken interest in ambulance developments and still ask for the ambulance “with oxygen in it” or “do you have a bag mask resuscitator in your ambulance” indicating to ambulance staff that we are considered to be ambulance “drivers”!

Tell all midwives we do all carry oxygen, Entonox and all ambulances are physically the same

Midwife wanted to run job, not at all interested in ambulance staff help

General