Local Improvement
Following National
Clinical Audit
Participation
Georgina Jones
13 April 2015
2
National Project
Ambulance Service Cardiovascular
Quality Initiative (ASCQI)
• University of Lincoln
• East Midlands Ambulance Service
• National Ambulance Research
Steering Group
3
ASCQI Project Aims
• Improve delivery of pre-hospital care for
cardiovascular disease
• Spread quality improvement methods
• Engage pre-hospital clinicians in clinical
audit
4
National Standards
Best clinical practice
NSF Coronary Heart Disease
National Stroke Strategy
Guidelines
Joint Royal Colleges Ambulance
Liaison Committee (JRCALC)
National clinical
performance indicators
National Ambulance Research
Steering Group
5
London Ambulance Service
3,651 clinicians
STROKE
8,500 patients
STEMI
3,000 patients
Paramedic lead local clinical audit project
6
Standards of Care
• JRCALC clinical practice guidelines
• Optimal care defined by care bundle:
Heart attack care bundle
7
Data Collection
84%
97%
CARE
BUNDLE
92%
42%
49%
8
Root Cause Analysis
Lack of a pain
assessment tool
Evidence for
Entonox use
Language
barriers
Analgesia
guidance
Analgesia
training
Clinicians’ beliefs regarding
patients' pain
9
Implementing Change
Clinical update

O
Pain Management
Penetrating

update
Medical Director’s
Bulletins
MDB 100: Key
clinical messages for
2012
MDB 102: EZIO
guidance

MDB 105: Updated
maternity packs

MDB 106: Medicines
management update
ASCQI News
ASCQI Champions have
now
been
recruited
service wide who will
soon be running ASCQI
events on complexes.
Look out for posters
advertising when they
are taking place, go
along, share your ideas
and learn more about
what crews are doing to
improve care. Also look
out for ‘ASCQI Gifts’
coming your way over
the next few months. Go
to the back page to find
out more…
March 2012
Clinical
Have You Seen?

O
Trauma
Safeguarding

Issue 28
Elderly fallers referrals: Update
Following the successful implementation of
the falls referral pathway last year, the
Service surveyed 278 GPs from across
London who had been sent a falls referral for
one of their patients to assess the impact of
the referral on patient care and how useful
GPs felt the service was. We also asked GPs
whether or not they would like us to consider
referring direct to falls teams. 111 GPs
responded to our survey and the majority
(64%) had reviewed their patient after
receiving the referral form on a home visit, in
the surgery or by telephone. Most patients
were not referred on by their GP with only
15% being referred to a local falls service.
GPs who did not refer their patient reported
that they were either already under a falls (or
other community healthcare) team or that a
referral was clinically inappropriate. The vast
majority of GPs (85%) felt that receiving a
referral was either very or quite helpful and
GPs made very positive comments including:



‘I feel it is good practice for you to fax
through this information as it increases
our awareness of patient problems and
highlights patients that we may not
previously have been aware of and now
need some form of support.’
‘A really good service – must continue’
‘Your referral triggered us to look at this
case. The patient is well known to us
and your referral made us review his
falls risk.’
59% of GPs did not feel that we should refer
patients directly to a falls service as they felt
they wanted to review their patients
themselves to decide if the referral was
appropriate. The overall results demonstrate
that the referrals crews are making (even
repeat referrals) are helpful to GPs and
trigger many to review their patient in an
effort to prevent further falls or to minimise
the risk of harm in older patients who fall.
In addition to this survey, we identified three
fallers who had fallen ten or more times in a
three month period. Daryl Mohammed
(Assistant Medical Director South Area, and
a GP) made contact with each of the GPs
who are involved with the care for these
patients. In two of the three patients, the
feedback was very positive. The GPs
appreciated receiving falls referrals and
wanted us to know they were trying to
address matters with these challenging
patients. Crews should avoid becoming
frustrated if they feel GPs are not acting on
the falls referrals as some patients are
challenging to manage. We are looking at
frequent fallers and how we can work closer
with primary care groups – the message
therefore being to continue making referrals.
As a final update, we achieved almost 1200
referrals in Jan 2012, which is a huge
achievement – keep up the great work! but
still means that approximately 1000 nonconveyed falls incidents are being
completed without a referral occurring.
Therefore, please don’t forget to refer all
appropriate patients.
Emma Williams, Service Development and
Policy Manager.
10
Implementing Change
ISCHAEMIC CARDIAC chest pain
Recorded blood
pressure
≥ 90 systolic
A guide to assist with ACS management
0-10
Pain
Score
?
GTN
400mcg
Pain
Score
?
12 LEAD
ECG Changes in
two or
more
adjacent
leads
Acute Coronary Syndromes Aide Memoire
Pain
Score
?
Aspirin 300mg
(Please note this does not replace a clinician’s own clinical judgement)
Repeat GTN, every 5 mins
if blood pressure ≥ 90 systolic
Pain remains
1-3
Entonox
4-10
Entonox
IV Morphine
Pain
Score
?
ST ↑ ≥1mm II,III, aVF
Inferior STEMI
V4R
ST↑ ≥ 0.5mm
RV STEMI
V7 V8
ST↑ ≥ 0.5mm
STEMI
ST↓ 2mm, +/- tall R in V1-V3
Posterior STEMI?
ST ↑ 2mm male /1.5mm femaleV2&V3
Anterior STEMI
ST ↑ ≥ 1mm 1, aVL, V5, V6
Lateral STEMI
T wave ↓ or ST ↓ any 2 leads
Wide QRS, no Q, aVL and V6
Patient
looks
unwell
and has
ACS pain.
Normal ECG but cardiac chest pain – not relieved by GTN.
Blue call to nearest ED.
BP ≤ 90
systolic
250ml fluid if
chest sounds
clear.
Once only.
Heart
Attack
Centre
PD09 BLUE CALL
High risk ACS
NEW LBBB
MONITOR TO PATIENT
HANDOVER:
Reassess
ECG
Pain Score
Analgesia
GIVE WHITE COPY
OF PRF TO HAC
All times completed
Destination code
Care Bundle
Complete
11
Spreading change
12
13
Evaluation
Aspect of care
Base Line
End of project
Aspirin
97%
95%
GTN
92%
92%
Pain scores
84%
84%
Analgesia
49%
85%
CARE BUNDLE
42%
63%
14
Thank you