Today’s correspondent asks me to
… discuss Victoria’s use of ‘Non-emergency Patient Transport” companies in 000 emergency call outs?
Private companies are now dispatched daily to facilitate emergency room admissions consisting of any possible diagnosis including elderly broken hips, severe back pain, people undergoing radiation and chemotherapy complications, pregnant women with abdominal pain and bleeding, patients undergoing severe psychiatric episodes and paediatric emergencies…
I work for a private provider and I am curious as to the legalities of using these severely under-resourced and under-qualified resources as a means of attending emergency jobs and supposedly easing pressure on emergency ambulances and their ability to have improved response times to code 1 cases. 8 of my last 10 jobs have been referred back to an emergency ambulance, and my employer informs me that in the last 3 days, 120 cases have been referred in-field back to emergency crews leaving patients in pain or delaying attendance at ED significantly as non-emergency crews have minimal means of intervention and are bound by stringent protocols that do not allow transport if patient vital signs are out of range …
My correspondent also provides details of workloads, time on shift, overtime, double loads etc but I can’t address everything and I don’t think those issues are relevant to the question of ‘the legalities of using these severely under-resourced and under-qualified resources as a means of attending emergency jobs’. They are industrial issues beyond the scope of this blog and arguably beyond the scope of Ambulance Victoria as Ambulance Victoria is not the licensing authority for NEPT providers. Licenses are granted by the Secretary of the Department of Health and Human Services (Non-Emergency Patient Transport Act 2003 (Vic) s 13).
The Ambulance Services Act 1986 (Vic) s 15 says that the objectives of ambulance services in Victoria are
(a) to respond rapidly to requests for help in a medical emergency;
(b) to provide specialized medical skills to maintain life and to reduce injuries in emergency situations and while moving people requiring those skills;
(ba) to provide safe, patient-centred and appropriate services;
(c) to provide specialized transport facilities to move people requiring emergency medical treatment;
(d) to provide services for which specialized medical or transport skills are necessary;
(da) to foster continuous improvement in the quality and safety of the care and services it provides;
(e) to foster public education in first aid.
Not everything in that list is about an emergency.
Ambulance Victoria operates a fleet of ambulances and employs paramedics but there is nothing in the Act to say that using the Ambulance Victoria fleet is the only way that they can respond to a request for ambulance services. It is well known, for example that the Metropolitan Fire Brigade form a crucial part of Ambulance Victoria’s response to calls for assistance.
The Non-Emergency Patient Transport Act 2003 (Vic) provides for licencing of non-emergency patient transport (NEPT) providers. Non-emergency patient transport service means (s 3):
a service that offers or provides for—
(a) the transport of persons on public roads to or from medical services—
(i) using a stretcher carrying vehicle; or
(ii) where the persons being transported are provided with specialist clinical care or monitoring while being so transported; or
(b) the transport of persons by air to or from medical services where the persons being transported—
(i) are transported on stretchers; and
(ii) are provided with specialist clinical care or monitoring by the person operating the transport service
The definition does not refer to the patient’s condition being not urgent. Neither the Ambualnce Services Act nor the Non-Emergency Patient Transport Act define ‘emergency’. The Non-Emergency Patient Transport Regulations 2016 (Vic) defines low, medium and high acuity patient. A high acuity patient (r 8)
(a) active management or intervention; and
(b) one or more of the following—
(i) cardiorespiratory support;
(ii) a higher level of care than that required for the transport of a medium acuity patient;
(iii) observation and monitoring of an intravenous infusion that contains vasoactive agents;…
No doubt in some cases those people are very sick.
My correspondent is indeed correct that there are clinical conditions where an NEPT provider must not transport the patient (r 10) however transport may be authorised by a doctor, nurse or paramedic ‘working in the communications centre of Ambulance Service—Victoria’ where transport is ‘necessary to avoid the possibility of the patient dying or suffering an adverse event were the patient required to wait for a different form of transport or for assessment’ (r 10(5)).
What is an emergency? Ambulance Victoria (like other ambulance services) operates a campaign to encourage people not to call triple zero except in an emergency. They say (https://www.ambulance.vic.gov.au/campaigns/save-triple-zero-emergencies/):
People sometimes hesitate to call Triple Zero (000) because they are not sure if the situation qualifies as an emergency. If in doubt, always call Triple Zero (000). Call takers are trained to help you and will direct you to the appropriate assistance.
An immediate life-threatening emergency needing an ambulance may include the following:
- chest pain or chest tightness
- difficulty breathing
- extreme pain
- large burns
- serious accidents or trauma
- severe bleeding
- sudden numbness or paralysis of the face, arm or leg
Conditions such as ‘broken hips, severe back pain, people undergoing radiation and chemotherapy complications, pregnant women with abdominal pain and bleeding, patients undergoing severe psychiatric episodes’ arguably don’t fit those definitions (unless there is ‘extreme pain’) so are a ‘non-emergency’. Ambulance Victoria also has in places process to triage calls to limit the use of emergency ambulances, they say (https://www.ambulance.vic.gov.au/wp-content/uploads/2017/06/revised-clinical-response-model-evaluation-report-faqs.pdf; emphasis added):
The Ambulance Victoria Referral Service is staffed by paramedics and registered nurses who assess less-urgent Triple Zero (000) calls. It is a safe and proven method of assessing these calls in greater detail to ensure we can meet the patient’s individual need and the urgency of their case. This may result in an ambulance being dispatched or referral to an alternative service, such as a locum doctor or nurse, provision of self- care advice, or return of the case for either emergency or non-emergency ambulance dispatch. The Referral Service has operated in metropolitan regions since 2003 and expanded to all regions of the state in April 2014.
An ambulance is ‘A vehicle equipped for taking sick or injured people to and from hospital, especially in emergencies’ (Oxford dictionary (online)). An NEPT vehicle is a non-emergency ambulance.
It stands to reason that triple zero call takers and those in the Ambulance Victoria Referral Service have to make assessments of the patient’s condition based on incomplete information and sometimes inaccurate reporting by bystanders (see for example, Coroner reports on first aid and QAS response to death in care (May 21, 2019)). No doubt some calls will be assessed as requiring an emergency ambulance when that is not the case, and some will be assessed as requiring a non-emergency response when that will also not be the case. At least sending an NEPT provider gets someone there and if they report back that emergency paramedics are required then it is a form of effective triage.
So what are the ‘legalities of using these severely under-resourced and under-qualified resources as a means of attending emergency jobs?’ There are no specific legalities. Ambulance Victoria is charged with providing ambulance services to the people of Victoria but that does not mean they are limited to only using its own staff and its own fleet.
As Ambulance Victoria says it tries to limit its resources to emergencies (not defined in law but with some guidance from their own publication). It can, and does, rely on other resources and providers to help meet the legislated objectives including responding rapidly to requests for help in a medical emergency (see http://www.mfb.vic.gov.au/Community/Emergency-Medical-Response.html). The use of NEPT providers to respond to requests for ambulance services may be seen to be consistent with providing ‘specialized medical skills to maintain life and to reduce injuries … while moving people requiring those skills’, ‘safe, patient-centred and appropriate services’ (where emergency paramedics are not ‘appropriate’) and ‘services for which specialized medical or transport skills are necessary’.
Clearly it’s legal to use NEPT providers, subject to the terms of their licence and the provisions of the Non-Emergency Patient Transport Act to respond to calls that are assessed as non-urgent. There may be disputes as to what is ‘urgent’ or what is ‘appropriate’. Like all definitions they may be matters on which minds differ but the ultimate call on who to dispatch is a matter for Ambulance Victoria.
If NEPT providers are under resourced, under qualified or overworked that is matter for the service providers and the Secretary of the Department.
What about the use of lights and sirens for these providers? I have seen some using them.
They are not an emergency vehicle as defined by the Road Safety Road Rules 2017 (Vic) so they must have some form of exemption or authority issued by the Corporation. There are suggestions that they are operating ‘by or on behalf of and under the control of’ Ambulance Victoria and that brings them into the definition of an emergency vehicle – for a discussion on that point (and more) see https://emergencylaw.wordpress.com/2017/07/21/what-is-a-vehicle-that-is-operated-by-or-on-behalf-of-and-under-the-control-of-ambulance-victoria/
I thought that might be the case.
Interestingly, but slightly OT, whilst your dictionary definition of ambulance encompasses the role provided by private (and internally run by Av) NEPT services, management are adamant that the term ambulance or the word placed anywhere on a vehicle providing nept services is absolutely forbidden And they will use legal consequences to enforce that. Thanks
That’s certainly true – it’s an offence to “use the word “ambulance” (other than on a registration label) on any vehicle that is not owned or operated by an ambulance service …” (Ambulance Services Act 1986 (Vic) s 39(1)(c))). NEPT vehicles aren’t labelled ‘ambulance’ but that does not mean they are not an ambulance within the meaning of the word in the English language. And if you can have ‘ambulance’ on a registration label then other vehicles can be ambulances, they just can’t have the word ‘ambulance’ marked on the side of the vehicle. That, no doubt, is why the Act is the Non-Emergency Patient Transport Act not the Non-Emergency Ambulance Service Act and providers are NEPT providers, not ambulance providers, but they are using ambulances.
My point was that AV says that they can triage a call and send a ‘non emergency ambulance’ and an NEPT vehicle fits the description of a non-emergency ambulance (even if it is not marked as an ambulance). So sending an NEPT vehicle is consistent with what they say they will do.
Only Ambulance Victoria can use the word ambulance but that does not mean that only Ambulance Victoria operates ambulances.