Coordinate My Care from the perspective of the London Ambulance Service.

Often, an emergency ambulance is called by a palliative care patient or their family when a crisis occurs, but on most occasions the attending crew will have never met the patient before. They may, therefore, have difficulty finding patient notes and medications in the house. Without information to guide management, or knowing the patient's preferred wishes, or contact details to obtain specialist help, the patient may be inappropriately conveyed to the emergency department. This lack of information has also, from our experience, led to inappropriate resuscitation attempts. In an effort to reduce such occurrences, the London Ambulance Service NHS Trust (LAS) have held paper-based records for end-of-life care patients since 2005, with more than 5000 records stored by 2012. There are several problems with paper-based records in this context; across London, the provision of care plans to the LAS has been sporadic and frequently the forms provide only limited information, which in turn limits their assistance with patient management. Coordinate My Care (CMC) now enables the LAS to access over 7250 patient records at the point of the 999 call. This ensures that crucial information can be provided to an ambulance crew before they arrive on scene, which is of particular importance when regarding those who do not want to be resuscitated (DNAR). This is achieved by the LAS placing a ‘flag’ on a patient's address once they are entered on to CMC. Should an emergency call be made at any point from this address, the ‘flag’ is activated, indicating to control room staff and the ambulance crew that a CMC record is held for a palliative care patient. Work is currently underway to develop a web interface that will enable address ‘flags’ for new patients, in addition to certain alterations to existing patients, to be automatically updated within LAS command and control systems every 12 hours. The LAS clinical support desk staff in the control room access CMC records and send a message about the patient to the ambulance crew via mobile data terminals in vehicles or personal radios. Once the crew is on scene, and have assessed the patient, they are able to telephone the paramedics who staff the clinical support desk to obtain further details, discuss the situation and use the information held on CMC to make decisions regarding treatment, referral or conveyance. Early feedback from staff about the CMC system is positive. CMC is now accessed daily by the clinical support desk. In April 2013, 67 records were shared with crews on scene – a number that is expected to grow as CMC expansion continues. Ambulance crews, who are not experts in end-of-life care, report satisfaction concerning the amount of information now available to them, assisting with complex decision-making. The introduction of CMC represents a significant advance towards greater integration between the LAS and other services that provide definitive end-of-life care, and is expected to reduce the frequency of unnecessary conveyance to emergency departments. Combined with the implementation of end-of-life care education for LAS clinicians, this will improve patient experience, quality of care provision and help to ensure that an individual's needs and wishes are met at the initial point of contact. We welcome the support of the clinical commissioning groups in encouraging the early identification of palliative patients by general practitioners (GPs) and their subsequent registration on CMC, allowing for shared communication and coordination of care. Although CMC at this time is primarily a tool used for palliative care patients, the LAS are keen to work with CMC, and other sectors of the healthcare community, to develop communication tools such as this. Further progress would include enhanced communication for the shared care of vulnerable patients or those with complex and/or chronic conditions that currently have paper-based plans, such as patient-specific protocols, held by the LAS and the special patient notes held by out-of-hours GP services. It is also hoped that as technology develops, an ambulance crew will be able to access CMC directly from the patient's side using an electronic patient report system. This will have the added benefit that ambulance crews can more efficiently communicate between electronic systems and share the care they have undertaken with the wider healthcare community.