Ambulance Quality Indicators – monthly update for England
Ambulance Systems Indicators for period January 2013 and Ambulance Clinical Outcomes for period October 2012
The following statistics were released today by the Department of Health:
Ambulance System Indicators; Category A (Red 1) 8 minute response time, category A (Red 2) 8 minute response time, 95th percentile of time from Call Connect to an emergency response arriving, 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 January 2013.
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 October 2012.
Main Findings – System Indicators for January 2013
The proportion of Category A (Red 1) calls resulting in an emergency response arriving within 8 minutes was 73.4% nationally, ranging from 81.2% to 67.2% across different ambulance trusts.
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Six Trusts – North East,North West,Yorkshire,East Midlands, East of England and South East Coast- failed to achieve the standard for 75% of Category A (Red 1) calls to receive an emergency response within 8 minutes.
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The proportion of Category A (Red 2) calls resulting in an emergency response arriving within 8 minutes was 75.6% nationally, ranging from 79.4% to 71.7% across different ambulance trusts
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Four Trusts,East Midlands,South East Coast,Yorkshireand East of England failed to achieve the standard for 75% of Category A (Red 2) calls to receive an emergency response within 8 minutes.
The 95th percentile of time from Call Connect of a Red 1 call to an emergency response arriving at the scene of the incident cannot be calculated nationally. The percentiles across the different ambulance trusts range from 10.5 minutes to 17.0 minutes.
The proportion of Category A calls resulting in an ambulance arriving at the scene within 19 minutes was 96.0%, ranging from 92.7% to 98.5%. Four Trusts -East Midlands, East of England,North Westand Great Western- 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. This is stable performance compared to the full year figure (October-September), where performance was 96.5%.
The proportion of calls abandoned by the caller before the call was answered by the ambulance service was 1.4%, which is stable compared to the full year figure (October-September), where the proportion of calls abandoned was 1.3%. Performance ranged from 3.9% to 0.2%.
The re-contact rate following discharge of care has two components:
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Re-contact following discharge of care by telephone, where 13.3 % of such calls resulted in the patient re-contacting the Ambulance Service within 24 hours. This is stable compared to the revised full year figure (October-September), where 13.2% of calls resulted in the patient re-contacting the Ambulance Service. This month performance ranged from 29.4% to 2.9% on mainlandEnglandand was 1.9% on theIsle of Wight.
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Where the discharge of care was from face-to-face treatment by the ambulance service at the scene, 6.4 % of such patients re-contacted the Ambulance Service within 24 hours, which is improved performance compared to the revised full year figure (October-September) which was 5.9%. The range this month was from 4.1% to 8.9% on mainland England.
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, 1.3% 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 2.5 %.
Data on the median, 95th and 99th percentiles was 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 67 seconds and the 99th percentile had a range of 9 seconds to 1 minutes and 34 seconds.
The median time to treatment ranged from 5.2 minutes to 6.5 minutes, the 95th percentile ranged from 13.3 to 20.9 minutes and the 99th percentile had a range of 22.1 to 36.8 minutes.
Where ambulance calls were closed with telephone advice, then 6.4% of emergency calls that received a telephone or face-to-face response were resolved by telephone advice, which is an improved performance compared to the revised full year figure (October-September), where 5.6% of emergency calls were resolved by telephone advice. The range across all trusts was 3.6% to 11.8%.
Of those emergency calls that received a face-to-face response, 35.2% 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 stable compared to the revised full year figure (April-March), which was 34.9%. This month’s performance ranged from 22.6% to 53.6%.
In January 2013, there were 421,739 emergency journeys, an increase from 407,412 during January 2012.
Main Findings – Clinical Outcomes for October 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).
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Of those patients who had an out-of-hospital cardiac arrest, 25.1% had ROSC on arrival at hospital where resuscitation was commenced or continued by ambulance personnel. This is stable performance compared to the full year (October-September) figure of 24.3%. Performance ranged from 16.2% to 32.3% across all Ambulance Trusts.
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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), 48.3% had ROSC on arrival at hospital where resuscitation was commenced or continued by ambulance personnel. This is stable performance compared to the revised full year (October-September) figure, where performance was 45.2%. Performance on mainland England ranged from 31.3% to 62.5%.TheIsle of Wighthad a single patient in this category who unfortunately did not have return of spontaneous circulation.
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.
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Of those who suffered an out-of-hospital cardiac arrest, where ambulance staff commenced/continued resuscitation, 7.4% were discharged from hospital alive. This is stable performance compared to the full year (October-September) figure of 7.5%. Performance on mainland England ranged from 0.7% to 12.8%. On theIsle of Wight, none out of eight patients survived, giving a performance of 0%.
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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, 22.0% were discharged from hospital alive, compared to 21.3% from October-September indicating 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 32.0% across mainlandEngland. Both the Isle of Wight and South East Coast had no survivors out of one and fourteen patients respectively in this category.
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Of those patients with an initial diagnosis of ‘definite myocardial infarction’ receiving thrombolysis where the first diagnostic ECG was performed by ambulance personnel, 71.4% received the thrombolysis within 60 minutes of the call being connected to the ambulance service. This is an improvement compared to the revised full year figure for October-September of 48.6%. As with the previous indicator, very small numbers were returned across those Trusts that are reporting data for this line. Seven Trusts returned zero returns for this element. Of those seven, four Trusts 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,South East Coast 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 89.1% of all such patients that fulfilled this criteria, stable compared to the figure of 88.9% from October-September. Performance ranged from 83.6% to 98.9% on mainland England. Performance was 0% on theIsle of Wight but this based on one patient.
78.4% of patients with a pre-hospital diagnosis of suspected ST-elevation myocardial infarction received the appropriate care bundle. This is stable performance compared to the revised full year figure from October-September, where 76.3% received the appropriate bundle. Performance ranged from 65.2% to 90.9% in mainlandEngland. On theIsle of Wightall six patients in this category received the appropriate care bundle.
62.6% of FAST positive 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 44.9% to 80.0%. This is a stable performance compared to the full year figure from October-September, where performance for this indicator was 64.6%.
Of the suspected stroke patients assessed face to face, 95.0% received an appropriate care bundle, showing a stable performance compared with the revised figure of 95.5% between October-September. Performance ranged from 88.1% to 100.0% across Trusts inEngland.
Statistical Notes
1. Data Collection
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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.
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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 – June 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
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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. The revisions protocol can be found on the Department of Health website.
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Ambulance Clinical Outcomes data for April 2011 – March 2012 was revised on 31st August 2012.
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Ambulance Systems Indicators data for April 2011 – March 2012 was revised on 11th January 2013 to fix a specific issue relating to the interpretation of the discharged at scene indicator by some trusts.
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Ambulance Systems Indicators data for April 2012 – October was revised on 11th January 2013.
*Ambulance Clinical Outcomes data for April 2012-August 2012 was revised on 1st February 2013.
5. Related Statistics
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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 29/05/2011can be found on the Department of Health website.
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Performance statistics on ambulance services in other countries of the UK can be found at:
Northern Ireland: http://www.niamb.co.uk/docs/corporate_info.html and http://www.niamb.co.uk/docs/corporate_info_trust.html
Additional Information
Full data tables for all Ambulance Trusts are available here
The Government Statistical Service (GSS) statistician responsible for producing these data is:
Stuart Knight
Knowledge and Intelligence
Department of Health
Room 4E40
Quarry House
Leeds LS2 7UE
E-mail: Unify2@dh.gsi.gov.uk
To contact the Media Centre, please refer to the Department of Health’s website for the relevant contact