We're well known for delivering emergency care to patients.
But do you know that nationally and internationally, we are also a major player in promoting and carrying out pre-hospital research?
In the past three years we have attracted over £3m in research revenues. We carry out our research in partnership with the Universities of Lincoln, Sheffield, Loughborough and Swansea, and also with the Comprehensive Clinical Research Network of the National Institute for Health Research.
And on behalf of England’s twelve NHS ambulance trusts we led the research behind the development and introduction of the national Clinical Performance Indicators which have been published by the Department of Health.
Behind these facts lies a fascinating story, which the rest of this document sets out. If you wish to find out more, please contact us at communications@emas.nhs.uk
Part 1
Research at EMAS – an introduction
From small beginnings, EMAS has developed a research profile worth shouting about.
This benefits our patients because we deliver evidence-based and improved care as a consequence of EMAS research.
The story begins with the regionalisation of ambulance trusts in England that took place in June 2006.
Lincoln GP Niroshan (Niro) Siriwardena, who is also a health academic at the University of Lincoln, was invited to join EMAS to introduce a programme of research.
“We derived a definite synergy from the combination of practising health organisation and academia,” says Niro. “The goal right from the beginning was to improve the quality of care for patients. The academic link gave access to a range of people and skills including statistics, health economics, research methodologies – and expertise in bidding for funds!
“Also, funders are more likely to support projects when they can see a strong link between NHS organisations and academic institutions – it brings additional credibility. We have certainly benefitted from our partnerships over the years.”
EMAS’ then Chief Executive Paul Phillips took on the brief to lead in two areas for the national ambulance trusts network when regionalised services were introduced. These two areas were research and clinical quality. This helped to give Niro and colleagues a clear sense of direction and a mechanism for dissemination – a fast-track way to turn research outcomes into impacts on policy and practice in England’s ambulance trusts.
“While there was a lot of research into what happens in an Accident & Emergency department,” says Niro, “there was relatively little about the stage before A&E. We have majored on the patient pathway, and this is what has been groundbreaking about our research at EMAS.
“We have looked at pre-hospital outcomes over a whole range of conditions, and this is the first time that this has been done.
“We have been aided in this by EMAS’ introduction of e-PRF (electronic patient report forms – a solution using Toughbooks on the frontline) as this allows us to access more data and to link electronic datainside and outside the hospital.”
The research team at EMAS has grown as Niro and colleagues have demonstrated their ability to break new ground. Professor Siriwardena is EMAS’ Associate Clinical Director; Anne Spaight is Head of Clinical Governance, Audit and Research; Debbie Shaw is Clinical Audit and Research Manager; Mohammed Iqbal is Research Associate; Stacey Knowles is Research Governance Administrator; Nadya Essam is Research Project Manager; Michael Fuller is Research Champion; Fiona Togher and Viet-Hai Phung are Research Assistants at the University of Lincoln.
The team’s philosophy is to make its research relevant to practitioners because they are our direct link to our patients. This is achieved in two main ways:
“Our first step is to involve practitioners as collaborators or as participants wherever possible,” says Niro. The scale of this involvement is impressive – two recent research projects have each involved around 100 paramedics, and a third project around 80 paramedics. The team also have practising paramedics within EMAS who act as Research Champions.
Each of these steps ensures that EMAS’ research is relevant and meaningful.
“Secondly, at the conclusion of our research we create amongst our EMAS staff an awareness of what has been done by putting plenty of energy into dissemination,” says Niro. Findings from the team’s research activities are used to inform the education packages and core courses delivered to all of the Trust’s clinical staff at the EMAS Education Centres in Lincoln, Derby and Leicester.
Every two months Alison Price at NHS Lincolnshire produces the Emergency Services Current Awareness Update on behalf of the National Ambulance Research Steering Group and this isdisseminated directly to ambulance trusts and via the National Electronic Library for Health. And theteam is increasingly invited to present at clinical research conferences at home and abroad – in the past18 months the team has presented in Paris, Berlin, Amsterdam, Singapore and Washington, scooping aresearch prize to attend the event in the US.
This international dimension underlines just how important EMAS’ clinical research is. The next two sections each provide an example of how our research has made a difference to patients in the East Midlands.
Part 2
Making a difference for patients - a case study about cannulation
Peripheral intravenous (IV) cannulation is a common and important intervention in the pre-hospital setting. Overuse, underuse, misuse and poor cannulation technique are all associated with potential risks.
The prevention of healthcare-associated infections is of course a major concern for everyone in the NHS so the rate, appropriateness and technique of pre-hospital cannulation have each become important issues.
IV cannulation enables administration of fluids or drugs by paramedics. Inappropriate use and poor technique carry risks for patients, including pain and infection. We aimed to investigate the effect of an educational intervention designed to reduce the rate of inappropriate cannulation and to improve cannulation technique.
We used a non-randomised control group design, comparing two of our divisions – Nottinghamshire (the intervention group, comprising 80 paramedics) and Lincolnshire (the control group, comprising 243 paramedics).
Our educational intervention was based on JRCALC (the Joint Royal Colleges Ambulance Liaison Committee) guidance. We delivered it to EMAS paramedic team leaders who cascaded it to their paramedic teams.
We analysed rates of inappropriate cannulation before and after the educational intervention using routine clinical data. We also assessed overall cannulation rates before and after the intervention. A sample of paramedics was assessed post-intervention on cannulation technique using a ‘model’ arm and a predesigned checklist.
The results of the research proved interesting. There was a non-significant reduction in inappropriate (no intravenous fluids or drugs given) cannulation and a significant reduction in overall cannulation rate in the educational intervention area. Paramedics in the intervention area were significantly more likely to use correct hand washing techniques post-intervention.
Paramedics in both intervention and control areas were correctly able to identify indications for cannulation. Clinicians in the intervention area were significantly less likely to cite “because the admitting staff expect it” as an indication. However, paramedics in the intervention area were more likely to cite “on the way to hospital to save time” as an indication for cannulation.
The research has shown an improvement for patients in terms of enhanced quality and safety, and for the Trust it has shown the potential for using paramedic team leaders as the conduit for spreading quality improvement.
Part 3:
Making a difference for patients - a case study about cardiovascular quality
Our Ambulance Service Cardiovascular Quality Initiative (or ASCQI for short) is the first national quality improvement project involving all twelve English ambulance trusts.
It looks at measuring and improving pre-hospital clinical care for heart attack and stroke. It also involves some preliminary work to develop patient reported outcome measures for cardiovascular emergencies.
In a competitive funding environment, we have secured £475,000 for this work from The Health Foundation under their ‘Closing the Gap in Clinical Communities’ award scheme.
The project builds on the development of the national clinical quality indicators for ambulance services, which EMAS took a leading role in developing. It is novel in seeking to deliver, demonstrate and evaluate sustainable improvements in acute myocardial infarction (AMI) and stroke care in all NHS ambulance trusts.
The research aims to improve the delivery to patients of pre-hospital care for cardiovascular disease by focusing on the care bundles for AMI and stroke. The former includes four elements: administration of aspirin, glyceryl trinitrate (GTN), two pain scores and analgesia. The stroke care bundle includes recording of FAST (face, arm, speech test), blood glucose and blood pressure.
We have ambitious objectives to improve patient experience, namely to increase the delivery of care bundles for AMI and stroke from a baseline at the start of the project of 43% (AMI) and 83% (stroke) to at least 90% in the two years of the project.
So how are we doing? Eighteen months into the project we have seen AMI rise to 65% and stroke to 90% for the care provided by EMAS.This is a promising start and we expect to see rates rise further as we continue to improve our systems. We anticipate similar increases across all ambulance trusts – a significant gain in patient care.
Our approach has been to establish Quality Improvement (QI) teams comprising QI Leads and QI Fellows who have set up QI Collaboratives in each trust. These groups have been using QI techniques such as Plan-Do-Study-Act cycles, interviews and surveys, process maps and feedback using statistical process control charts to understand the gaps in care, the barriers to improvement and how to address these.
We can already identify some of the actions that are needed in order to embed sustainable improvement for patients. We need even better connection between executive teams and the work taking place at the front line, greater support from senior management teams to remove barriers which are impeding improvement, and more joined up thinking to translate learning from the research project into improved systems of care.
Effective clinical leadership at the front line and throughout the organisation is emerging as a critical factor to success.
Part 4
Research at EMAS – Looking to the future
We are proud of the research carried out within EMAS, not least because it is known that ‘research active’ organisations provide excellent care to their patients and here at EMAS we put patients first.
We are proud that our research team is groundbreaking. For example, the Medicines and Healthcare Regulatory Agency (MHRA) recently inspected us as part of its STREAM trial – we were the first ambulance trust to undergo such an inspection and we emerged with a very positive set of results.
Our 5-year £2 million funding award from the National Institute for Health Research for a Programme of Applied Health Research is a first for an ambulance trust in terms of duration, as well as being the Institute’s highest funding award. The programme, named Pre-Hospital Outcomes for Evidence Based Evaluation (PHOEBE), aims to develop new ways of measuring the impact of pre-hospital care provided by ambulance services, to provide better information about the effectiveness and quality of the different types of care delivered to our patients and to support quality improvement and evaluation of future changes in services.
We involve patients in our research and we also involve large numbers of our frontline staff as educators within the Trust. We support research from Board level, through managers to practitioners.
We have been able to work in partnership with an impressive range of universities and we have accessed external funding to bring about improvements to patient care.
We are privileged to work with all eleven of our fellow NHS ambulance trusts. Our regional structure has enabled us to collect data accurately and frequently. Measuring activity, sharing data and acting on findings in this way makes us unique across the NHS and even internationally – other networks are too large and diverse, but we can show real benefits to patients through our research.
For the future, we want to continue to develop outcome measures for ambulance service care so that we can understand the effects of interventions and innovations in the ambulance setting.
This includes current work on developing new patient-reported outcome measures.
We are researching new approaches to care – for example in relation to falls services. We are researching pain measurement and pain relief. We will continue in these areas and add research into new technologies for assessing and then treating people with new drugs and new types of treatment.
Each of these areas emphasise quality of pre-hospital care to go alongside speed of arrival.
We are proud to declare our ambition that patients will continue to see improved services as a consequence of the research we carry out at EMAS.
