Patients’ and emergency clinicians’ perceptions of improving pre-hospital pain management: a qualitative study

Background: The authors aimed to investigate patients' and practitioners' views and experiences of pre-hospital pain management to inform improvements in care and a patient-centred approach to treatment. Methods: This was a qualitative study involving a single emergency medical system. Data were gathered through focus groups and semi-structured interviews. Participants were purposively sampled from patients transported by ambulance to hospital with a painful condition during the past 6 months, ambulance service and emergency department (ED) clinicians. Interviews were audiotaped, transcribed and thematic analysis was conducted. Results: 55 participants were interviewed: 17 patients, 25 ambulance clinicians and 13 ED clinicians. Key themes included: (1) consider beliefs of patients and staff in pain management; (2) widen pain assessment strategies; (3) optimise non-drug treatment; (4) increase drug treatment options; and (5) enhance communication and coordination along the pre-hospital pain management pathway. Patients and staff expected pain to be relieved in the ambulance; however, refusal of or inadequate analgesia were common. Pain was commonly assessed using a verbal score, but practitioners' views of severity were sometimes discordant with this. Morphine and Entonox were commonly used to treat pain. Reassurance, positioning and immobilisation were used as alternatives to drugs. Pre-hospital pain management could be improved by addressing practitioner and patient barriers, increasing available drugs and developing multi-organisational pain management protocols supported by training for staff. Conclusions: Pain is often poorly managed and undertreated in the pre-hospital environment. The authors' findings may be used to inform guidance, education and policy to improve the pre-hospital pain management pathway

A case study framework for design and evaluation of a national project to improve prehospital care of myocardial infarction and stroke

Background: Cardiovascular disease (CVD) affects 1.8% of the population annually, 0.9% with stroke and 0.8% with coronary heart disease. People suffering from CVD often present acutely to ambulance services with symptoms of acute myocardial infarction or stroke. Early and effective treatment prevents death, improves long term health and reduces future disability. Objective: Our aim is to develop a rational approach for informing the design and evaluation of a national project for improving prehospital care of myocardial infarction and stroke: the Ambulance Services Cardiovascular Quality Initiative (ASCQI), the first national improvement project for prehospital care. Methods: We will use a case study methodology initially utilising an evaluation logic model to define inputs (in terms of resources for planning, implementation and evaluation), outputs (in terms of intended changes in healthcare processes) and longer-term outcomes (in terms of health and wider benefits or harms), whether intended or incidental and in the short, medium or long term. Results: We will present an evaluation logic model for the project. This will be expanded to show the analytical techniques which we will use to explain how and why the project achieves its outcomes. This includes times series analyses, pattern matching, cross case syntheses and explanation building to inform an explanatory logic model. We will discuss how this model will be useful in determining the data that will need to be collected during the course of the project to inform the detailed explanation of how and why the project delivered its outcomes. Conclusion: The case study approach will enable us to evaluate the impact of this collaborative project in constituent ambulance services as well as the initiative as a whole. It will enable us to show whether and to what extent the project has had an impact, but also how and why this has happened

To cannulate or not to cannulate? Variation, appropriateness and potential for reduction in cannulation rates by ambulance staff

Background: Peripheral intravenous (IV) cannulation is a key intervention in the prehospital setting, but inappropriate use may cause unnecessary pain, distress or risk of infection. The aim of this study was to examine the rate and appropriateness of prehospital cannulation and the relative importance of factors associated with increased likelihood of cannulation. Design and setting: Cross-sectional survey of patients transported in Lincolnshire, East Midlands Ambulance Service. Methods: Retrospective non-identifiable data for September 2006 were extracted. Clinical conditions were classified according to whether they warranted, did not warrant or were uncertain as to the need for cannulation. Other potential indications for cannulation including IV drug administration, reduced consciousness, systolic hypotension, respiratory depression and haemorrhage were combined to determine whether cannulation was indicated. Other variables were investigated as predictors of cannulation. The method of analysis was agreed at the outset. Results: Paramedics cannulated 14.6% (1295/8866) of patients. IV drug administration, clinical indication, reduced conscious level, respiratory depression and hypotension were associated with greater likelihood of cannulation (p,0.001). Cannulation was more likely in older patients but was not associated with gender, haemorrhage or hypoglycaemia. Multivariate logistic regression showed IV drug administration as the strongest predictor of cannulation. Cannulation rates varied threefold by ambulance station (mean 13.4%, 5.8% to 19.0%). It was estimated that 202 (15.6%) of the cannulations performed could potentially have been avoided. Conclusion: Rates of cannulation were higher than previous studies with wide variations between ambulance stations. 15.6% of cannulations performed could have been avoided, thus reducing pain, distress and other potential complications such as thrombophlebitis, extravasation and infection. The generalisability of this study was limited by use of a single site, short duration and dependence on accurate retrospective data. The data demonstrating wide variations suggest that there may be scope for consideration of interventions to reduce cannulation rates

An evaluation of an educational intervention to reduce inappropriate cannulation and improve cannulation technique by paramedics

Background: Intravenous cannulation enables administration of fluids or drugs by paramedics in prehospital settings. Inappropriate use and poor technique carry risks for patients, including pain and infection. We aimed to investigate the effect of an educational intervention designed to reduce the rate of inappropriate cannulation and to improve cannulation technique. Method: We used a non-randomised control group design, comparing two counties in the East Midlands (UK)as intervention and control areas. The educational intervention was based on Joint Royal Colleges Ambulance Liaison Committee guidance and delivered to paramedic team leaders who cascaded it to their teams. We analysed rates of inappropriate cannulation before and after the intervention using routine clinical data. We also assessed overall cannulation rates before and after the intervention. A sample of paramedics was assessed post-intervention on cannulation technique with a ‘‘model’’ arm using a predesigned checklist. Results: There was a non-significant reduction in inappropriate (no intravenous fluids or drugs given) cannulation rates in the intervention area (1.0% to 0%) compared with the control area (2.5% to 2.6%). There was a significant (p,0.001) reduction in cannulation rates in the intervention area (9.1% to 6.5%; OR 0.7, 95% CI 0.48 to 1.03) compared with an increase in the control area (13.8% to 19.1%; OR 1.47, 95% CI 1.15 to 1.90), a significant difference (p,0.001). Paramedics in the intervention area were significantly more likely to use correct hand-washing techniques post-intervention (74.5% vs. 14.9%; p,0.001). Conclusion: The educational intervention was effective in bringing about changes leading to enhanced quality and safety in some aspects of prehospital cannulation

Leadership, innovation and engagement in quality improvement in the Ambulance Services Cardiovascular Quality Initiative: cross sectional study

Introduction: Clinical leadership and organisational culture are important contextual factors for successful Quality Improvement (QI) programmes. The relationship between these and with organisational performance is complex and poorly understood. We aimed to explore the relationship between leadership, culture of innovation, and clinical engagement in QI for organisations participating in a large-scale national ambulance Quality Improvement Collaborative (QIC). Methods: We used a cross sectional survey design. An online questionnaire was distributed to 22,117 frontline ambulance staff across all 12 ambulance services in England. Scores (0-100%) were derived for each key aspect: clinical leadership; culture of innovation; use of QI methods; and effectiveness of QI methods. Responses to an open-ended question were analysed and complemented the quantitative findings. Results: There were 2,743 (12%) responses from 11 of 12 participating ambulance services. Despite only a small proportion of responders (3%) being directly involved with ASCQI, leadership behaviour was significantly higher for ASCQI members than for non-ASCQI members. Involvement in ASCQI was not significantly associated with responders’ perceptions of the culture of innovation of their organisation, which was generally considered to be poor. ASCQI members were significantly more likely to use QI methods but overall uptake of QI methods was low. The use of QI methods was also significantly associated with leadership behaviour and service tenure. Limitations: There was a low response rate, although sufficient responses to enable comparison of those who participated in ASCQI with those who did not. Conclusion and recommendations: Although participants reported a lack of organisational culture of innovation, considered a prerequisite for QI, the collaborative achieved significant wide-scale improvements in prehospital care for myocardial infarction and stroke. We postulate that improvement was mediated through a ‘QI subculture’ developed from ASCQI’s distributed leadership and network. Further research is needed to understand success factors for QI in different complex healthcare environments

Leadership, innovation and engagement in quality improvement in the Ambulance Services Cardiovascular Quality Initiative: cross sectional study

Introduction: Clinical leadership and organisational culture are important contextual factors for successful Quality Improvement (QI) programmes. The relationship between these and with organisational performance is complex and poorly understood. We aimed to explore the relationship between leadership, culture of innovation, and clinical engagement in QI for organisations participating in a large-scale national ambulance Quality Improvement Collaborative (QIC). Methods: We used a cross sectional survey design. An online questionnaire was distributed to 22,117 frontline ambulance staff across all 12 ambulance services in England. Scores (0-100%) were derived for each key aspect: clinical leadership; culture of innovation; use of QI methods; and effectiveness of QI methods. Responses to an open-ended question were analysed and complemented the quantitative findings. Results: There were 2,743 (12%) responses from 11 of 12 participating ambulance services. Despite only a small proportion of responders (3%) being directly involved with ASCQI, leadership behaviour was significantly higher for ASCQI members than for non-ASCQI members. Involvement in ASCQI was not significantly associated with responders’ perceptions of the culture of innovation of their organisation, which was generally considered to be poor. ASCQI members were significantly more likely to use QI methods but overall uptake of QI methods was low. The use of QI methods was also significantly associated with leadership behaviour and service tenure. Limitations: There was a low response rate, although sufficient responses to enable comparison of those who participated in ASCQI with those who did not. Conclusion and recommendations: Although participants reported a lack of organisational culture of innovation, considered a prerequisite for QI, the collaborative achieved significant wide-scale improvements in prehospital care for myocardial infarction and stroke. We postulate that improvement was mediated through a ‘QI subculture’ developed from ASCQI’s distributed leadership and network. Further research is needed to understand success factors for QI in different complex healthcare environments

Ergonomic redesign using quality improvement for pre-hospital care of acute myocardial infarction

Context: Frontline emergency ambulance clinicians collaborated in a national quality improvement (QI) initiative to improve pre-hospital care for patients with acute myocardial infarction (AMI). Problem: The National Ambulance Clinical Performance Indicator (CPI) care bundle for AMI (consisting of aspirin, GTN, pain assessment and administration of analgesia) highlighted a consistent shortfall in patient pain assessment and inadequate provision of analgesia. Ineffective pain management in AMI has negative physiological and psychological effects that can be detrimental to patient outcomes. The aim is to increase the delivery of the entire AMI care bundle to 90% by March 2012 Assessment of problem and analysis of its causes: We explored barriers to effective pain management using process maps, cause-and-effect diagrams and thematic analysis of audio recordings from QI collaborative workshops and semi-structured interviews. We found that ergonomic factors (interaction between human and system factors), which included ineffective and inefficient pain assessment methods, ineffective feedback processes and poor access to analgesia were root causes for suboptimal pain management in AMI. Intervention: Through collaboration with frontline ambulance clinicians, solutions were found to overcome these root causes. These included: •Provider prompts (e.g. aide memoires and checklists) to prompt care bundle delivery. •Modified pain assessment tools (integrating Wong-baker faces, numerical verbal scores from 0 to 10 and descriptive intensity scales). •Individual clinical feedback by a clinical leader. •The introduction of small nitrous oxide canisters to increase availability and administration of analgesia earlier in the care pathway. Strategy for change: We used Plan-Do-Study-Act (PDSA) cycles to improve processes of care in AMI. Once improvements developed through PDSA cycles were identified, these were spread to county divisions and then trust-wide. Results were shared through QI workshops, face-to-face dialogue, e-forums, bulletins, newsletters and magazines locally and nationally. Measurement of improvement: Statistical Process Control (SPC) control methods were used to evaluate the effects of changes implemented. Improvements in the delivery of analgesia and the entire care bundle were achieved through initial awareness raising and implementation of system changes; e.g. provider prompts and revised pain assessment tool etc. We have already seen improvements in performance in the delivery of analgesia and also the care bundle as a whole. Effects of changes: An increase in pain assessment and the delivery of analgesia for patients experiencing AMI will help improve patient outcomes. The preliminary results of this study show improvement in the pain management in AMI. The sustainability of improvements recognised so far, and any variations that may occur as a consequence of subsequent interventions, continue to be monitored. Lessons learnt: A deeper understanding of the current system of care has been achieved by adopting a collaborative approach using QI methods focusing on ergonomics. Greater efforts earlier in the project to nurture a culture for improvement and to foster ownership and support from senior executives could have been an additional facilitator for these activities. Message for others: Systems of care can be ergonomically designed using QI methods to foster an environment that minimises opportunities for mistakes, accidental slips, lapses as well as routine (i.e. purposeful) and exceptional (i.e. unavoidable) violations in pre-hospital pain management

The effect of a national ambulance Quality Improvement Collaborative on performance in care bundles for acute myocardial infarction and stroke

Background: National ambulance service indicators showed considerable variation in care for acute myocardial infarction (AMI) and stroke. 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. Methods: We analysed change over time using logistic regression with three predictor variables: time (measured in weeks), sex, and age, to measure the effect of the national QIC on delivery of pre-hospital care bundles for AMI (aspirin, glyceryl trinitrate, pain assessment and analgesia) and stroke (face-arm-speech-test, blood pressure, blood glucose). The coefficient for time and its standard error were then extracted from each fit and plotted using forest plots. Results: There were statistically significant improvements in nine (of 12) participating trusts for the AMI care bundle (OR 2.06, 95% CI 1.88 to 2.07) and nine (of 12) for the stroke care bundle (OR 2.84, 95% CI 2.45 to 3.30). Eleven of 12 trusts showed a significant improvement in either the AMI or stroke care bundle, and seven (of 12) showed significant improvements for both AMI and stroke. 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. Limitations: Our analysis was limited by lack of a comparison group. Conclusion and recommendations: Implementing care bundles as part of a national QIC led to significant improvements care for AMI and stroke provided by English ambulance services. We are using a multisite comparative case study to explain why and how the QIC changed care

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

Pre-hospital pain management by ambulance staff

BACKGROUND In the 2004 Healthcare Commission report the majority of patients (4 out of 5) said they had suffered pain from their presenting conditions while in the ambulance. Although 81% felt that the ambulance crew did everything they could to control pain, 1 in 5 wanted more pain relief: 14% said the crew did this to some extent and 5% that the crew did not do everything they could to control the pain. The management of pain in the pre-hospital environment has been shown to be an important determinant of subsequent pain in the emergency department. How ambulance services manage pain is therefore clinically important and a key indicator of quality of service. Management of pain can be differentiated into a number of essential components. Recording of pain both at the scene (either the patient's home or the scene of an emergency) and on arrival at hospital has been shown to be feasible using numerical, verbal 1 and visual analogue scales 2 . Recording pain scores is valuable, not only because it is a simple method of assessing pain, but because it has been shown to increase the likelihood of administration of analgesia and facilitates an estimation of the effectiveness of treatment. 3 In one study, a reduction in pain score of at least 20mm out of 100mm on a visual analogue scale corresponded to a clinically meaningful reduction in the level of pain reported by patients experiencing acute pain 4 . The type, dose, route 5;6 and timeliness 7 of analgesia are important determinants of the effectiveness of pain relief. Strong analgesics including opiates have been available for use by paramedics for the management of pain since the early 1990s.. The feasibility of pain assessment in the prehospital setting. Prehosp.Emerg.Care 2004;8:155-61. 2 Lord BA,.Parsell B. Measurement of pain in the prehospital setting using a visual analogue scale. Prehospital.Disaster.Med. 2003;18:353-8. 3 Silka PA, Roth MM, Moreno G, Merrill L, Geiderman JM, Pain scores improve analgesic administration patterns for trauma patients in the emergency department. Acad.Emerg.Med. 2004;11:264-70. 4 Kelly AM. Setting the benchmark for research in the management of acute pain in emergency departments. Emerg.Med.(Fremantle.) 2001;13:57-60. 5 Woollard M, Jones T, Pitt K, Vetter N. Hitting them where it hurts? Low dose nalbuphine therapy. Emerg.Med.J. et al. Less IS less: a randomised controlled trial comparing cautious and rapid nalbuphine dosing regimens. Emerg.Med.J. 2004;21:362-4. 7 Karlson BW, Sjolin M, Herlitz J. Clinical factors associated with pain in acute myocardial infarction. Cardiology 1993;83:107-17. RESEARCH AIMS The aim of the study is to examine whether factors such age, sex, condition of the patient, and distance from hospital etc affect decisions to assess pain and/or administer analgesia