Improving the quality and outcomes of prehospital care for emergencies

Prof A Niroshan Siriwardena
University of Lincoln
Quality Improvement in research and education


Partly because of escalating pressure on hospital and emergency services, current UK policy, articulated in Taking Healthcare to the Patient (DH 2005) emphasises the importance of clinical care provided by ambulance services rather than the previously narrower focus on time taken for ambulance services to respond and transport people to hospital. Studies, including those from our group, which have shown significant variations in prehospital ambulance service care for urgent and non-urgent conditions, have led to an increasing need to measure care provided in more meaningful ways.  Our research programme focussed on new ways of measuring the impact of prehospital care provided by ambulance services, an NHS research priority, to provide better information about the effectiveness and quality of different types of ambulance care to large populations, to support quality improvement, audit and evaluation of future service changes. A central theme of our research activity is translational research relating to quality improvement in health and social care. We have investigated aspects of health and social care quality, determining how to improve care through innovation, quality improvement, service redesign and evaluation of the effects of interventions designed to bring about improvement.

What are the Aims?

The research programme aims to develop new process and outcome measures of prehospital care for assessment and improvement of care for injuries and emergencies.

Who was/is involved?

The research is being conducted by members of The Prehospital and Emergency Care Outcomes (PEQO) Group, part of the Community and Health Research Unit (CaHRU), led by Prof Siriwardena working closely with the research team at East Midlands Ambulance Service NHS Trust (EMAS), the East Midlands Ambulance Research Alliance (EMARA) and the National Ambulance Research Steering Group (NARSG), which latter is chaired by Prof Siriwardena.

What has changed/will change?

The research has broadly impacted on healthcare provision and care received by patients from ambulance services. The research directly informed policy and was a key factor in improving prehospital care for emergencies by directly influencing care systems, regulators, ambulance services, paramedics, and service users, initially in the East Midlands and subsequently throughout England from 2008 onwards.

The research which aimed to improve quality of ambulance care led to: development of new clinical quality indicators for ambulance services in England; benchmarking of service quality; initiatives to address gaps in care; measurable improvements in managing pain, heart attack, stroke, asthma and diabetes across all English ambulance services. Regulators now use these quality indicators to assess ambulance trusts in England.

What lessons have we learnt?

The research has led to changes in national policy and benefits to national practice by contributing to a better understanding of deficiencies in care and both developing and testing methods which have improved delivery of prehospital care. It has improved working practices of ambulance services leading to better care for patients and increased performance measurement tools for commissioners of ambulance services and regulators. Service users, the public and health practitioners have been involved in the conception, design and dissemination of the work which has been undertaken in collaboration with East Midlands Ambulance Service (EMAS) NHS Trust and all ambulance services in England.

The initial impact of our work was nationally in England with the our published work to develop and pilot national prehospital clinical quality indicators for ambulance services for the first time.7 This was undertaken with the wider support of stakeholders including chief executives, clinical directors and clinical governance (quality) leads of National Health Service (NHS) ambulance services throughout England. The quality indicators have been informed by our research on primary care indicators (the Quality and Outcomes Framework) and our research showing specific deficiencies in care, for example in pain assessment and treatment.

A key benefit for patients, practitioners and services nationally has been our data showing demonstrable improvement in clinical care delivered by paramedics for heart attack (measured as an improvement in national performance in the care bundle for heart attack comprising provision of critical-to-quality measures including aspirin, nitrate, pain assessment and pain relief to every patient with heart attack from 43% to 79%), stroke (care bundle comprising Face-Arm-Speech-Time, blood pressure and blood glucose from 83% to 96%), asthma (care bundle comprising respiratory rate, peak flow, oxygen saturation and bronchodilator treatment from 28% to 72%) and diabetes (care bundle comprising blood glucose before treatment, glucose administration and direct referral to an appropriate health professional from 92% to 96%) across all English ambulance services.10 As a result of this work more patients receive a high standard of care from ambulance services across England. The significance of this work was recognised in a national report published on behalf of the Association of Ambulance Chief Executives, “Taking Healthcare to the Patient 2” which directly cited our work as an exemplar of good practice.

This work has also led to changes in the culture (attitudes and behaviours) of ambulance clinicians nationally where they have adopted quality improvement methods and staff as a means of improving care.

Contact details

Professor Niro Siriwardena

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