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South Wales Programme – Emergency Medicine Service Model document
Planning Framework Annex 6
ANNEX 6
Document History
Version
Date Issued
Brief Summary of Change
Draft 1
11 Jan 13
First draft.
Draft 2
31 Jan 13
Draft 3
13 March 13
GR/HE
Second draft following
1st
CRG on
Third draft following EM CRG
Draft 4
2 April 13
Fourth draft following
Final Draft
22 April 13
FINAL DRAFT
Owner
3rd
CRG
7th
14th
Jan
Feb, 2 x clinical summits
18th
Introduction
Context
2.1 Scope, Vision, Planning Principles, Service Aims and Objectives
2.2 Clinical Standards
3.
Service Model
3.1 Service Models at Each Level of Care
3.2 Pathways of Care
3.3 Clinical Service Interdependencies
3.4 Key Characteristics of Local Acute Hospital Service
3.5 Risks
4.
Workforce
4.1 Major Acute Hospital
4.2 Local Acute Hospital
5. Specialised, Tertiary & Networked Services
APPENDICES:
A – Baseline activity data
B – Flow Assumptions
C – Flow Algorithm
D – Clinical Reference Group – Membership & Terms of Reference
SWP SERVICE MODEL EM
GR/HE
March and comments from HBs
CONTENTS
1.
2.
GR/HE
GR/HE
GR/HE
Page
2
2
6
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South Wales Programme – Emergency Medicine Service Model document
Planning Framework Annex 6
SERVICE MODEL – EMERGENCY MEDICINE
1.
Introduction
This paper describes the proposed service model for Emergency Medicine (also known as A&E) services for South Wales.
The service model has been developed under the direction of the South Wales Programme Clinical Lead for Emergency Medicine (EM) and
with the involvement of EM clinicians from the participating South Wales Health Boards through a number of clinical conferences and summits.
It has been further refined through a Clinical Reference Group of key clinicians of each Health Board. This service model has been developed
in line with the service modeling work that is being undertaken in the participating Local Health Boards e.g. Clinical Futures in Aneurin Bevan
and Changing for the Better in Abertawe Bro Morgannwg. This outline service model will require further local service detail to be developed with
local clinicians and stakeholders as they will need to reflect local variation in terms of both health needs and existing services. The process for
developing service models is iterative and they will need to be reviewed on a regular and ongoing basis.
The workforce model for EM services will be developed alongside the service model. A high level analysis of the impact on hospital inpatient
beds, theatre capacity and core supporting services will be developed and will be used to underpin a high level financial plan.
This service model should be considered in conjunction with:
 the development of a Trauma Network for South Wales.
 the development of a retrieval service in Wales
 the SW paediatric service model
2. The scope, vision, planning principles, service objectives
2.1. Details of the scope, vision, planning principles, service objectives used in developing the service model are provided in this section.
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South Wales Programme – Emergency Medicine Service Model document
Scope
Planning Framework Annex 6
This service specification covers the reconfiguration of services traditionally described as Accident & Emergency (A&E)
departments but currently referred to in the profession as Emergency Departments. In also covers related services such as
Minor Injury Units.
“Emergency Medicine” is the term given to the branch of medical doctors specialising in ED services
Nomenclature of ED, Emergency and urgent services is becoming increasing important and this service model will be reviewed
to reflect the emerging consensus on appropriate nomenclature of major “A&E” and local emergency/urgent services.
It is recognised that EM services interface with a number of other services at the hospital “front door” and in core clinical
services such as radiology, pathology.
In describing key elements of the future of EM services it will be necessary to describe the interface with other services such as
acute medicine, diagnostics, and critical care. This service model does not describe a reconfiguration of these other services.
As directed by the SWP Programme Team following clinical summit discussions and the recent communication from the
Deanery on Core Surgical Trainee numbers, emergency general surgery will be brought into scope in so far as it will be
assume that EGS services will reconfigure to be on the sites of the major EDs.
Vision
To ensure patients have appropriate, timely access to reliable, safe, timely, high quality, sustainable emergency medical and
emergency surgical services.
Planning
Principles
Some key principles underpin the ongoing planning processes:
 South Wales can sustain four or five 24/7 consultant-led Emergency Medicine units, based on demand, available
staffing and transport links.
 The need to ensure that initial transfer of patients is to the ‘definitive place of treatment’ to avoid delays in the patient
pathway
 All local hospitals currently offering “Accident and Emergency” services should continue to offer unscheduled care
services. These should, wherever possible, be linked to out of hours primary care services.
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South Wales Programme – Emergency Medicine Service Model document
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Planning Framework Annex 6
Services should be designed from the patient’s point of view
Safe services should be provided as locally as possible, not local services provided as safely as possible.
Services should be designed to meet clear quality service and workforce standards ((based on Royal College
guidelines)
Access to senior medical advice (at ST4 or equivalent) and treatment should be available 24/7 for major emergencies
Service models must be underpinned by realistic and deliverable workforce models
Nomenclature of services must be clear, consistent and communicated to public
Local services should be developed as part of a wider network to ensure that patients can be “escalated” to more
specialist care where necessary.
Services should demonstrate continuous improvement and the adoption of best practice
Services should be planned to meet peaks and troughs in demand
Service
To improve the quality and safety of care for patients by:
Aims
and  Ensuring that services meet agreed national clinical standards.
Objectives
 Focusing scarce specialist emergency resources on those who need them
 Providing specialist opinion consistently 24/7
 Delivering services in fit-for-purpose emergency care environments.
 Reducing risk as far as possible for patients by developing robust clinical policies and procedures.
 Ensuring that clinical staff have the appropriate skills and experience to provide effective assessment, advice and/or
treatment.
 Ensuring that appropriate support and/or specialist services are available in a timely way.
To improve the sustainability of services to patients by:
 Providing robust staffing arrangements that comply with employment legislation (e.g. Working Time Directive) and meet
the requirements of the Deanery/General Medical Council for clinical training and supervision where appropriate.
 Developing clinical roles to provide future workforce flexibility e.g. emergency nurse practitioners
 Ensuring the whole population has access to the major emergency services within a reasonable timeframe
 Planning capacity to meet demand over a 24 hour period and throughout the week
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South Wales Programme – Emergency Medicine Service Model document
Planning Framework Annex 6
To improve access for patients by:
 Ensuring effective triage and assessment of emergencies so that there is prompt treatment.
 Optimising the range of primary care, health education and local emergency services.
 Optimising the number of patients receiving care locally where it is safe to do so.
 Improving information and support to patients and families to encourage them to be active participants in their care.
 Streaming patients to appropriate services as quickly as possible
 Developing robust urgent care services at a local level making services more convenient for patients
 Developing shared informatics, telemedicine and clinical reporting systems by the application of technological links
between every sector of the service model
2.2
National Clinical Standards
The College of Emergency Medicine (CEM) in The Way Ahead (September 2011) has identified some of the key service and workforce
requirements. Key issues to note are:
 Emergency Care should be provided by senior clinicians throughout the 24 hour period:
o A minimum of 16 hours coverage by an ED consultants but 24/7 presence of experienced ED doctors (ST4 or above)
o A minimum of 10 ED consultants are required to provide 16/24 hrs coverage. This number increases as the number of
attendance rises from 50,000 (10) to >100,000 which equates to 16 ED consultants
o The ED workforce must be multi disciplinary, integrating doctors, nurses, therapists and other specialties
 Key aspects of modern EM practice should include:
o Early involvement of senior EM clinicians
o Rapid expert early assessment
o Prompt commencement of time critical interventions
o Unrestricted access to imaging (CT, US, Plain film) by EM doctors to allow immediate diagnosis of life threatening conditions
o Expertise in relevant critical care skills in collaboration with colleagues form anesthesia and intensive care
o The extended presence of Emergency Medicine consultants providing leadership and supervision
o Development of Clinical Decision Units (CDUs) as a core component of Emergency Department activity providing protocoldriven periods of investigation, observation and review for patients.
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South Wales Programme – Emergency Medicine Service Model document
Planning Framework Annex 6
3. Service Model
This section of the paper outlines the Service Model which is described across the health community, from out of hospital care to local hospital
services and major acute services. Inter dependencies with other services are noted, as are the key issues, risks and dependencies identified
by the clinical representatives.
3.1
Service Models at Each Level of Care
Major acute services
Out of hospital care
Local Hospital services
(Regional/Specialist services)
Will deliver high volume, low acuity services
 General Practice

Model
for
local
services
must
reflect
and
 Out of Hours Service
respond to local circumstances
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 WAST (incl APPs)
 NHS Direct (including patient self-help
 Nurse led Minor Injuries on a 24/7 basis
services)
 Prehospital assessment and access to  Nurse led paediatric minor injuries

 Acute medical take (selected)
same day GP services
 Wider Primary Care including community  OOH Service co-location
 Opportunities for Rapid Access “hot” Clinics
nursing, Pharmacy, Dental and optometry.
 Intermediate Care / Health and Social Care  Opportunities for Observation and short
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Frailty Teams
Community Mental Health Teams
Outreach specialist services
Local authority services
Third sector services
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SWP SERVICE MODEL EM
stay facilities for emergency admissions not
requiring NIV, HDU, ACU or ICU care or
immediate transfer to for major emergency
centre.
Appropriate stabilisation skills and facilities
Opportunity to develop Clinical Decision
Unit that combines the service components
Routine diagnostics such as point of care
Emergency assessment centre for ‘major’
emergencies and trauma
Emergency assessments / admissions
potentially
requiring
specialist
care,
specialist diagnostics or NIV, ACU, HDU or
ICU
As a minimum Level 2 trauma unit working
as part of a Trauma Network. (one/two of
the major acute centres may be the Level 1
Trauma Centre)
Co-located with:
 24/7 stroke thrombolysis service
 Emergency Surgery (including vascular)
 GI bleeds (upper and lower)
 Emergency PCI
 Major medical emergencies
 Dedicated emergency theatres 24 hours a
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South Wales Programme – Emergency Medicine Service Model document
Planning Framework Annex 6
Major acute services
Out of hospital care
Local Hospital services
testing, plain film x ray and ultrasound
 Diagnostics such as hot lab for pathology,
CT scanning or MRI provision
 Clear links with Main ED unit and major
acute centre (telemedicine etc) – working in
networked approach.
 Intermediate care assessment services
 Redirection to General Practice when
clinically
appropriate,
opportunity
to
improve integration with local GPs
 Potential Base for Ambulance Services
 Underpinned
by
safety
escalation
procedures and transfer policies and
decision making tools and protocols
(Regional/Specialist services)
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day
NIV
ACU
HDU
ICU
Access to comprehensive high-level
diagnostics 24/7 including main pathology
laboratory, CT and MRI provision
24/7 access to specialist opinion
Central to the further development of this model are the clinical pathways underpinning the unscheduled care presentations that are reflected
and validated against available workforce.
3.2 Pathways of care
An indication of the type of presentation to the major acute centres is illustrated in the table below. These must be jointly agreed by Local
Health Boards and WAST and represent physiological indications rather than confirmed diagnosis in order to reflect the reality of the presenting
patient and support clinical signposting.
Examples of the type of presenting conditions are shown in the table below. These lists are not exhaustive. The groupings and casemix
information come from existing recording systems.
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South Wales Programme – Emergency Medicine Service Model document
OUT OF HOSPITAL (egs only)
Examples include
 Rash
 Cough
 Colds
 CDM
 Constipation
 D&V
 Excema
 Cysts
 Anxiety
 Blisters
 Boils
SWP SERVICE MODEL EM
LOCAL HOSPITAL
Examples:
 Foreign body
 Stings
 Dressing
 Pneumonia
The table below provides some qualification on
type of cases suitable for MIUs
Planning Framework Annex 6
MAJOR ED (egs only)
Summary:
 Compromised airway
 Inadequate or ineffective breathing
 Inadequate or ineffective circulation
(including bleeding that is uncontrolled)
 Altered level of consciousness
 Deformed limbs
 Dislocated major joints
 Infants < 1 yr old
Examples:
 RTAs
 Chest Pain
 Other Cardiac presentations (AF, LVF,
SVT)
 Stroke
 TIA
 Cardiac Conditions
 Overdose/poisoning
 Attempted suidice
 Head injuries
 Difficulty breathing
 Prolapse
 CVA
 Epistatix
 Haematemsis
 Syncope
 Collapse
 Abdo pain
 Inhalation, carbon monoxide
 Electrobution
 choking
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South Wales Programme – Emergency Medicine Service Model document
Planning Framework Annex 6
The CRG has undertaken a detailed casemix mapping exercise to determine the future “destination” for certain types of cases, currently going
through an ED (A&E). This has been based on an analysis of “presenting condition” information. Outcomes decided on include:
 Primary Care
 Straight to a specialty service (paeds, cardiac, other)
 Suitable to remain local (either MIU and acute medicine)
 Requiring ED services
In addition to this mapping undertaken by the CRG, the WAST Standard Operating Procedure (SOP) for YYF also provides further identification
of the type of cases that can remain at a local site:
Chief Complaint (Examples)
Minor allergies (reactions) / envenomation (stings & bites)
Provided:
E.g. Weaver fish stings provided no difficulty in breathing or swallowing with symptoms
Animal bites / attacks
Assault
Providing injuries not considered serious
Burns (scalds)
Provided:
< 3% BSA burn
SWP SERVICE MODEL EM
Exclude
Exotic spider bites
Any suspicion of anaphylaxis
Exotic animal bites.
Snake bites.
Wounds with avulsed and/or crushed tissue
Sexual assault
Suspected NAI
LOC
Head injuries if(NICE 56):
High energy
GCS < 15 at any time
Amnesia before or after the injury
Any vomiting before of after the injury
Any seizure since the injury
Head injury with drug or alcohol involvement
Any suspicion of skull fracture
History of bleeding or clotting disorder (inc current anticoagulant therapy)
Burns >3% BSA.
Any burn that may compromise the airway, breathing or
circulation.
Electrical burns.
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South Wales Programme – Emergency Medicine Service Model document
Chief Complaint (Examples)
Eye problems / injuries
Including:
Minor eye injury (abrasions; contact lens problems; small FB’s; arc eye)
Medical eye problems (allergies; infections; watery discharge)
Falls
Provided:
From a standing height
Injury is minor
Public assistance has been requested (no injuries and no significant symptoms)
Heat & cold exposure
Haemorrhage / lacerations
Provided:
Bleeding is controlled
Wound is ‘uncomplicated’
Overdose / poisoning – only following consultation with TOXBASE via clinical desk / control
Provided:
Substance is non / low toxicity
It was accidental (i.e. no suicidal / self harm intent)
Sick persons / miscellaneous
Examples:
Requests to cut ring off finger
Retained foreign objects
Object swallowed (without choking or difficulty breathing, able to talk)
Pain
Infected wound
SWP SERVICE MODEL EM
Planning Framework Annex 6
Exclude
Inhalational burns.
NAI’s
Penetrating wound to the globe
Alkali burns; (chemicals in eye/s).
Falls as a result of ‘collapse’.
Fall from any height or > 5 steps/stairs
Falls from twice a child’s height (if paediatric patient)
Neurological, vascular, tendon injury.
Compound fractures.
Deformed limbs.
Patients in severe pain (uncontrolled by analgesia)
If patient requires significant social assessment &
intervention (see falls / frailty pathways & use MDT).
Core temperature < 35.5 or >39.5 centigrade (if
measurement available).
Cardiac dysrhythmias.
Deep / penetrating wounds involving underlying
structures.
Significant neck wound
Facial laceration > 1cm
Severe crush injuries.
Severe nose bleed (shocked).
Moderate to high lethality
Previous suicide.
Active suicidal intent.
Previous history of mental health problems.
Inappropriate history / clinician concern.
Behavioural emergencies.
All other conditions to be considered on its merits (may
be discussed with MIU nurse/ NHSDW Nurse Advisor /
Clinical desk for further advice)
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South Wales Programme – Emergency Medicine Service Model document
Planning Framework Annex 6
Chief Complaint (Examples)
Exclude
Road Traffic Crashes / transportation accidents
Provided:
Low energy / low risk mechanism of injury
Velocity <30mph
Injuries are minor
Any suspicion of major trauma.
High risk mechanism of injury (>30 mph; ejection,
rollover)
If other occupants have sustained severe injuries or if
fatalities at scene.
Any complaints of neck pain that cannot be cleared
clinically.
Head injuries (NICE 56) if:
High energy
GCS < 15 at any time
Amnesia before or after the injury
Any LOC
Any vomiting before of after the injury
Any seizure since the injury
Head injury with drug or alcohol involvement
Suspicion of skull fracture
History of bleeding or clotting disorder (inc current anticoagulant therapy)
Age >65 years
Deformed limbs
Chest / truncal injuries
Severe crush injuries
Traumatic injuries (general injuries)
Provided:
Injuries not serious
Minor crush injuries to extremities (distal to wrist or ankle)
Peripheral entrapment only
Transfer / interfaculty / palliative care
If a healthcare professional makes a transfer request and the patient’s
condition/ailment/injury falls into the above criteria, then transfer to an appropriate MIU
may be considered.
If direct specialist opinion has been arranged in a
specified location.
A Flow Algorithm has been developed to inform the activity modelling. The Flow algorithm is based on the casemix groups and some key
assumptions around how WAST and self presenters will access the service in the future. The Flow algorithm is found in Appendix C.
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South Wales Programme – Emergency Medicine Service Model document
Planning Framework Annex 6
Underpinning the Service model, casemix mapping and flow algorithm are a number of assumptions which frame the approach. These
assumptions are summarised in Appendix B. It is essential that as service and workforce models develop, the assumptions log is reviewed
and updated.
3.3
Clinical Service Interdependencies: Emergency Medicine services have a number of critical interdependencies with other services
and cannot be reconfigured in isolation. Consideration for impact on the following services must be had when reconfiguring major Emergency
Medicine:
 Emergency General Surgery
 Trauma Network solution
 Acute medical take
 Critical Care
 Diagnostics
 Pathology
 Paediatric assessment unit
 Obstetrics
 Gynaecology
 PCI within 90 minutes
 Interventional radiology
 Anaesthetic cover
 Clear protocols for working with WAST
In order to clarify the nature and degree of clinical service interdependencies the following framework has been developed for paediatric
services which has been adapted in order to establish and describe the relative importance of the co-location of specific hospital services to
support EM services in both local (Level 2) and regional (Level 3) hospital paediatric services.
The relationship between services is colour coded as follows:
Absolute dependency, requiring co-location on
Red
the same hospital site
Relationship under some circumstances,
requiring varying levels of access and contact
Amber
between specialists, but not necessarily colocation
Indirect or no relationship
Green
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3.4
R
R
R
A
Opthalmology
G
ENT
A
Urology
Max Facs
Acute
medicine
Pathology
R
Trauma
R
R
Critical Care
R
G
Neurology
R
G
Gastro
R
G
Respiratory
G
Planning Framework Annex 6
Cardiology
R
Obs & Gynae
G
Paediatrics
Local services MIU
Major ED(Acute
site services)
Em Gen
Surgery
EM Services
Radiology
Anaesthetics
South Wales Programme – Emergency Medicine Service Model document
G
G
G
G
G
G
G
G
R
A
R
A
R
A
A
A
Key Characteristics of Local Acute Services
The College of Emergency Medicine gives some direction on local facilities in its document “ Unscheduled Care Facilities – Minimum
requirements for units which see the less seriously ill or less injured (July 2009)”. This suggests that the viability of a local “A&E” service, ie
one which is not a major centre, is dependant on:
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Local understanding - It is of paramount important that local populations, Health Boards and other key stakeholders understand the
remit of such a unit underpinned by clear guidance within operational and governance policies
Protocols are essential to the development of level 2 unscheduled care facilities
Staff at such units can be doctors, primary care practitioners, nurse, depending on local adoption of service models but must be
appropriately trained, ideally rotate through major units
Where acute patients present, staff must be able to do initial management of patients and initiate transfer protocols to the acute site
Minimum staff education and competency should be assured in areas of:
o Dealing with minor injuries practical skills such as wound closure, plaster casting and cannulation
o History taking, examination, formulation of a diagnosis and treatment plan
o Competency as a first responder in care of the acutely ill
o ILS, PLS, PILS and primary survey assessment
o Competent prescribers or sufficient PGDs to support treatment of common injuries and ailments
o Competence in assessment and management of children and young people ad vulnerable groups
Close working links, supported through IT, PACS between local units and acute centre
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South Wales Programme – Emergency Medicine Service Model document
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Planning Framework Annex 6
Consideration for professionals in MIUs to have referral rights to agreed specialties, social care services, community services and if
possible primary care services
Appropriate procedures in place with Ambulance Trusts to ensure timely response and transfer according to clinical need
Minimum staffing of 2 health professionals per shift (one must be qualified in adult and paed injury)
Trigger system in place for recognition of deteriorating patients
Appropriate resuscitation equipment, defibrillator and drugs to treat complications of routine care should be available at all times.
The exact details of local services will be subject to Local Health Board interpretation and determination to allow for local nuances in line
with local issues and community models of care. It is likely however that Acute Medical services will be co-located with the MIU service and
therefore opportunities for developing an integrated front doors can be explored. Further opportunities exist for co-location of Out of Hours
services and developed of elderly/frail assessment services.
3.5
Risks
There are a number of risks associated with the reconfiguration of Emergency Medicine services:
 Reducing training posts combined with inability to appoint sufficient permanent or temporary middle-grade level specialty doctors may
result in existing EM rotas becoming unsustainable before the implementation of the South Wales Plan
 Ability to agree suitable rotas for training purposes and align with acceptable rotas for non training grades
 Availability of alternative workforce, eg ENPs, note training lead in time
 Timescales of the programme and alignment to service pressure milestones
 Lack of regional clinical consensus on service model
 WAST engagement in developing the service model
 Lack of clarity on retrieval, transfer arrangements
4.
Workforce
This section of the Service Model document should be read in conjunction with the Workforce Modelling EM paper.
The proposed future service and workforce models are based on the following principles:
 The new service models must significantly improve compliance against staffing guidelines and standards.
 Some professional staff groups maybe required to rotate between the major acute site and local hospitals to maintain and enhance
skills or work across more than one site on a sessional basis.
 Medical staff at major site must be Senior emergency doctor (ST 4 competence or above)
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South Wales Programme – Emergency Medicine Service Model document
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Planning Framework Annex 6
GMC and Deanery Standards will be factored into workforce plans. FP1/2 trainees cannot be resident in the hospital at night without
resident middle grade cover from within the specialty.
Emerging workforce plans will assist with the development of Recruitment and Training & Education strategy to ensure that the Health
Board “recruits for the future”.
The workforce plans will create a sustainable workforce that provides a flexible workforce that will plan to retain capacity and skills.
The role of non training grades, and advanced nurses should be explored and tested in workforce planning.
All workforce plans will be continually reviewed to reflect key service drivers and advances in innovation and technology.
This section summaries the medical and advanced nurse practitioner practitioner roles and requirements to provide level 3 and level 2 hospital
services.
4.1
Major Acute Hospital Services: Regional/specialist A&E/ED Services
Royal college guidance recommends a level of Consultants service depending on size of unit (Way Ahead Dec 2011):
o A minimum of 16 hours coverage by an ED consultants (but 24/7 presence of experienced ED doctors (ST4 or above))
o A minimum of 10 ED consultants are required to provide 16/24 hrs coverage. Typically this will be 8am to midnight.
o The number of EM consultants increases as the number of attendance rises from 50,000 (10) to >100,000 which equates to 16
ED consultants
.
ED size by attendance per
Rec min no wte ED cons to
annum
achieve 16/7 shopfloor
leadership
<50,000
10
50,000 – 80,000
10
80,000 – 100,000
12
>100,000
16
Middle Grade cover:
A minimum of 11 wte are required on the rota to cover out of hours to ensure compliance with European Working Time Directive.
In order to secure training accreditation, trainees should be concentrated on major ED sites, should resources allow there is opportunity for
middle grades to rotate out to local sites on an in-hours planned basis. Whilst a middle grade rota can include a mix of training grade and
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Planning Framework Annex 6
specialty doctors (or consultants), there should be a minimum of 2 trainees on the rota to ensure appropriate peer support. Differentiated rotas
with Training grades doing a lower intensity of on call compared with non training grades will be explored. In the majority of cases, middle
grade trainees will be ST4 and above to ensure appropriate skill and experience for the responsibility of providing out of hours medical cover.
Junior Grade cover:
A minimum of 11 wte are required on the rota to cover out of hours to meet the requirements as outlined for middle grades above. The junior
rota may include advanced nurse practitioners, but there should be a minimum of 2 trainees on the rota to ensure appropriate peer support.
The junior rota will comprise trainees with the equivalent skill level of ST1-3.
4.2
Local Hospital Emergency/urgent services
The workforce requirement for this level of care will depend on the type of service offered in each Health Board and on each site and also the
frequency and hours of availability. The workforce model assumes:
 No EM out of hours doctor presence (other than co-located GP OOH and Physicians)
 Options for in hours junior presence to satisfy training requirements
 Options for senior doctors presence on an in hours rostered basis dependent on number of available trainees
 Availability of Emergency Nurse Practitioner to run local service, networking with the Major site
 Paediatric skills in ENP or nursing workforce to deal with paediatric minor injuries
 A minimum of 2 Health Practitioners on each shift with one a registered practitioner with required competencies
 Local workforce will need to be scaled according to demands on service
 Options for daily rapid access or ‘hot’ clinics (or appointment slots within existing outpatient clinics) to manage low risk cases locally.
These clinics could be available either 7 days a week or Monday to Friday, depending on workforce availability.
The MIUs will be largely staffed by Nurse Practitioner /or Emergency Nurse Practitioner (ENP) / or Autonomous Nurse Practitioner (ANP) who
will have received training in the assessment and management of minor injuries / minor ailments. They will have been assessed as competent
within the Health Boards’ policy and they will recognise and work within the limits of their competence.
Examples of skills required by ENP at MIUs
 Adult Basic Life Support
 Immediate Life Support, including the use of AED
 Paediatric Basic Life Support
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South Wales Programme – Emergency Medicine Service Model document
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Planning Framework Annex 6
Management of anaphylaxis
Child Protection
Protection of Vulnerable Adults (POVA)
Administration of medication, within Patient Group Directives or Nurse Prescribing
Source (CEM – Way Ahead 2011)
The Nursing & Midwifery Council highlight competency required within The Code: a nurse must have the knowledge and skills for lawful, safe
and effective practice when working without direct supervision (NMC 2009)
4.3
Ambulance Services
WAST currently have three types of ambulance available to support this service redesign:
Paramedic Ambulance: These ambulances provide adult and paediatric ALS. They respond to 999 calls in the community and inter-facility
transfers where the requesting clinician has identified the need for ALS during the journey. Paramedics are registered under the Health Care
Professions Council but do not have specific training in paediatric assessment for anything other than red flag paediatric emergencies.
Urgent Care Ambulance:
These ambulances are staffed by two Urgent Care Assistants. These ambulances provide blue light service and can provide blue light transfer
between healthcare facilities. The crews are trained to the level of a Health Care Assistant.
Patient Care Service:
These are non emergency ambulances which are equipped with a automated defibrillator and oxygen. The crew is trained to provide first aid.
PCS ambulances do carry a stretcher. They will not provide a blue light transfer between sites.
The ambulance transport specification will be key prior to WAST providing assurance of its ability to support redesigned acute services
The Wales Air Ambulance Service also plays an integral role in the delivery of Emergency Care Services.
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South Wales Programme – Emergency Medicine Service Model document
5.
Planning Framework Annex 6
Specialised Tertiary and Networked Services:
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Development of Trauma Network assumed between Cardiff and Swansea
Neurosurgery remains at UHW
Paediatric Intensive Care Unit (PICU) will remain at UHW.
Burns services will remain at Morriston.
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