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SAVCS coordinates ambulance and paramedic services with hospital care delivery, providing support for health system care at the scene of a patient’s location. The clinical workflow is integrated with these services and allows care to be delivered collaboratively, enhancing the effectiveness of care delivery at the patient scene while also reducing demand on emergency services and hospital capacity. Within the context of the South Australian health system, ambulance and paramedic services provided by the SA Ambulance Service (SAAS) operative relatively independently of hospital services, and the enhanced collaborative supported by SAVCS allows a greater effectiveness of health service delivery. In addition to the coordination of ambulance and paramedic staff with hospital administrative and clinical staff, SAVCS provides a greater level of integration with data and information systems, including the statewide electronic medical records, which allows the holistic patient journey to be better understood and applied to medical care.
The following describes the processes of the clinical workflow, from the time of medical emergency onset to the service conclusion. Particular reference is made to the times of clinical and operational decision-making, with description of impact to service delivery and patient outcome.
The clinical workflow of the SA Virtual Care Service (SAVCS) begins when a patient calls Triple Zero (000) with a medical emergency. SAAS may coordinate with SAVCS to provide enhanced health system service delivery and care. SAVCS supports service delivery by functioning as a virtual emergency department, with clinical operations and workforce able to engage with the patient before, during, and following the scene of patient care. These services are further enhanced with capabilities to support greater clinical decision-making through integrated health information and analytics systems, including real-time digital applications and technologies such as supportive artificial intelligence.
The initial point of contact for a patient is when the patient contacts SAAS. This typically occurs through a call through a call to Triple Zero (000) as a medical emergency. This process will connect the patient with the SAAS Emergency Operations Centre, where an Emergency Medical Dispatch Support Officer will provide assistance and will organise the emergency response process.
Through the process the dispatch support officer will request details of the patient, including:
- The patient’s current location.
- The patient’s contact details.
- Information about the patient, including:
- Date of birth.
- Reason for medical emergency.
- Current medical situation.
- Medical history.
The dispatch support officer will assess the patient’s medical situation and will assign the level of ambulance response. This response is a category ranging between 1-9, where a category 1 response is life-threatening emergency requiring immediate care.
Following the connection with SAAS, an ambulance response may be issued which will issue an ambulance response team to present to the patient’s location. When this ambulance response team arrives at the patient’s location, the patient is furthered assessed with paramedic medical intervention where required.
The coordination with SAVCS can occur at any of the following times of the service workflow:
- At the scene of the patient’s location.
- During the transit from the patient’s location.
This can occur by a SAAS team member requesting coordination with SAVCS, or by a SAVCS team member contacting an active SAAS ambulance response team.
In the context of the South Australian health system, ambulance and paramedic services operate with some autonomy to hospital services, and it is important to note that the corresponding information and operational systems are relatively independent. SAAS maintains records for ambulance responses and some information about patient presentations, while SAVCS, as a service of the greater hospital system, maintains medical records relating to use of hospital services. By effectively bridging SAAS services with SAVCS services, the combined systems are able to operate with greater collaboration, including the sharing of information between these systems, and the enablement of hospital-based service delivery throughout the active ambulance response.
For these purposes, SAVCS effectively functions as a virtual emergency department and is able to provide enhanced care before the patient physically arrives at the hospital, and in many cases is able to provide appropriate care to the patient without needing to transit the patient to a physical emergency department.
With the patient in the care of the SAAS ambulance response team, a SAVCS operator will connect with the patient via telehealth, and provide clinical triage and assessment of the patient’s medical situation. This process includes is initiated by the operator performing a quick-registration, where basic patient details are requested for the purpose of creating a medical record in the primary electronic medical record (Sunrise EMR). The creation of a medical record is assigned key information about the service activity, including:
- A unique identifier for the record.
- The time of formation of the record, in this context as an admission time.
- A unique identifier for the patient.
- The patient’s name.
- The patient’s address.
- The patient’s date-of-birth.
- The patient’s Medicare number, where applicable.
For the assignment of a unique identifier, the current implementation of the electronic medical records system attempts to link provided patient details, such as name, address, and date-of-birth, to the Enterprise Master Patient Index (EMPI), where a series of deterministic and probabilisitic linkage occurs to determine if an identifier already exists for the patient. In the case that a linked identifier is found, this identifier is used for the record, otherwise a new identifier is created. In some cases, the linkage process fails to find an suitable match even when the patient has an existing identifier. In these instances, the patient identifier may be aliased post-hoc, resulting in a unique primary identifier for the patient and one or more secondary linked identifier aliases.
Followinq patient registration, a triage nurse will perform a clinical triage and will collect information relevant to the medical status of the patient. This may include the collection of information such as:
- The acute medical situation of the patient.
- The patient’s medical history.
- The patient’s vital signs.
- Any additional notes.
The triage process assigns an acuity category in alignment with the Australasian Triage Scale (ATS). This process assigns a triage category ranging from 1-5, with 1 indicating a life-threatening emergency, and 5 representing a lower medical acuity. The following table summarises the ATS categories:
|Australasian Triage Scale Category||Specified maximum wait time for medical assessment and treatment|
|ATS 2||10 minutes|
|ATS 3||30 minutes|
|ATS 4||60 minutes|
|ATS 5||120 minutes|
SAVCS currently only provides service to lower-acuity patients with an ATS category of 3, 4, or 5.
The patient will then reside in a virtual waiting room until they are attended by an emergency physician. Typically with SAVCS admissions, this is a relatively timely process and patients are seen more promptly than the conventional ambulance carry to an emergency department.
The Virtual Emergency Service (VES) enables a point-of-contact for SA Ambulance Service clinicians by providing live telehealth integration and supporting services. This allows real-time paramedic and emergency care to be delivered while ambulance services are on the scene with a patient. These capabilities support clinical decision-making and may offer alternative services for care delivery, such as care-in-place service delivery, helping to alleviate emergency department and inpatient admissions.
The Rural Virtual Care Service (RVCS) provides virtual and remote access to clinical services for regional and remote health services and patients with potentially urgent medical conditions, by enabling virtual specialist and advanced services to be delivered to these sites on the basis of health system need. In addition, RVCS also supports regional transfers to metropolitan hospitals, including appropriate site transfer planning and bed allocation.
The Health Navigator service (HNAV) provides additional support to ambulance and paramedic services through the integrated capabilities of SAVCS. Through this service, paramedic support and liaisons on-site at SAVCS connect with SAAS paramedic staff at the patient location, and provide additional guidance to the treating team. This process also enhances SAAS services by utilising EMR capabilities within SAVCS, creating a more holistic view of the patient journey with additional information about history, medical management, and health system engagement. SAAS staff on-site at SAVCS may also request a clinical consultation, where the patient will be transferred to a SAVCS clinical for review.
The Clinical Telephone Assessment (CTA) service provides enhanced and integrated clinical care for patients in residential care facilities. This service supports nursing staff located at these facilities with SAAS paramedic services delivered via telehealth from SAVCS, including registration into the EMR and integration with the general patient journey. Through this process, the patient may receive supportive care remotely, or where beneficial the SAVCS team can coordinate the organisation of an on-site paramedic response.
|ADV||Advice provided in place. This includes review of current medication and recommendation to consult with a GP.|
|CAR||Referred to SALHN CARE service.|
|CAR||Referred to Children’s & Adolescents Virtual Urgent Care Service.|
|CIP||Care provided in place. The patient should remain at their location with the delivery of paramedic care being provided on the scene, including: fluids, medications, and/or referrals for radiology, prescriptions, pathology requests. There will be a review of the patient’s care plan with suggestions for modification if beneficial.|
|COV||Referred to COVID Care Centre or COVID Response Care Team, and/or referred for COVID Treatment (e.g MAB).|
|DNW||Did not wait – The caller terminated the visit before the service was completed.|
|DTB||Transfer to an in-patient medical unit as an admission.|
|DTH||Directed to hospital . SAVCS may be at capacity and SAAS is advised to transfer to hospital without medical officer review.|
|ED||Transfer to hospital Emergency Department.|
|EECU||Transfer to hospital Extended Emergency Care Unit.|
|GP||Referred to the patient’s General Practitioner, with the appointment organised by SAVCS.|
|HASDS||Referred to HASDS.|
|LHN||Referred to other Local Health Network service.|
|MHC||Mental Health Core|
|MHH||Referred to My Home Hospital.|
|MHT||Mental Health Triage|
|PCC||Referred to Primary Care Centre.|
|PRIV||Referred to other private system. This may include other private emergency departments or community care services.|
|OTH||Other hospital avoidance.|
|NIL||Advise and reassure patient. Continue with existing care plan. No further action taken.|
|UMH||Urgent Mental Health Care service.|