The ambulance services in northern Norway 2004–2008: improved competence, more tasks, better logistics and increased costs

The running cost of the ambulance fleet in northern Norway has almost doubled during the study period. Whereas an increasing number of tasks have been performed, the number of kilometres driven has been stable. The level of competence among workers was significantly improved.

We have analysed the 5-year data on personnel resources and ambulance operations and focused on trends, kilometres driven and level of competence. However, we had no access to data on patients being transported and the quality of the medical service offered to them. Furthermore, we did not include air or boat ambulances. When the ambulance fleet in the near future will be equipped with an EPR system, data on patient care and administration while onboard can be analysed.

The slight drop in number of kilometres driven at the end of the study period may be partly due to a campaign on correct use of transportation (public transportation and taxi when appropriate). Another explanation may be the introduction of the TransMed/TransMobil fleet coordination system and consequently improved logistics. The latter is in accordance with the study by Ong et al. [1] who analysed ambulance calls in Singapore. They reported that the utility of geographic information systems (GIS) had significant implications for maximizing the effectiveness of ambulance deployment. Schuessler and Cotter [2] also concluded that an effective strategic plan for the area of operations must be in place to provide a cost-effective service. This was also elucidated by Dean [3] who concluded that computer-aided dispatch (CAD) systems capable of tracking unit locations outside of their stations were to be recommended.

Finnmark Hospital Trust was the last one implementing our administration and coordination system. This may have caused the lack of any measurable effect on kilometres driven in this area. Furthermore, they had limited access to air ambulances in late 2008 due to new European regulations concerning the staffs’ working time. These regulations caused a temporary lack of pilots.

The numbers of ambulance tasks are 36% higher in northern Norway than in the other regions (central, western, southeast). This may be due to the distinctive characteristics of the northern region. In populated areas in southern Norway, busses with beds are employed. Air and boat ambulances are more frequently employed in our region and cause a need for an ambulance “at both ends”. An increasing number of communities in northern Norway are arranging common casualty clinics causing an increased distance of transportation. In the future it should be discussed whether the cost of a steadily increasing number of ambulance services offered to intercommunity common casualty clinics should be taken care of by the hospital trusts or these clinics themselves.

Life-saving prehospital interventions are one of the main reasons for a steady upgrade of the crew. However, life-saving operations are rare. A Danish study [4] has documented that only 4% of patient contacts were life-saving and most of them were related to opioid poisoning and cardiac arrest. In April 2010, new European regulations will be introduced where every ambulance must be manned by at least one employee with a fagbrev. This indicates that significant effort still has to be put into educational programmes. Whereas the ambulance workers’ competence has been improved, a recent study revealed that only 19% of them reported their competence being appreciated by cooperating medical staff [5]. We have invested in education and consequently improved the salary among workers hoping for an improved service. Whyte and Ansley [6] evaluated a system of financial reward for emergency medical technicians who met selected quality marker goals. Following the incentive, reports were completed within 3 h 99.7% of the time (64% prior to incentive). Aspirin use in adult non-traumatic chest pain improved from 60 to 96.3% and ECG performance in this group improved from 43 to 87.8%. Documentation of the time of onset of symptoms in stroke patients improved from 97 to 100%, and the assessment of and intervention for pain in traumatic hip pain patients improved from 56 to 100%.

According to today’s trend, the population of Norway is aging and one third will be above the age of 67 years in 2030. This indicates a rising need for ambulance services as the elderly are more often transported by ambulance [7]. Kawakami and co-workers [8] reported that elderly, male, low household income and no possession of a car were all factors causing an increase in the use of ambulances in non-emergency situations. These four factors together potentially produced 16.8–19.2% of all incremental demands, depending on scenario selected.

One way of keeping the costs down may be reinstallation of the family physician as the important gatekeeper. This is especially important in less populated areas. Beillon and co-workers [9] have documented variations between less and more densely populated Swedish areas with the former having a more appropriate use. Jacob and colleagues [7] asked whether the treating physician agreed with the patient’s decision on transport method. There was agreement in 68% of ambulance transports and 92% of non-ambulance transports. This indicated that there were few “unmet needs” but some “inappropriate use” in Pennsylvania.

We have indicated that logistic systems can improve the effectiveness of the service. Davis and co-workers [10] employed industrial engineering techniques in the evaluation of the efficiency and effectiveness of the services. By such means, they showed that by a reduction of the number of service units during time of least demand and combining some jobs, money could be saved without affecting the level of service. A similar system streamlining care has been described by Su and Shih in Taiwan [11].

When EPR systems have been installed, further analysis on quality of care should be done and air and boat ambulances included. Today, we hope that an improved level of competence causes medics to do the right things and do them well. However, at present we can document the improved results of the “whole treatment chain”, but not the specific contribution by the medics. This may be possible when the EPR has been implemented.

Computer-based ambulance fleet coordination systems may cause reduction in distance travelled and consequently savings, but cost-effectiveness analyses should be performed.