2014/15
QUALITY
ACCOUNT
“Quality means doing it right when no-one
is looking.”
Henry Ford
Contents
Summary and introduction...................................................4
Part 1: statements of quality and accountability...............8
Part 2: Our priorities for 2015/16...........................................14
Part 3: Our priorities for 2014/15...........................................46
Stakeholder feedback..........................................................64
Glossary..................................................................................74
Providing feedback..............................................................82
SUMMARY
W
elcome to the East of England Ambulance Service NHS
Trust Quality Account for 2014/15. This document has
been approved by the Trust Board and is an accurate
account of the level of quality of service provided to patients. In
developing this Quality Account, the Chief Executive has set out
a summary of achievements for 2014/15, and goals for 2015/16.
Improving quality is an overarching priority of the Trust and
this report lays out plans for developing future services to
improve patient care and patient outcomes by delivering the
right resources at the right time so that the service is publicly
accountable for driving clinical quality higher.
In order to help do this, the Quality Account is based on
data from a range of sources and, in setting the priorities for
2015/16, we have engaged with staff and service users to
identify the key clinical areas which require focus in order
to further improve the quality, and meet patient and public
expectation. We have also acknowledged the core/mandatory
priorities for improvement published by the Department of
Health (DH).
Contributions to this document
Ipswich and East Suffolk Clinical Commissioning Group (CCG)
EEAST Quality Account 2014/15
(the lead commissioner), the Trust User Group, Healthwatch
groups and the region’s health overview and scrutiny
committees (HOSCs) have been asked to comment on this
document.
There is a glossary for reference on pages .
Where can you get hold of this document?
This Quality Account is available on the NHS Choices website
from 30th June, 2015:
http://www.nhs.uk/aboutNHSChoices/professionals/
healthandcareprofessionals/quality-accounts/Pages/aboutquality-accounts.aspx
East of England Ambulance Service NHS Trust Headquarters
Whiting Way
Back Lane
Melbourn
Cambridgeshire
SG8 6EN
Tel: 0845 601 3733
A copy of the account will be submitted to the Secretary of
State.
4
Background and profile
About us
The East of England Ambulance Service NHS Trust (EEAST) has provided emergency, urgent and
primary care services throughout Bedfordshire, Cambridgeshire, Hertfordshire, Essex, Norfolk
and Suffolk since 1st July, 2006. Our dedicated and skilled staff work 365 days a year, 24 hours a
day to make sure patients receive the best possible care.
We have more than 4,000 staff operating from 140 sites and a fleet of 1,000 vehicles. We
are supported by more than 1,500 volunteers who provide community first responder and
volunteer ambulance car services.
The eastern region is made up of both urban and rural areas with a population of nearly six million,
as well as several thousand more tourists who enjoy visiting the area in peak seasons. It includes
major airports and docks which increase the number of people in our region on a daily basis.
The emergency 999 service
About 2,400 emergency 999 calls come into the ambulance service every day and are answered and
managed in our emergency operations centres in Bedford, Chelmsford and Norwich, depending on
where the call is made. The call handler records information about the nature of the patient’s illness
or injury to make sure they get the right kind of medical help.
Our call handlers use sophisticated software to put the patient’s condition into a particular category,
depending on how urgent it is. This is known as triaging, and allows us to make sure the most
seriously ill patients can be prioritise and get the fastest response.
Once this key information is established, the response will range from either an emergency ambulance
dispatched on blue lights, through to further clinical assessment over the phone for patients with minor conditions which
could be advice over the phone from a paramedic or a referral to their GP, pharmacist or local walk-in center.
EEAST Quality Account 2014/15
5
Not just an emergency service
As well as providing the 999 emergency ambulance service, we also provide a
range of other services including:
• Patient transport services and primary care: We provide non-emergency
patient transport services around the region to help people who need
assistance because of their medical condition or age, from home to
outpatient appointments at hospitals or other care centres. This service also
provides specialist neonatal transfers between hospitals for babies in need
of special care. We also ran the 111 non-emergency health service number
in Norfolk but sadly were not awarded the contract for the next five years
and will cease operations in September.
• Special and partnership operations: The Trust operates two hazardous area
response teams and has a resilience and emergency planning department
who work closely with critical care charities and community volunteers to
respond to a variety of emergency situations.
• Commercial services: We operate a number of services which generate
income for the Trust. These include training for blue-light drivers and first
aid at work. In addition there is a contact centre and a medical service
which cover events, festivals and medical repatriation.
EEAST Quality Account 2014/15
6
Quality Account amendment
regulations 2011
T
hese Regulations require the Trust by law to publish a Quality Account by 30th
June, 2015. This will be the Trust’s sixth Quality Account, it is presented in three
parts and includes a quality statement from the Board, the priorities for quality
improvement for the year 2015/16 and a review of the quality improvements made in
the past year 2014/15 with regards to the three domains of quality:
1 – Patient safety
2 – Clinical effectiveness
3 – Patient experience
The Quality Account 2014/15 is set out into:
• Part 1, containing a statement summarising our view of the quality of NHS services
provided (or sub-contracted) during the reporting period, and a written statement
signed by Chief Executive Dr Anthony Marsh that to the best of his knowledge the
information in the document is accurate (refer to Regulation 6)
• Part 2, describing the areas for improvement in the quality of NHS services
provided (or subcontracted) by the Trust during the reporting period which is
prescribed for the purposes of section 8 (1) or (3) of the 2009 Act by paragraph (2)
and the information required by Regulation 7
• Part 3, containing information about the review of the Trust’s quality performance
of NHS services provided (or sub-contracted) by it during the reporting period.
EEAST Quality Account 2014/15
7
PART 1
EEAST Quality Account 2014/15
PART 1
8
Statement on quality from the Board
W
elcome to the East of England Ambulance Trust NHS Trust’s Quality
Account for 2014/15. This is my second Quality Account as Chief
Executive of the Trust after coming into post in January 2014. The
start of the new financial year gives us all an opportunity to move forward in a
positive manner. It allows us to further improve the high quality service that we
already provide to our patients ensuring that it is a service in which they can
have confidence, and in which our staff can take pride. The previous 12 months
have again been extremely challenging due to increasing demands on the service
but a strong team effort has resulted in the East of England becoming a high
performing ambulance Trust.
The purpose of the Quality Account is to ensure that the Trust is focused on
quality improvement as a primary function of the organisation. It enables us to
be held accountable by the public and our commissioners for the quality of the
care that we provide.
The Quality Account reflects on the progress made during the previous year and
identifies our priorities for the coming year. This year, we are focusing on seven
key priorities for the Trust ensuring that our patients are seen promptly, treated
effectively and are satisfied with the service they receive from our staff.
In our last Quality Account, we identified a number of key priorities and I am
happy to say that we have seen improvement across a wide range of priorities,
which will be identified in this report. In particular we have made significant
clinical improvements which have had a positive impact on both patients and
staff including the recognition of patients who have the early signs of SEPSIS,
developed a frequent caller framework, and consistently made improvement
on conveying patients to a specialised stroke unit within 60 minutes. We have
made strides in our drive to recruit and train more paramedics and put more
ambulances on the road, with additional emergency ambulances delivered and
in use; recruited over 400 student paramedics and have successfully a number
of emergency care assistants on their six week conversion course to emergency
medical technician.
There are also areas we are determined make further improvements most
notably in meeting the R2 performance target. We are focusing on improving
our performance against these targets for the
coming
year. We are implementing further significant
improvements that will allow us to improve the
speed of our response to our patients.
I would like to take this opportunity to
thank our staff for their dedication and
professionalism throughout this year and
without whom our achievements would not
have been possible. Please be assured of my
continued full support, as we work together to
transform this organisation.
Dr Anthony Marsh QAM SBStJ DSci (Hon) MBA MSc FASI
Chief Executive Officer
EEAST Quality Account 2014/15
9
Statement of accountability
A
s Accountable Officer and Chief Executive of the Trust, I have responsibility for maintaining the performance and standards achieved within
the Trust’s services, and to support an environment of continuous quality improvement.
This is the sixth Quality Account produced by the East of England Ambulance Service NHS Trust, in line with the requirements of the Health
Act 2009. The Quality Account contains details mandated by the regulations and also identifies the measures that the Trust, in association with
our NHS and public partners, has decided will best demonstrate the work that has been done to improve the standards and quality of clinical care.
The results of these measures show that much work has been undertaken this year to improve the quality of care to patients; however, there are
areas in which the Trust needs to improve to ensure all patients have a positive experience in using the ambulance service.
As Accountable Officer, it is also my responsibility to ensure both the quality and accuracy of the data within this Quality Account and to confirm
that it presents a balanced picture of the Trust’s performance. I can provide this assurance based on the Trust’s internal processes for ensuring
the quality of data and the opinion of our Internal Auditors, who completed and delivered an annual audit programme including an audit on
the Quality Account and the processes used to develop it. Therefore to the best of my knowledge the information contained within this Quality
Account for the East of England Ambulance Service NHS Trust is a true and accurate record.
Dr Anthony Marsh QAM SBStJ DSci (Hon) MBA MSc FASI
Chief Executive Officer
EEAST Quality Account 2014/15
10
Statement on Quality from the
Director of Nursing & Clinical Quality
T
his last year has been one of fundamental change for EEAST: an ambitious frontline recruitment
programme and realignment of support staff to enable our patients to receive emergency and
urgent care in a timely manner, a new Trust Board bringing together a wealth of experience and
commitment to the Trust and financial stability in a climate of cost improvement challenge has been
the focus for the year. Whilst all this has been embedding, the organisation has not lost its focus and
determination to deliver a high quality service for our patients.
I have seen great commitment from staff, managers and volunteers since I joined the organisation
in February 2015. Their professionalism has been impressive and their desire to provide a
compassionate and safe service to the public has been evident and, with the consultation on the
Trust’s Quality Strategy about to be launched, I am confident that the Trust will continue to meet the
three main domains of quality: patient safety, clinical effectiveness and patient experience.
“There is a right thing to do with regard to quality
of care: improve it. If that takes courage, so be it.”
Donald Berwick
EEAST Quality Account 2014/15
11
This year has seen an overall improvement in our Ambulance Clinical Quality Indicators which means that more of our patients received timely and appropriate
care despite periods of high demand and activity across the Trust. This year has also seen a high number of Serious Incidents reported and although very
disappointing, the Trust has taken every opportunity to learn from those incidents, whilst acknowledging the profound effect they have had on people’s lives. The
patients and relatives of those involved in these investigations have been courageous in telling us their stories and how care, that is not always to the standard
we would expect, has affected them and their loved ones. We do not take this lightly and will continue to strive for excellence in patient care which will support a
much more positive patient experience as we move forward.
The NHS will continue to change and it is important that we adapt and proactively meet the demands of our patients within our communities with the help of our
staff and volunteers. Everyone has a role in quality and we will continue to work with our commissioners to support quality patient care.
I am looking forward to the coming year to ensure we build our programme of improvement and continue to adapt to the changing needs of our patients within
the East of England. This will include working closely with our partner providers to provide a more effective and efficient integrated service.
Sandy Brown
Director of Nursing & Clinical Quality
EEAST Quality Account 2014/15
12
Care Quality Commission
(CQC) registration
T
he Trust was registered with the CQC under the Health and Social Care
Act 2008 (Regulated Activities) Regulations 2009 on 1st April, 2010. The
Trust was registered without conditions or restrictions and is registered
to provide services under three of the regulated activities to cover the services
agreed under contract and service level agreements. As a registered healthcare
provider the Trust has to demonstrate continuous compliance to these
regulations and uses electronic software to upload evidence and monitor each
outcome.
Following an unannounced routine inspection in December 2013, it
was reported that the Trust remained non-compliant with Regulation 9
Outcome 4 (Care and Welfare of People who use services) however, the
CQC acknowledged that since that time the Trust had made significant
improvements in a number of areas; decrease in staff sickness absence rates,
complaints relating to ambulance delays, the number of serious incidents,
long waits (more than 25 minutes) for back up vehicles to transport people
to hospital in life-threatening instances in some areas as well as spending on
private ambulance services. In addition, the CQC concluded that the Trust were
also non-compliant with Regulation 22 Outcome 13 (Staffing). The CQC found
EEAST Quality Account 2014/15
that the Trust did not have the numbers of suitably qualified staff it required to
ensure that national ambulance response times were met and people received
the care they needed in a timely way.
After careful consideration, the CQC found that the Trust was taking
reasonable steps to address the breaches in regulations and that it would not
be appropriate to take further enforcement action at that point.
To address this, the Trust’s new Chief Executive, Dr Anthony Marsh set an
ambitious six priority plan for 2014/15 which included recruiting more than
400 more clinicians and up skilling current staff as well as the purchase of new
ambulances and equipment.
To ensure that the Trust continues to work towards full compliance for all
regulations, in 2014/15 it invested in a new robust monitoring tool which
provides members of the Trust Board, including non-executive directors
dashboard to all regulations and any associated action plans. The Trust has
worked with the providers to ensure this meets the revised regulations as well
as the new Key Lines of Enquiry due to be implemented on 1st April, 2015.
13
PART 2
EEAST Quality Account 2014/15
14
Stakeholder engagement
S
ignificant work was undertaken during the reporting year to engage with key
stakeholders and staff. Methods of engagement included:
• A public opinion poll on our internet site
• Articles on ‘Need to Know’, the internal news site, and an opinion poll on the Trust
intranet
• Complaints and patient feedback
Comments received back from stakeholders in relation to continuing the priorities for
2015/16 have all been in support of the proposal and work has been completed to ensure
that all reporting systems are in place to collect data going forwards.
The Trust has also taken the Quality Priorities to the lead commissioners Quality Review
Meeting for discussion, and to the Patient Safety & Care Standards Committee.
Further feedback on the Quality Account has been included following circulation to
stakeholders. The Trust is also looking to continue and improve upon the level of stakeholder
engagement over the coming year via a number of mechanisms including social networks and
YouTube.
EEAST Quality Account 2014/15
15
Setting Quality Account priorities for 2015/16
T
he Quality Account for 2015/16 will continue to focus on the core priorities
which match the mandatory indicators for ambulance trusts set by the
Department of Health (DH). A range of stakeholders including health and
overview scrutiny committees (HOSCs), clinical commissioning groups (CCGs) and
the Trust’s own User Group also supported our decision to continue with this
focus.
In 2012 the DH and Monitor, following consideration by the National Quality Board
(NQB), introduced changes to the Quality Account reporting requirements in order
to strengthen quality accounts by introducing mandatory reporting against a small,
core set of quality indicators. The core set of quality indicators are based on NQB
recommendations and are aligned closely with the NHS Outcomes Framework.
They are based on data we already collect and which is reported to the DH. The
Trust will be required to report:
Mandatory indicator
Category ‘A’ ambulance
response times
Patients with a pre-hospital
diagnosis of suspected
ST elevation myocardial
infarction who received an
appropriate care bundle
• performance against the mandatory core set of quality indicators
• a comparison of performance against the national average
• a supporting commentary, to explain any variation from the national average
and any steps to be taken or planned to improve the quality of service/care.
The list of core indicators is for a variety of healthcare providers. The following
list has been selected as being applicable to the ambulance service, and reporting
against these is mandatory.
In addition to these mandatory requirements, the Trust also identified the Friends
and Family Test, management of the septic patient, and frequent callers as
priorities in 2014/15. These will continue into 2015/16.
EEAST Quality Account 2014/15
Suspected stroke patients
assessed face to face who
received the appropriate
care bundle
Percentage of staff who
would recommend the
provider to friends or family
needing care
Related NHS Outcomes
Framework Domain
Domain 1: Preventing
people from dying
prematurely
Domain 1: Preventing
people from dying
prematurely
Domain 3: Helping people to
recover from episodes of ill
health or following injury
Domain 1: Preventing
people from dying
prematurely
Domain 3: Helping people to
recover from episodes of ill
health or following injury
Domain 4: Ensuring people
have a positive experience
of care
16
Timely responses
The following table shows the local contracted quality requirements for these measures in 2015/16.
Response code
Definition
Standard
% to be
Maximum response
time
Red 1
Calls which may be immediately life threatening and should receive an emergency
response within 8 minutes
8 mins
75%
30 minutes
Red 2
Calls which may be life threatening but less time-critical and should receive an
emergency response within 8 minutes
8 mins
75%
40 minutes
Category A19 (Red Calls which may be immediately life threatening and should receive an ambulance
1 and Red 2)
vehicle response at the scene within 19 minutes
19 mins
95%
60 minutes (ambulance
only)
Green 1
Serious calls but not life threatening which require an emergency response to arrive
within 20 minutes.
20 mins
75%
60 mins
Green 2
Serious calls but not life threatening which require an emergency response to arrive
within 30 minutes.
30 mins
75%
90 mins
Green 3 Telephone Low acuity calls which require further telephone assessment by our clinicians within
advice
20 minutes.
20 mins
75%
N/A
Green 3 Face-toface
50 mins
75%
120 mins
Green 4 Telephone Lowest acuity calls which require further telephone assessment by our clinicians
advice
within 60 minutes.
60 mins
75%
N/A
Green 4 Face-toface
90 mins
75%
120 mins
1 hour
2 hours
4 hours
75%
75%
75%
N/A
N/A
N/A
GP Urgents
Low acuity calls which require a non-blue light emergency (normal road speed)
response within 50 minutes.
Our lowest acuity calls which require a non-blue light (normal road speed)
emergency response within 90 minutes.
Transport to hospital request made by a Healthcare professional
EEAST Quality Account 2014/15
17
Cardiac arrest care
Rationale: Around 30,000 people each year in the UK suffer cardiac arrests in the pre-hospital environment
– less than 10 per cent will survive to be discharged from hospital, according to data from the Resuscitation
Council UK. Evidence shows that around two thirds of cardiac arrests outside of hospital are in the home, and
that nearly half in a public place are witnessed by bystanders. With each minute that passes in cardiac arrest
before defibrillation, chances of survival are reduced by about 10 per cent.
Immediate cardiopulmonary resuscitation (CPR) in a shockable pre-hospital cardiac arrest can improve the
chances of survival by up to a factor of three. The British Heart Foundation campaigns to train the public in
emergency life support to build a Nation of Lifesavers, and in an attempt to train young people to deal with
cardiac arrests, wants to get it on the National Curriculum in England and for it to include skills training as part
of the National Citizen Service. This year, we installed 1,000 public defibrillators (AEDs) across the entire region
to support a successful resuscitation campaign in line with the British Heart Foundation.
Baseline: The table below shows the baselines achieved within this category. Return of Spontaneous
Circulation (ROSC) refers to the point at which a pulse is regained following life-saving techniques.
Category
Average 2014/15
Target for improvement
2015/16
ROSC – all patients
24.1%
25%
ROSC – Utstein patients
Survival to discharge – all patients
Survival to discharge – Utstein patients
50%
6.5%
20.6%
51%
7%
25%
Goal: To improve outcomes from cardiac arrest and work towards an increase in return of spontaneous
circulation (ROSC) and Survival to Discharge figures.
Improvement: The Trust will aim to see improvements in both the ROSC (overall and Utstein) and the Survival
to Discharge (overall and Utstein) figures on a consistent basis. These targets have been set within EEAST’s A&E
contract.
EEAST Quality Account 2014/15
18
CASE STUDY
Cardiac arrest ROSC
An ambulance was called to a 58 year old man who was in cardiac arrest.
The history leading up to the call was that the patient complained of
indigestion, abdominal and shoulder pain the night before. A 999 call
was placed in the early hours of the morning. Upon arrival six minutes
later, the patient was displaying no signs of life. Advanced life support
protocol was initiated which included performing chest compressions
and ventilating the patient (aiding them to breathe) as well as other set
procedures in line with protocol. Two biphasic shocks were delivered to
the patient who was in a ventricular fibrillation heart rhythm and intravenous access was achieved through using a cannula.
The patient had a return of spontaneous circulation (ROSC) seven minutes
thereafter. Shortly afterwards, the patient was making respiratory effort
and was taken to the nearest hospital for further care and treatment.
EEAST Quality Account 2014/15
19
Heart attack care
Rationale: Most deaths in the UK from heart disease are caused by a
heart attack. Around 103,000 heart attacks happen each year, with some
people having more than one. Approximately 50,000 of those heart
attacks are suffered by men, and around 32,000 by women. The British
Heart Foundation estimates that one in three people die of a heart attack
in the UK. This is why the care in the pre-hospital arena is vital. Most heart
attacks are caused by coronary heart disease which is when the coronary
arteries narrow due to a gradual build-up of atheroma (fatty material)
within their walls and a piece breaks off leading to a blood clot. Because
of the life-threatening risk with a heart attack, providing patients with a
pre-hospital assessment for a STEMI and administering an appropriate
care bundle means a significant improvement on patient outcomes,
thereby supporting the NHS to reduce the number of patients dying
prematurely and to help people to recover from episodes of ill health or
following injury.
Baseline: We measure the AQIs for the percentage of patients suffering
a STEMI who are directly transferred to a centre capable of delivering PPCI
and angioplasty within 150 minutes of call, and the percentage of patients
suffering a STEMI who receive an appropriate care bundle. The baseline
EEAST Quality Account 2014/15
figure for STEMI 150 for 2015/16 was 93.4% and the care bundle was
80.2%.
Goal: The Trust intends to achieve 95% PPCI within 150 minutes and 80%
STEMI care bundle compliance.
Improvement: To reduce the on-scene times for those patients who are
having confirmed STEMI and to continue to give high standards of care to
those patients experiencing cardiac chest pain.
Category
Average
2014/15
The percentage of patients suffering a STEMI
who are directly transferred to PPCI and
angioplasty within 150 minutes of call
93.4%
95%
The proportion of patients with STEMI who
received an appropriate care bundle
80.2%
80%
Target for
improvement
2015/16
20
Stroke care
Rationale: Each year more than 110,000 people in England will have a stroke; it is the
third biggest cause of death in the UK and the largest single cause of severe disability.
Face-Arm-Speech-Time (FAST) is a simple test to help people recognise the signs of stroke
and understand the importance of emergency treatment. The faster a stroke patient
receives treatment (care bundle), the better their chances are of surviving and reducing
long-term disability.
Baseline: We measure the percentage of FAST positive stroke patients (assessed face-toface) potentially eligible for stroke thrombolysis who arrive at a hyper-acute stroke centre
within 60 minutes. The baseline figure for YTD (March 2015) is 96.4% for the care bundle
and 55.3% for Stroke 60.
Goal: We aim to achieve continuous improvement in Stroke 60, and to see continually
high care bundle compliance.
Improvement: To reduce on scene times for patients who are having a stroke and
continue to give high quality care. These targets have been set within EEAST’s A&E
contract.
Category
Baseline at
Target for
end of March improvement
2015
2015/16
The percentage of stroke patients (assessed face-to-face) who
received an appropriate care bundle
96.4%
95%
The percentage of Face Arms Speech Time (FAST) test
55.3%
positive stroke patients (assessed face-to-face) potentially
eligible for stroke thrombolysis who arrive at a hyperacute stroke centre within 60-minutes of call
56%
EEAST Quality Account 2014/15
21
Sepsis care
Rationale: Sepsis claims the lives of more than 37,000 people in the
UK, which is more than lung cancer and more than breast and bowel
cancer combined. The estimated cost to the NHS for sepsis is around
£2 billion annually for treatment. It is shown in recent research that
early recognition of the signs and symptoms of sepsis will save lives,
possibly as many as 12,500 per year in the UK, (Robson et al. 2009:
p535-538.) The paper is quoted as stating, The care of the critically
ill or injured patient often begins in the prehospital setting, and in
time-critical conditions such as AMI or stroke, specific interventions
by prehospital practitioners make a significant difference to mortality.
Severe sepsis is no different—the use of a prehospital severe sepsis
screening tool and the implementation of a modified ‘‘sepsis six’’ may
significantly improve patient outcomes.
By using the screening tool developed by the UK Sepsis Trust in
2014/15, staff are able to recognise red-flag sepsis and septic shock
in adults, and the need for urgent and timely interventions and
transportation to hospital.
Neutropenic sepsis is a significant cause of death in cancer patients
receiving chemotherapy, and causes delays and changes to planned
treatments. In England and Wales, relative to the increasing number
of cancer diagnoses, the proportion of deaths due to neutropenic
sepsis continued to rise for all age groups between 2001 and 2010.
EEAST Quality Account 2014/15
Recent National Institute for Health and Care Excellence (NICE)
guidance recognises neutropenic sepsis is a medical emergency
requiring immediate hospital investigation and treatment, and
recommends improving the clinical care pathways of cancer patients
undergoing chemotherapy, immediate access to antibiotics and
appropriate healthcare staff training.
Baseline: In 2013/14, a month on month audit was undertaken
where it was determined that crews recognised sepsis in about 75%
of cases. For 2014/15 the Trust intended to increase the number
of sepsis cases the crews recognised and recorded to 85%. Due to
resource pressures, the audit for this year was confined to one month,
October 2014, however the target was exceeded with the crews
correctly identifying 93% patients with sepsis.
Goal: We intend to set a target above 90% for the number of sepsis
cases the clinicians recognise and record and expand the audit to
include care bundles given.
Improvement: Continue to increase the recognition of sepsis and
neutropenic sepsis supported by the delivery of the sepsis care bundle
to provide the highest standards of pre-hospital care.
22
CASE STUDY
Sepsis
An ambulance was called to attend to a 64 year old female who was noted as confused
and semi-conscious.
Upon arrival the primary complaint had been noted as query sepsis which was
determined through obtaining the patient’s history. The patient went to bed feeling
drowsy with a headache and had increased confusion. The patient was showing sepsis
markers:
• Increased heart rate of 144bpm
• Increased temperature of 39.9 degrees centigrade
• Increased blood sugar reading of 8.3
• An acutely altered mental state
Other observations were noted but the four listed above are sepsis markers. If two or
more are present then sepsis protocols should be initiated which is prescribing high
flow oxygen therapy with fluid therapy (sodium chloride) via vein gained through Intra
Venous access.
Examination notes included that the chest was clear with no wheeze or crackles or
productive cough. No diarrhoea or vomiting, no paleness, sweating or seizure. No cold
hands or loss of consciousness, no photophobia, stiff neck, cough cold or blood loss.
EEAST Quality Account 2014/15
23
Frequent callers
Rationale: A frequent caller is someone who calls 999 regularly, with
contact with the ambulance service ranging from daily calls to multiple
calls within a month. A frequent caller should not necessarily be
considered a nuisance caller; many suffer from long term conditions which
may necessitate more regular contact with the service. These calls only
represent a small number of the Trusts overall call volume but can make
it more challenging to respond to those patients who have serious, lifethreatening emergencies. An alternative way to manage these patients
who will invariably have complex health and social care needs is required,
which will necessitate us working closely with other health care partners.
Baseline: Currently this AQI measures the number of frequent callers
as a percentage of all calls received. Each ambulance service has its own
definition of a frequent caller and can manage them locally as they see
fit. This leads to huge variations between ambulance trusts and the data
cannot be compared fairly. The Trust is still awaiting the completion of the
EEAST Quality Account 2014/15
national frequent caller methodology. The baseline will be defined during
the year when this new guidance is in place.
Goal: To ensure that the Trust implements the new frequent caller
guidance when it is released. This should facilitate local processes to
ensure an increase in the number of patients with a locally-agreed
frequent callers procedure in place.
Improvement: Adoption and implementation of the new national
guidance. If patients are identified, their GP details will be obtained
and call volume details recorded via an established format and made
available to the patient’s GP. If they are not registered with a GP, the local
commissioning group or other relevant organisation will be approached.
We should provide quarterly analysis relating to management plans in
place for patients identified as frequent callers.
24
Friends and family test
Rationale: The Friends and Family Test (FFT) is a feedback tool which supports the principle that people who use the NHS should be given
the opportunity to feedback on their experiences. The FFT is now a national directive and from April 2015, the Trust is required to provide all
‘see and treat’ Emergency Service (ES) patients (i.e. those we do not convey), all Patient Transport Service (PTS) patients and all patients who
have had face to face contact in the Primary Care Service (PCS) (such as in a primary care centre or home visit) with the opportunity to provide
feedback on the service they have received. The FFT is considered to be a continuous ‘real-time’ feedback loop between patients and the
providers providing the services, with patient feedback being available more quickly than traditional survey methods. Such a feedback loop
not only highlights areas of good practice but also areas for service improvement and will enable the Trust to take swift action if required.
The FFT is a response to the question: ‘How likely are you to recommend our service to friends and family if they needed similar care or
treatment?’ The Trust is required to report the results from the FFT to both the commissioners and NHS England from May 2015.
Following recommendations by NHS England, the calculation of the FFT score is to move away from a net promoter scoring system and instead
be based on the percentage of respondents that would recommend/would not recommend the service. The net promoter scoring system has
been used for the continuous patient experience surveys during 2014/15, with the results being retrospective due to the postal methodology
undertaken (results up to December 2015). However, the ‘real-time’ method and new FFT calculation was undertaken for the pilot phase of
the FFT, with this method and calculation being adopted by the Trust for the FFT from April 2015.
EEAST Quality Account 2014/15
25
FFT results from the continuous postal surveys during 2014/15:
During the previous year (April 2014 to February 2015), the FFT scores ranged as follows:
• Emergency services: +82
• Primary care services: +69
• Patient transport services: +72
FFT results from the pilot real-time FFT
Results from the pilot phase of the ‘real-time’ FFT (which was undertaken in Norfolk for ES and PCS patients and in
Suffolk for PTS patients from the 1st of December 2014 to the 9th of January 2015) can be seen below:
• 100.0% of patients who used the ES responded that they would be ‘extremely likely’ to recommend the service.
• 100.0% of PTS patients answered that they would be at least ‘likely’ to recommend the service, with 77.0%
responding that they would be ‘extremely likely’ to do so.
• 98.2% of patients who had used the PCS advised that they would be at least ‘likely’ to provide a recommendation,
with 93.0% of patients answering that they would be ‘extremely likely to do so.
(Caution must be undertaken when interpreting the pilot FFT results, due to the small sample sizes which may not be
representative.)
Goal: To ensure that all ‘see and treat’ ES patients, all PTS patients and all patients who have had face to face contact
in the PCS are provided with the opportunity to provide feedback in relation to the service they have received. Once
the national average is known, the Trust will aim to maintain the FFT score at the national level or above for those
patients who would be ‘likely’ or ‘extremely likely’ to recommend the East of England Ambulance Service NHS Trust to
a friend or relative across the service lines.
Improvement: To see an increase in the number of FFT feedback forms completed by the patient and to see a rise in
the proportion of ‘likely’ or ‘very likely’ responses received from patients who complete the feedback forms. The FFT
results will give an indication as to how our patients view the Trust and the services provided and also highlight areas
which may require service improvement.
This is discussed in detail later in the report.
EEAST Quality Account 2014/15
26
Monitoring priorities 2015/16
A
number of indicators are in place to measure process and outcome
for each of the priorities. Performance will be reported through the
clinical quality governance channels and provided to managers to
share with their teams. This will allow for performance benchmarking and
taking any actions to improve areas of underperformance or recognising
where good performance has made a real difference to the service.
Outcome indicators monitor specific criteria achieved; for example, a
percentage improvement in patients who are transported to a Primary
Percutaneous Cardiac Intervention (PPCI) centre within 150 minutes of
call.
The following objectives and indicators will be measured for the list of
improvement priorities for 2015/16 and performance against these will
be published throughout the year and will be made available to key
stakeholders. Targets against categories have been set by our Clinical
Commissioning Groups within our Accident and Emergency Contract
2015/16.
EEAST Quality Account 2015/16
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Category
The percentage of patients suffering a STEMI
who are directly transferred to a centre capable
of delivering PPCI and angioplasty within 150
minutes of call
The proportion of patients with STEMI who
received an appropriate care bundle
Numerator
EEAST Quality Account 2014/15
Target for
improvement
93.4%
95%
80.2%
80%
96.4%
95%
55.3%
56%
Number of sepsis patients as per
the clinical impression
93%
90%
All patients who had resuscitation
(advanced or basic life support)
commenced/continued by
ambulance service following an
out-of-hospital cardiac arrest
24.1%
25%
The number of patients conveyed Number of eligible cardiac
to a heart attack centre within
patients
150 minutes
The percentage of patients
suffering a STEMI who receive an
appropriate care bundle
The percentage of stroke patients (assessed
Patients with suspected stroke
face-to-face) who receive an appropriate care
assessed face-to-face who
received an appropriate care
bundle.
bundle FAST, BP, BM
The percentage of Face Arms Speech Test (FAST) Patients with new onset stroke
positive stroke patients (assessed face-to-face) like symptoms of known time
potentially eligible for stroke thrombolysis who <4.5hours conveyed to a hyper
arrive at a hyper-acute stroke centre within 60
acute stroke centre within 60
minutes
minutes of call
Sepsis early intervention
The number of patients whose
symptoms are correctly identified
as sepsis.
Cardiac care
ROSC at time of arrival at hospital overall
Average
2014/15
Denominator
Of the patients included in
the denominator, the number
of patients who had return
of spontaneous circulation
on arrival at hospital. Time of
arrival refers to the point at
which clinical responsibility
for the patient is handed over
from ambulance service to the
receiving hospital
Patients with a pre-hospital
diagnosis of suspected ST
elevation MI confirmed on ECG
The number of suspected
stroke patients who receive an
appropriate care bundle
Number of eligible stroke patients
arriving at a hyper acute stroke
centre within 60 minutes of 999
call
28
Category
ROSC at time of arrival at hospital (Utstein
comparator group)
Survival to discharge-Overall survival rate
Survival to discharge - Utstein Comparator
Group survival rate.
Frequent callers
EEAST Quality Account 2014/15
Numerator
Denominator
Of the patients included in the
denominator, the number of
patients who had return of
spontaneous circulation on arrival at hospital. Time of arrival
refers to the point at which
clinical responsibility of the
patient is handed over from
the ambulance service to the
receiving hospital
All patients who had
resuscitation (advanced or
basic life support) commenced/
continued by ambulance
service following an out-ofhospital cardiac arrest of
presumed cardiac origin, where
the arrest was bystander - or
emergency medical service
witnessed and the initial
rhythm was VF or VT
All patients who had
resuscitation (advanced or
basic life support) commenced/
continued by ambulance
service following an out-of–
hospital cardiac arrest
All patients who had
resuscitation (advanced or
basic life support) commenced/
continued by ambulance
service following an out-ofhospital cardiac arrest
No of patients deemed as
‘frequent callers’
Of the patients included in
the denominator, the number
of patients discharged from
hospital alive
Of the patients included in
the denominator, the number
of patients discharged from
hospital alive
No of patients deemed as
‘frequent callers’ with an
agreed management plan
Average
2014/15
Target for
improvement
50%
51%
6.5%
7%
20.6%
25%
0.2%
To be
determined
29
Category
75% of Category A calls resulting in an
emergency response arrival within 8
minutes
95% of Category A calls resulting in an
ambulance arrival at scene within 19
minutes
Numerator
Denominator
The proportion of Red 1
Category A calls requiring an
Number of calls
emergency response that were
responded to within 8 minutes
The proportion of Red 2
Category A calls requiring an
Number of calls
emergency response that were
responded to within 8 minutes
The proportion of Category A
calls requiring an emergency
Number of calls
response that were responded
to within 19 minutes
Average
2014/15
Target for
improvement
70.99%
75%
62.79%
91.22%
95%
Emergency
Service
+81
Norfolk 111
and OOH
+70
Friends and Family Test (CQuIN)
The proportion of patients
who would be extremely likely
to recommend EEAST, minus
the proportion of patients who
would not recommend EEAST.
The number of patients
confirming they would
recommend the Trust to
friends and family
Bedford OOH
call handling
+57
Patient
Transport
Service +72
Clarification
of national
results and
proposed
national
target may be
published in
2015
All services
+73
EEAST Quality Account 2014/15
30
CASE STUDY
STEMI
An ambulance crew were called out to an 85 year old patient that was
suffering with chest pain.
The patient was experiencing symptoms of central chest pain radiating
into both arms, anxious, breathing at a fast rate and suffering with nausea
and vomiting. These are all typical symptoms of a patient experiencing
an acute coronary syndrome. Observations taken, including an ECG
confirmed that this patient was having a heart attack. In line with
protocol, the patient was administered aspirin, Glyceryl Trinitrate (nitrate),
morphine (for the pain but also helps with anxiety), metoclopramide (anti
sickness drug) and Clopidogrel (an antiplatelet).
The patient was continually monitored by the paramedics. The ambulance
conveyed the patient directly to a specialist centre and received primary
percutaneous cardiac intervention (PPCI) treatment where the patient was
fitted with a stent.
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31
National targets
A
mbulance Clinical Quality Indicators (ACQIs) provided the
Trust and its stakeholders with a broad overview of the clinical
quality achieved during 2014/15, and allow for comparison with
other ambulance services providers. Data is submitted monthly to the
Department of Health (DH) and the Trust Board receives the information
within two months of the incident date; however the Department of
Health (DH) publication date is some months after this. Published results
can be found here:
or injuries.
http://www.england.nhs.uk/statistics/statistical-work-areas/
ambulance-quality-indicators/ambulance-quality-indicatorsdata-2014-15/
• within eight minutes in 75% of cases
With the exception of the eight-minute response time standard and
the 19-minute transportation standard for Category A (immediately
life-threatening) calls, no thresholds have been set by the DH to denote
‘poor’ clinical performance for the ACQIs. However, we set our own
targets to encourage performance improvement.
Emergency 999 calls are separated into Red 1 and Red 2 to support and
improve the service provided to patients with life-threatening conditions
EEAST Quality Account 2014/15
• Category A (Red 1) - presenting conditions which may be
immediately life-threatening and should receive an emergency
response within eight minutes in 75% of cases
• Category A (Red 2) - presenting conditions which may be lifethreatening (but less time critical than Red 1) and should receive an
emergency response
• Category A (both Red 1 and Red 2) - presenting conditions which may
be immediately life-threatening and should receive an ambulance
response at the scene within 19 minutes in 95% of cases.
For both of these eight-minute standards, an emergency response can
include an ambulance, rapid response car, a community first responder
equipped with a defibrillator or a healthcare professional.
The clock stops when the first response arrives at the scene of the
incident for the eight-minute standards and when the first ambulance
response vehicle arrives at the scene for the 19-minute standard.
32
In 2014/15, the Trust dealt with 964,917 emergency calls during the year and conveyed 506,053 patients to hospital. The table below
summarises the Trust’s performance against the national response time standards:
Indicator
Category A (Red 1)
Category A (Red 2)
Category A19 (Red 1 and
2)
National
standard
Eight minutes
Eight minutes
19 minutes
Trust
performance
70.99%
62.79%
91.22%
National
average*
71.9%
69.1%
93.9%
Clinical audit
The Trust has focused on national mandatory reporting requirements for ambulance clinical quality indicators and national clinical performance
indicators within this year’s clinical audit programme, this has been caused with the restructure of support services to invest corporate spend
in frontline delivery of services. This process is due to be completed in quarter two 2015/16 and work has already begun on expanding the
clinical audit programme for this year.
EEAST Quality Account 2014/15
33
Patient experience and feedback
The patient services team coordinates all complaints, concerns and compliments, as well as legal claims
against the Trust, inquests involving staff, and requests for information such as those received from coroners,
police or access requests under the Data Protection Act 1998.
The feedback, both positive and negative, is managed by the department and enquirers are kept informed
throughout the process and informed of the outcome of their feedback.
The Trust’s Complaints Policy was reviewed in 2014 to include information about the risk grading of
complaints and the development of peer review panels.
Complaints
The Trust received 974 complaints in 2014/15 compared to 798 in 2013/14, which is an increase of 22%.
The following table shows the number of complaints received by directorate over the past three years.
Complaints in relation to all three sectors increased. There has been an increase in most complaint types,
except for delay which decreased. Complaints relating to medication incidents have increased significantly.
EEAST Quality Account 2014/15
34
PALS / concerns
In 2014/15 the Trust received 540 concerns compared to 1,231 in 2013/14, a decrease of 41%. The most frequent types of concerns raised are broadly
similar to the complaints.
The Trust received 416 PALS enquiries, including comments on the Trust’s activities and enquiries about lost property, making a total of 956 issues
received.
201213
Emergency 980
care
Scheduled 102
transport
Primary
94
care
Clinical
quality
1
201314
Percentage
change:
2012-13 to
2013-14
2014- Percentage
15
change:
2013-14 to
2014-15
611
37.0
750
23+
126
26.5
155
15+
60
36
68
13+
1
0
EEAST Quality Account 2014/15
1
0
Type
201213
201314
Percentage
change
2012-13 to
2013-14
201415
Percentage
change:
2013-14 to
2014-15
Attitude
Clinical care
Communication and call
handling
Delay
Equipment
Medication
Patient property
Privacy/dignity
Transport and driving
Other
176
229
78
162
163
56
7.8 28.8 28.2 -
209
213
85
29 +
31+
52+
622
11
0
4
3
44
10
315
5
1
7
3
72
14
49.5 54.5 -
300
7
10
11
3
112
24
540+
900+
57+
0
56+
71+
75 +
0
63.6 +
40 +
35
Patient safety incidents
There were seven incidents causing serious harm or death during 2014/15, and
these occurred in Quarters 2 and 3. This equates to 0.11% of all reported patient
safety incidents compared to the national average of 2.85% (national data source
NPSA latest published data for the period of 01 April – 30 September 2014).
The Trust did not experience any ‘never events’ during 2014/15.
EEAST Quality Account 2014/15
36
Learning into action
T
he team is committed to using the feedback from complaints
and PALs to help identify themes and trends; linked with learning
from other sources such as clinical audits, staff reported incidents,
claims made by staff and patients and health and safety issues, this can
help make improvements to the service. Examples include:
• A notice disseminated to all stations about the importance of
appropriate parking and ensuring that other road users are not
obstructed
• A refresher training event focussing on trauma-related injuries to
the neck, spine and pelvis, including spinal immobilisation
• Implementing a ‘Pre-Hospital Communication Guide’ to enable staff
to communicate with people with a range of different needs
The main theme from complaints was around delays in ambulance
response. One of the Chief Executive’s six key priorities this year has
been to increase the number of qualified staff in the Trust by way of
a recruitment drive and to ensure the Trust has more ambulances
available to respond to calls. This has helped to reduce complaints and
provides patients with a better service.
The other two main themes were attitude of staff and clinical care.
EEAST Quality Account 2014/15
Customer care was included in the Professional Update programme for
this year and a new ‘Customer Care’ Programme is being developed for
operational staff where issues are raised about the member of staff’s
attitude or professionalism. With respect to clinical care, the Clinical
Manual was republished this year and a non-conveyance checklist was
produced for staff to complete for patients who are not conveyed to
hospital. In addition, the importance of clinical reasoning behind patient
assessment was included on the Professional Update programme.
Parliamentary and Health Service Ombudsman (PHSO): Although
most complaints are resolved through the Trust’s complaints process,
complainants are able to refer their complaint to the Parliamentary
and Health Services Ombudsman (PHSO) if they feel it has not been
resolved. In 2014/15, the Trust received 20 referrals, comparable to
21 in 2013/14 as a result of a change in PHSO procedures, which has
resulted in an increase across the NHS in the amount of cases referred
by the PHSO for formal investigation.
Where complaints were upheld, appropriate action was taken by the
Trust in response to recommendations made by the Ombudsman. For
example, the guidance for emergency operation centre staff using the
Healthcare Professional algorithm has been reviewed.
37
Compliments
In 2014/15 more than 1538 compliments were made about the service, an average
of 128 a month.
Compliments are reported to the Trust Board and the staff names are published
internally. Local management teams are informed of all compliments so they can be
passed onto the staff and an acknowledgement letter is sent to the person making
the compliment by the Chief Executive.
Looking forward
The department will be holding quarterly peer review panels in order to critically
evaluate the current complaints process and will be working with the Patient’s
Association to develop these panels further.
The current complaints survey will be reviewed to ensure that the new
Parliamentary and Health Service Ombudsman’s framework (My expectations
when raising a complaint or concern) is embedded within both the patient
services department and the organisation.
EEAST Quality Account 2014/15
38
Patient experience
T
he Trust operates a well-established system of obtaining feedback
from patients, mostly run from a team acting independently from
departments delivering patient services. The patient experience
system includes liaison with the Trust’s User Group, and the involvement
of such volunteers has proved to be of great value especially with design
of patient surveys and reporting to external patient groups. The design
of all patient experience surveys is done with great care to ensure all
respondents involved are able to take part and feedback on the service
received.
Our annual patient experience programme of surveys include
continuous, rolling surveys for the three main service areas: emergency
services, out of hours primary care (the Norfolk 111 Service, the Norfolk
out of hours service and the Bedford out of hours call handling service)
and the patient transport service. Ad-hoc patient experience projects
are also conducted throughout the year, focusing on specific topic areas
e.g. a new service or an area of care that is being developed, or an area
where there may be a value in re-auditing.
Patient experience results are analysed and written into full/standard
reports which are then distributed to the service managers to monitor
patient satisfaction and identify areas for improvement. Patient
experience reports are published on the Trust’s website, and publicised
via the media, Twitter and Facebook.
As part of each patient experience survey, data on the patient’s
EEAST Quality Account 2014/15
Key Performance Indicator (KPI) is collected. The KPI calculates the
overall satisfaction of the patient in relation to the service they have
received and is used as a benchmark across the Trust. The KPI result
is calculated by dividing the proportion of ‘very satisfactory’ and
‘satisfactory’ responses (numerator) by the overall number of responses
(denominator).
The ‘Friends and Family Test’ (FFT) score was a CQUIN and quality
priority for 2014/15 and is also a national directive, and we are required
to report the FFT results to both commissioners and NHS England from
May this year. The FFT is a response to the question ‘How likely are you
to recommend our service to friends and family if they needed similar
care or treatment?’. The FFT score is calculated by using the proportion
of patients who would strongly recommend our service minus those
who would not recommend it, or who are indifferent (subtracting the
proportion of respondents who provided ‘neither likely nor unlikely,’
‘unlikely’ and ‘extremely unlikely’ responses from the proportion of
patients who provided ‘extremely likely’ responses). Alongside the KPI,
the FFT score is used as a general performance marker and a means to
benchmark across the Trust. This score is also reported as part of the
Trust’s dashboard.
Following recommendations by NHS England, the calculation of the
FFT score will now be based on the percentage of respondents who
would recommend/would not recommend the service. The original
net promoter scoring system has been used in the continuous patient
39
experience surveys during 2014/15, with the results being retrospective due to the postal methodology used (results up to December 2014).
However, the ‘real-time’ method and new FFT calculation were done for the pilot phase of the FFT and we adopted this method and calculation from
April this year.
The chart below includes the KPI and FFT figures over the time period from April to December 2014:
Trust patient
experience:
April to December
2014
Emergency services
Norfolk 111 and
OOH
Bedford OOH call
handling
Patient transport
service
All services
‘Overall satisfaction’
‘Recommend to family or friends’
Quantity of patients
KPI performance
Recommend
– would not
recommend/
indifferent
FFT performance
957/976
98.1%
84.1 – 3.3
+81
781/846
92.3%
75.8 – 6.3
+70
104/113
92%
65.8 – 9.0
+57
2080/2193
94.8%
75.6 – 3.7
+72
3922/4128
95%
77.3 – 4.3
+73
Data is always collected about patient demographics and every patient experience survey includes an equality and diversity information collection
form, with the responses to this section of the questionnaire reported on every patient experience report. The overall satisfaction of the patient is
analysed against patient demographics to ensure that separate patient group levels of satisfaction are recorded.
Every survey also encourages comments from patients and which are written up as part of the reporting process. The number of positive comments
received always far outweigh the number of negative comments. However, it is often the negative comments which are the most useful from the
perspective of learning and finding areas for possible improvement. These comments are passed to the Patient Services Department for action.
In addition to the patient experience projects the results of the national ambulance patient survey by the Care Quality Commission (CQC) were
published in July 2014. This national project was conducted as a telephone survey and asked patients for their feedback in relation to the service
they received from the EEAST after they had called 999. This survey focused on ‘Hear and Treat’ patients, rather than patients who were visited
EEAST Quality Account 2014/15
40
by ambulance staff, and the results were benchmarked against
other ambulance trusts. Overall, the Trust performed similarly to
other ambulance services across the different areas of the service
received. Such national surveys are considered to be a valuable
tool in obtaining feedback from patients and to see where we are
performing highly, along with areas where improvement may be
required.
Future patient and carer survey strategy
We are committed to developing the patient experience and
engagement activity and seeking new methods of collecting
information and feedback from patients in relation to their
experiences when using the services provided. The continuous
patient experience surveys, along with any ad-hoc patient experience
projects as part of the patient experience programme, will carry on,
as will patient discovery interviews following on from such surveys.
Patient satisfaction levels will continue to be reported as a KPI and
FFT scores, with the ‘real-time’ FFT patient feedback forms already
underway across the region from April this year.
For 2015/16, all three main service areas will continue to actively
collect feedback from patients:
Emergency services
• Postal survey to random samples of 999 and GP urgent patients,
with monthly management reports and annual Trust reporting
• Specific surveys of patients in relation to certain aspects of the ES
(e.g. patient experience surveys in relation to obstetric patients,
young patients with pain, trauma, falls and mental health
patients have previously been undertaken)
EEAST Quality Account 2014/15
• Face to face interviews with quarterly reports.
Primary care services
• Postal survey to a random sample of patients who used the
Norfolk 111 service, with monthly management reports and
annual Trust reporting. Surveys for this service will continue until
the end of August when EEAST will no longer be the provider.
• Postal survey to a random sample of patients who used the
Norfolk out of hours service, with monthly management reports
and annual Trust reporting
• Postal survey to a random sample of patients who had used
the Bedford out of hours call handling service, with monthly
management reports
• Face to face interviews with quarterly reports
Patient transport service
• Postal survey of patients organised by contract, with rolling
management reports (quarterly or monthly depending on
contract) and annual Trust reporting
• Quarterly ‘patient transport clinical assessment and advice
service’ surveys, with quarterly management reports
• Specific surveys of patients in relation to a certain aspect of the
PTS (e.g. a patient experience survey in relation to the experience
of bariatric patients has previously been undertaken). During
2015/16, a project on the experiences of dementia patients who
have used the patient transport service is planned
• Face to face interviews to continue with quarterly reports
41
CASE STUDY
Hypoglycaemia
A 999 call was placed and an ambulance responded to a patient at their
home address who was a known diabetic. The call was received by the
patient’s spouse who found her husband confused and aggressive in
bed. The ambulance crew arrived and carried out their assessment of the
patient.
The patient’s blood sugar was critically low with a reading of 1.5mmol.
The normal range is between 5-9mmol. The ambulance crew
administered 1mg of glucagon as an injection into the patient’s arm.
Glucagon is a drug which converts stored glucose known as glycogen
(stored in the liver) into glucose and raises the blood sugar level. This
treatment had good effect and the patient then was able to follow up with
consuming some sugary drink and carbohydrates.
The patient made a full recovery and was left at home with a reading of
8.6mmol. The GP practice was made aware and an advice leaflet was left
with the patient.
EEAST Quality Account 2014/15
42
Participation in clinical research
R
esearch helps all NHS services improve the
current and future health of the people
it serves. It is essential in successfully
promoting health and plays a major part in
continuing to improve services and supporting
safe and effective care. Research identifies and
evidences new ways of preventing, diagnosing
and treating conditions.
During 2014/15 538 patients and five members
of staff were enrolled onto research approved
by a Research Ethics Committee. This activity
arose from participation in three projects on the
National Institute for Health Research (NIHR)
Portfolio:
• Epidemiology and outcome from out of
hospital cardiac arrest registry study (OHCAO)
• Early evaluation of the integrated care and
support ‘Pioneers’ in the context of the Better
Care Fund and the Integrated Care Policy
Programme
• Variation in rates of ambulance service nonconveyance of patients to an emergency
department (VAN).
We also participated in a Collaborations for
Leadership in Applied Health Research and Care
EEAST Quality Account 2014/15
(CLAHRC) project looking in more detail at use
of the emergency ambulance service by people
with dementia. In addition, Research Support
Services (RSS) supported a number of smallerscale student level projects being undertaken by
internal and external members of staff. Continued
participation in such clinical research activity has
demonstrated the Trust’s on-going commitment
to improving the quality of care offered, and
to making a contribution to wider health
improvement.
In terms of capacity-building activity during
2014/15, RSS continued to publish access to
relevant emerging research evidence on on the
Trust intranet. In addition, more than 90 members
of staff have received introductory training about
research in the NHS and completed the Good
Clinical Practice (GCP) e-learning course.
The RSS activity was supported by funding from
the new Local Clinical Research Network Eastern
and through recruitment of subjects to Portfolio
studies where applicable. In 2015/16, we will
take part in a number of large-scale research
projects, one of which involved the sponsorship
of research for the first time.
43
Goals agreed with commissioners
C
ommissioning for Quality and Innovation (CQUIN) enables commissioners, which are the NHS bodies charged with provision and funding
of services, to reward innovation and excellence. A proportion of the Trust’s income during 2014/15 was conditional on achieving quality
improvement and innovation goals for the provision of emergency and urgent ambulance NHS services, as agreed by the commissioning
Clinical Commissioning Groups (CCGs).
The programme supported EEAST in delivering its transformation objectives and providing care to patients as quickly as possible by providing stretch
response objectives at a more local level. In addition in line with national guidance the CQUIN schemes supported implementation of a robust
‘Friends and Family’ test for patients and our staff. This has since been mainstreamed into our organisational approach to supporting staff and
patients and constantly improving the service that we deliver.
EEAST Quality Account 2014/15
44
To access more detailed information about the CQUIN guidance for
commissioners and providers in 2015/16 please go to:
http://www.england.nhs.uk/wp-content/uploads/2015/03/9-cquinguid-2015-16.pdf
In 2015/16 the Trust is looking at the presence of a GP within the
Emergency Operations Centre (EOC) to review the Green calls which
are normally lower in acuity as its primary CQUIN scheme. This is in
line with Urgent and Emergency Care schemes identified nationally.
Data quality
Data quality continues to be a significant focus and a Data Quality
Compliance and Strategy Group was formed to gain confidence and
assurance that systems, policies, and procedures are in place and
operating to the best possible level of data quality and compliance.
A CAD Data Quality Policy supports the activities of the Data Audit
Team. The team have completed various audits across the Trust and
have a programme of regular checks to verify information that is
reported nationally.
The activities of the Data Audit Team are subject to independent
external audit and continue to support the Trust’s Data Quality Action
Plan.
NHS Number and General Medical Practice code
validity
Service for inclusion in the Hospital Episode Statistics.
Information governance toolkit attainment levels
The toolkit is an online assessment produced by the Department of
Health (DH) and administered nationally by the Health and Social
Care Information Centre (HSCIC). It draws together legal requirements
and central NHS guidance for information security best practice,
and presents them as a set of specific information governance
requirements.
The toolkit requires NHS organisations to carry out an annual
self-assessment against each of these requirements, to enable
organisations to ascertain whether information is handled correctly
and protected from unauthorised access, loss, damage and
destruction. The ultimate aim is to demonstrate that the organisation
can be trusted to maintain the confidentiality and security of personal
information.
For 2014/15, the Trust has declared an overall ‘satisfactory’ rating,
having achieved level 2 or level 3 on all applicable toolkit standards.
The Information Governance Toolkit is available on the HSCIC website:
https://nww.igt.hscic.gov.uk/
Clinical coding error rate
The Trust is not subject to the Payment by Results clinical coding audit
undertaken by the Audit Commission.
No records were submitted during 2014/15 to the Secondary Uses
EEAST Quality Account 2014/15
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PART 3
EEAST Quality Account 2014/15
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EEAST Quality Account 2014/15
47
Priority 1: Saving lives
- Heart attack care
- Stroke care
- Cardiac care
- Sepsis treatment
EEAST Quality Account 2014/15
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Heart attack care
Rationale: Heart attack (STEMI) is the single biggest cause of death in the UK. Most heart
attacks are caused by coronary heart disease, when the coronary arteries narrow due to
a gradual build-up of atheroma (fatty material) within their walls and a piece breaks off
leading to a blood clot. A heart attack is life-threatening and, by providing patients with
a pre-hospital assessment for a STEMI and administering an appropriate care bundle, a
significant improvement on patient outcomes will result - supporting the NHS to reduce the
number of patients dying prematurely and to help people to recover from episodes of ill
health or following injury.
What did the Trust set out to do? The Trust set out to improve the care for patients
suffering a STEMI by improving the STEMI care bundle provided by the clinicians, and by
improving the time it takes to take a patient with a confirmed STEMI directly to a heart
attack centre for primary PCI treatment.
Achievement attained:
STEMI 150
The target percentage of patients suffering a STEMI who are directly transferred to a centre
capable of delivering PPCI and angioplasty within 150 minutes of call was 93. 4%. There is
still much work to be done to meet the target of 95% consistently; however EEAST PPCI 150
figures remain consistently above national average. (Latest national data published - Dec14)
STEMI care bundle
The Trust set out to achieve 87% compliance with the care bundle but did not reach this
target with a yearly average figure of 80.2%. This includes recording two pain scores, giving
aspirin to break down the fibrin clot, giving Glyceryl Trinitrate (GTN) to dilate the coronary
arteries, and providing analgesia. The patient care record is audited against all these criteria
and deemed to be either compliant or non-compliant. (Latest national data published Dec14)
EEAST Quality Account 2014/15
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Stroke care
Rationale: Stroke is the third biggest cause of death in the UK and the largest single cause of severe disability. Each year more than 110,00
people in England will have a stroke. Most people affected are over 65, but anyone can have a stroke including children and babies. Face-armsspeech-time (FAST), is a simple test to help people recognise the signs of stroke and understand the importance of emergency treatment. The
faster a stroke patient receives treatment (the care bundle), the better the chances are of surviving and reducing long term disability.
What did the Trust set out to do? Achieve continuous improvement in stroke 60 and continually achieve high care bundle compliance.
The goal set for stroke 60 was to ensure 56% of all patients eligible for stroke thrombolysis arrived at a hyper-acute stroke unit within 60
minutes. The actual figure was 55.3% for the year 2014/15.
The care bundle target set for 2014/15 was 95%; we achieved 96.4% (2014/15) which is slightly better than last year’s figure of 96%. (Latest
national data published - Dec14)
EEAST Quality Account 2014/15
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Cardiac care
Rationale: Around 30,000 people each year in
the UK have cardiac arrests in the pre-hospital
environment, but less than 10% of those will survive
to be discharged from hospital (according to data
from the Resuscitation Council UK). Around two
thirds of cardiac arrests outside of hospital happen in
the home, but that nearly half of those that occur in
public are witnessed by bystanders.
With each minute that passes in cardiac arrest before
defibrillation, chances of survival are reduced by
about 10%. Immediate CPR in a shockable pre-hospital
cardiac arrest can improve the chances of survival by
up to three times.
What did the Trust set out to do? The Trust
set out to improve the Trust’s outcomes from cardiac
arrest and work towards an increase in ROSC and
‘survival to discharge’ figures. (Latest national data
published - Dec14)
The Trust embarked on a huge project to improve
the life-saving capabilities of communities across the
region with 1,000 defibrillators delivered in the east of
England over the last three months.
EEAST Quality Account 2014/15
The project, which was launched in January 2015, has
seen the defibrillators being handed over to a host of
organisations and businesses, including village halls,
shops, sports clubs, pubs, tourist attractions, schools,
hotels, and libraries.
Of the 1,000, 263 have been delivered in Norfolk, 195
in Essex, 180 in Suffolk, 175 in Cambridgeshire, 94 in
Hertfordshire and 93 in Bedfordshire
Chief Executive Anthony Marsh said: “I’m really proud
that we have managed to deliver 1,000 defibrillators
to key locations in our communities in under three
months. This project will undoubtedly save lives now
and for many years to come.”
Now work will start on training the staff and firstaiders that have received a defibrillator on how to use
it in case they are ever called into action.
The Trust has launched a new campaign, Their Life,
Your Hands, to help take the fear out of using a
defibrillator. For more information we encourage you
to view the campaign video on the Trust website and
see our video about our community public access
defibrillator sites.
51
EEAST Quality Account 2014/15
52
Sepsis
Rationale: Sepsis claims the lives of more than 37,000 people in the
appropriate healthcare staff training.
UK, which is more than lung cancer and more than breast and bowel
cancer combined. The estimated cost to the NHS for sepsis is around
£2 billion annually for treatment.
What the Trust set out to do: By using the screening tool
It is shown in recent research that early recognition of the signs and
symptoms of sepsis will save lives, possibly as many as 12,500 per
year in the UK, (Robson et al. 2009: p535-538.) The paper is quoted
as stating, The care of the critically ill or injured patient often begins
in the prehospital setting, and in time-critical conditions such as AMI
or stroke, specific interventions by prehospital practitioners make
a significant difference to mortality. Severe sepsis is no different—
the use of a pre-hospital severe sepsis screening tool and the
implementation of a modified ‘sepsis six’ may significantly improve
patient outcomes.
Baseline: In 2013/14, a month on month audit was undertaken
Neutropenic sepsis is a significant cause of death for cancer patients
receiving chemotherapy and causes delays and changes to planned
treatments. In England and Wales, relative to the increasing number of
cancer diagnoses, the proportion of deaths due to neutropenic sepsis
continued to rise for all age groups between 2001 and 2010.
Recent National Institute of Healthcare and Clinical Excellence (NICE)
guidance recognises neutropenic sepsis is a medical emergency
that requires immediate hospital investigation and treatment and
recommends improving the clinical care pathways of cancer patients
undergoing chemotherapy, immediate access to antibiotics and
EEAST Quality Account 2014/15
developed by the UK Sepsis Trust in 2014/15, staff would be more
able able to recognise red-flag sepsis and septic shock in adults, and
the need for urgent and timely interventions and transportation to
hospital.
where it was determined that crews recognised sepsis in about 75%
of cases. For 2014/15 the Trust intended to increase the number of
sepsis cases the crews recognised and recorded to 85%. The audit for
this year was confined to one month (October 2014) and the target
was exceeded with the crews correctly identifying 93% patients with
sepsis.
Goal: The Trust intends to set a target of above 90% for the number
of sepsis cases the clinicians recognise and record. It also intends to
expand the audit to include care bundles given.
Improvement: Continue to increase the awareness and delivery
of the sepsis care bundle and neutropenic sepsis to provide the
highest standards of pre-hospital care.
53
Priority 2: Keeping
patients safe
- Frequent callers
EEAST Quality Account 2014/15
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Frequent callers
F
requent callers are handled in accordance with The Management
of Patients with Defined Individual Needs Policy. There are frequent
callers who have individual care needs and hospital-led treatment
plans for terminally sick patients. There are also frequent callers who access
the service inappropriately, resulting in a high demand on the service and
putting other patients at risk.
A frequent caller over 18 is defined as someone who calls more than five
times in a one-month period, 12 calls in a three- month period or 15 calls in
a one-month period from a communal address. A frequent caller under 18
is defined as someone who calls two or more times in a six-monthly rolling
period.
The cost of each emergency ambulance journey to A&E or ‘See and Treat’
at scene is in excess of £200. Patients taken to A&E will incur further
attendance tariffs , whereas a ‘Hear and Treat’ cost is considerably less.
Frequent callers may typically overstretch the service with multiple calls on
any given day; this will affect call handling, dispatching to other callers, and
ultimately end up with multiple inappropriate attendances to an address or,
if conveyed, further costs to the NHS.
EEAST Quality Account 2014/15
55
Due to the dynamic complexity i.e. number of calls received during
longer time periods, it is difficult to provide a month-on monthpercentage of the number of plans in place versus the number of
frequent callers. However the last published ambulance quality indicators
(AQI) system indicator for frequent callers from October 2014 identified
the following:
• Total calls received: 75,469
• Calls from patients where a plan is in place: 167
• Proportion of calls from patients for whom a locally agreed frequent
caller procedure is in place: 0.2%
Once a patient is identified as a frequent caller, we write to their GP
to agree an Ambulance Management Plan. Although some cases are
different, instead of sending a response to these patients every time they
call, they will be offered one Clinical Support Desk (CSD) triage a day and
sometimes an ambulance response, then further calls not coded as an
immediate threat to life are reviewed for a 24-hour period. Typically,
most frequent callers who are being managed, once they have been
written to informing them that they are being managed, will reduce their
call volume. Prolific frequent callers are then managed with a MultiDisciplinary Team and in extreme cases legal action can be taken.
On average, the service identifies approximately 200 frequent callers a
month and there are 202 Ambulance Management Response Plans in
place to manage certain frequent callers.
EEAST Quality Account 2014/15
Case study 1:
One of the highest frequent callers called 590 times between 1 March
2014 – 1 March 2015. Between 1 January 2014 – 9 August 2014 the
caller called us 261 times, resulting in a cost in excess of £26,000. An
ambulance attended 22% of these calls, they were triaged through
‘Hear and Treat’ 39% of the time, and their Ambulance Management
Response Plan managed them 39% of the time. Without the Ambulance
Management Response Plan this frequent caller would have cost more
financially, used more ambulance unit hours and put other service users
at greater risk. We are now pursuing court action with this frequent
caller.
Case study 2:
Another frequent caller called 702 times between 1 March 2014 – 1
March 2015. Before they had a plan in place they would call every day
and then ignore the CSD call backs, therefore an ambulance response
had to be sent. The ambulance would arrive on scene and they would
generally refuse treatment and transport and often just tell the crew
to go away. After consulting with their GP, their plan stipulated that if
they didn’t take the Trust’s call backs after three attempts, the job was
able to be closed. Their plan was put in place in August (seven months
before this, they made 251 999 calls and were sent approximately 94
ambulance responses). Seven months after the plan was put in place, the
patient made 463 calls, they have had approximately 80 CSD triages and
only been sent an ambulance response on five occasions. Unfortunately
the patient still ignores call backs resulting in 83% of their calls being
managed by the Ambulance Management Response Plan.
56
Priority 3: Giving a positive
experience of our care
- Friends and family
EEAST Quality Account 2014/15
57
Friends and family test (FFT)
Results from staff survey question(s) against national scores
T
he survey was distributed to all staff employed by the Trust during November and December 2014. A total of 4048 paper surveys were
posted, due to the Trust’s restructure activities a total of 78 staff were excluded from the survey because they had left the Trust.
The final response rate to the National Staff Survey was therefore 27% (1078 usable responses from a final sample of 3970) this is below
the national response rate of 35% for Ambulance Trusts. Approximately 77% of the total responses were captured from operational frontline
staff.
The Friends and Family Test question within the survey asks staff ‘If a friend or relative needed treatment I would be happy with the standard of
care provided by this organisation’, the score for EEAST decreased from 40% in 2013 to 30% in 2014.
Top five improved scores
• Agreed that they would be happy with standard
of care for friend/relative
• Appraisal left staff feeling that their work is
valued by the organisation
• Agreed they are able to deliver patient care they
aspire to
• Agreed thet they know who the senior managers
are where they work
• Agreed that commnunication between senior
managment and staff is effective
EEAST Quality Account 2014/15
Top five declined scores
• Staff have had an appraisal/review in the last 12
months
• Received equality & diversity training in the last
12 months
• Received health and safety training in the last 12
months
• Agreed that organisation encourages staff to
report errors, near misses or incidents
• Staff saying in an avergae week they have not
worked additional PAID hours over and above the
hours they are contracted for
58
CASE STUDY
Stroke
An ambulance was called to a medical practice.
The GP was suspecting that a 67-year-old patient was
displaying signs of stroke. The crew took over care of the
patient and completed a full set of observations as well as
the history of onset time as part of their initial assessment. A
neurological assessment was completed which included the
FAS test (face, arm, speech test) which concluded that the
patient had no facial droop, right arm weakness and slurred
speech. None of these were normal for the patient.
The patient was transported by the ambulance crew under
emergency conditions to the emergency department of
the nearest receiving hospital with provisions for stroke
treatment.
EEAST Quality Account 2014/15
59
Actions from results
Workstream
Objective
Activity
To increase the ‘citizenship’ of the organisation
• Publish a Staff Engagement & Culture
• Hold regular Chief Executive sounding boards
strategy
• Implement quarterly pulse surveys
• Develop strong organisational brand
• Increase staff morale through empowerment
and engagement
Develop values/vision for EEAST
Roll out quality leadership and management
programmes incorporating our values and
vision which targets junior, mid and senior
management roles
• Develop senior leadership forums
• Use leadership programmes offered by HEE
• Assign managers with a coach from the East
of England HEE coaching network
• Make a compassion film with specific focus
on values and behaviours
• Incorporate values into JD and PS for all roles
Develop people and their careers
Implement a quality appraisal process based on
specific work performance measures and values
based behaviours
• Design new appraisal pro-forma
• Draft Appraisal Policy and guidelines
• Roll our appraisal training for managers
EEAST Quality Account 2014/15
60
Response times
O
ver 2014/15 we have seen significant improvements to our
performance in the last six months of the year. The improvements in
performance were, as is documented throughout this report, due to:
• hundreds of frontline staff recruited and major up skill training
introduced place for emergency care assistants and emergency medical
technicians
• hundreds of new ambulances delivered with new and upgraded
equipment
• increased ambulance cover
• ambulances back on road faster after handing over patients at hospital
• 999 calls being picked up more quickly
• £14m efficiency savings made in management and support functions
since January 2014, money that is being reinvested in the frontline.
These performance improvements have been against a backdrop of
increased demand on the 999 service – nearly a 6% increase in 999 calls and ongoing issues of ambulance crews having to wait extended times at
hospitals to hand over patients. In 2014/15, the Trust lost around 3,500 12
hour double staffed ambulance shifts to these delays.
The table on the next page shows that we have not met national
performance targets for the year (Red 1, Red 2 and Red 19). However, as
we have seen more staff joining the frontline and ambulance cover increase
we have seen continued and sustained improvements across all national
targets in the last half of the year. This graph shows the improvements
made, month on month to Red 1 performance.
EEAST Quality Account 2014/15
61
Category/measure
999 calls
Red 1
Red 2
Red 19
Green 1
Green 2
Green 3
2013/14
activity
2013/14
performance
912,474
13,093
73.57%
15,734
70.99%
250,695
69.42%
289,264
62.79%
262,270
92.92%
303,702
91.22%
46,954
79.12%
36,770
78.67%
218,592
82.97%
238,306
79.08%
31,372
90.72%
10,016
85.54%
19,113
92.12%
41,659
93.40%
19,162
58.90%
17,559
76.85%
17,287
86.45%
Green 3 (face to face)
95,628
92.99%
Green 4 (telephone)
Urgent
Urgent (1 hour)
Urgent (2 hours)
Urgent (4 hours)
EEAST Quality Account 2014/15
2014/15
performance
964,917
Green 3 (telephone)
Green 4
2014/15
activity
60,242
75.14%
62
Statement of directors’ responsibilities
T
he Board of Directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The
Department of Health (DH) has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal
requirements in the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended by the
National Health Service (Quality Accounts) Amendment Regulations 2011).
In preparing the Quality Account, directors are required to take steps to satisfy themselves that:
• the Quality Accounts presents a balanced picture of the Trust’s performance over the period covered
• the performance information reported in the Quality Account is reliable and accurate
• there are proper internal controls over the collection and reporting of the measures of performance included in the Quality
Account, and these controls are subject to review to confirm that they are working effectively in practice
• the data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified
data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review
• and the Quality Account has been prepared in accordance with DH guidance.
The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the
Quality Account.
By order of the Board
30th June, 2015
EEAST Quality Account 2014/15
63
Statements from Healthwatch and
health, overview and scrutiny
committees (HOSCs)
H
ealthwatch is an independent consumer champion created to gather and
represent the views of the public.
Healthwatch England will also advise the NHS Commissioning Board, English
local authorities, Monitor, and the Secretary of State who have the power to
recommend that action is taken by the Care Quality Commission (CQC) when there
are concerns about health and social care services.
Healthwatch, who are represented within each local authority, will play a role at
both national and local level and will make sure that the views of the public and
people who use the services are taken into account.
Local Healthwatch will :
• represent the views of people who use services, carers and the public on the
health and well being boards set up by local authorities
• provide a complaints advocacy service to support people who make a
complaint about services
• report concerns about the quality of health care to Healthwatch England who
can then recommend that the CQC take action.
All local Healthwatch bodies and HOSCs received a draft Quality Account for
comment and these are published in the following pages.
EEAST Quality Account 2014/15
64
Healthwatch Hertfordshire
Healthwatch Hertfordshire welcomes the opportunity to comment on
EEAST’s Quality Account. Healthwatch Hertfordshire commends the
seven priority objectives put forward for 2015/16.
and improve many of the issues it faces. The first priority must be to
get to patients quicker and to improve the quality of care provided to
patients.
Stroke Care is very much a concern of Healthwatch Hertfordshire
and we are pleased that the Trust is committed to raising awareness
about stroke and all aspects of stroke care within the organisation. The
location of stroke units is key and this may need to be reviewed to give
reassurance that these are in the right places for patients.
We look forward to seeing the progress on the work to improve sepsis
care as this is a key concern.
Healthwatch Hertfordshire is pleased that action was undertaken to
implement a set of priority actions to address issues of insufficient staff
and resources and welcomes the news that all of the 400 staff have
been recruited under the Student Ambulance Paramedic programme
and that it is hoped to recruit and train 400 more Student Paramedics
in 2015/16. This is significant as there are currently a large number of
vacancies in areas of Hertfordshire that need to be filled.
Hospitals in our area have seen a large rise in emergency admissions
over the winter and spring period which has impacted on ambulance
turnaround times and resulted in many ambulance crews having to
wait long periods at hospitals to hand over patients. Healthwatch
Hertfordshire supports the use of Hospital Ambulance Liaison Officers
(HALOs) at the acute hospitals to support hand-overs and hopes joint
working with commissioners and the hospital trusts will achieve a
longer term solution.
It is also good news that the Trust will continue with the fleet
replacement programme to maintain all frontline vehicles less than five
years old.
Healthwatch Hertfordshire is looking forward to supporting the
Trust in the coming year to achieve their aspirations outlined in the
report. These present a challenging programme of activities, which
will require the Trust to have in place rigorous systems to achieve the
improvements they seek.
The Trust has demonstrated robust results against patient experience
surveys which we support. We were also pleased to see that a
complaint by a Hertfordshire resident was presented to an EEAST Board
meeting following feedback from Healthwatch Hertfordshire and we
hope that learning from that event will now be implemented.
We look forward to meeting with the Hertfordshire team for further
involvement and updates on progress.
The Trust has faced considerable challenges in recent years and as a
result there has been significant changes in the last year to address
EEAST Quality Account 2014/15
Michael Downing, Chairman Healthwatch Hertfordshire
June 2015
65
Healthwatch Bedford Borough
Thank you for giving Healthwatch Bedford Borough (HBB) the opportunity to comment on this.
In general terms it is good to see that EEAS has set clear indicators and targets – positive outcomes will also help to boost staff morale.
However there is no specific reference to dealing with Mental Health issues/ patients. As signatories to the Mental Health Crisis Care Concordat,
it would be a positive step if EEAS could indicate what it intends to do in terms of staff training/continuing development. It would be good to see
some indicators/targets being specified for this – particularly as one in four adults experience mental health problems.
The document also refers to “Stakeholder engagement”, but HBB does not appear to have been included in this process at all.
Whilst appreciating the large geographical area covered by EEAS, on page 52 it would be more positive to state that each local Authority has
their own Healthwatch; viz in Bedfordshire these are:
• Healthwatch Bedford Borough.
• Healthwatch Central Bedfordshire.
• Healthwatch Luton.
This is important because each of these areas are very different both in population mix and geography. The local Healthwatch organisation
is usually well placed to help support in the improved delivery of health and social care services. As EEAS is a major service provider the
relationships with the local Healthwatch are an important factor, particularly because they are each full members of the local Health and
Wellbeing Board.
I trust that these comments are of positive assistance to you.
Yours sincerely
Anne Bustin
Chair Healthwatch Bedford Borough
EEAST Quality Account 2014/15
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Healthwatch Norfolk
Healthwatch Norfolk is pleased to have the opportunity to comment
on the Quality Account. Overall we believe the document is clearly
laid out, logical and easy to follow but it would be helpful to include
reference to how to access the report and the different formats
available.
In general, the report is an easy read, but there are a few instances
where some technical terms are used which are not explained and
would be difficult for a layperson to understand. For example, in
relation to cardiac arrest care, the term “Utstein patients” is used,
whilst this is defined in the glossary at the back of the report it still
does not convey clearly what the term means.
Healthwatch Norfolk considers that overall the document illustrates
that the Trust is operating a quality service. Its performance against
national standards for Category A (red 1); Category A (Red 2) and
Category A19 were all slightly below the national average but we
acknowledge that national standards do not take into account that
a large proportion of the area covered is rural and, therefore, it is
difficult to compare this with other more metropolitan areas.
The layout which includes the rationale, what the Trust set out to do
and the achievement makes it easy to understand the progress made
on the 2014-15 priorities. The information on frequent callers is useful
to help make clear how resources are best used particularly at a time
when there is an increased demand on the 999 service.
We are pleased to note that the document clearly identifies the
EEAST Quality Account 2014/15
priorities for next year and we note in particular the proposed work to
continually improve stroke care in terms of the percentage of patients
eligible for stroke thrombolysis who arrive at a hyper-acute stroke unit
within 60 minutes.
The examples of ‘learning into action’ are helpful to reassure members
of the public of specific examples where changes have been made as a
result of their feedback.
With regard to the audits undertaken as mentioned in the section
headed Data Quality, a brief summary of the outcome of those audits
would make that section more meaningful.
We note that the report does not mention the introduction of a
permanent 24/7 Hospital Ambulance Liaison Officer (HALO) at the
Norfolk and Norwich University Hospital NHS Foundation Trust which
we believe has been shown to improve turnaround times at the
hospital and has a beneficial effect on ambulance response times.
Finally Healthwatch Norfolk confirms that we will continue to ensure
that any feedback we receive from patients, carers and their families
is fed back to the Trust as part of our developing relationship with all
health and social care providers in Norfolk.
Alex Stewart
Chief Executive
June 2015
67
Statements from clinical
commissioning groups (CCGs)
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68
Essex CCGs
The 7 Essex NHS CCGs NHS welcome the opportunity to comment on the annual Quality Account prepared by EEAST.
To the best of the CCGs’ knowledge, the information contained in the Account is accurate description of the quality of provision of services for
the service as a whole. The account should include reference to CQC registration and any updates on performance and we would suggest that
this is included within the final version of the account.
The Essex CCGs welcome the update relating to the key priorities for 2015/16 which include trajectories for ambulance response times,
optimising outcomes for patients with suspected ST elevated myocardial infarction (STEMI), ensuring suspected stroke patients are assessed and
put on the correct pathway and the staff Friends & Family Test. In addition the early detection and recognition of sepsis continues as a priority.
Measures to signpost frequent callers to more appropriate services are noted, some of whom have been calling the service 6 -700 times per
year. The CCG requests more information relating to the 2014-15 Quality Account actions and how these will be carried through into 2015-16, to
stream and further reduce such calls.
The Account identifies in detail the trajectories for 2015-16 for each of these measures and ambulance clinical quality indicators (ACQIs) which
will be monitored by the CCGs through the operational and quality meetings.
The CCGs recognise that 2014/15 was a challenging year for EEAST, in particular within the Essex locality, with intensive focus on performance
and outcomes in the face of staffing concerns and recruitment campaigns. The CCGs would welcome the presentation of the data in line with
the mandated guidance and by locality in future accounts. This would enable the reader to have a clearer understanding of performance and the
impact of changes and improvements within the service. It would be useful to feedback on actions planned in the 2014-15 quality account and
how these have developed and enhanced the service.
The CCG acknowledge that the volume and quality of data which was presented at both the quality and operational locality meetings has
improved during the year, although there were issues relating to the timely completion of investigations due to staffing reorganisation. The CCGs
will continue to actively monitor clinical quality performance during 2015/16.
Continued on next page
EEAST Quality Account 2014/15
69
Patient experience is a key monitoring tool for any service, and the use of Friends & Family Test; and national patient surveys have provided
detailed explanation of patient engagement. It is noted that EEAST are committed to the ongoing development of patient experience and
engagement activity including the action plan from results from staff surveys and the Friends and Family Test. It would be of value to add the
outcomes of staff feedback to enable the Service to share the voice of their staff.
The CCG note that the report details the numbers of complaints received and some of the serious incident data. It would add value if there was a
section on learning and implementation, the triangulation of data and changes to practice as a result of the investigations.
It is interesting to note that during 2014/15, 538 patients and 5 staff were enrolled into research projects. The CCGs would welcome the sharing of
the outcomes from these projects and audits to demonstrate how this has enhanced the service provided.
During 2014/15, EEAST reported the considerable difficulties encountered to deliver minimum mandatory professional update training to all clinical
staff due to system pressures. The CCGs seek assurance there is a robust plan in place for 2015/16 to ensure that staff receive the mandatory
training they require to deliver a safe and quality experience to patients.
Part 3 of the Account details clinical outcomes for patients. The CCGs are pleased to note that across the service, as a whole, EEAST report that the
majority of measures were met. In seeking openness and balance, the CCG suggest that this too could be presented by locality to highlight peaks,
troughs and demands in activity.
The CCGs recognise that there have been difficulties in achieving response times relating to staffing, skill mix, increased activity and waiting times
for hand-over at hospital. The CCGs are seeking resolution to these ongoing issues across the Essex economy.
The Essex CCGs actively support the priorities identified by EEAST and is looking forward to working with the Trust in the forthcoming year.
Lisa Llewelyn
Director of Nursing and Clinical Quality
North East Essex Clinical Commissioning Group (on behalf of the 7 Essex CCGs)
EEAST Quality Account 2014/15
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Ipswich & East and West Suffolk CCGs
Ipswich and East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group, as the commissioning
organisations for East of England Ambulance Service Trust (EEAST), confirm that the Trust has consulted and invited comment regarding
the Quality Account for 2014/2015. This has occurred within the agreed timeframe and the CCGs are satisfied that the Quality Account
incorporates all the mandated elements required.
The CCGs have reviewed the Quality Account data to assess reliability and validity and to the best of our knowledge consider that the
data is accurate. The information contained within the Quality Account is reflective of both the challenges and achievements within
the Trust over the previous 12 month period. The priorities identified within the account for the year ahead reflect and support local
priorities.
Ipswich and East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group are currently working with
clinicians and managers from the Trust and with local service users to continue to improve services to ensure quality, safety, clinical
effectiveness and good patient/carer experience is delivered across the organisation.
This Quality Account demonstrates the commitment of the Trust to improve services. The Clinical Commissioning Groups endorse the
publication of this account.
EEAST Quality Account 2014/15
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Feedback from the Trust User Group
T
he Trust User Group (TUG) is a group of keen and enthusiastic
volunteers who are willing to participate and support the
Trust where ever they can, but also to be a critical friend when
necessary.
service. Their performance against national standards for Category
A (Red 1); Category A (Red 2) and Category A19 were all slightly
below the national average but we must take into account the fact
that a large proportion of the area covered is rural and, therefore,
cannot be fairly compared with other more metropolitan areas.
The introduction of a permanent 24/7 HALO at the NNUH has
been shown to improve turnaround times at the hospital and has
a beneficial effect on ambulance response times, no mention was
made of this in the report.
They have their own work plan and members of the group sit on many
of the Trust's groups and committees to ensure patient and public
representation is integral at all levels of Trust activity. Their key work
areas include: undertaking station cleanliness audits and assisting
with patient discovery interviews, being ambassadors for the service,
and working on community first responder survey projects.
• The report appears to cover all the statutory requirements.
They were also asked to provide feedback on the Trust’s Quality
Account which is summarised below:
• Inclusion of information on the contribution made by community
first responders.
• In general, the report was an easy read, however, there were some
technical terms that were used which were not explained and
would be difficult for a layperson to understand.
• Inclusion of information on staff morale and staff training.
• The layout of the report was logical and easy to follow.
• The document showed that the EEAST are operating a quality
EEAST Quality Account 2014/15
All comments have been responded to and where relevant, will be
considered when compiling next year’s report, however, it should be
noted that ambulance services are not currently required to report
against these topics.
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Further information
The Trust produces a number of other annual reports,
including:
• Trust annual report
• Safeguarding annual report
• Infection prevention and control annual report
These can all be found on the Trust website:
www.eastamb.nhs.uk
EEAST Quality Account 2014/15
73
Glossary
Term
Acronym
ABCD2 algorithm
ABCD2
Accident and emergency
A&E
Automated external defibrillator
AED
Advanced life support
ALS
Advanced medical priority dispatch
system
Ambulance (clinical) quality indicators
AMPDS
ACQIs
Audit commission
Basic life support
BLS
Better care fund
Biphasic shock
Blood pressure
EEAST Quality Account 2014/15
BP
Description
A simple score (ABCD2) to identify individuals at high early risk of stroke after a transient
ischemic attack (TIA).
A medical treatment facility specialising in acute care of patients who present without prior
appointment, either by their own means or by ambulance. The emergency department is
usually found in a hospital or other primary care centre.
Portable electronic device that automatically diagnoses the life-threatening cardiac
arrhythmias of ventricular fibrillation and ventricular tachycardia in a patient, and is able to
treat them through defibrillation.
A set of life-saving protocols and skills that extend basic life support to further support the
circulation and provide an open airway and adequate ventilation (breathing).
Licensed software to clinically triage the category of emergency calls.
A set of national measures to benchmark clinical quality against eleven indicators to improve
quality and safety of patient care.
An independent body that monitors public spending, especially that by local government, on
behalf of the government.
Basic life support is the level of medical care which is used for victims of life-threatening
illnesses or injuries until they can be given full medical care at a hospital.
A Government initiative to support transformation and integration of health and social care
services to ensure local people receive better care.
A type of defibrillation waveform where a shock is delivered to the heart via two routes.
Blood pressure is the pressure exerted by circulating blood upon the walls of blood vessels,
and is one of the principal vital signs.
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Term
Acronym
Beats per minute
Bpm
Cardiopulmonary resuscitation
CPR
Care Quality Commission
CQC
Category A19
Category A8
Cat A19
Cat A8
Collaborations for Leadership in Applied
Health Research and Care
Clinical commissioning group
CLAHRC
Clinical support desk
CSD
CCG
Commissioning
Commissioning for quality and
innovation
Community first responders
EEAST Quality Account 2014/15
CQUIN
CFR
Description
The speed of the heartbeat measured by the number of poundings of the heart within a
minute.
An emergency procedure, performed in an effort to manually preserve intact brain function
until further measures are taken to restore spontaneous blood circulation and breathing in a
person in cardiac arrest.
The independent watchdog for healthcare in England. It assesses and reports on the quality
and safety of services provided by the NHS and the independent healthcare sector, and
works to improve services for patients and the public.
National response time standard for 999 calls where a transportable resource should arrive.
National response time standard for 999 calls where a transportable resource should arrive
for immediately life-threatening calls.
A collaboration of the local providers of NHS services and NHS commissioners, universities,
other relevant local organisations and the relevant Academic Health Science Network.
Clinical commissioning groups are NHS organisations set up by the Health and Social Care Act
2012 to organise the delivery of NHS services in England.
Clinically trained individuals providing telephonic support following an emergency call.
Generally utilised for lower acuity calls not necessarily requiring attendance at scene or a
transportable response.
The processes which local authorities and clinical commissioning groups undertake to make
sure that services funded by them meet the needs of the patient with the financial envelope.
The incorporation of quality metrics within quality and innovation three-year contracts. Full
reimbursement of activity is made upon delivery of quality initiatives.
Teams of volunteers who are trained by the ambulance service to a nationally recognised
level and provide lifesaving treatment to people in their local communities.
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Term
Acronym
Description
Computer aided dispatch
Data quality compliance and strategy
group
Department of Health
CAD
DQCSG
Double staffed ambulance
East of England Ambulance Service NHS
Trust
Electrocardiography
Electronic patient care record
DSA
EEAST
Computer hardware used to record all patient system calls and patient activity.
Trust group for providing assurance that systems, policies and procedures are in place to
manage data quality.
A department of the Government with responsibility for government policy for health
and social care matters and for the NHS in England along with a few elements of the
same matters which are not otherwise devolved to the Scottish, Welsh or Northern Irish
governments.
An ambulance manned by two clinicians.
Ambulance service which operates in the east of England.
ECG
ePCR
An ECG is used to measure the rate and regularity of heartbeats.
A patient care record which is in electronic format.
Emergency service
ES
A 999 ambulance service providing patient care.
Emergency care assistant
ECA
Emergency medical technician
EMT
Emergency operations centre
Face arm speech test
EOC
FAST
Friends and family test
FTT
General practitioner
GP
An NHS ambulance service worker used to support paramedics in responding to emergency
calls.
A clinician who works either autonomously, making their own clinical decisions within their
training and remit, or as assistants to a higher skilled paramedic.
Control centre for managing call receipt, triage and dispatch functions.
A campaign highlighting the most common tell-tail signs indicating a person is having a
stroke.
A single question survey which asks patients whether they would recommend the NHS
service they have received to friends and family who need similar treatment or care.
A GP is a medical practitioner who treats acute and chronic illnesses and provides preventive
care and health education to patients.
EEAST Quality Account 2014/15
DH
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Term
Acronym
Glyceryl trinitrate
Hyper-acute stroke unit
GTN
HASU
Hazardous area response team
HART
Healthwatch
Health Enterprise East
HEE
Health and Social Care Information
HSCIC
Centre
Health overview and scrutiny committee HOSC
Hear and treat
Information governance toolkit
IG toolkit
Integrated care policy programme
Intravenous
Key performance indicator
EEAST Quality Account 2014/15
IV
KPI
Description
Drug for heart patients. Delivered as a spray or in tablet form.
A specialist centre which provides the initial investigation, treatment and care immediately
following a stroke.
Specialist ambulance unit that provides medical care to patients in hazardous or ‘hot’
environments. They utilise special vehicles and equipment.
A new, independent national body with the power to monitor the NHS and to refer patients’
concerns to a wide range of authorities. It represents the interests of patients as consumers,
strategic commissioning, pursues and refers patient complaints and contributes to national
public debate on the NHS.
An organisation which provides a broad range of services to NHS organisations, providing
expert advice, funding and support to NHS innovators to translate their ideas into practice.
The national provider of information, data and IT systems for commissioners, analysts and
clinicians in health and social care.
The committee provides external assessment of any NHS consultation process giving local
assurance that the business cases for any future NHS developments are robust.
The telephone advice that callers who do not have serious or life-threatening conditions
receive from an ambulance service after calling 999.
An online system which allows NHS organisations and partners to assess themselves against
Department of Health information governance policies and standards.
A pioneer programme which is part of a wider programme of work to support the delivery of
integrated care at pace and scale.
Into the vein.
Clear, comparative gauge for CCGs, boards, local authorities, patients and the public to monitor about the quality of health services commissioned by CCGs and the associated health
outcomes.
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Term
Acronym
Local Clinical Research Network Eastern
Metrics
Monitor
Millimole
Myocardial infarction
National clinical performance indicators
National Health Service
LCRNE
National Institute for Health and Care
Excellence
NICE
National Institute for Health Research
NIHR
National Patient Safety Agency
NPSA
National Quality Board
NQB
National Reporting and Learning Service
National staff survey
NRLS
EEAST Quality Account 2014/15
Mmol
MI
NCPIs
NHS
Description
The clinical research delivery arm of the NHS in the east of England.
Set of ways of quantitatively and periodically measuring performance.
The sector regulator for health services in England.
A medical measurement used to determine the patient’s sugar levels within their blood.
Clinical term for a heart attack.
A national set of clinical benchmarking for specific illness and/or injuries.
Is the publicly funded healthcare system of England. It is the largest and the oldest singlepayer healthcare system in the world.
A non-departmental public body of the Department of Health in the United Kingdom, serving
both the English NHS and the Welsh NHS. NICE publishes guidelines in three areas; the
use of health technologies within the NHS (such as the use of new and existing medicines,
treatments and procedures), clinical practice (guidance on the appropriate treatment and
care of people with specific diseases and conditions), and guidance for public sector workers
on health promotion and ill-health avoidance.
An organisation funded through the Department of Health to improve the health and wealth
of the nation through research.
The NPSA is an arm’s length body of the Department of Health. It was established in 2001
with a mandate to identify patient safety issues and find appropriate solutions.
A multi-stakeholder board established to champion quality and ensure alignment in quality
throughout the NHS.
A central database of patient safety incident reports.
A way of ensuring that the views of staff working in the NHS inform local improvements
and input in to local and national assessments of quality, safety, and delivery of the NHS
Constitution.
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Term
Acronym
Never-event
NHS 111
NHS outcomes framework
Out-of-hours
Paramedic
OOH
Parliamentary and Health Service
Ombudsman
PHSO
Patient advice and liaisons service
PALS
Patient and public involvement
PPI
Patient care record
Patients Association
PCR
Patient transport service
PTS
Payment by results
EEAST Quality Account 2014/15
Description
A serious, largely preventable patient safety incident that should not occur if the available
preventative measures have been implemented.
An NHS service to provide access to local health services for non-life-threatening (urgent)
illnesses.
A framework which reflects the vision set out in the white paper Equity and Excellence:
Liberating the NHS, and contains a number of indicators selected to provide a balanced
coverage of NHS activity.
GP services provided outside of normal business hours.
A registered healthcare professional, working predominantly in the pre-hospital and out-ofhospital environment.
Investigate complaints that individuals have been treated unfairly or have received poor
service from government departments and other public organisations and the NHS in
England.
PALS are processed by the patient services department who are the first point of contact for
enquiries from the public or other healthcare organisations.
Involving the public in shaping care system developments, and keeping patients well
informed of clinical processes and decisions.
All NHS providers are required to record the care given to a patient on a patient care record.
A registered charity a lobby group operating in the UK that aims to improve patients’
experience of healthcare.
Provides transport to and from premises providing NHS healthcare and between NHS
healthcare providers. This is also known as scheduled transport.
The payment system in England under which commissioners pay healthcare providers for
each patient seen or treated, taking into account the complexity of the patient’s healthcare
needs.
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Term
Acronym
Primary and urgent care
Primary percutaneous coronary
intervention
Professional update
P&UC
PPCI
Quarter 1 (2,3,4)
Research ethics committee
Q1 (2,3,4)
REC
PU
Resuscitation Council (UK)
Return of spontaneous circulation
ROSC
Scheduled transport service
STS
See and treat
Sepsis
Serious incident
Service user
EEAST Quality Account 2014/15
SI
Description
The term for out-of-hospital health services that play a central role in the local community.
Commonly known as coronary angioplasty or simply angioplasty, is a therapeutic procedure
to treat the narrowed coronary arteries of the heart found in coronary heart disease.
An updating of professional knowledge and development the improvement of professional
competence throughout a person’s working life. It is a commitment to being professional,
keeping up to date and continuously seeking to improve.
Financial year (1st April – 31st March) quarter indicator.
Committee which is responsible for the ethical conduct of research studies designed to
increase understanding of workplace factors that contribute to ill-health and workplace
accidents.
An organisation which exists to promote high-quality, scientific, resuscitation guidelines that
are applicable to everybody, and to contribute to saving life through education, training,
research and collaboration.
The resumption of sustained perfusing cardiac activity associated with significant respiratory
effort after cardiac arrest.
A non-emergency service provided to patients who are unable to convey themselves for
outpatients’ appointments.
When a patient is assessed and treated on scene by the ambulance service rather than being
taken to hospital for treatment.
Whole-body inflammation caused by an infection.
An event or circumstance that could have resulted, or did result, in unnecessary damage, loss
or harm such as physical or mental injury to a patient, staff, visitors or members of the
public.
Anyone who uses, requests, applies for or benefits from health or local authority services.
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Term
Acronym
Stakeholders
ST-elevation myocardial infarction
STEMI care bundle
STEMI
Stent
Stroke
TIA
Stroke care bundle
SCB
Thrombolysis
Trust user group
Utstein
Ventricular fibrillation
VF
Ventricular tachycardia
VT
EEAST Quality Account 2014/15
Description
Anyone with an interest in the way services are delivered including service users, carers,
patients, service providers, staff, health professionals and partner organisations, councils and
other community or voluntary groups.
A heart attack recognised by characteristics on and ECG.
A set of interventions that when used together significantly improve patient outcomes for a
heart attack.
A short narrow metal or plastic tube often in the form of a mesh that is for example inserted
into a vein or artery to keep a previously blocked passageway open.
A stroke happens when the blood supply to the brain is disturbed.
Transient ischaemic attack (TIA) or ‘mini-stroke’ has similar symptoms to stroke but these
symptoms are resolved faster and the person usually will get better within 24-hours. The
TIA may be a warning sign of a more serious stroke and always requires further immediate
medical attention.
A set of interventions that when used together significantly improve patient outcomes for a
stroke.
A treatment to dissolve dangerous clots in blood vessels, improve blood flow, and prevent
damage to tissues and organs.
A group of volunteers who participate and support the Trust wherever they can, but are also
a critical friend where necessary.
The Utstein Style is a set of guidelines for uniform reporting of cardiac arrest. The Utstein
Style was first proposed for emergency medical services in 1991.
A condition in which there is uncoordinated contraction of the cardiac muscle of the
ventricles in the heart, making them quiver rather than contract properly.
Fast heart rhythm that originates in one of the ventricles of the heart. The ventricles are the
main pumping chambers of the heart.
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Providing feedback
East of England Ambulance Headquarters
Whiting Way
Off Back Lane
Melbourn
Cambridgeshire
SG8 6EN
T: 0845 601 3733
W: www.eastamb.nhs.uk
@EastEnglandAmb
/EastEnglandAmbulance
EEAST Quality Account 2014/15
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