Lead: Dr Carole Fogg, Senior Research Fellow, University of Southampton

Team: Dr Dianna Smith, University of Southampton, Professor Bronagh Walsh, University of Southampton.

Collaborators:

Phil King – Senior Business Analyst, South Central Ambulance Service (SCAS)

Vivienne Parsons – Specialist Business Analyst, SCAS

Simon Mortimore – Assistant Director of Business Intelligence, SCAS

Martina Brown – Research Manager, SCAS (and additional members of the research team – Helen Pocock – Senior Research Paramedic, Chloe Lofthouse-Jones – Education Lead, Patryk Jadzinski – Paramedic/Senior Lecturer)

Nic Dunbar – Head of Community First Responder Operations, SCAS (and Operational Leads David Hamer and Jack Ansell)

Starts: 13th March 2023

Ends: 31st July 2023

Summary

What is the project about?

This is a new project that will explore the feasibility of using geospatial techniques to map emergency 999 calls from older adults, including those living with dementia.

What is the rationale for this proposal?

NHS ambulance services are under intense pressure to deliver timely and safe care. Immediately life-threatening conditions have to be prioritised. Older people with falls and symptoms related to long-term chronic conditions with lower category calls may experience long delays before an ambulance arrives. Such patients often have recurring needs for emergency care due to lack of alternative care pathways or long waits for social care assessments. These patients may also have dementia, putting them at greater risk of clinical deterioration whilst waiting for their needs to be met.

Geospatial projects are of particular interest to emergency services, as a single service covers a wide geographical area and a dispersed population. Currently SCAS uses mapping to identify clusters of self-harm, suicide attempts and other trauma incidents. Impacts of geospatial projects in other ambulance services include improving cardiac arrest response times and identifying vulnerable communities during Covid-19.

Adults aged ≥65 represent a large proportion of SCAS demand (2022: 17% of 111 calls, 48% (21,200 per month) of 999 calls), with around 14% living with dementia [3]. Better information on the location and outcomes of these calls through applying geospatial techniques can shape service provision to meet population needs, improve patient experience and outcomes, and enable existing resources to be used to best effect.

What are we currently doing?

Applicant CF is leading a project collaborating with South Central Ambulance Service (SCAS) to systematise recording of dementia on the ambulance electronic patient record. Ambulance staff are now able to record data about dementia in a specific place, and initial analyses show around 70 entries daily across the South Central region (November 2022). Improved recording of dementia in ambulance data provides an opportunity to explore factors associated with service demand related to dementia, such as deprivation, and to inform configuration of emergency and associated services to meet older people’s care needs more generally. These may include attendance by Community First Responders (CFRs) with additional training regarding dementia, or referral to a social care line to organise care for older people.

What are the next steps?

We propose to explore the feasibility of using geospatial data to map low category calls to older adults (aged ≥65), including a subgroup of those with dementia. Data on older adults in patients with emergency 999 calls will enable understanding of understand areas of greatest need and identify areas of inequality. Geospatial mapping will also highlight areas in which there are high frequencies of calls so that multi-sector appropriately-trained resources may be focussed in particular geographical areas. Initial results can be used to design prospective studies of care models which are informed by, and evaluated using, geospatial data.

    How will we achieve this?

    Project Objectives:

1.     Test feasibility and methods of data specification, extraction and aggregation from the SCAS data warehouse.

2.     Produce geospatial maps representing the extracted data to identify areas of highest demand, or where Community First Responders and specialist frailty cars may be most needed, and with which equipment.

3.     Present the data to stakeholders and identify priorities for follow-on research grant(s).

    Project Methods:

    We will meet the objectives by:

1.     Working with the SCAS Business Intelligence (BI) team to understand and define data items for specification for a combination of geospatial, administrative (interval between call time and attendance, time on scene), sociodemographic and clinical (main reason for call, record of dementia in patient record following attendance) data for low acuity calls (category 3 and 4) for people aged ≥65 over a one year period.

2.     Using ArcGIS software to produce new choropleth maps (Lower Super Output Area [LSOA] scale in the SCAS region (Berkshire, Buckinghamshire, Hampshire, and Oxfordshire) of the frequency of 999 calls and ambulance attendances overall and categorised by sub-groups, e.g. patients presenting with falls /  with dementia / experiencing a ‘long wait’. Using Office of National Statistics (ONS) and Census data to estimate the proportion of the population of highest risk for frailty and falls (age, ill health, living alone).

Holding at least one stakeholder meeting, involving SCAS staff, CFRs, the public, representatives from services providing urgent care to older people in the community (e.g. specialist frailty cars, social care, general practitioners, fire and police services) to share results, identify immediate impacts and agree areas for further research.

What did we find out?

•Making maps of who uses healthcare services and where they live is a technique previously used by emergency services to understand patterns in ambulance response times and to identify vulnerable communities. The growing older population and increased demand for emergency care presents an opportunity to use these maps to better understand how the level of patient need for ambulance services varies by geographical area, and if there are differences in what happens to patients after they are seen.

•Our study involved developing an academic-healthcare collaboration which included people with the relevant skills and abilities to identify the data that was needed, extract and collate it from healthcare data systems, translate it into geographical maps, and then interpret what the maps could tell us about older people’s use of emergency services in the area. We discussed maps which included the way older patients were distributed across the South Central region, the number of calls, response times, falls, dementia cases and hospital conveyance rates.

•We found that there are large geographical differences in the number and type of emergency calls and ambulance requirements for older adults, particularly in how many people were then taken to hospital (“conveyance rates”). The geographical distribution of falls and calls to people living with dementia corresponded with patterns of where older people live in the region. Response times varied by location. Stakeholders recommended adding more information on other available services, including community first responders, to help map interpretation,  and identified areas to be explored in more detail, particularly in addressing conveyance rate disparities for falls.

What did we do with this new Knowledge?

We are continuing discussions with stakeholders to see how the methods and results of this initial study can be incorporated into practice and into future research.

We will take on board the suggestions from the SCAS staff on how to improve the maps, and include these in our next analyses.

We will collate this information and present it to the SCAS Board to see how the methods may be used in practice now, and what further improvements could be made.

The publication from the study provides a clear framework and methods so that other organisations providing emergency care and the Integrated Care Boards that they are a part of so that they can also consider these techniques to evaluate their provision of care to older people.

What next?

We are going to discuss the results in two workshops at the SCAS 2025 Volunteer Conference to see what volunteers think should be done next in using this data to improve emergency care of older people.

We are going to share the results with external stakeholders such as those in the healthcare improvement Q Community Special Interest Group on emergency care to seek wider collaboration for further work.

We are developing a grant application to NIHR HSDR to further explore potential explanatory factors for the differences in response times and hospital conveyance rates  between geographical areas for older people with non-life-threatening calls, which may identify modifiable factors which could improve the care older people receive in these situations.