Hospital and emergency ambulance link: using IT to enhance emergency pre-hospital care

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Abstract

Emergency ambulances traditionally inform receiving hospitals of impending arrival of patients only in instances of load and go situations, which on average constitute less than 5% of ambulance runs. Information transmitted is usually sparse. For all other runs, information is made available only on arrival at the emergency department (ED). There have also been numerous limitations associated with voice transmissions.

A comprehensive electronic ambulance case record was created as a pilot project in Singapore between three emergency ambulances and the busiest ED there. All information captured by the ambulance crew, including vital signs information and ECGs was entered or downloaded onto a ruggardised PC in the ambulance and this complete ambulance record was transmitted to the ED. Transmission was wireless via the public mobile data network. A 3-month analysis of this pilot run revealed the following.

(1) It was possible to capture a complete ambulance case record electronically at a mean time of 94 s vs 7 min 7 s for the traditional written record.

(2) Air transmission time for data was ≈4 s unless ECG wave forms were also transmitted resulting in transmission times frequently exceeding 60 s.

(3) At least 68% of data was transmissible in 75% of Hospital & Emergency Ambulance Link (HEAL) ambulances as opposed to only 25% in less than 5% of non-HEAL ambulances.

(4) Paramedics’ time in the ED decreased from 15 to 8 min as a result of HEAL.

(5) The waiting time for critical care patients to be seen at the ED decreased from 35 to 17 min if brought by HEAL ambulances.

(6) The HEAL system was able to effectively prompt paramedics in carrying out critical aspects of treatment in close to 100% of instances.

(7) The pilot HEAL system was able to demonstrate a limited amount of automated audit of specific aspects of ambulance runs.

Having demonstrated the feasibility of the HEAL system, it is a matter of time before enhanced features such as electronic data collection at patient site, voice activated data entry, transmission of data from site, automated ambulance audits and an enhanced level of professional care in the ambulances become common-place reality.

Introduction

Ambulances were for many decades regarded primarily as means for transportation of the sick and wounded from homes, work sites and public places to medical institutions where real treatment usually began. With the advent of cardio-pulmonary resuscitation (as we know it now) in the early 1960s and later electrical cardiac defibrillation by trained crew, ambulances became venues for initiating life-saving treatments.

A number of evolving health care issues have shown the need for diagnoses to be made as early as possible and treatments initiated earlier:

  • 1.

    Identification of an increasing array of time-sensitive diseases and treatments and the realisation that earlier diagnosis and earlier treatments create the potential for better outcomes and lesser mortality and morbidity.

  • 2.

    The acceptance that health care is a continuous process from the point of injury/sickness to the hospital and that prompt knowledge of care provided earlier can only enhance the level of care to be given at the subsequent level.

  • 3.

    The increasing cost of health care especially as provided in institutional settings has meant that health care planners are constantly on the lookout for more cost-efficient ways of providing medical care in out-of-hospital settings.

  • 4.

    The realisation that ambulance crew (paramedics) can be trained to provide many forms of urgent medical care in ambulances and other pre-hospital environments has opened up the potential for earlier medical interventions to the patient's eventual benefit.

With the increasingly useful role of ambulances and paramedics in the provision of emergency medical care, receiving hospitals are being forced to polish up their acts in ensuring that they review their investigational and treatment processes so as to maximise the benefits of patients arriving in hospital in a medically better condition than previously. While at one time, hospital staff would have known about ambulance transported patients only on arrival at the emergency department (ED), the advancements in voice communication devices has meant that ambulance crew are now able to verbally alert the hospital of impending arrivals. Such verbal communications (radio and cellular phone) have had their limitations in terms of quality of voice transmission, the need to make records of such communication and the technical problems of capturing and transmitting the increasing variety of information that ambulance crew are now able to obtain.

Section snippets

Historical development

In 1993, the Singapore General Hospital in consultation with the country's National Computer Board first proposed a system linking the Emergency Ambulance Services (EASs) that handled the most critically ill patients electronically with the receiving ED so as to speed up the transfer of information on these patients. The team that began work on this idea had to address the problems of data entry in a moving ambulance, electromagnetic interference by communication equipment in the ambulance on

System availability

Initially, only 69.1% of Central ambulance runs used the HEAL system. By the third month, this increased to 93.9% (set target was 95%).

Transmission times

(a) HEAL runs – load-and-go cases onlyTransmission
Cardiac arrest with pre-arrival information only3 s
Non-trauma with pre-arrival information+vital signs5 s
Trauma with pre-arrival information+mechanism of injury+vital signs4 s
Non-trauma with pre-arrival information+vital signs+ECG42 s
Trauma with pre-arrival information+mechanism of injury+vital signs+ECG42 s

Discussion

This pilot run of the HEAL system was to our knowledge, the first to be conducted of a comprehensive electronic ambulance case record system that consisted of patient biodata, information on clinical history and physical findings, vital signs data, electrocardiographic data and patient management information. A critical post-implementation review of the HEAL system and the ambulance run workflow resulting from it has revealed the following

Conclusion

The HEAL pilot project that was conceived 6 yr ago demonstrated the feasibility of a comprehensive, electronic hospital and emergency ambulance link with tremendous potential for emergency care. It is also very likely that enhancements using currently available technology and integration of systems that currently exist would pave the way for a revolution in the way information is captured in emergency ambulances, the raising of standards of professional care in ambulances and speeding up of the

Acknowledgements

This article was written with inputs from the various organisations that contributed to the development of the HEAL system, viz. Singapore Civil Defence Force, Ministry of Health, National Computer Board, Singapore General Hospital and Singapore Network Services Pte Ltd.

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