Delivering Western Australia’s Ambulance Services – Follow-up Audit

Audit finding – SJA has improved clinical governance and support for volunteers but coordinating services in country areas remains a challenge

SJA and WACHS report difficulties coordinating services despite SJA’s creation of regional offices to respond to local needs

Between 2007 and 2015, SJA established regional offices in Albany, Bunbury, Northam, Kalgoorlie, Geraldton and Broome to support sub-centres and make administrative decisions locally that were previously made at head office. The aim of this project was to make the organisation more flexible and responsive. However, SJA and other local health services do not always work together efficiently and effectively in country areas. Neither SJA nor WACHS have developed better indicators of country ambulance performance that could be included in future contracts and might help them improve services in country areas.

Coordination between SJA and local health services in the regions is not always smooth. The coordination of IHPT is of concern to both WACHS and SJA. SJA’s contract makes it the sole provider of IHPT in country areas and it uses the income from this service to support its emergency services. Unlike in the metropolitan area, there is no system in place that shows country hospital and ambulance capacity in real time and that can be used to manage bookings. This makes planning IHPT in country areas more challenging. Also, IHPT is generally carried out by volunteers whose availability cannot always be guaranteed to coincide with requests from country hospitals. Conversely, country hospitals may not always take account of the limitations of the country ambulance system when requesting IHPT services.

The service is hard to manage for country hospitals. Small country hospitals may be staffed by only 6 nurses, rostered on 2 at a time and need to send very ill patients to larger regional hospitals for treatment. Nurses are often required to travel with the patient and may have to make their own arrangements for their return journey. In these circumstances, IHPT can impact the ability of these small hospitals to meet community needs. Staff at these small hospitals report that it can be hard to find a crew for IHPT when needed, creating uncertainty and taking up significant staff time.

SJA charges for IHPT the same way everywhere in country WA. The charge is based on a fixed fee plus a fee per kilometre.

Country IHPT to and from locations outside the 10 kilometre range operate without performance targets or a clear policy about service levels. SJA measures how timely IHPT is in the metropolitan area but only reports the number of transfers by country ambulances outside the 10 kilometre range.

SJA has developed criteria with the DoH and WACHS for allocating career and community paramedics to country areas and employed more of them to support volunteers

SJA has developed a set of objective criteria to allocate paid career and community paramedics to volunteer ambulance stations. These are based on historical case volume and are included in the contract.

There are now 5 more paid community paramedics than there were in 2013-14, bringing the total to 27. Since 2013-14, 1 community paramedic in Kununurra and 2 in Karratha have been replaced by full-time career paramedics, reducing the total by 3. However, SJA has appointed 8 more, 1 each to Onslow, Paraburdoo, Denmark, Wundowie, Ravensthorpe, Coolgardie, Corrigin and Dalwallinu. This has increased the level of support and the quality of training provided to volunteers in the country.

Career and community paramedics are paid SJA employees. Community paramedics are career paramedics who provide support to country ambulance sub-centres and volunteers. Under the existing contract, SJA allocates career paramedics to country sub-centres based on the number of cases in the previous financial year. The number of paramedics assigned to a location ranges from 2 where case numbers are between 1,000 and 1,500, up to 9 where case numbers exceed 3,000. Where cases number between 250 and 1,000, SJA bases a community paramedic there. Community paramedics provide support to all locations with fewer than 1,000 cases a year.

New criteria for allocating community paramedics have been developed by WACHS and SJA but are yet to be formally adopted. These go beyond case load to include geographical and other considerations:

  • cases per community paramedic area of coverage
  • volunteer capacity, including numbers, experience and exposure, noting that in some areas community paramedics are allocated to boost recruitment and sustainability
  • distances spanning community paramedic total area
  • community paramedic fatigue management
  • proximity to a neighbouring community paramedic, allowing for leave coverage and the need to make up a crew in case of emergency.

SJA has strengthened the way it maintains standards of patient care in all its services, metropolitan and country

SJA more effectively maintains standards of patient care in all its services, metropolitan and country, than we found in 2013. In addition to increasing the number of community paramedics to support country volunteers and monitor their performance, it has increased clinical audits in country areas and appointed 3 Clinical Quality Managers to focus on clinical standards and carry out the audits. This means residents of country towns can have greater confidence in the quality of ambulance services in their area.

Other improvements include:

  • random samples used for clinical audits have been adjusted to ensure there is a reasonable geographical distribution of audits
  • in 2016-17, SJA appointed a Resuscitation Improvement Coordinator and an Infection Prevention and Control Officer to improve clinical performance throughout the state. These roles ensure crews stay up to date with clinical practices
  • SJA reports to the DoH on training it delivers to country volunteer ambulance crew and how many staff enrol in continuing education. (Figure 5)

Source: OAG

Figure 5: Demonstration of the Jaws of Life for car rescues at a regional ambulance sub-centre during our visit in April 2019

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