The Development and Testing of Australian Prehospital Care Quality Indicators

Abstract

Background: The traditional function of ambulance services was to provide rapid transport of patients to hospital. Correspondingly, prehospital care quality has historically been measured using simple and evidence-poor indicators forming a deficient reflection of the true quality of care and providing little direction for quality improvement efforts. Prehospital care is the term used throughout this thesis describing the care and services provided by modern ambulance services. It does not imply that all patients will be transported to a hospital. Modern Australian prehospital care provided by ambulances services involves the delivery of complex mobile healthcare for patients across the lifespan presenting with a range of injuries and illnesses of varying acuity as well as transport or referral to a hospital, transport or referral to other appropriate ongoing care, or discontinuation of care when there is no need for any follow-on healthcare. Measurement of quality is central to quality assurance and quality improvement in healthcare. Measurement starts with the development of quality indicators (QIs) against which performance can be gauged. QIs need to parallel the developments of healthcare systems and services. Thus, the aim of this research was to develop and test prehospital care QIs for the Australian setting. Methods: This is a thesis by publication which presents a research project containing three studies. First, a scoping review was conducted in accordance with JBI methodology to locate, examine, and describe the international literature on indicators used to measure prehospital care quality. Second, a modified RAND/UCLA appropriateness methods (RAM) was undertaken to develop a suite of prehospital care QIs and to assess the QIs for validity. Preparatory work for the expert consensus process included streamlined evidence syntheses guided by the JBI approach for rapid reviews and evidence summaries. Finally, an explanatory sequential mixed methods study was conducted to test the prehospital care QIs for acceptability. Details of the methods utilised in each of the studies are described in the scoping review protocol (manuscript 1), the study protocol (manuscript 3) as well as the methods sections of the other manuscripts. Results: The scoping review identified a total of 17 attributes of prehospital care quality and its findings suggested that quality in this setting is characterised by timely access to appropriate, safe, and effective care, which is responsive to patients’ needs and efficient and equitable to populations. A total of 526 QIs were identified, comprising 283 (53.8%) clinical QIs and 243 (46.2%) organisational/system QIs. QIs relating to out-of-hospital cardiac arrest (OHCA) (n=57; 10.8%) and time intervals (n=75; 14.3%) contributed the most. Most QIs were process indicators (n=386, 73.4%). Systematic preparation of the QIs produced a suite of 111 QIs within a guiding framework and with supporting evidence summaries for consideration by the nine-member expert panel participating in the modified RAM. An additional six QIs were proposed by panel members. Of the 117 QIs, 84 (72%) were rated as valid, including 26 organisational/system QIs across 7 subdomains and 58 clinical QIs within 10 subdomains. Most of the valid QIs were process indicators (n=62; 74%). Structural and outcome QIs were less common (n=13; 15% and n=9; 11%, respectively). Non-exclusively, 18 (21%) QIs described access to healthcare, 21 (25%) detailed elements of safety and 64 (76%) identified aspects contributing to effective prehospital care. With consideration of best available evidence the expert panel did not deem any indicator describing general time intervals, such as response time, as valid. Paramedics and ambulance services managers participating in the initial quantitative survey of the explanatory sequential mixed methods study generally rated the acceptability of the 84 QIs highly. Analysis of qualitative data gathered in the subsequent semi-structured interviews suggested a positive association between acceptability and other key characteristics of QIs. Clarity, scientific validity, practicality, and meaningfulness positively affected acceptability amongst the nine participants. To be acceptable, outcome indicators needed to be attributable to prehospital care. QIs which described time interval targets needed to be specific about time-sensitive interventions. Participants considered the proposed suite of QIs to be reflective of their professional values and qualities, in part explaining the high acceptability ratings. However, participants expressed some scepticism about the use of patient experience and satisfaction as valid QIs to evaluate prehospital care quality. Conclusion: There is growing interest and understanding about the importance of the measurement of prehospital care quality. The validity and acceptability of evaluating timeliness as an indicator of prehospital care quality in specific time-sensitive patients remains self-evident but fixating on response time targets in general cannot comprehensively evaluate modern prehospital care quality. This research systematically developed and tested prehospital care QIs for the Australian setting. Systematically developed QIs possessing key characteristics appear to be more acceptable to prehospital care providers. Before implementation, there may be a need to subject these QIs to further testing.