Identifying barriers and facilitators to improve prehospital care of asthma

Abstract

Context: The National Ambulance Services Clinical Quality Group is responsible for benchmarking and driving improvement in the quality of clinical care provided by front line ambulance staff (paramedics and ambulance clinicians) across all twelve ambulance services in England. Problem: In 2008/09 there were nearly 80,000 emergency hospital admissions for asthma. Current UK guidelines emphasise the importance of evidence-based prehospital assessment and treatment of asthma for improving patient outcomes and reducing hospitalisation, morbidity and mortality. Assessment of problem and analysis of its causes: National benchmarking of ambulance clinical performance indicators for asthma, with performance analysed and compared using funnel plots, revealed important unexplained variations in care across ambulance services. Despite gradual improvements in care quality poor levels of prehospital assessment of asthma persist, particularly in recording of peak expiratory flow rates (PEFR: mean 42%, range 8-50% recorded) and saturation of peripheral oxygen (SpO2: mean 90%, range 66-100% recorded). Intervention: We aimed to collect data about ambulance clinicians’ perceptions and beliefs around asthma management, the barriers and facilitators to implementing current guidelines and what measures would improve prehospital care and pathways for asthma. Study design: We used a phenomenological qualitative approach focusing on participants’ lived experiences of care delivery for asthma. We used focus groups of ambulance clinicians to gather data on of barriers and facilitators to better asthma care. Recordings and notes were taken, transcribed and then analysed using QSR NVivo 8. A coding framework was developed based on a priori concepts but with emergent themes added during the analysis. Strategy for change: A number of preliminary themes were identified: 1. perceptions and beliefs of paramedics on the management of asthma, 2. barriers and facilitators to following asthma guidelines, 3 measures to improve prehospital asthma care and pathways. Measurement of improvement: Ambulance clinicians believed that asthma guidelines were usually followed with the exception of PEFR recording. They felt the guidelines were more suitable for the hospital environment, and that they were confusing or not always practical in the prehospital environment. Pre-treatment objective assessments were not seen as a priority where airway or breathing difficulty was apparent and where these were not thought to affect patient outcome. Oxygen measurement was more likely to be carried out where equipment was readily to hand. Peak flow measurement was believed by some to be detrimental to patients in respiratory distress and sometimes difficult to obtain. Reasons for not carrying out objective assessment were not always recorded. Ambulance guidelines and training were seen as barriers to pre-treatment assessment as the emphasis is on correcting breathing difficulties before carrying out other assessments. Development of better pathways and co-operation between health agencies was advocated. Effects of changes: Our findings will inform system interventions to address current deficiencies in care. Improvements will be measured using control charts. Lessons learnt: Important barriers to improving care are often not evident without involving front line clinicians, gathering information from them in order to understand the issues affecting care delivery from their perspective. Perceptions and beliefs held by ambulance clinicians for asthma management need to be addressed in order to change practice. Ambulance training and guidelines need to reinforce the reasons for taking objective assessments, reinforcing the place of pre-treatment assessment in the overall patient journey and highlighting the dangers of overreliance on non-objective assessment. Message for others: Detailed analysis of barriers and facilitators is an important precursor to real, sustained and systematic improvements in care