Healthier happier staff = healthier patients

Author: Alan Lofthouse

Published in: Summer 2018 Edition of Ambulance Today Magazine

At the end of 2014, and early 2015, we went through a period of industrial action in the NHS over pay involving two 4-hour stoppages. In the ambulance sector, many staff were not prepared to come to work, even under emergency life and limb cover arrangements. This led the government to put the army on standby. So, what happened and what have we learnt? 

Why were staff not prepared to come in? Well the answer lies in the fact that ambulance staff have been raising issues with workload, pressure, demand and lack of support for a number of years. Trouble was no one was listening. Performance dominated Trust boards and finance fixated commissioners missed the warning signs. 

Here came an opportunity for staff to make themselves heard. They voted with their feet in the knowledge that their legal right to take lawful industrial action would protect them. When it came to settling the dispute, we made sure that ambulance staff wellbeing was part of the final settlement. 

So, what has happened since then? Well, we have been working to develop a collaborative approach between Ambulance Employers, Trade Unions and NHS Employers to improve the mental health and wellbeing of the ambulance services workforce. 

We started by bringing together staff and employers to discuss the challenges each group faced. We have to recognise, whether we agree or not, that there is a policy of austerity in government meaning budgets are increasingly tight and the expectation is that employers will do more with less. However, this policy leads to problems for employers as staff leave jobs for less stressful and better paid work leading to recruitment and retention problems. 

Employers listened to staff concerns about working conditions, not just for the operational staff working on ambulances, but also the staff working in the contact centres and corporate services. Fewer people doing more work in an increasingly challenging environment. This is not easy listening for employers, many of whom work in managerial roles to help support staff in the delivery of 999, 111 and PTS services. Ultimately, they have little control of the government’s public sector funding policy. 

However, they do have to deal with the consequences – the dropping job satisfaction, morale and motivation; the loss of organisational commitment and discretionary behaviour. This leads to a worsening engagement, stress symptoms and burnout. Then they have to account for increasing absence rates and unfilled shifts. 

At first it seems like an impossible puzzle with too many pieces that don’t seem to fit together. How do you improve wellbeing, especially when you know what is making people unwell, but it feels out of your control and when taken as a whole it seems an impossible task? 

We started by grouping the pieces of the puzzle together based on the key issues. 

Mental health and resilience. Helped by Mind and the Blue Light Programme we know that ambulance staff are more likely to suffer from mental health problems but less likely to do anything about it. 

Bullying and harassment. Whether it is a manager and staff relationship, a control and road relationship or a hospital and ambulance relationship, we know they are already strained. Cultures in ambulance services need to change. External and internal pressures lead to poor behaviour but we need to eliminate bullying. 

Reducing violence and aggression. Too many times we read reports about staff being assaulted. I have written about this subject before and no one disagrees – we need to tackle this issue. With the right focus on prevention and prosecution we can reduce the harm caused by violence. 

Leadership behaviour. Ambulance staff take on managerial roles and then are not given the support or training needed to discharge their duties. We hear of senior management teams that are out of touch with staff. Line managers have a major role in supporting and developing staff. Senior management need to give them the training, autonomy and trust to support their staff. 

Working patterns and role design. Ambulance work takes years off your life! More and more evidence shows us that long hours, shift working and night working is bad for us and leads to preventable diseases. Some staff like working longer shifts to get longer periods of time off, but with no guaranteed meal breaks and the likelihood of a long shift overrun it’s time we looked seriously at this issue to make work less demanding but recognising peoples’ needs to spend time with their friends and family. 

Equality and inclusion. The experience of BME ambulance staff is of inequality in career progression, increased experiences of harassment and bullying and underrepresentation at senior level. 

Recognition and staff engagement. Each year the NHS Staff Survey shows how poorly engaged ambulance staff are. They are the lowest scores across the NHS. I do not honestly think it is deliberate but you get very little recognition for a job well done, whereas you do hear about a missed performance target or a complaint. Ambulance services need to get better and reap the rewards of telling staff they recognise the effort they are making, especially in difficult times. 

Healthy lifestyles. Last but by no means least. Ambulance work does not lend itself to healthy lifestyles. Shift work, late night snacking on poor quality food, combined with lack of consistent exercise and the physical demands of the job are a bad mix. However, looking after your own health is important and we want to see more employers supporting staff to live more healthily. 

The real trick for the national bodies, employers and trade unions will be getting the buy-in from staff and for them to trust that this is more than just a new initiative. The benefits are proven and what we have been saying for a long time. To get good patient care you need to start with good employee care. At the end of the day, healthier happier staff = healthier happier patients. 

Accidents are no film set

Author: Thijs Gras

Published in: Spring 2019 Edition of Ambulance Today Magazine

EMS staff have enough to deal with when responding to a call, the last thing they need is members of the public making harder work of it. In this column, Thijs Gras explains the difference between ‘innocent inquisitiveness’ and ‘sick sensationalism’ when it comes to the scene of an accident.

We got a call: probable resuscitationin a tram. When we arrived we founda man of about 70 years lying on the ground in a tiny space inside the tram. It was cold and rainy, so carrying him outside was not an option, at least not without proper preparation for which we had no time. The police were already performing CPR, all the passengers were out of the tram. We pulled the man a little under to create a bit more space and took over the resuscitation. While I was ballooning the man I suddenly noticed someone on the outside, looking curiously through the window of the tram as to what we were doing there.I was amazed and so were the police. After this guy was chased away, only a couple of moments later a woman took over. She gazed inside.

Now I must admit I have a certain degree of understanding, people being inquisitive when something happens involving lights and sirens. Mankind is naturally curious. In my younger years hearing the fire service acceleratedmy heartbeat and if I knew where they were going to, I went as well. A fire is fascinating to see. Smoke and flames, lights and sirens attract attention, which generally is okay, as long as you do not come too near or hamper rescue and/or fire fighting operations.

Labelling it positively, one could referto this as interest in the community, in society, in other people. The attraction could even have an evolutionary use: it is a way to mobilize help and assistance. It is only relatively recently that rescue and emergency medical care outside the hospital is professionalized and trusted to specially trained people from dedicated organizations and services. But even nowadays we value first responders and bystanders because they have one big advantage over the professionals: time. Professionals need to be informed there is a problem,find out where it is and who shouldbe handling this, and then alert the required units to rush to the scene. All these steps take time, so having people around to extinguish a fire, control a bleeding or perform CPR may be of great value.

But there are boundaries. Some people prefer filming to rendering first aid.This is ridiculous of course. Even after emergency services arrived on the scene and are doing their job, people may come very close, sometimes too close for comfort. Being a historian, I went through a lot of pictures of accidents. One would be amazed by the number of people watching accidents on some of the older pictures. Apparently this is of all ages. In the Netherlands we call this ‘disaster tourism’.

But do not forget, it may be dangerous! Even in The Netherlands we had a nasty experience in this field with the big explosion of a firework factory in the town of Enschede in May 2000. Among the 22 fatalities (including four fire fighters) and about 950 injured, were a number of people that had come to the incident just out of curiosity.

In recent years cell phones and iPhones have taken sensationalism a step further; everything is filmed nowadays. You make your own reality TV and broadcast it among your friends or nasty news channels. With a bit of luck your footage goes viral.

Last year in August there was a big collision on one of the Dutch highways. One person was so seriously injured he had to be resuscitated. People were filming everything. They bashed through the accident scene trying to get the best pictures, destroying important marks for the police investigation. They used lanes, marked with red crosses. A car even stopped on the opposite side of the motorway to film the accident, almost causing another accident with an oncoming lorry. Police noted as many registration plates as possible to give these people a big fine. Will they learn?

There are thin lines between innocent inquisitiveness, caring curiosity,sick sensationalism and pathologic papparazionism. The first two are relatively okay and can be dealt with, the other two are not okay and refutable.

As ambulance crews we ask the right honourable members of the public not to film patients and victims. And if you are struggling against the temptation, just reflect before you film: “What if this was me or my mother or my father? Do I want to go viral?” Accidents are no film sets. . .

‘MDA Teams’ App

Technology applied to the health sector has made immensely positive strides saving lives in the smartphone era – the proliferation of mobile phones within communities has resulted in faster response times than ever before. Emergency services can be notifiedof incidents significantly quicker with mobile phones than compared to landlines. Smartphone applications have offered the ability to pinpointthe location of callers with a clickof a button so that ambulances can arrive on scene as quickly as possible. Now, smartphones can even minimize unnecessary waiting times at the ER during emergencies.

It is only fitting that Israel’s (thestate affectionately nicknamed the ‘Start-up Nation’) national emergency medical, disaster, ambulance andblood bank service Magen DavidAdom (MDA) represents the pinnacleof this trend of life-saving devicesand applications. Dating back even further than the State of Israel itself, the organization continues until today as a global leader in EMS innovation, including through the development of smartphone applications that provide simple yet innovative solutions to some of the greatest challenges of modern ambulance services.

One of the Israeli organization’s most innovative and recent technological infrastructures is the ‘MDA Teams’ mobile application. With the goal of minimizing any unnecessary waiting or consultation times before ST-segment elevation myocardial infarction (STEMI) treatments, the app streamlines direct communication between field paramedics, responding ambulances, Magen David Adom dispatch centers, on-call cardiologists and receiving hospitals.

With the click of a button, MDA Teams transmits ECGs and patient vitals, combining the main methods used to bypass the time-consuming emergency department in cases of patients suffering acute myocardial infarction ECG showing ST-segment elevation: utilizing automated ECG/ computer interpretation of the ECG and easy transmission to the on-call cardiologists.

For an organization that boasts a 7.6 minutes average response time for ambulances (and half that time forFirst Responders) it is no surprise that Magen David Adom is also working to cut down on the vital minutes between diagnosing the patient and transporting them to any necessary procedures. Developed in collaboration with the intensive cardiac care units, the Magen David Adom technology has shortened the time from symptom onset to catheterization by nearly 40.3%.

The technology also represents a better process to record and document events securely and directly via the smartphone application. First, on-call cardiologists activate their app to indicate they are on-call. When a mobile intensive care unit is calledto a patient having a STEMI, the paramedic can choose the receiving hospitals from a list of hospitals with ICCU and cath labs available. Then, the paramedic can take the ECG and send it securely through the system, also eliminating the risk of a wrong ECG being transferred. The ECG is uploaded via cellular connection from the monitoring device to the patient’s file on the server. The app then sends the ECG directly from the patient’s file to the cardiologist.

Listed in the application are on-call cardiologists, event date and time, ambulance number, main complaint, nearest hospital, urgency level, region and address of the call and patient destination. App features also include documented calls between the paramedic, regional dispatch, medical consult centers, hospitals and on-call cardiologists, along with ECG record and mapped ambulance tracking during transport with the estimated time of arrival. In keeping with privacy standards, no phone numbers are shown on the dialing server.

According to Eli Jaffe, PhD, EMT-P, director of training, PR, volunteer activities, marketing and international relations for Magen David Adom, before the application’s development, Magen David Adom paramedics “used mobile phones to orally describe the patient, symptoms and the ECG. Since smartphones are currently widely used, transmission of the ECG is possible through personal messaging applications such as WhatsApp.”

But this method is not without risks, he noted. “The paramedic may accidentally send the wrong ECG from an earlier patient to the on-call cardiologist, or the paramedic could transmit the ECG to the wrong person, which could lead to a breach in patient confidentiality.”

Additionally, photos taken by phone when in a hurry transporting the patient often results in transmitting a blurry ECG. “These methods are neither effective, secure nor documented”, said Jaffe. “For a true reductionin the symptoms-to-balloon time, EMS-to-balloon time should have a secure, well documented and effective infrastructure.”

Given the grave importance of quick coronary intervention during the deadliest type of heart attack, the combination of clinical diagnosis by trained paramedics and streamlined transportation of the ECG and patient makes the process fast and efficient, substantially decreasing the chance of severe complications, neurological damage, disability and death.

With new smartphone technologies such as the MDA Teams application, such infrastructure is now available to emergency medical teams, yet again highlighting the advantages of mobile tech devices in effectively and efficiently saving lives.