Paramedics’ views on their role in an ambulance based trial of ultra-acute stroke

N0013781 Cerebral infarctNovel treatments for stroke are increasingly being tested and delivered in the ultra-acute period during initial presentation to ambulance services. In the first feasibility trial of nitroglycerin (glyceryl trinitrate) in ultra-acute stroke (RIGHT) there were early indications of improvements in outcomes and disability at three months. The research team was led by Prof Philip Bath and his team at Nottingham University, together with Sandeep Ankolekar, Prof Niro Siriwardena from CaHRU and researchers at East Midlands Ambulance Service NHS Trust.

N0029297 Young man using a nicotine patchA nested qualitative study entitled ‘Views of paramedics on their role in an out-of-hospital ambulance-based trial in ultra-acute stroke: qualitative data from the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial (RIGHT)‘ explored facilitators and barriers to paramedic involvement in clinical trials. The fieldwork was conducted by Dr Sandeep Ankolekar and the team. Barriers to participation included the pressure of the emergency setting, difficulties  obtaining informed consent, institutional support for research, the steep learning curve for research naive staff and relative rarity for individual paramedics of clinical conditions seen, and difficulty in attending training sessions.

N0030773 Paramedic driving an ambulanceSuggestions for improvement included a simple diagnostic tool for stroke, use of assent and proxy consent on behalf of patients (as in the trial), and simpler trial processes.Recruitment became easier with each new randomisation attempt. Paramedics in the study were motivated to participate in research. Treatment of acute stroke in the out-of-hospital environment was feasible, but important barriers needed to be addressed.

The impact of New Public Management in the Ambulance Service

The use of performance indicators has been a feature of public policy for over three decades. They were first introduced by the EMAS - PTS 7Conservative Government to tackle perceived inefficiencies in the UK public sector. The answer lay in the New Public Management (NPM) reforms, which imported private sector techniques into the public sector to achieve better value-for-money. Consequently, NPM viewed the relationship between public service providers and users through the prism of a producer-consumer dichotomy, with the emphasis on producing quantifiable outputs. While the NPM reforms were introduced by the Conservatives, they were continued apace by New Labour, who wanted to avoid being too closely-identified with ‘producer’ interests, as Labour had traditionally been.  New Labour, through their emphasis on greater competition and choice, wanted to provide public services that were sensitive to ‘consumer’ needs.

Until April 2011, ambulance service quality has mainly been measured in terms of response times. These response time targets were: for Category A high-emergency calls, 75 per cent of calls to arrive at the scene in less than eight minutes and 95 per cent to arrive within 19 minutes; for serious but not life-threatening Category B calls, an ambulance to arrive within 19 minutes 95 per cent of the time; and Category C calls, which are neither serious nor life-threatening, where the target response time is negotiated locally.

The Category B response time targets were abolished by the Department of Health from 1 April 2011, and a set of Clinical Quality Indicators (CQIs) were introduced to complement the Category A eight-minute response time target. From June 2012, the Category A target was sub-divided into Red 1 and Red 2 calls. The former covers the most time-critical incidents and includes patients with cardiac arrest, breathing difficulties and obstructed airways. Red 2 calls are still serious but less time-critical and include patients suffering from strokes and fits. Some Category B and all existing Category C calls became the new Category C ‘Green calls’, and these were sub-divided into four groups: two serious, but non-threatening and two non-life-threatening groups.

The politically-important Category A eight-minute response time target has focused service delivery priorities on improving outcomes for life-threatening conditions and meets public expectations for a rapid response from the ambulance service. Research evidence suggests that timely interventions significantly improve survival outcomes among patients suffering from Out-of-Hospital Cardiac Arrests (OHCAs), but this condition typically accounts for only 1-2 per cent of the pre-hospital population. Cardiac arrests are part of a ‘first hour quintet’ of conditions, which also includes severe trauma, chest pain, stroke and respiratory distress, where early treatment and shorter pre-hospital times can improve survival outcomes.  Even this quintet of potentially life-threatening conditions only represents 15-20 per cent of pre-hospital calls. Indeed, many ambulance service users do not present with life-threatening conditions at all.

By focusing on such a small proportion of the pre-hospital population, the Category A eight-minute target has led to a number of unintended consequences, not least of which has been the mismatch between resources and patients’ needs. For instance, some ambulance services concentrated vehicles in urban areas, where it was easier to achieve a faster response time, thus creating a potential spatial mismatch between resources and need. There have also been reports of gaming, when staff are under pressure to record the ‘right’ answer, even when response times are longer than eight minutes. Security of tenure for Chief Executives of ambulance services in England depends critically on meeting the eight-minute target, so it was inevitable that resources were channelled into meeting it.[1]  The prioritisation of the Category A target may have led some ambulance services to regard a sub-eight-minute response as a success, even if the patient outcome was poor, and interpreting a response time of more than eight minutes that led to a good patient outcome as a failure.

The target culture in ambulance services may have created tensions between ambulance service managers and frontline clinicians, with diverging priorities between the two. Previous studies have suggested that managers’ key focus may be on meeting external targets while frontline ambulance clinicians are more concerned with delivering high quality care to patients.[2,3] A recent Health Foundation-funded quality improvement project in England, the Ambulance Service Cardiovascular Quality Initiative (ASCQI), which includes a collaboration between East Midlands Ambulance Service NHS Trust, the University of Lincoln, the National Ambulance Research Steering Group and the National Ambulance Services Clinical Quality Group is seeking to investigate the issue of culture in more detail.

The National Institute for Health Research (NIHR)-funded programme for applied health research, Prehospital Outcomes for Evidence-Based Evaluation (PhOEBE), is currently attempting to generate more meaningful measures of prehospital outcomes. The programme aims to achieve this by systematically reviewing the international evidence base relating to prehospital outcomes and linking Hospital Episode Statistics (HES) and Office of National Statistics (ONS) mortality data to risk-adjustment measures of ambulance service care.

While the introduction of CQIs to supplement the response time targets represents progress, there is still an ongoing need to generate a broader range of meaningful outcome measures that better capture the often-complex nature of patients’ experiences of the ambulance service. In generating new quality and outcome measures, there is always a risk of over-complication. Therefore, the new quality and outcome measures need to be sufficiently meaningful without being overly-complex. The PhOEBE programme should make a valuable contribution to this debate.

Viet-Hai Phung, CaHRU


1.   Bevan G, Hamblin R. Hitting and missing targets by ambulance services for emergency calls: effects of different systems of performance measurement within the UK. J R Stat Soc Ser A Stat Soc 2009:172: 161-190.

2.   Wankhade P. Performance measurement and the UK emergency ambulance service: Unintended consequences of the ambulance response time targets. International Journal of Public Sector Management 2011:24: 384-402.

3.   Wankhade P. Different cultures of management and their relationships with organizational performance: evidence from the UK ambulance service. Public Money and Management 2012:32: 381-388.


SAFER 2 (Support and Assessment for Fall Emergency Referrals) trial protocol published

The SAFER 2 study is a randomised controlled trial of the clinical and cost effectiveness of new protocols for emergency ambulance personnel to assess and refer older people who fall to appropriate community based care.  The protocol for the study, led by Prof Helen Snooks at Swansea University and including Prof. Niro Siriwardena of the CaHRU and East Midlands Ambulance Service NHS Trust as a collaborator, has recently been published in BMJ Open:

Snooks H, Anthony R, Chatters R, Cheung WY, Dale J, Donohoe R, Gaze S, Halter M, Koniotou M, Logan L, Lyons R, Mason S,  Nicholl J, Phillips C, Phillips J, Russell I, Siriwardena AN, Wani M, Watkins A, Whitfield R, Wilson L. Support and assessment for fall emergency referrals (SAFER 2) research protocol: cluster randomised trial of the clinical and cost effectiveness of new protocols for emergency ambulance paramedics to assess and refer to appropriate community-based care. BMJ Open 2012;2: e002169. doi:10.1136/bmjopen-2012-002169

The study measured the costs and benefits of a novel protocol implemented by emergency ambulance paramedics caring for older people who had fallen, allowing the paramedic to assess and refer appropriate patients to a community based falls service. The study involved ambulance services in London,Wales,East Midlands. Stations were randomly allocated to implement the new protocol (intervention) or continue to provide care according to their standard practice (control).

Paramedics based at the stations selected for the intervention group received additional training, protocols and clinical support to enable them to assess older people and decide whether they need to be taken to the Emergency Department (ED) immediately, or whether they could benefit from being left at home, with a referral to a community falls service. The study compared costs, processes and outcomes of care (particularly subsequent 999 calls and ED attendances for falls) at 1 and 6 months for patients aged 65 or over who had fallen together with other quantitative and qualitative data.

The study was recently been completed and, currently in the final data collection phase, is due to be published next year.

New study published investigating patient experiences of using the ambulance service for suspected stroke and heart attack

A study by members of the CaHRU team, Fiona Togher, Dr Zowie Davy and Professor Niroshan Siriwardena, to better understand the elements of care that are most important to patients with stroke and heart attack accessing the ambulance service, has been published in the Emergency Medicine Journal

The qualitative study involved interviewing both patients and clinicians about their experiences of either receiving or providing care prehospital care for stroke or heart attack. Four main themes emerged:

  • communication
  • professionalism
  • treatment of condition
  • transition from home to hospital.

The technical knowledge and relational skills of clinicians’ together contributed to patients’ perceptions of professionalism in ambulance personnel. We found that the patient experience was enhanced when physical, emotional and social needs were attended to. Effective clinician–patient communication was also found to be a key component of high quality patient care.

Fiona Togher, who was lead author for the study, has recently been awarded a PhD studentship at Lincoln. The findings will be used to inform her doctoral research, which will examine the potential for developing a generic patient reported experience measure (PREM) for routine use in ambulance services in the UK

ASCQI presented at International Forum on Quality and Safety in Health Care in Paris, April

In April 2012 Professor Niro Siriwardena and Fiona Togher travelled to Paris with colleagues, Nadya Essam, Debbie Shaw (East Midlands Ambulance Service [EMAS]) and David Francis (East of England Ambulance Service) to attend the 17th International Forum on Quality and Safety in Healthcare.

The team presented work undertaken as part of the Ambulance Service Cardiovascular Quality Initiative (ASCQI) a two year nationwide project involving all 12 ambulance trusts in England and the University of Lincoln funded by the Health Foundation.

From the 2,000 poster submissions that were originally received, around 900 were selected for display following a two stage peer review process. Fiona, Nadya and Debbie were all invited to present their work during the poster presentation session held. This provided a brilliant opportunity to talk to interested delegates from around the world about the quality improvement work and research that is being undertaken at the University and East Midlands Ambulance Service.

Fiona Togher

Fiona represented the IS-PROVE team, which also includes Professor Siriwardena and Dr Zowie Davy. Their poster entitled “The importance of qualitative methods for generating patient reported outcome measures and patient reported experience measures for pre-hospital and emergency care of stroke and heart attack” attracted attention from French, Swedish and American delegates that were keen to find out more. Nadya Presented on ergonomic redesign to improve care for heart attack and Debbie presented on ‘Joining the dots’ and the use of annotated control charts for quality improvement in ASCQI.

Debbie Shaw

With a tough act to follow from last years’ excellent event in Amsterdam, Paris was just as enjoyable,  thought provoking and inspiring. The key note speakers were again outstanding and captivated the audiences with their motivational reflections on working in health care and how to improve the quality of care provided to patients.

The opening keynote by Maureen Bisagnano from the Institute for Healthcare Improvement focused on goal oriented patient care, ‘what matters to patients’ and the redesign of services for patients. We heard about leadership from Dr David Williams, a Canadian professor of surgery who has been an astronaut and now leads a regional health organisation in Toronto.

Another highlight of the conference was the session entitled “Delivering better care to rural communities inAfrica” which focused on the application of quality improvement methods including Plan, Do, Study, Act cycles, to reducing asphyxia in newborn babies and mortality rates in children under the age of five. The success of the initiatives was amazing, more so because of the limited resources of equipment and manpower available.

Nadya Essam

One of the most inspiring speeches was given by Dr. Nancy Snyderman, who is not only a paediatrician and an ENT surgeon but also chief medical editor for NBC news in America – and an award winning journalist! Her speech focused on the importance of listening to patients and hearing what they are actually saying as opposed to what health care professionals presume they are saying. This central message resonated with what we are aiming to achieve through the patient experience studies that we are conducting in prehospital care in Lincoln and EMAS.

The take home message from this conference was that the application of quality improvement methodologies makes a real difference to the standard of care that is provided to patients; there were hundreds of examples of fantastic successes from around the world and in some instances the evidence translated to a significant contribution of quality improvement projects to saving lives.

Fiona Togher and Niro Siriwardena