Abstract

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.