International Innovations: Improving Prehospital Care Around the World

It’s mid-day in downtown Doha, Qatar, a small country off the east coast of Saudi Arabia. Hamad Ambulance Service Charlie and Alpha units receive a priority call for a person complaining of chest pain in a local medical facility. We enter the building and rush down a hallway passing a courtyard where a doorway is neatly surrounded by empty shoes. It’s a prayer room where Muslim men pray. At the top of a flight of stairs sits a man with a classic presentation of an acute myocardial infarction: sweaty, puking and clutching his chest with his fist as he appears to grasp for air in a panic.

The ambulance service team quickly begins to assess and treat the man. The consultant paramedic from the Charlie Unit (a SUV quick response vehicle) is relatively new to the system—an expat from South Africa. His partner is Tanzanian and the Alpha crew (transport) ambulance is from the Philippines and another Arab country I didn’t catch. The team quickly notifies the designated heart hospital, initiates protocol-based treatment and prepares for transport. In the ambulance, he deteriorates into ventricular tachycardia and arrests as the stretcher crosses the threshold of the emergency department. A multinational team of nurses, doctors and respiratory therapists continue the resuscitation as the patient is handed over.

While this patient event could have occurred anywhere, it happened in one of the many EMS systems around the globe that are striving to improve the outcomes of prehospital care systems. A place where ambulance service leaders and paramedics are working to build on the successes of healthcare improvement to improve the results for prehospital patients. This article shares the stories of three cases: England and Scotland in the United Kingdom, and Qatar.

Scotland

Prior to this last year’s referendum for independence, must Americans only knew of Scotland for its distinct accent, great whiskey and a food offering known as haggis. In healthcare, Scotland is also known as one of the pioneer success stories of the quality and patient safety movements.¹ Over the last decade, the entire country has produced striking results as it has applied improvement science to reduce infections and patient harm. It’s now spread its efforts to include early childhood development and primary through secondary education.

The Scottish Patient Safety Programme (SPSP) started as a single in hospital acute collaborative in 2008. The original in-hospital effort has become more embedded in daily work and initiatives have since spread into collaboratives, improving pediatric patient outcomes from birth to 5 years old—Early Years Collaborative—and in primary education—Raising Attainment for All. The Scottish Ambulance Service continues to be involved in these efforts and has also adopted and applied these methods to their own national EMS-specific initiatives.

Since 2008, paramedics from the Scottish Ambulance Service have attended learning sessions—think working conferences—and participated in improvement projects to enhance patient safety in prehospital care. Paul Gowens, a paramedic assigned to the Scottish Government Quality Unit, says, “Ten years ago, we were using data for judgment, not improvement. Our thinking was very binary: we were good or bad; meeting our targets or not.” Today, Gowens describes a very different strategic philosophy focused on using data for learning and improvement across a broad spectrum of care areas.

A prime example of the types of projects Scotland is pursuing is the use of bundles to improve the reliability care processes like intravenous cannulation and airway management. A care bundle is a prepackaging of equipment and procedures for particular care where patient harm can occur that are “bundled” together. The bundles ensure reliable and evidence-based care, and the aim is to improve the process so 95% of patients get it right every time. This results in reduced infection rates, shortened hospital stays, lower costs and healthier patients.

When Scottish paramedics started using the peripheral vascular cannulation (PVC) bundle, they quickly realized simple things like IVs were being pulled in the emergency department because paramedics had no way of properly labeling the insertion, all of which caused patient discomfort, increased risk and increased cost. By studying their process and using rapid cycle, small tests of change to make improvements, they saw their PVC bundle process measure data improve over time (see line chart). “When we first started this process, everyone called it the ‘new PVC bundle,’” shares Gowens, but today, providing highly reliable care is how they do business.

Over the years their work has expanded to include the use of leadership WalkRounds, early warning scores and sepsis. These are all direct carryovers from the acute care in-hospital patient safety program.

Leadership WalkRounds is a process developed by Dr. Allan Frankel to encourage senior leaders to have weekly interaction with patients and frontline caregivers.² Leaders use a structured conversation to specifically look for patient harm or proactively identify processes that risk harming patients. Leadership addresses problems identified and organizations measure the frequency of these WalkRounds over time as well as the closure of issues identified as continuous organizational performance metrics.

Sepsis has long been a focus of in-hospital patient safety programs and recent papers predict paramedics may play a big role in sepsis intervention.^3,4 The Scottish Ambulance Service is using a prehospital sepsis screening tool that blends the use of the early warning score with protocol-based assessment criteria to identify potential sepsis patients, initiate treatment and notify the emergency department to expedite continued treatment.^5,6

Patient safety initiatives are challenging to implement for any organization, but imagine doing it nationwide. The Scottish Ambulance Service uses a framework for spread that starts with a pilot area and then follows a plan to implement to scale.⁷ For example, they are currently embarking on a journey to improve out-of-hospital cardiac arrest survival. Several projects have been piloted, including improving the resuscitation process and post-hospital care.⁸ As initiatives achieve measureable results, the framework for spread helps with rolling out reliable processes and lessons learned methodically across the country with the aim of replicating similar results.

Improvement science and patient safety has transformed the way the Scottish Ambulance Service serves its citizens. By adopting the methods used to improve in-hospital care, paramedics are showing the prehospital environment is also capable and ready to improve.

England

Just south of Scotland is England, home of 13 Ambulance Service Trusts, including one of the busiest EMS systems in the country that’s served by the London Ambulance Service Trust. Almost a decade ago, the English ambulance system consolidated from 34 trusts to its current state. Like the U.S., and other counties, the NHS England ambulance trusts have limited metrics to appreciate reliability and performance.⁹ Each trust was held to strict targets for response time reliability and there was some measurement of cardiac arrest survival, but key care pathways were not uniformly measured. Dr. Niro Siriwardena is a professor of primary and prehospital healthcare and the associate clinical director for East Midlands Ambulance Service NHS Trust. A few years ago, he was asked to look at the performance measurement in the NHS ambulance trust system. “What I quickly discovered was there was poor measurement and limited systems in place,” says Siriwardena. As a result, he helped support the creation of groups to work to develop a clinical measurement system to aid improvement in care.

Like in Scotland, English ambulance trusts were also exposed to improvement science through similar improvement work in England. Championed by the ambulance trust chief executives, ambulance leaders learned about statistical process control and other improvement methods like benchmarking and plan-do-study-act cycle testing. They also developed a measurement strategy to address key clinical conditions like stroke, STEMI and cardiac arrest. Ambulance trusts reported their data to Dr. Siriwardena’s team, which would convert the data into time series charts and share back.

“At first there was a lot of variation and people questioned if the data matched what was actually happening,” describes Siriwardena. Starting with data that was “good enough” to learn, being able to see the data helped everyone appreciate deficits in data capture in the field and the thoroughness of documenting care. Just measuring the data improved the quality of data collection and supported pursuing process improvement. Modeling the Institute for Healthcare Improvement’s Breakthrough Series Collaborative Model,¹⁰ trusts begin to share and collaborate to improve care. The result has been several posters¹¹ and peer-reviewed papers, and measureable improvement in STEMI and stroke care reliability.¹² Their work has also been used to inform other improvement efforts in the United States and abroad, including American Medical Response’s Caring for Maria improvement collaborative, the recently announced EMS performance measures initiative in partnership with the National Highway Traffic Safety Administration, and the National Association of State EMS Officials, and ongoing innovation work in U.S. and Middle East at the Institute for Healthcare Improvement.^13–15

“Frontline paramedics bought into a focus on clinical indicators vs. just response time targets,” shares Siriwardena, and now leaders are talking about improving care and sharing ideas. They are slowly changing the mindset to focus on the care and use improvement methods to improve results and there’s hope that clinical indicators will join, or eventually replace, response time targets as a measure of ambulance service performance. This is similar to one of the aims of the NASEMSO/NHTSA performance measure initiative and builds on case examples like AMR in Evansville, IN, which studied clinical indicators including the Rapid Acute Physiology Score and out-of-hospital sudden cardiac arrest survival rates as balancing measures while extending response time performance standards.^16,17

Qatar

A world away from Scotland and England is Qatar. A very small peninsula off the eastern coast of Saudi Arabia and surrounded by the Persian Gulf, Qatar is best known by many westerners as the home of the Al Jazeera news network, future site of the 2022 FIFA World Cup and location of the U.S. Central Command’s Forward Headquarters and Combined Air Operations Center. It’s also the service area of the Hamad Medical Corporation Ambulance Service (HMCAS), the official EMS provider for the country.

The cranes that mark the skyline around Doha, Qatar’s capital city, make the growth of U.S. boom cities like Austin, TX, look tiny in comparison. A modern city is under construction all around and signs on work sites display their vision: “Qatar deserves the best.” As the richest country in the world per capita this may be possible, and the ambulance service is just one of the many services evolving at a rapid clip.

As this small country rapidly grows, so does HMCAS. It is striving to develop a world class and innovative system for delivering integrated prehospital care. In April 2014, it became the first country in the Middle East to achieve the International Academies of Emergency Dispatch Accredited Center of Excellence¹⁸ designation and in October achieved reaccreditation by the Joint Commission International.¹⁹ At the same time the entire health system has been engaged with the Institute for Healthcare Improvement (IHI) to improve patient safety and embed improvement science into their standard work.²⁰

For the ambulance service, work on improving prehospital care began with the IHI innovation team to develop and prototype an ambulance trigger tool modeled after the IHI Global Trigger Tool²¹ to identify patient harm. A trigger tool involves using a biweekly audit of 20 charts looking for specific “triggers,” or potential causes of patient harm. The results help identify categories of harm ripe for improvement projects and the data can be tracked over time as a key performance indicator. As HCMAS’s chief executive officer, Dr. Robert Owen says, “The trigger tool is an exciting innovation to develop for ambulance service and it has the potential to aid improving prehospital patient safety.” The innovation project helped develop the tool and this year it will be further tested and the results published in a peer-reviewed journal.

The Ambulance Service Trigger Tool is part of an ecosystem for improving prehospital care systems that HMCAS is pursuing. Other drivers include improving key clinical care pathways, developing an integrated communications and mobile doctor service to provide care in the community, and embarking on a system-wide effort to integrate quality as a business strategy.

Similar to the work described in England’s NHS and also found in the Caring for Maria¹³ initiative at American Medical Response in the U.S., HMCAS aims to increase the process reliability of care delivery to improve the outcomes of STEMI, stroke, trauma and out-of-hospital cardiac arrest patients. To do this a consultant paramedic is assigned to each care pathway and charged with defining a clear and measureable aim for improvement, creating a measurement strategy with process and outcome measures, and developing a change package, also known as a driver diagram. The consultant paramedics are champions of the individual care pathway and will use improvement science methods including rapid cycle, small scale PDSA testing and time-series run charts to pilot test change ideas. Once a change is measurably reliable, they will use the same methods to spread the change from the pilot area across the entire system.

HMCAS is taking a comprehensive approach to better understand its EMS system and will use improvement methods to design and improve key care processes and organizational quality. The leadership team, in conjunction with partners from IHI, plan to share the results of the work in peer-reviewed journals, upcoming conference presentations and other venues so other systems can learn from the work.

Conclusion

Prehospital care is continually evolving profession. No matter what country you live and work in, it’s easy to not hear or know about innovations occurring in other pioneering systems around the world. Sadly, some of the most progressive work doesn’t always make it onto the agenda of a professional conference, or the pages of an EMS magazine or peer-reviewed journal. Taking the extra time to search it out through your network, social media or a simple Google search can be worth the effort. Also, it’s exciting to see the early adoption of improvement methods by ambulance services building on the work of organizations like the Institute for Healthcare Improvement and partner organizations around the world. EMS has a lot of opportunity for improvement and innovation.

References

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2. Frankel A. Patient Safety Leadership WalkRounds. Institute for Healthcare Improvement, www.ihi.org/resources/Pages/Tools/PatientSafetyLeadershipWalkRounds.aspx.
3. Seymour CW, et al. Severe Sepsis in Pre-Hospital Emergency Care. Am J Respir Crit Care Med, 2012; 186(12): 1264–71.
4. Studnek JR, et al. The impact of emergency medical services in the emergency department care of severe sepsis. Am J Emerg Med, 2012; 30(1): 50–56.
5. Williams DM. Early Warning Score Systems for Ambulance Service. NAEMSP News, www.medichealth.com/early-warning-score-system-for-ambulance-service/.
6. The UK Sepsis Trust. Prehospital sepsis screening tool, https://sepsistrust.org/wp-content/uploads/2013/10/PrehospitalSepticScreeningTool_EEAST.pdf.
7. Massoud MR, Nielsen GA, Nolan K, Nolan T, Schall MW, Sevin C. A Framework for Spread: From Local Improvements to System-Wide Change. Cambridge, MA: Institute for Healthcare Improvement, 2006.
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18. The Journal of Emergency Dispatch. A first for the Middle East: Hamas Medical Corporation achieves region’s first medical ACE, www.iaedjournal.org/content/first-middle-east.
19. Gulf Times. HMC ambulance service gets JCI re-accreditation, www.gulf-times.com/qatar/178/details/413327/hmc-ambulance-service-gets-jci-re-accreditation.
20. Gulf Times. HMC signs new pact to improve healthcare, www.gulf-times.com/qatar/178/details/341728/hmc-signs-new-pact-to-improve-healthcare.
21. Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events, 2nd ed. Cambridge, MA: Institute for Healthcare Improvement, 2009.
22. Associates in Process Improvement. Quality as a business strategy. An overview. Austin, TX: Associates in Process Improvement, 2007.
23. Deming WE. Out of Crisis. Cambridge, MA: The MIT Press, 1986.

David M. Williams, PhD is the founder and chief executive officer of the international consulting firm Medic Health (MedicHealth.com; @Medic_Health). He is an improvement advisor and lead prehospital care and ambulance service system faculty at the Institute for Healthcare Improvement.