Increasing ambulance demand requires enhanced indicators of quality and safety

To the Editor: My observations over the past 10 years as an ambulance paramedic are consistent with the growth in demand for emergency and non-emergency ambulance services in Melbourne.1 Strong demand has been forecast to continue because 60% of patients who are eligible for emergency transport do not currently use ambulance services.2 The increasing demand for ambulance services — an essential component of the Australian health care network — necessitates the development of valid, reliable indicators of quality and safety in prehospital health care, to maintain and improve the quality of that care.

As part of the Australian Commission on Safety and Quality in Health Care’s National Indicators Project, the Australian Institute of Health and Welfare (AIHW) has proposed 55 indicators of quality and safety in health care that represent a whole-of-system approach.3 However, this cannot be achieved without the inclusion of ambulance indicators. The AIHW indicators focus mainly on facility-based services (eg, hospitals) and underestimate the interdependence of the health care network.

Ambulance services routinely collect information from the wider health care community, representing transported and non-transported patients, including clinical intervention and outcome parameters. These data can be used to identify interventions and outcomes attributable to prehospital health care practice. Improvements in patient sequence management,4 based on Ambulance Victoria research and data from specialised trauma and cardiac arrest registries,5 suggest that ambulance interventions can result in tangible benefits.

Ambulance-specific process and outcome indicators would enable more precise attribution of outcomes to prehospital care and assist in apportioning health outcomes across the wider health network. This would directly benefit hospitals because pressure for increased public accountability currently ascribes performance based on risk factors that hospitals cannot influence. Enhanced prehospital indicators could supplement and expand the range of risk parameters that hospitals currently use to adjust hospital performance indicators; this would help mitigate the limitations inherent in comparative public reporting.6

Longer-term benefits include the implementation of alternative models of evidence-based practice, encompassing “treat-and-leave protocols”, and identification of non-hospital referral avenues. Safety is a crucial aspect of alternative practices, and protocols must be formulated and monitored in the light of valid and reliable indicators.

Inclusion of ambulance indicators in the National Indicators Project would place ambulance services in a key position to ensure that timely access to safe, high-quality health care is maintained and improved.