Nadya Essam

The effect of a national quality improvement collaborative on prehospital care for acute myocardial infarction and stroke in England.

BackgroundPrevious studies have shown wide variations in prehospital ambulance care for acute myocardial infarction (AMI) and stroke. We aimed to evaluate the effectiveness of implementing a Quality Improvement Collaborative (QIC) for improving ambulance care for AMI and stroke.MethodsWe used an interrupted time series design to investigate the effect of a national QIC on change in delivery of care bundles for AMI (aspirin, glyceryl trinitrate [GTN], pain assessment and analgesia) and stroke (face-arm-speech test, blood pressure and blood glucose recording) in all English ambulance services between January 2010 and February 2012. Key strategies for change included local quality improvement (QI) teams in each ambulance service supported by a national coordinating expert group that conducted workshops educating staff in QI methods to improve AMI and stroke care. Expertise and ideas were shared between QI teams who met together at three national workshops, between QI leads through monthly teleconferences, and between the expert group and participants. Feedback was provided to services using annotated control charts.ResultsWe analyzed change over time using logistic regression with three predictor variables: time, gender, and age. There were statistically significant improvements in care bundles in nine (of 12) participating trusts for AMI (OR 1.04, 95% CI 1.04, 1.04), nine for stroke (OR 1.06, 95% CI 1.05, 1.07), 11 for either AMI or stroke, and seven for both conditions. Overall care bundle performance for AMI increased in England from 43 to 79% and for stroke from 83 to 96%. Successful services all introduced provider prompts and individualized or team feedback. Other determinants of success included engagement with front-line clinicians, feedback using annotated control charts, expert support, and shared learning between participants and organizations.ConclusionsThis first national prehospital QIC led to significant improvements in ambulance care for AMI and stroke in England. The use of care bundles as measures, clinical engagement, application of quality improvement methods, provider prompts, individualized feedback and opportunities for learning and interaction within and across organizations helped the collaborative to achieve its aims.

A15 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.