Abstract
BackgroundPrevious studies have shown wide variations in prehospital ambulance care for acute myocardial infarction (AMI) and stroke. We aimed to evaluate the effectiveness of implementing a Quality Improvement Collaborative (QIC) for improving ambulance care for AMI and stroke.MethodsWe used an interrupted time series design to investigate the effect of a national QIC on change in delivery of care bundles for AMI (aspirin, glyceryl trinitrate [GTN], pain assessment and analgesia) and stroke (face-arm-speech test, blood pressure and blood glucose recording) in all English ambulance services between January 2010 and February 2012. Key strategies for change included local quality improvement (QI) teams in each ambulance service supported by a national coordinating expert group that conducted workshops educating staff in QI methods to improve AMI and stroke care. Expertise and ideas were shared between QI teams who met together at three national workshops, between QI leads through monthly teleconferences, and between the expert group and participants. Feedback was provided to services using annotated control charts.ResultsWe analyzed change over time using logistic regression with three predictor variables: time, gender, and age. There were statistically significant improvements in care bundles in nine (of 12) participating trusts for AMI (OR 1.04, 95% CI 1.04, 1.04), nine for stroke (OR 1.06, 95% CI 1.05, 1.07), 11 for either AMI or stroke, and seven for both conditions. Overall care bundle performance for AMI increased in England from 43 to 79% and for stroke from 83 to 96%. Successful services all introduced provider prompts and individualized or team feedback. Other determinants of success included engagement with front-line clinicians, feedback using annotated control charts, expert support, and shared learning between participants and organizations.ConclusionsThis first national prehospital QIC led to significant improvements in ambulance care for AMI and stroke in England. The use of care bundles as measures, clinical engagement, application of quality improvement methods, provider prompts, individualized feedback and opportunities for learning and interaction within and across organizations helped the collaborative to achieve its aims.
Highlights
Previous studies have shown wide variations in prehospital ambulance care for acute myocardial infarction (AMI) and stroke
All twelve English ambulance services originally agreed to participate in the Quality Improvement Collaborative (QIC)
The effect of time was for universal improvement for all trusts for AMI and stroke despite considerable heterogeneity; some trusts made substantial changes in performance compared with others (Figures 2 and 3)
Summary
Previous studies have shown wide variations in prehospital ambulance care for acute myocardial infarction (AMI) and stroke. The annual incidence of acute myocardial infarction (AMI) in the United Kingdom (UK) is approximately 268,000 cases [1], two-fifths of which result in sudden death. Recent studies of ambulance service indicators in England have shown variations and shortfalls in prehospital care for AMI and stroke [5], making this a priority for improvement [6]. Such variations are often due to clinician, patient or organizational factors [7,8]
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