Abstract

Background: National ambulance service indicators showed considerable variation in care for acute myocardial infarction (AMI) and stroke. We aimed to improve reliability of pre-hospital care processes for these conditions using a Quality Improvement Collaborative (QIC). The QIC involved educating ambulance staff in Quality Improvement (QI) methods, and the use of plan-do-study-act cycles (PDSA) to implement changes. Ambulance staff were provided with feedback on the effect of the PDSA cycles and the QIC provided an environment to share successful strategies within and across services to improve care bundles for AMI and stroke.
Methods: We analysed change over time using logistic regression with three predictor variables: time (measured in weeks), sex, and age, to measure the effect of the national QIC on delivery of pre-hospital care bundles for AMI (aspirin, glyceryl trinitrate, pain assessment and analgesia) and stroke (face-arm-speech-test, blood pressure, blood glucose). The coefficient for time and its standard error were then extracted from each fit and plotted using forest plots.
Results: There were statistically significant improvements in nine (of 12) participating trusts for the AMI care bundle (OR 2.06, 95% CI 1.88 to 2.07) and nine (of 12) for the stroke care bundle (OR 2.84, 95% CI 2.45 to 3.30). Eleven of 12 trusts showed a significant improvement in either the AMI or stroke care bundle, and seven (of 12) showed significant improvements for both AMI and stroke. Overall performance for the care bundle for AMI increased nationally in England from 43 to 79 percent and for stroke from 83 to 96 percent.
Limitations: Our analysis was limited by lack of a comparison group.
Conclusion and recommendations: Implementing care bundles as part of a national QIC led to significant improvements care for AMI and stroke provided by English ambulance services. We are using a multisite comparative case study to explain why and how the QIC changed care.