Ambulance Services Cardiovascular Quality Improvement Initiative (ASCQI)

• Professor Niroshan Siriwardena, Associate Clinical Director / Professor Primary and Pre-hospital Health Care, East Midlands Ambulance Service NHS Trust  & School of Health & Social Care, University of Lincoln
• Anne Spaight, Head of Clinical Governance Audit & Research, East Midlands Ambulance Service NHS Trust
• Deborah Shaw, Clinical Audit and Research Manager, East Midlands Ambulance Service NHS Trust
• Nadya Essam, Research Project Manager, East Midlands Ambulance Service NHS Trust
• Kate Wood, Isle of Wight Ambulance Service
• Sarah Black, South Western Ambulance Service NHS Trust
• Gurkamal Virdi, London Ambulance Service NHS Trust
• Zowie Davy, Senior Lecturer, School of Health and Social Care, University of Lincoln
• Fiona Togher, Research Assistant, School of Health & Social Care, University of Lincoln
• Dr Zahid Asghar,  Senior Lecturer, School of Health and Social Care, University of Lincoln
• Viet-Hai Phung, Research Assistant, School of Health & Social Care, University of Lincoln

• We aimed to improve reliability of pre-hospital care processes for these conditions 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 and the QIC provided an environment to share successful strategies within and across services to improve care bundles for AMI and stroke.
• We analysed change over time using logistic regression to measure the effect of the national QIC on delivery of pre-hospital care bundles for AMI and stroke.
• We undertook a questionnaire survey investigating the use of QI methods and its relationship with leadership behaviour and culture.
• We conducted a multiple case study to understand how and why change occurred in those services where care bundles improved.

• ASCQI members were significantly more likely to use QI methods.  The intended aim of the QIC was to educate staff in the use of such methods, but overall uptake of QI methods was low.
• The use of QI methods was also significantly associated with leadership behaviour and service tenure.
• Overall performance for the care bundle for AMI increased nationally in England from 43 to 79 percent and for stroke from 83 to 96 percent.
• Implementing care bundles as part of a national QIC led to significant improvements care for AMI and stroke provided by English ambulance services.

Peer reviewed publications and conference presentations.

Peer reviewed publications

Siriwardena AN, Shaw D, Essam N, Togher FJ, Davy Z, Spaight A, Dewey M (2014) The effect of a national quality improvement collaborative on prehospital care for acute myocardial infarction and stroke in England. Implementation Science, 9 (17): 1-9.

Togher FJ  Davy Z, Siriwardena AN (2013) Patients’ and ambulance service clinicians’ experiences of prehospital care for acute myocardial infarction and stroke: a qualitative study. Emergency Medicine Journal, 30 (11). pp. 942-948.

Siriwardena led the team that developed the first clinical performance (quality) indicators used by English ambulance services. The UK regulator, the Care Quality Commission, adopted several of these clinical indicators for their performance assessment of services using ambulance quality indicators. ASCQI was a landmark in English ambulanc e services using quality indicators to benchmark and improve care.

ASCQI has contributed to improving the delivery of critical-to-quality pre-hospital care nationwide.Nationally, the delivery of the AMI care bundle increased from 43% to 79% (ranging from 54.5% to 100% across trusts) and for stroke, delivery has increased from 83% to 96% (range 92% to 100%). To illustrate the benefits, 1,065 more AMI patients are now being given aspirin. The ‘International Study of Infarct Survival’ (ISIS-2) found patients who received aspirin within the first five hours of onset of cardiac chest pain had a 13% reduced risk of mortality, compared to those who were given aspirin between 5-12 hours after onset. We estimate an additional 138 patients’ lives per year are being saved following the improvements achieved through ASCQI by just increasing the administration of aspirin.We calculated 4,266 more stroke patients are having their blood glucose levels assessed by ambulance clinicians before arrival at hospital.

Through ASCQI we have successfully created an environment which facilitates on-going shared learning and cross-fertilisation of ideas between ambulance trusts. QI methodologies have been received enthusiastically by frontline clinicians. The introduction to, and sustained usage of, QI tools and SPC charts have proved effective in identifying gaps, developing solutions and measuring effects.Their usage has spread to improve other areas of clinical care, such as asthma, hypoglycaemia and cardiac arrest. Similar methods are now being applied to improve other areas such as reducing on-scene times and usage of e-PRFs.

This work featured in a national report on progress in the quality of ambulance services, ‘Taking healthcare to the patient 2’