Joining the dots: measuring the effects of a national quality improvement collaborative in ambulance services

Context: We undertook a national collaborative to improve cardiovascular care by frontline clinicians in 12 English Ambulance Services. Data were collected by clinical audit staff and submitted centrally where they were collated and analysed. Problem: Cardiovascular disease is the commonest cause of death in the United Kingdom (UK). Acute Myocardial Infarction (AMI) causes 250,000 deaths per year and 1 in 3 heart attack victims die before reaching hospital. There are approximately 152,000 strokes per year causing more than 49,000 deaths. Early and effective treatment decreases death rates for AMI and stroke, improves long-term health and reduces future disability. National guidelines for ambulance clinicians are based on evidence for best clinical practice for AMI and stroke care by ambulance services as defined in the National Service Framework for CHD and National Stroke Strategy. Whilst ambulance clinicians were good at delivering specific aspects of care they were less effective at delivering whole bundles of care. Assessment of problem and analysis of its causes: The process of care delivered by English ambulance services is now assessed using National Clinical Performance Indicators (nCPIs) which include measures of complete bundles of care. The care bundle for AMI is: administration of aspirin and GTN, pain score recorded before and after treatment and administration of analgesia. The stroke care bundle consists of recording of FAST, blood glucose and blood pressure. A key project aim was to produce a sustained improvement in the national rate of care bundle delivery for AMI from 43% (range 26.2%-90.32%) to 90% and for stroke from 83.1% (range 39.4 %– 97.6%) to 90% within 2 years. Intervention: Frontline clinicians identified barriers and facilitators to delivery of care bundles and designed and tested new processes using quality improvement (QI) methods after being trained in process mapping, root cause analysis and Plan Do Study Act cycles. The effects of interventions were tracked using annotated control charts. Strategy for change: Quality Improvement Teams and Fellows were appointed in each service to form QI collaboratives. Collaboratives were responsible for developing and trialling localised interventions and spreading successful interventions more widely within Trusts. QI Fellows were to meet regularly to share learning. Measurement of improvement: Statistical Process control (SPC) methods were utilised to measure the effectiveness and sustainability of interventions. Effects of changes: With 6 months of the project left to run, the nCPIs have shown improvements in the care bundle for STEMI (mean 58.8%) and Stroke (mean 89.8%) with significant improvements in some trusts. There is evidence in some Trusts that interventions (particularly those affecting a whole Trust) are being reflected in the data although more data is needed to see whether these changes will be sustained. Lessons learnt: Small sample sizes sometimes made local level measurement of change problematic and ways of overcoming this were developed. Barriers in service reconfiguration caused delays in starting collaboratives or trialling interventions; this highlighted the importance o f ensuring that corporate bodies clearly understood the scale and purpose of the collaboratives. Baseline and prospective data collection took longer than expected and resources for this were stretched, particularly in Trusts without electronic systems. If running similar projects on a similar scale greater clarity about roles and expectations around resourcing data collection would be needed from the outset. Annotation of the control charts proved invaluable in monitoring the effects of interventions and their sustainability. Message for others: Annotated control charts were a powerful tool in determining whether and to what extent interventions led to improvements in care. This enabled an evidence base for spreading intervention within and beyond ambulance services on a national scale

EuReCa ONE—27 Nations, ONE Europe, ONE Registry A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe

AbstractIntroductionThe aim of the EuReCa ONE study was to determine the incidence, process, and outcome for out of hospital cardiac arrest (OHCA) throughout Europe.MethodsThis was an international, prospective, multi-centre one-month study. Patients who suffered an OHCA during October 2014 who were attended and/or treated by an Emergency Medical Service (EMS) were eligible for inclusion in the study. Data were extracted from national, regional or local registries.ResultsData on 10,682 confirmed OHCAs from 248 regions in 27 countries, covering an estimated population of 174 million. In 7146 (66%) cases, CPR was started by a bystander or by the EMS. The incidence of CPR attempts ranged from 19.0 to 104.0 per 100,000 population per year. 1735 had ROSC on arrival at hospital (25.2%), Overall, 662/6414 (10.3%) in all cases with CPR attempted survived for at least 30 days or to hospital discharge.ConclusionThe results of EuReCa ONE highlight that OHCA is still a major public health problem accounting for a substantial number of deaths in Europe.EuReCa ONE very clearly demonstrates marked differences in the processes for data collection and reported outcomes following OHCA all over Europe. Using these data and analyses, different countries, regions, systems, and concepts can benchmark themselves and may learn from each other to further improve survival following one of our major health care events

Using London Ambulance Service activity as a metric for quality improvement in asthma, assessment of activity data

Aim The Healthy London Partnership (HLP) aims to improve quality of care in the capital, with a focus on children and young people, who face some of the poorest health outcomes compared with the rest of the country. Using the distribution of paediatric asthma emergency calls to London Ambulance Service (LAS) as a metric, and the HLP Asthma toolkit, we can assess the impact of our findings. Methods We gathered data from the LAS for all asthma related calls during the period of 01/01/2015 to 01/01/2016 regarding paediatric calls, ages 0–19 years. Data was analysed with attention to the distribution of calls against time, gender and conveyance to hospital. Results In the period analysed, there were a total of 10 498 asthma calls to the LAS, where 80.53% of calls were conveyed to Emergency Departments (EDs). 2946 (28.06%) were made from the 0 to 19 years age group. In the 0 to 4 years age group, 68.52% of calls were for males, to 31.48% of females in the same age group (5.39% to 2.47% respectively of all calls). There is a greater incidence of calls from males until 15 years, later more are from females. From the total number of calls, 5829 (55.52%) were made for females, with the highest incidence in September (9.94%). Weekly analysis shows most calls are made on Monday (15.91%), the busiest times are between 10am– 12pm, and from 7 pm to midnight. The data presented is generic, not specific to the location or severity of calls, but it can facilitate whole system changes. Conclusions Age, gender and time distribution of calls to the LAS provide a useful metric to enable strategies for a London-wide system change. This can be assessed using the HLP toolkit, which has provided examples of good practise and audit strategies, accessible to all healthcare providers. The data from our research can improve asthma education to parents, teachers and carers, and highlight areas for improvement. This ensures everyone involved in asthma care can benefit from the findings of our research. https://adc.bmj.com/content/102/Suppl_1/A9.3 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/archdischild-2017-313087.2

Survival of resuscitated cardiac arrest patients with ST-elevation myocardial infarction (STEMI) conveyed directly to a Heart Attack Centre by ambulance clinicians

This study reports survival outcomes for patients resuscitated from out-of-hospital cardiac arrest (OHCA) subsequent to ST-elevation myocardial infarction (STEMI), and who were conveyed directly by ambulance clinicians to a specialist Heart Attack Centre for expert cardiology assessment, angiography and possible percutaneous coronary intervention (PCI)

Mismatch negativity in schizophrenia: a family study

Background: Mismatch negativity (MMN) is a measure of cortical activity that occurs in response to a change in auditory stimuli. We investigated whether MMN is a potential marker of genetic vulnerability to schizophrenia by comparing MMN in a group of patients with schizophrenia, their unaffected relatives, and controls. Method: There are 25 schizophrenic patients, 37 of their unaffected first-degree relatives, and 20 unrelated controls that performed the MMN task. Linear regression with robust standard errors, and accounting for correlations within families, was employed to test for differences in MMN amplitude between the groups. Results: Patients had significantly smaller MMN amplitudes compared to both their unaffected relatives and controls at FZ (P<0.01) and at F3 (P=0.01), whereas relatives and controls did not differ at FZ or at F3. No differences were found between any of the groups at F4. Furthermore, we found no strong evidence that the MMN amplitude is a familial trait. Conclusions: Our results confirm that the MMN amplitude is reduced in schizophrenia. However, the MMN does not show a significant familial influence and is normal among the unaffected relatives. We conclude that while the MMN is abnormal in patients with schizophrenia, it is a weak or unreliable marker of vulnerability when applied to subclinical populations, and therefore is unlikely to be an endophenotype for the disorder

Impact of inter-hospital transfer for primary percutaneous coronary intervention on survival (10 108 STEMI patients from the London Heart Attack Group)

Background Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in patients with ST-segment elevation myocardial infarction (STEMI). We evaluated whether direct transfer to a cardiac centre performing primary percutaneous coronary intervention (PPCI) leads to improved survival compared with transfer via a non-PPCI performing hospital in STEMI patients in a regional network. Methods This was an observational cohort study of 10 108 patients with STEMI treated with PPCI between 2004 and 2011 at eight tertiary cardiac centres across London, UK. Patient ’s details were recorded at the time of the procedure into the British Cardiac Intervention Society (BCIS) database. Outcome was assessed by all-cause mortality. Anonymous datasets from the eight centres were merged for analysis. The primary end-point was all-cause mortality at a median follow-up of 3.0 years (IQR range 1.2 – 4.6 years). Results 6492 patients (64.2%) were transferred directly to a PCI performing centre (direct) and 3616, (35.8%) were transferred via a non-PCI performing centre (indirect). There were higher rates of previous MI and previous CABG in the indirect group, with higher rates of poor LV function in the direct group (table 1). Median time to reperfusion (symptom to balloon) in transferred patients was 58 min longer compared to patients admitted directly (p0.0001) at presentation compared to those transferred directly. Kaplan-Meier analysis demonstrated no significant difference in mortality rates between patients with and without transfer (12.3% direct vs 14.3% indirect, p=0.060). Age-adjusted Cox analysis revealed inter-hospital transfer for PPCI was associated with all cause mortality (HR 0.89 (95% CI 0.79 to 0.99)), however this was not maintained after multivariate adjustment (HR 0.84 (95% CI 0.62 to 1.14)). Conclusions In this large registry survival appear comparable in patients with STEMI admitted directly versus transferred for primary PCI. This is despite longer symptom to balloon times. This unexpected finding may reflect the earlier initiation of medical therapy (eg, anti-platelets and GpIIb/IIIa receptor inhibitors) and earlier pharmacological reperfusion, reflected by lower IRA TIMI 0 rates at angiography in the patients transferred from a non-PCI hospital. https://heart.bmj.com/content/heartjnl/99/suppl_2/A22.2.full.pdf This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/heartjnl-2013-304019.3