Emergency care protocol benefits stroke and heart attack patients

A new study has demonstrated that having checklists and better mechanisms for feedback for frontline staff considerably improves the emergency care that people suffering from stroke or heart attack receive.

Taken together, heart attack and stroke are the most common cause of death in the UK. There are more than a quarter of a million heart attacks (acute myocardial infarction) in the UK each year and two fifths result in sudden death. There are another 150,000 incidences of stroke each year.

The treatment given by paramedics before a patient reaches hospital is a critical factor in their chances of survival and recovery. Paramedics use a standardised approach for assessment and treatment, or 'care bundles'.  A care bundle is a series of actions that are clinically recognised to improve a patient's prognosis.

For a heart attack the actions include taking verbal pain score, giving aspirin, administering a drug called glyceryl trinitrate (GTN) and offering pain relief. For stroke it includes the FAST (face, arm, speech, time) assessment and taking blood glucose and blood pressure readings. This protocol should be followed in full whenever a heart attack or stroke is suspected. However, until recently, there was widespread geographical variation between English regions in how consistently these steps were followed.

In an attempt to address these regional disparities researchers from the University of Lincoln, working with East Midlands Ambulance Service together with all English ambulance services, have led a national quality improvement programme, the Ambulance Services Cardiovascular Quality Initiative (ASCQI).

This type of project is known as a Quality Improvement Collaborative (QIC) and this was the world's first large-scale national QIC to focus on ambulance clinicians. It involved all 12 publicly funded English ambulance trusts, which between them employ more than 22,000 ambulance clinicians, and was funded by the Health Foundation.

The project encouraged frontline staff and management to introduce small procedural changes, such as checklists, aide memoires, and individual and group feedback. It also enabled sharing of information within and between different trusts.

The first full analysis of the results of the shows statistically significant improvements in all 11 ambulance trusts who completed the project.

The study examined the period between January 2010 and February 2012. Across England the percentage of emergency cases where care bundles were delivered in full increased from 43% to 79% for heart attack and from 83% to 96% for stroke.

Detailed analysis suggested the introduction of checklists and other aide memories, coupled with better mechanisms for feedback for frontline staff, had the most profound impact.

Professor Niro Siriwardena, from the School of Health and Social Care at the University of Lincoln, who led the ASCQI project, said: "We know that paramedics are good at making accurate diagnoses of heart attack and stroke. What we needed to understand better was how they actually manage emergency patients with suspected heart attack or stroke before they reach hospital. It is important that care bundles are followed in full for each case, even if an initial diagnosis is not clear-cut.

"Our analysis shows that this national quality improvement project - the first of its kind anywhere in the world - has led to significant increases in the use of care bundles by ambulance crews responding to heart attack and stroke patients. We found that frontline staff were willing to make small changes to the way they worked because they were able to see the benefits for patient care."

Future research will investigate the impact of these improvements on patient outcomes and whether similar changes could benefit emergency patients with other conditions such as asthma.

The results of the analysis were published in the international online academic journal Implementation Science.

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