Statistical press notice: Ambulance Quality Indicators

Ambulance Systems Indicators for period April 2012 and Ambulance Clinical Outcomes for period January 2012

The following statistics were released today by the Department of Health:

Ambulance System Indicators; Category A 8 minute response time, category A 19 minute response time, call abandonment rate, re-contact rate following discharge of care, time to answer call, time to treatment, ambulance calls closed with telephone advice or managed without transport to A&E, ambulance emergency journeys; for period April 2012.

Ambulance Clinical Outcomes; Outcome from cardiac arrest – return of spontaneous circulation, outcome from acute ST-elevation myocardial infarction (STEMI), outcome from stroke for ambulance patients, outcome from cardiac arrest – survival to discharge; for period January 2012.

Main Findings – System Indicators for April 2012

The proportion of Category A calls resulting in an emergency response arriving within 8 minutes was 76.0% nationally, ranging from 78.3% to 71.9% across different ambulance trusts. Performance is comparable to the full year figure (April-March), where performance was 76.1%.

- One Trust – London Ambulance Trust – failed to achieve the standard for 75% of Category A calls to receive an emergency response within 8 minutes.

The proportion of Category A calls resulting in an ambulance arriving at the scene within 19 minutes was 96.8%, ranging from 94.8% to 98.4%. One Trust – North West Ambulance Trust – failed to achieve the standard for 95% of Category A calls to receive an ambulance vehicle capable of transporting the patient within 19 minutes of the request for transport being made. Performance is comparable to the full year figure (April-March), where performance was 96.8%,
The proportion of calls abandoned by the caller before the call was answered by the ambulance service was 0.7%, which is an improvement on the full year figure (April-March), where the proportion of calls abandoned was 1.2%. North West Ambulance Service was unable to return data for this line for this month, due to changes to their telephony systems.
The re-contact rate following discharge of care has two components:

- Re-contact following discharge of care by telephone, where 14.0% of such calls resulted in the patient re-contacting the Ambulance Service within 24 hours. This is comparable to the full year figure (April-March), where 13.1% of calls resulted in the patient re-contacting the Ambulance Service.

- Where the discharge of care was from face-to-face treatment by the ambulance service at the scene, 5.8% of such patients re-contacted the Ambulance Service within 24 hours, which is a worse performance than the full year figure (April-March) which was 5.2%. The range this month was 8.7% down to 1.2%.

There is a separate element on those re-contacting the Ambulance Service and that deals with those for whom there is a locally agreed frequent caller procedure in place. Nationally, 1.0% of patients for whom a frequent caller handling procedure is in place re-contacted the ambulance service within the month; however, frequent caller procedures are locally determined and protocols will vary across ambulance services. Six Trusts were not able to identify frequent callers. For those Trusts that were able to supply both a numerator and denominator, the corresponding figure was 1.7%.
Data on the median, 95th and 99th percentiles were collected, at Ambulance Trust level, for both Time to Answer Calls and Time to Treatment. However, it is not possible to produce a national median/95th/99th percentile.
For the time to answer a call, the median ranged from less than asecond to 3seconds. The 95th percentile ranged from1to 59 seconds and the 99th percentile had a range of 11 seconds to 2 minutes and 14 seconds.
The median time to treatment ranged from 4.8 minutes to 6.1 minutes, the 95th percentile ranged from12.1to 18.3 minutes and the 99th percentile had a range of 18.5 to 30.7 minutes.
Where ambulance calls were closed with telephone advice or managed without transport to A&E, then 5.5% of emergency calls that received a telephone or face-to-face response were resolved by telephone advice, which is comparable to the full year figure (April-March), where 5.3% of emergency calls were resolved by telephone advice. The range across all trusts was 9.8% to 2.8%.
Of those emergency calls that received a face-to-face response, 34.8% were either discharged at the scene, transferred to a destination other than a Type 1 or Type 2 A&E, or were referred to an alternative care pathway. This month’s performance is comparable to the full year figure (April-March), which was 33.9%. This month’s performance ranged from 22.8% to 48.2%.
In April 2012 there were 384,409 emergency journeys, which is an average of 12,814 per day. This is fewer than in April 2011 when there was an average of 12,980 per day. Please note, however, that data for April 2011 was collected under a different collection – the Weekly Situation Reports – from which a daily figure has been calculated.

Main Findings – Clinical Outcomes for January 2012

This return runs with a 3-month lag on the Systems Indicators, as this time is required in order for those patients transported by ambulance to have their outcomes resolved.

The Return of Spontaneous Circulation (ROSC) is calculated for two patient groups. The overall rate measures the overall effectiveness of the urgent and emergency care system in managing care for all out-of-hospital cardiac arrests. The rate for the Utstein comparator group provides a more comparable and specific measure of the management of cardiac arrests for the subset of patients; where timely and effective emergency care can particularly improve survival; (e.g. 999 calls where the arrest was not witnessed and the patient may have gone into arrest several hours before the 999 call are included in the figures for all patients but are excluded from the Utstein comparator group figure).

- Of those patients who had an out-of-hospital cardiac arrest, 21.6% had ROSC on arrival at hospital where resuscitation was commenced or continued by ambulance personnel. This is stable performance when compared to the year-to-date (April-January) figure of 22.7%. Performance ranged from 12.1% to 36.7% across all ambulance trusts.

- For those patients who had an out-of-hospital cardiac arrest that was witnessed, and where the patient had a heart rhythm that was suitable for defibrillation (i.e. the Utstein comparator group), 40.9% had ROSC on arrival at hospital where resuscitation was commenced or continued by ambulance personnel. This is a deterioration compared to the year-to-date (April-January) figure, where performance was 43.7%. Performance ranged from 22.6% to 54.5%.

As with the Return of Spontaneous Circulation, survival to discharge following cardiac arrest is reported separately for all patients, and for the subset of patients in the Utstein comparator group.

- Of those who suffered an out-of-hospital cardiac arrest, where ambulance staff commenced/continued resuscitation, 5.9% were discharged from hospital alive. This is stable compared to the year-to-date (April-January) figure of 7.0%. Performance ranged from 3.1% to 7.7%.

- For those patients who had an out-of-hospital cardiac arrest that was witnessed, and where the patient had a heart rhythm that was suitable for defibrillation and resuscitation was commenced or continued by ambulance personnel, 17.6% were discharged from hospital alive, compared to 22.6% from April-January, a stable performance. This indicator is characterised by small numbers. Performance percentage figures derived from these figures are likely to be subject to large variation, within and across months. This month performance ranged from 10.0% to 28.9%.

Of those patients with an initial diagnosis of ‘definite myocardial infarction’ receiving thrombolysis where the first diagnostic ECG was performed by ambulance personnel, 57.9% received the thrombolysis within 60 minutes of the call being connected to the ambulance service. The year-to-date figure from April-January is 53.6% so performance is stable. As with the previous indicator, very small numbers were returned across those Trusts that are reporting data for this line. Five Trusts returned zero returns for this element. Of those five, three Trusts do not return this data and have confirmed that this indicator is not applicable to them, as their clinical pathway does not include thrombolysis, only PPCI. These trusts are Great Western, South Central and North East.
Those patients for whom a primary angioplasty occurred within 150 minutes of the call being connected to the ambulance service following the first diagnostic ECG being carried out by ambulance personnel, represented 91.2% of all such patients that fulfilled this criteria, stable compared to 89.8% from April-January. Performance ranged from 100.0% to 83.1%.
76.4% of patients with a pre-hospital diagnosis of suspected ST-elevation myocardial infarction received the appropriate care bundle. This is stable performance on the year-to-date figure from April-January where 73.6% received the appropriate bundle. Performance ranged from 95.2% to 63.5%.
63.5% ofFASTpositive patients, who were assessed face to face, arrived at a hyperacute stroke centre within 60 minutes of the call being connected to the ambulance service. Performance ranged from 86.3% to 45.0%. This is stable compared to the year-to-date figure from April-January 2012, where performance for this indicator was 66.0%.
Of the suspected stroke patients assessed face to face, 95.5% received an appropriate care bundle, showing a stable performance than the 93.9% between April and January 2012. Performance ranged from 100.0% to 81.8%.

Statistical Notes

1. Data Collection

The Ambulance Quality Indicators data are collected from the 12 Ambulance Trusts inEnglandeach month. The collection is divided into two parts – the ‘System Indicators’, which relate to the initial 999 call and which runs three months ahead of the ‘Clinical Outcomes’. The Clinical Outcomes data relates to the outcomes of those patients transported by ambulance – the three month lag is required in order for those outcomes to be resolved.
With the exception of the 8-minute response time standard and the 19-minute transportation standard for Category A (immediately life-threatening) calls, no thresholds to denote “poor” care have been set for these indicators. Instead, the data on the indicators will be used to reduce variation in performance across trusts (where clinically appropriate) and drive continuous improvement in patient outcomes over time.

2. Clinical Dashboards

In line with recommendations from the National Ambulance Director and the National Clinical Director for Urgent and Emergency Care, the information for the indicators will also be published in clinical dashboards that will use statistical process control to indicate whether these fluctuations in performance are statistically significant, or whether they merely represent the variation in performance that is unavoidable even when a health system is performing well. These statistical process control measures will take at least seven months worth of data to be reliable, but they will help ensure that performance changes over time are seen in the proper clinical context. Dashboards containing data for April 2011 – February 2012 have already been published on several ambulance trust websites.

3. Data Quality

We are continuing to work with all the Trusts involved in this return to further improve data quality.

4. Revisions

Revisions to previous month’s data are made in line with the Department of Health’s revisions protocol for performance monitoring data. Future revisions will be made on a six-monthly cycle. Revisions protocol
Ambulance Systems Indicators data for April 2011 – February 2012 and Ambulance Clinical Outcomes data for April 2011 – November 2011 were revised on 4^th May 2012.

5. Related Statistics

The total number of category A and category B calls made to ambulance trusts in England, and of these how many were responded to within 8 minutes (category A) or 19 minutes (category B), and the number of urgent and emergency journeys, were previously collected by the Weekly Situation Reports collection. The collection also included data on instances of delayed handover to A&E staff. Data covering the period 08/11/2010 to 29/05/2011
Performance statistics on ambulance services in other countries of the UK::

Wales

Scotland

Northern Ireland and Northern Ireland Ambulance Service

Additional Information

Full data tables for all Ambulance Trusts

For press enquiries, please contact the DH press office: Tel: 020 7210 5962

The Government Statistical Service (GSS) statistician responsible for producing these data is:

Stuart Knight

Knowledge and Intelligence

Department of Health

Room 4E40, Quarry House, Quarry Hill,Leeds,LS2 7UE

E-mail: Unify2@dh.gsi.gov.uk