Tef Jansma Master thesis May 2014 1 2 Summary technical system. The analysis and redesign suggestions are based on calculations from This thesis provides suggestions for a redesign for spreadsheet software and two simulation software increasing the survival rates for out-of-hospital packages. One of these simulation software packages cardiac arrest (OHCA) victims in the province of is Optima Predict, which is a dedicated geographical Drenthe. An OHCA is cessation of cardiac mechanical information system simulation package for EMS activity that is confirmed by the absence of signs of providers. circulation and occurs outside a hospital setting. One out of thousand people each year have an OHCA, so The results show that it is impossible to strive for an the region of Drenthe has to cope with about 500 EMS-only solution to attain the desired estimated victims each year. survival rate of 25%. Even the addition of three new posts, located according to a call hotspot strategy, will The traditional treatment of an OHCA is to have a only increase the survival rate with 1%. This does not bystander call the emergency number 112 and wait justify the annual costs of 2 million euro that comes for an ambulance from an Emergency Medical with such a solution. Other possible changes, which Services (EMS) provider to arrive. Unfortunately, the include other post positions, alternative vehicle EMS provider often arrives too late to provide strategies, and different dispatch logic, also have no adequate care. This is partly because the EMS significant positive impact in survival rates. network is primarily optimized to meet the legal requirements: these only prescribe that any EMS Hence, UMCG Ambulancezorg needs to rely on provider needs to arrive within fifteen minutes in 95% supplementary networks. Four networks have been of the high-priority calls. However, effective OHCA considered: those of the firefighters, police, treatment consists of specific sequence of steps, volunteers and publicly placed AEDs. If multiple which have much tighter time requirements. networks cooperate appropriately, results indicate that attaining a survival rate 25% should be possible These consecutive steps are called ‘The Chain of for the region of Drenthe. Survival’, and consist of timely recognition, cardiopulmonary resuscitation (CPR), defibrillation, On a region-wide level, active engagement of the and advanced cardiac care. Quicker execution of firefighters and police network shows promising these steps will directly increase the survival results, in which the overall survival rates increase to probability. Currently, the estimated survival 18.6%. If 150 vehicles from the firefighters and police probability for this region in an EMS-only treatment region-wide would be equipped with an AED, which strategy is estimated to be about 11%. However, translates to three equipped vehicles per post, the some known examples of civilized Western countries investment cost would be 225.000 euros. The annual manage to achieve survival rates up to 25%. Hence, costs, primarily for maintaining defibrillation the research objective for this thesis is: procedure knowledge, would be 30.000 euros. … to deliver a cost-efficient system redesign for UMCG Of the considered networks, CPR is best provided by Ambulancezorg that improves the estimated survival the volunteer network, since this is the only network rate for out-of-hospital cardiac arrests to 25%. effectively able to arrive within 4 minutes relatively often. This network could also be very well used for The quantitative data that was used in this thesis was: defibrillating the victims, given that advanced care arrives shortly thereafter. Simulations for an urban EMS call data; from the control center area show that a volunteer-only response supported Meldkamer Noord-Nederland (MKNN) and by AEDs gives survival rates of 17.1% - 25.8%. These UMCG Ambulancezorg. numbers assume that the volunteers put effort in Volunteer alert data; from the MKNN . traveling quickly (16 km/h - bike speed) and that the Average vehicle speed data per road link from number of publicly available AEDs is doubled; in the ambulances; delivered by CityGIS. simulated case this means that there is nearly 1 AED Location data of registered volunteers and per square kilometer. Such a doubling of AEDs for the automated external defibrillators (AED); from the region of Drenthe means the installment of 230 new HartslagNu platform AEDs and costs about 345.000 euros, with negligible annual costs. Qualitative data was extracted through interviews with people from the MKNN, UMCG Ambulancezorg Expanding the volunteer and AED base is essential to and Hartslag voor Nederland. increase the probability of a successful response. Also, more data needs to be collected in the future This thesis was executed by an Industrial Engineering about the performance to allow more data-driven & Management student and therefore the decision-making. This applies specifically for the suggestions for the redesign are limited to a socio- volunteer alerting platform. 3 4 Foreword & Acknowledgements There is an incoming sound of sirens. Just moments later, you can see the flashing lights. Next, a yellow vehicle is passing you with high velocity. And it disappears just as quickly as it showed up. The world of ambulances is one that is rather invisible for most of us. Yet, we all know how important they are when medical care is quickly needed. In the Netherlands, ambulances are operated by Emergency Medical Services providers and their goal is to provide adequate and timely care and transport. One of them, UMCG Ambulancezorg, wishes to know what they could do to increase the survival probability of victims having an out-of-hospital cardiac arrest. The results show that it is definitely possible to improve the timeliness, although the way in which this could be achieved, may be surprising to some. This thesis would never have been possible without the aid of my supervisors. Therefore, I would like to thank my University of Groningen supervisors dr. ir. Durk-Jouke van der Zee and dr. ir. Wilfred H. M. Alsem for their guidance, discussions and feedback. The same applies to my company supervisor ir. Jaap Hatenboer, the vice president of UMCG Ambulancezorg. His enthusiasm and innovative mindset was inspiring and motivated me throughout my research. As a student with a non-medical background, I would also like to thank Harriëtte Holt and Hessel Jonker for their time to make me familiar with the terminology and procedures in the world of an Emergency Medical Services provider. Also, I would like to thank all those who have cooperated in interviews and tours, and provided me with valuable information in person, by phone or in some digital form: Jacques Besseling, Rob van Meer, Christina Westerbeek, Myrthe Mos, Marco Janssen, Ron Gerrits, Theo Schrijnemaekers, Ruud Pijls, employees at UMCG Ambulancezorg, MKNN call takers and dispatchers, Optima Predict support, and all other individuals that helped me in one way or another. Last but not least, I would like to thank my girlfriend, friends, and family that supported me whenever I experienced a setback. 5 Contents 3.7.1 Survival probability curves (for VF/VT) .............. 19 3.7.2 Adjusting for CPR / no CPR ................................. 20 Summary ........................................................................... 3 3.7.4 Survival depletion for non-shockables .............. 20 Foreword & Acknowledgements ...................................... 5 3.8 Summary: logistical requirements ............................ 21 Glossary ............................................................................ 8 4. Emergency Medical Services Design ............................ 22 Abbreviations .................................................................... 9 4.1 Introduction ................................................................ 22 1. Introduction .................................................................10 4.1.1 Literature search approach ................................ 22 1.1 Topic ............................................................................ 10 4.1.2 Primary and supplementary networks.............. 22 1.2 Company description ................................................. 10 4.2 Primary network setup .............................................. 22 1.3 Structure of thesis ...................................................... 10 4.2.1 Implications of care strategy .............................. 22 2. Research design ...........................................................12 4.2.2 Post locations ...................................................... 22 2.1 Problem context ......................................................... 12 4.2.3. Vehicle decisions ................................................ 22 2.1.1 Introduction ........................................................ 12 4.2.4 Staffing ................................................................. 23 2.1.2 Out-of-Hospital Cardiac Arrest (OHCA) ............. 12 4.2.5 Control logic ........................................................ 24 2.1.3 Medical context .................................................. 12 4.3 Supplementary networks .......................................... 25 2.1.4 Legal context ....................................................... 12 4.3.1 Introduction ........................................................ 25 2.1.5 Relevance ............................................................ 13 4.3.2 Police and/or