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
