Abstract

Title
Preventable mortality in patients at low risk of death requiring prehospital ambulance care: structured judgment case note review

Siriwardena AN, Akanuwe J, Crum A, Coster J, Jacques R, Turner J.

Background
Reviewing patient records for quality of care can help to identify deaths that could have been avoided. Any failures identified can inform measures to improve the quality of patient care. Mortality reviews are increasingly being conducted in hospitals but the evidence for their validity in pre-hospital ambulance settings is limited. We aimed to review the records for avoidable deaths relating to care provided by emergency ambulance services.

Methods
Ethical approval was sought and gained to link ambulance call, dispatch and clinical data with hospital and mortality data from patients attended by one UK ambulance service for records over a period of 6 months in 2015. The anonymised dataset was used for analysis.

Patients who died within 3 days of the initial ambulance call were selected for case review. Cases were stratified according to age group (age 0-2, 3-10, 11-20, 21-30, 31-40, 41-50, 51-60, 61-70, 71-80, 81-90, and 91-120 years), dispatch code classification and urgency (Red1 - Green4) to ensure maximum variation.

The number of calls within each group, and the number of deaths (within 3 days of a call) within each group was calculated. The death rate for each group was determined and groups were sorted by this rate (lowest first), selecting 6 patients from those with the lowest mortality rate in each group.

A structured judgement case note review method with 5 reviewers (GP, nurse, 2 paramedics and a medically qualified health service manager) was used to assess in detail anonymised patient records for quality of care and avoidable mortality relating to the care provided by one ambulance trust.

Results
In total, 153 records were selected from 150037 where the patient had been subsequently transported to hospital or died. These represented patients from different age, condition and urgency groups with the lowest risk of death. Most patients selected for review (81%; 124/153) were transported to hospital.

At initial assessment 10% (16/153) of cases showed strong or probable evidence of avoidability and 2% (3/153) possible evidence of avoidability based on lack of care provision according to current national UK guidance. Evidence of avoidability was more likely in those patients that were not transported to hospital (38%; 11/29).

A further assessment was made in light of the diagnosis of death which reduced the number of cases showing strong or probably evidence of avoidability to 7% (11/153).

Conclusion
Structured judgment cases reviews can be used to assess avoidable mortality in prehospital ambulance care and to inform deficiencies and improvements in care processes. This requires access to ambulance records linked to hospital and mortality data to ensure that accurate assessments are made in light of the final diagnosis and cause of death.