Pre-hospital Emergency Quality and Outcomes (PEQO)

Please find below our current and recent projects on pre-hospital emergency quality and outcomes:

Active projects: 

Recently completed projects


Pre-hospital Outcomes for Evidence-Based Evaluation (PhOEBE) 2011-16
Funded by the National Institute for Health Research (NIHR), awarding £2,035,959. Key contact: Professor Niro Siriwardena
This is a five-year NIHR funded Programme Grant for Applied Health Research co-led by Professor Niro Siriwardena from the University of Lincoln with colleagues from the University of Sheffield School of Health & Related Research (ScHARR), East Midlands Ambulance Service (EMAS), Yorkshire Ambulance Service (YAS), the University of Swansea and East Midlands Public Health Observatory (EMPHO).  The work programme adopts a range of different methods, including systematic reviews, service user interviews and data linkage.  The aim of the programme is to develop meaningful outcome measures for the pre-hospital care delivered by the ambulance service.  This project will change the way in which the quality of ambulance service is measured.  It is anticipated that PhOEBE will impact on the operation of the ambulance service from one that concentrates on meeting response time targets towards one that is geared to improving the quality of patient care.


Network exploring Ethics of Ambulance Trials (NEAT) 2016-17
Funded by the Wellcome Trust, awarding £49,681. Key contact: Professor Niro Siriwardena
The aim of this project is to develop a network exploring the ethics of conducting randomised controlled trials (RCTs) involving ambulance services, to undertake a systematic review of ethical approaches in published RCTs and protocols involving ambulance services since 2000 and to conduct pilot qualitative studies with patients and ambulance staff to explore perceptions of the ethics of ambulance trials.


Exploring factors increasing Paramedics’ likelihood of administering Analgesia in pre-hospital pain (ExPLAIN) 2016-17
Funded by the Falck Foundation, awarding €33,000. Key contact: Professor Niro Siriwardena
The aim of this study is to investigate patient and practitioner factors affecting paramedic pain management practice in adult patients attended by ambulance services and to explore whether paramedic initiated analgesia differs according to factors such as the age, sex, ethnicity or type of pain of the adult patient and paramedic factors such as sex or role seniority.


Improving Cardiac Arrest Recognition and Effectiveness (ICARE) 2015-16
Funded by the NIHR Policy Research Programme, awarding £595,408. Key contact: Professor Niro Siriwardena
The aim of the ICARE study is to explore whether the recognition of, and response to, out of hospital cardiac arrest by English ambulance services can be improved.


The ‘Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial’ (RIGHT-2) 2015-18
Funded by the British Heart Foundation, awarding £1,370,708. Key contact: Professor Niro Siriwardena
The aim of the RIGHT-2 trial, a major trial following the results of the RIGHT trial, is to assess the safety and efficacy of transdermal glyceryl trinitrate (GTN)  in ultra-acute stroke . Its primary objective is to compare GTN versus no GTN  for death, disability, mood, cognition and quality of life in patients with hyper-acute stroke.


Preventing Repeat Hypoglycaemic Episodes in People with Diabetes: the Ambulance Hypo Study 2014-16
Funded by East Midlands Collaboration for Leadership in Applied Health and Care, awarding £291,952. Key contact: Professor Niro Siriwardena
This randomised controlled study has as its main aim to implement and evaluate an enhanced care pathway for patients with diabetes who request an ambulance call out to treat a hypoglycaemic event. Its objectives include: reporting increases in uptake of advice and/or change in medication aimed at preventing future hypoglycaemia. Other outcomes to be measured include rates of repeat ambulance call out, rates of cardiovascular disease, cardiovascular related mortality and all-cause mortality, patient satisfaction, fear of hypoglycaemia and knowledge about hypoglycaemia.


Understanding Variation in Rates of Ambulance Service ‘Non-conveyance of Patients to an Emergency Department’ (VAN) 2015-18
Funded by National Institute for Health Research Health Services and Delivery Research Programme, awarding £328,706. Key contact: Professor Niro Siriwardena
This mixed methods study aims to investigate the determinants of variation between and within ambulance services for non-conveyance and potentially inappropriate non-conveyance of patients to hospital. The study seeks to understand how to increase non-conveyance rates without compromising patient safety in terms of higher recontact rates or other adverse consequences.


Pre-hospital Care of Patients After a Suspected Seizure: Incidence, Patient Characteristics and Costs’ (Prehospital Seizures) 2015-18
Unfunded study. Key contacts: Dr Zahid Asghar
This study aims to investigate the incidence, patient characteristics and costs of suspected seizure and which clinical factors predict transport to hospital.


Prehospital Differences In Care by eThnicity’ (PreDICT) 2015-18
Unfunded study. Key contacts: Dr Zahid Asghar and Viet-Hai Phung
This study aims to investigate how processes and outcomes of prehospital care for common emergencies attended by ambulance staff vary by ethnicity and to conduct a systematic review of the barriers and facilitators for ethnic minority groups in accessing urgent and pre-hospital care.


Ambulance Service Cardiovascular Quality Initiative (ASCQI) 2009-12
Funded by the Health Foundation: Closing the Gap in Clinical Communities Award, awarding £475,000. Key contact: Professor Niro Siriwardena
The aim of ASCQI was to improve delivery of pre-hospital cardiovascular care through collaboration with frontline clinicians. All patients presenting with Acute Myocardial Infarction (AMI or heart attack) or stroke were to receive critical-to-quality care. The objectives were to increase the delivery to at least 70 per cent of AMI patients and more than 90 per cent of stroke patients by April 2012 using a Quality Improvement Collaborative (QIC). The QIC involved educating ambulance staff in Quality Improvement (QI) methods, and the use of plan-do-study-act cycles (PDSA) to implement changes. Ambulance staff were provided with feedback on the effect of the PDSA cycles using control charts and the QIC provided an environment to share successful strategies within and across services to improve care bundles for AMI and stroke. The delivery of the AMI care bundle has increased from 43% to 79% of patients nationally. For stroke, the delivery of the care bundle has increased from 83% to 96% of patients nationally. The main results were published in a highly accessed paper in Implementation Science: Siriwardena AN, Shaw D, Essam N, Togher F, Davy Z, Spaight A, Dewey M. The effect of the Ambulance Services Cardiovascular Quality Initiative on prehospital care for acute myocardial infarction and stroke in England. Implementation Science 2014; 9:17. doi:10.1186/1748-5908-9-17.


The ‘Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial’ (RIGHT) 2010-13
Funded by Nottingham University Hospital Charity, awarding £9,038. Key contact: Professor Niro Siriwardena
This study had two main aims: to assess the feasibility of using ambulance service practitioners to assess and deliver treatments for stroke in the ultra-acute setting after stroke; and to assess the effect of GTN use in ultra-acute stroke on safety, clinical, functional, and haemo-dynamic outcomes. Its objectives included: reporting the proportion of randomised patients with a final diagnosis of ischaemic stroke, primary intra-cerebral haemorrhage, or transient ischaemic attack; and assessing the proportion of patients randomised and treated according to protocol.  Comparison of systolic blood pressure at two hours post randomisation between GTN and no GTN groups was chosen as a primary outcome since it represented the sum of the trial feasibility and intervention. The RIGHT trial is the world’s first completed ambulance-based, randomised, controlled stroke trial and has tested using GTN patches within four hours of a stroke by recruiting and treating 41 patients in the ambulance. The results of the RIGHT trial were published in Stroke: Ankolekar S, Fuller M, Cross I, Renton C, Cox P, Sprigg N, Siriwardena AN, Bath P. Feasibility of an ambulance-based trial, and safety of glyceryl trinitrate, in patients with ultra-acute stroke: the ‘Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial’ (RIGHT, ISRCTN66434824). Stroke 2013; 44(11): 3120-3128. doi: 10.1161/STROKEAHA.113.001301. An accompanying paper was published in the Annals of Emergency Medicine: Ankolekar S, Parry R, Sprigg N, Siriwardena AN, Bath PMW. Views of paramedics on their role in an out-of-hospital ambulance-based trial in ultra-acute stroke: qualitative data from the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial (RIGHT). Annals of Emergency Medicine 2014 (online first). doi.org/10.1016/j.annemergmed.2014.03.016


Interview Study of Patients and Practitioners for Developing PROVE (IS-PROVE) 2009-12
Funded by the Health Foundation, awarding £475,000 as part of ASCQI. Key contact: Fiona Togher
Patient Reported Outcome Measures (PROMs) and Patient Reported Experience Measures (PREMs) are questionnaires designed to measure outcomes and experience of care that are important to patients. Their routine use is becoming increasingly important in the evaluation of health care services. The purpose of this study was to undertake the preliminary work which would inform development of a PROM and PREM for patients presenting with stroke or heart attack in the pre-hospital setting that could be routinely used by ambulance clinicians to improve the quality of care provided in the pre-hospital setting. The results were published in the EMJ: Togher F, Davy Z, Siriwardena AN. Patients’ experiences and outcomes for prehospital care of acute myocardial infarction and stroke: qualitative study of patients and ambulance clinicians. Emergency Medical Journal 2013;30(11):942-8. doi: 10.1136/emermed-2012-201507.


Improving Prehospital Ambulance Care and Treatment following the Ambulance Services Cardiovascular Quality Initiative (ImPACT-ASCQI) 2014-15
Funded by the Health Foundation: Spreading Improvement Award, awarding £29,572. Key contact:  Professor Niro Siriwardena
The aim of ImPACT-ASCQI  is to widen the impact of the Ambulance Services Cardiovascular Quality Initiative (ASCQI) by providing a sustainable and long-term increase in quality improvement (QI) knowledge and skills to a wider proportion of ambulance staff ((including front-line staff, managers, executives) and to extend this further to other healthcare (medical, nursing and allied health) staff. We will achieve this aim by applying the learning from ASCQI through a variety of educational activities (including local workshops, webinars, E-learning and an electronic toolkit), disseminating knowledge from both ASCQI and ImPACT-ASCQI to a range of key stakeholders, opinion leaders and decision-makers in order to continue to improve outcomes for patients with a broader range of emergency and non-emergency conditions.


Decision-Making and Safety in Emergency Care Transitions 2010-13
Funded by the National Institute for Health Research, Service Delivery and Organisation (NIHR SDO), awarding £168,690. Key contact: Professor Niro Siriwardena
This study aims to identify areas of high-risk regarding decision-making about service user options. It has three objectives: to map the emergency care system in a sample of ambulance services; to investigate the factors influencing decision-making by ambulance service staff; and to feedback study findings to participating ambulance services and stakeholders. The study uses a range of qualitative methods to explore influences on safe decision-making during key emergency care transitions. These include: interviews with key members of ambulance service staff; ethnographic methods involving operational ambulance service staff; and focus groups with operational ambulance service staff and service users. It is expected that the findings of the study will be directly relevant to emergency care services in identifying potential influences on decision-making and the delivery of safe care.