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Ambulance Service Association
The voice of the NHS ambulance service

National Clinical Effectiveness Programme

A Survey of U.K. Ambulance Services
on behalf of the Joint ASA/JRCALC Clinical Effectiveness Committee

PATIENT REPORT FORMS

October 2000

Produced by : Stuart Nicholls, Manager, ASA Clinical Effectiveness Programme

CONTENTS

EXECUTIVE SUMMARY
Background
Aims
Method
Results
Discussion
Recommendations

Appendix A - Frequency of ALL fields found on Patient Report Forms

Appendix B - List of Fields by Frequency Found on Patient Report Form

EXECUTIVE SUMMARY

Aims

- To ascertain the breadth of data collected on UK ambulance service patient report forms
- To ascertain adherence to the ASA/JRCALC minimum data set on all UK ambulance service patient report forms
- To ascertain the appropriateness of the ASA/JRCALC minimum data set
- To determine current best practice in patient report form design and data collection

Recommendations

- The ASA NCEP to create a register of current patient report forms in use by UK ambulance services.
- The ASA NCEP to create a register of other data collection methods in use by ambulance services, including arrangements for data collection required as part of the National Service Framework for Coronary Heart Disease (CHD NSF).
- All ambulance services to adopt standard data collection procedures for the CHD NSF through the use of the ASA/JRCALC clinical audit database for prehospital cardiac care.
- All ambulance services to share best practice in patient report form design and data collection, including the standardisation of codes used.
- All ambulance services to revise the design of their patient report form in terms of content in light of NSF's and JRCALC guidelines.
- All ambulance services to ensure data is collected for every patient episode.

- The following principles should be adopted when redesigning patient report forms:

a) Move towards real time data collection
b) Improve the efficiency and accuracy of data collected from the PRF
c) Reduce 'waste' both on the form and in the processes of collection and analysis i.e. remove anything that does not add value or takes value away
d) Ensure the patient report form meets the needs of patient data requirements e.g.NSF's and national guidelines
e) Reduce or eliminate the variation in the quality of data collected, both between individual patient report forms and between ambulance services

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National Survey of Patient Report Forms

Background

In June 1999 the Ambulance Service Association (ASA) and the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) launched the ASA/JRCALC Minimum Data Set at the annual Ambex conference and exhibition.

The minimum data set was designed as a guide for use by ambulance services to collect the most relevant, acute and timely information from patient report forms.

Aims

To ascertain the breadth of data collected on UK ambulance service patient report forms
To ascertain adherence to the ASA/JRCALC minimum data set on all UK ambulance service patient report forms
To ascertain the appropriateness of the ASA/JRCALC minimum data set
To determine current best practice in patient report form design and data collection

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Method

In January 2000 the ASA’s National Clinical Effectiveness Programme (ASA NCEP) asked for all UK ambulance services to send in copies of their patient report forms. These were then correlated against the minimum data set and the above aims.

At the same time the ASA NCEP issued the ‘Evidence for Change III’ survey which asked questions about data collection methods in the UK’s ambulance services.

This report discusses the main findings of the patient report form survey and the key data collection issues from the ‘Evidence for Change III’ survey. It will attempt to highlight current best practice in patient report form design and data collection.

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Results

A total of 40 patient report forms were returned to the ASA NCEP from UK ambulance services.

Aim - To ascertain the breadth of data collected on UK ambulance service patient report forms

Table 1. Total data collected against the minimum data set

 

Number

Percent

Total number of fields in ASA/JRCALC minimum data set 1

270

100%

Maximum number of fields recorded on a single PRF

133

49.3%

Minimum number of fields recorded on a single PRF

42

15.6%

50% range of number of fields

69 to 97

25.6% to 35.9%

Median number of fields

86

35.9%

Figure I. Boxplot showing range of data collected

1 The ASA/JRCALC minimum data set contains both mandatory and discretionary fields. No distinction was made between these types for the purposes of this survey. Data were collected against explicit field names only.

Aim - To ascertain adherence to the ASA/JRCALC minimum data set on all UK ambulance service patient report forms

The tables in appendices A and B depict the frequencies of occurrence of the fields on the PRF's.

Aim - To ascertain the appropriateness of the ASA/JRCALC minimum data set.

The data required to monitor the prehospital management of acute coronary heart disease is used here as an example to determine the appropriateness of the minimum data set.

Table 2. Frequency of data collected as required to monitor the prehospital management of acute coronary heart disease

Data Field

Number of PRF's where field present

Percentage of PRF's where field present

Incident type
Work

17

42.5%

Leisure

14

35%

Home

19

47.5%

Cardiac Arrest

26

65%

Pain

10

25%

Other

34

85%

Time of incident

5

12.5%

Location of incident

30

75%

Medication

22

55%

PMH

25

62.5%

Events prior to call

34

85%

Witnessed arrest

18

45%

                By whom

9

22.5%

CPR/ALS prior to ambulance service arrival


15


37.5%

                By whom

9

22.5%

Treatment by ambulance service

13

32.5%

Rhythm strip

10

25%

ECG

13

32.5%

Initial rhythm

22

55%

Defibrillation

26

65%

Manual

10

25%

AED

11

27.5%

Time of 1st shock

25

62.5%

Time of ROSC

5

12.5%

Onset of chest pain time

1

2.5%

ROSC (anytime)

7

17.5%

ROSC (at hospital)

5

12.5%

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Discussion

At first glance there appears to be a significant underutilisation of the ASA/JRCALC minimum data set. The maximum number of fields used on any patient report form only represented 49% of the total number of available fields.

However, there are legitimate reasons for this apparent underutilisation. Firstly, the minimum data set contains both mandatory and discretionary fields. It is common practice to collect discretionary data via open fields on the PRF. Secondly, this survey only measured adherence against explicit field names, accounting for much of the discrepancy between the number of fields utilised and the total number of fields available. Open fields collect discretionary data which is not identified through comparison against explicit field names.

There is, however, still a significant variation in the proportion of the minimum data set collected on PRF's between ambulance services.

The tables in appendices A and B show that the fields considered to be mandatory are those which are prevalent on the majority of PRF's, with discretionary fields accounting for the majority of data which is found infrequently. There are anomalies, however, which can not be explained.

There are only a few mandatory fields apparent on all PRF's. Indeed it would be expected that the proportion of mandatory fields found on the majority of forms would be higher, and that the proportion of forms with the majority of mandatory fields would also be higher.

This is shown in the example of the prevalence of fields required to monitor acute prehospital coronary heart disease. Cardiac arrest and defibrillation are only explicitly noted on 65% of PRF's , with key indicators such as time of first shock (62.5%), return of spontaneous circulation (17.5%) and time of onset of chest pain (2.5%) being recorded far less frequently than would be expected or is desirable. Again this depicts the variation in the collection of important patient data.

It is likely this situation has improved since this survey was conducted in January 2000, as many services revise their PRF's in line with National Service Framework for Coronary Heart Disease (CHD NSF) as published in March 2000.

Data collection varies greatly between ambulance services both in terms of the technology used (manual, electronic etc.) and more importantly the amount of data collected. This latter point relates not only to the adherence to the ASA/JRCALC minimum data set as described in this survey, but also to the number of patient/ PRF's analysed by ambulance services. 40% of ambulance services collect data on extended skills used by paramedics only, and an insufficient 17% of ambulance services collect data from all patient records (Evidence for Change III, ASA National Clinical Effectiveness Programme, 2000).

The introduction of the JRCALC national prehospital clinical guidelines should ensure that the breadth of data recorded on PRF's is increased. With the Commission for Health Improvement soon to visit NHS ambulance services with a brief to monitor clinical governance and the uptake of best practice through national guidelines, ambulance services should ensure that the fields within the ASA/JRCALC minimum data set which cover data required by the JRCALC guidelines are included on their patient report forms.

Also, the accountability of both ambulance services as organisations and individual practitioners through clinical governance and professionalisation means that ambulance services should endeavour to collect data from all patient records, and that a patient report form is created for all incidents. In combination these will help facilitate the 'no-blame' culture which will encourage best practice and life-long learning leading to a more clinically effective ambulance service.

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Recommendations

The ASA NCEP to create a register of current patient report forms in use by UK ambulance services.

The ASA NCEP to create a register of other data collection methods in use by ambulance services, including arrangements for data collection required as part of the National Service Framework for Coronary Heart Disease (CHD NSF).

All ambulance services to adopt standard data collection procedures for the CHD NSF through the use of the ASA/JRCALC clinical audit database for prehospital cardiac care.

All ambulance services to share best practice in patient report form design and data collection, including the standardisation of codes used.

All ambulance services to revise the design of their patient report form in terms of content in light of NSF's and JRCALC guidelines.

All ambulance services to ensure data is collected for every patient episode.

The following principles should be adopted when redesigning patient report forms:

a) Move towards real time data collection
b) Improve the efficiency and accuracy of data collected from the PRF
c) Reduce 'waste' both on the form and in the processes of collection and analysis i.e. remove anything that does not add value or takes value away
d) Ensure the patient report form meets the needs of patient data requirements e.g.NSF's and national guidelines
e) Reduce or eliminate the variation in the quality of data collected, both between individual patient report forms and between ambulance services

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Appendix A - Frequency of ALL fields found on Patient Report Forms

ASA/ JRCALC MINIMUM DATA SET
    Field Found Field Not Found Field Not Explicit    
Form Details  
Ambulance Service   37 1 2  
Date of Call   4 36 0  
Incident Number   18 19 3  
Report Form Number   20 19 1  
Patient Details  
Name     40 0 0  
Address     39 1 0  
Age     32 6 2  
Date of Birth   40 0 0  
Sex     39 1 0  
GP     29 11 0  
Contact     12 23 5  
Postcode     9 30 1  
Response details    
Date     39 1 0  
Vehicle call sign   31 9 0  
Vehicle home station 36 1 2  
Vehicle location at time of call 4 36 0  
Type of call  
  999 + MPDS/CBD code

7

33 0  
  GP Urgent   14 25 1  
  Other   8 32 0  
Times Call received by AS 16 20 4  
  Time passed 8 30 2  
  Mobile   19 21 0  
  At scene   28 9 3  
  At patient   13 27 0  
  Left scene   32 6 2  
  At Hospital 35 5 0  
  Clear   16 24 0  
Destination hospital   22 13 5  
Hospital department   4 35 1  
Incident Details (Link to AMPDS/CBD Codes where possible)  
Type Work   17 23 0  
  Leisure   14 26 0  
  Home   19 21 0  
Cardiac Arrest   26 13 1  
  Pain   10 27 3  
  Other   34 6 0  
Respiratory    
  Asthma   20 20 0  
  Other   12 28 0  
Neurological    
  CVA   20 20 0  
  Convulsion 17 23 0  
Medical     Found Not Found Not Explicit
  Diabetes   21 16 3  
  Other   12 27 1  
DSH Overdose   16 19 5  
  Injury   7 30 3  
GI Pain   3 36 1  
  Acute Abdomen 16 23 1  
  GI Bleed 8 23 9  
Obs & Gynae    
  Miscarriage 6 29 5  
  Ectopic   9 31 0  
  Labour   5 35 0  
  APH   7 33 0  
  Foetal movements 7 33 0  
  Delivered   8 31 1  
  PPH   7 33 0  
Assault Blunt   8 32 0  
  Penetrating   6 32 2  
Fall <2m   13 15 12  
  >2m   13 15 12  
RTA Vehicle occupant 24 16 0  
  Driver 24 16 0  
  front/rear passenger 27 13 0  
  Pedestrian 33 7 0  
  Motorcycle 33 6 1  
  Cycle   33 6 1  
  Entrapment & duration 36 4 1  
  Ejection   31 9 0  
  Fatality   4 36 0  
  seatbelt   30 10 0  
  head restraint 5 35 0  
  air bag   20 20 0  
  child restraint 12 28 0  
  crash helmet 29 11 0  
  alcohol   7 33 0  
Drowning     20 20 0  
Psychiatric   9 31 0  
Burns     33 4 3  
  Area%   21 16 3  
  Severity   1 36 3  
Other     17 23 0  
Time of incident   5 33 2  
location of incident   30 10 0  
history of incident   19 21 0  
Significant Past Medical History  
None     10 30 0  
Not known   2 38 0  
Details     12 24 4  
  Signs & Symptoms 3 32 5  
  Allergies   14 26 0  
  Medication 22 17 1  
  PMH   25 12 3  
  Last meal   8 32 0  
  Events prior to call 34 6 0  
  Other   3 37 0  
WHERE APPROPRIATE INCLUDE PERTINENT NEGATIVES  
Primary Survey   Found Not Found Not Explicit
Airway Clear   30 10 0  
  Blocked   31 9 0  
  Aspirated   3 27 0  
Spine Normal   2 35 3  
  suspect   3 35 2  
Breathing Normal   15 21 4  
  Absent   14 24 2  
  Abnormal   30 7 3  
Circulation Radial pulse palpable 11 17 12  
  capillary refill >2secs 14 23 3  
AVPU            
Secondary Survey  
ABCD's          
Summary of injuries & clinical findings Nausea
buccal mucosa
pallor
sweating
fitting
13
4
25
23
21
25
34
8
17
17
2
2
7
0
2
 
Picture of body outline 37 3 0  
  closed#          
  open#          
  pain   24 15 1  
  echymoses 3 36 1  
  abrasion   20 19 1  
  laceration   23 16 1  
  burns   34 6 0  
  foreign body 14 26 0  
WHERE APPROPRIATE INCLUDE PERTINENT NEGATIVES  
Serial Observations  
Pulse     38 2 0  
BP     39 1 0  
Respiratory rate   29 11 0  
Pupil size     38 2 0  
Pupil reaction   33 6 1  
GCS     34 4 2  
TRTS     3 19 18  
Oxygen saturation   24 12 4  
Peak flow     22 18 0  
Blood glucose   15 25 0  
Temperature   38 2 0  
WHERE APPROPRIATE INCLUDE PERTINENT NEGATIVES  
Cardiac Care  
Witnessed arrest   18 21 1  
  by whom   9 27 4  
CPR/ALS prior to AS arrival 15 23 2  
by whom times/duration 9 29 2  
Treatment by AS   13 22 5  
  BLS   3 17 20  
  ALS   3 16 21  
Monitor Rhythm strip 10 28 2  
  ECG 13 26 1  
Initial rhythm   22 17 1  
Defibrillation   36 4 0  
  Manual   10 30 0  
  AED   11 26 3  
  Bi/Uni-Phasic 0 22 18  
Times Bystander CPR 20 18 2  
  EMS CPR   7 19 14  
  first shock   25 10 5  
  Cannulation 31 8 1  
  Drugs/fluids 34 0 6  
  Time respiration returned 4 35 1  
  Time circulation returned 5 34 1  
  Time CPR stopped 3 35 2  
  Time onset of chest pain 1 39 0  
Shocks Initial rhythm 19 19 2  
  number   28 9 3  
  size   7 33 0  
  result (ROSC) 7 33 0  
Other cardiac treatment 5 34 1  
WHERE APPROPRIATE INCLUDE PERTINENT NEGATIVES  
Resuscitation    
Airway & Breathing   23 13 4  
  Head/chin tilt/lift 14 25 1  
  Jaw thrust   14 26 0  
  Oropharyngeal airway 12 28 0  
  Nasopharyngeal airway 12 28 0  
  other device 0 40 0  
  BVMR   0 17 23  
  pocket mask 1 36 3  
  LMA/ Combi Tube 0 40 0  
Suction     18 22 0  
Manual clearance   12 27 1  
Intubation     24 16 0  
  size   19 21 0  
  by whom   11 27 2  
  failed attempt 12 27 1  
  ventilator settings 1 39 0  
Oxygen flow rate   11 25 4  
  %   23 17 0  
Circulation cannulation 32 7 1  
  size   29 10 1  
  site   10 27 3  
  failed attempt 24 15 1  
  total volume given 3 34 3  
WHERE APPROPRIATE INCLUDE PERTINENT NEGATIVES  
Splints  
cervical collar   31 5 4  
  size   1 38 1  
spinal board   20 7 13  
vacuum mattress   3 27 10  
traction splint   20 16 4  
vacuum splint   17 20 3  
box splint     24 14 2  
inflatable splint   2 38 0  
frac straps   34 5 1  
Sam splints   1 38 1  
peripheral circulation in tact 2 38 0  
RED     6 34 0  
Other     20 19 1  
Other procedures  
cricothyrotomy   4 36 0  
needle thoracocentesis 4 36 0  
Intraosseous needle   5 35 0  
Other treatment  
Drugs/Fluids   38 0 2  
Time     37 2 1  
dose     37 2 1  
route     35 5 0  
by whom     13 25 2  
WHERE APPROPRIATE INCLUDE PERTINENT NEGATIVES  
Condition on arrival  
Working diagnosis   36 2 2  
Second CBD/AMPDS
Code defined by crew
0 25 15  
Spontaneous respiraton 2 25 13  
spontaneous circulation 5 27 8  
AVPU/GCS   1 27 8  
Dead     16 16 8  
  Recognised at scene 10 28 2  
  by whom   9 29 2  
  confirmed by doctor 8 26 6  
    name 12 25 3  
Crew signature          
Hand over            
to whom     8 29 3  
time     2 38 0  
position     2 38 0  
signature     9 31 0  
Disposition of property 1 39 0  
Disclaimer  
suitable wording   18 21 1  
signature of patient/ responsible adult 17 23 0  
Additional Information  
WHERE APPROPRIATE INCLUDE PERTINENT NEGATIVES  
 

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Appendix B - List of Fields by Frequency Found on Patient Report Form

Found on 35 or more PRF's

Found on 26-35 PRF's

Found on 16-25 PRF's

Found on 5-15 PRF's

Found on Less than 5 PRF's

1. Service Name
2. Name
3. Address
4. Date of Brith
5. Sex
6. Date
7. Vehicle home station
8. Entrapment & duration
9. Picture of body
10. Pulse
11. BP
12. Pupil size
13. Temperature
14. Drugs/fluids
15. Time drug given
16. Dose
17. Working diagnosis
18. Age
19. GP
20. Vehicle call sign
21. Time at scene
22. Time left scene
23. Time at hospital
24. Cardiac arrest
25. Other (cardiac)
26. Front/rear passenger
27. Pedestrian
28. Motorcycle
29. Cycle
30. Ejection
31. Seatbelt
32. Crash helmet
33. Burns
34. Location of incident
35. Events prior to call
36. Clear (airway)
37. Blocked (airway)
38. Abnormal (breathing)
39. Respiratory rate
40. Pupil reaction
41. GCS
42. Defibrillation
43. Cannulation
44. Size of cannula
45. Number of shocks
46. Cervical collar
47. Inflatable splint
48. Drug route
1. Incident no.
2. PRF form no.
3. Time call received (AS)
4. Time mobile
5. Time clear
6. Destination hospital
7. Incident - work
8. Incident - home
9. Asthma
10. CVA
11. Convulsion
12. Diabetes
13. Overdose
14. Acute abdomen
15. Vehicle occupant
16. Driver
17. Air bag
18. Drowning
19. % area brun
20. Other (trauma)
21. History of incident
22. Medication
23. PMH
24. Pallor
25. Sweating
26. Fitting
27. Pain
28. Abrasion
29. Laceration
30. Oxygen saturation
31. Peak flow
32. Witnessed arrest
33. Initial rhythm
34. Bystander CPR
35. First shock (time)
36. Size of shock
37. Airway & breathing
38. Intubation
39. Size (tube)
40. Failed attempt
41. Spinal board
42. Traction splint
43. Vacuum splint
44. Box splint
45. RED
46. Dead
47. Suitable disclaimer
48. Signature patient
49. Contact
50. Postcode
51. 999 + priority code
52. Urgent
53. Other
54. Time passed
55. Time at patient
56. Incident - leisure
57. Incident - other
58. Injury
59. GI bleed
60. Miscarriage
61. Ectopic
62. Labour
63. APH
64. Foetal movements
65. Delivered
66. PPH
67. Blunt
68. Penetrating
69. <2m
70. >2m
71. head restraint
72. child restraint
73. alcohol
74. psychiatric
75. time of incident
76. None (PMH)
77. Details of incident
78. Allergies
79. Last meal
80. Normal
81. Absent
82. Radial pule palpable
83. Capillary refill >2sec
84. Summary of injuries
85. Nausea
86. Foreign body
87. Blood glucose
88. Treatment by whom
89. CPR/ALS prior to arrival
90. CPR by whom
91. Treatment by AS (CPR)
92. Rhythm strip
93. ECG
94. Manual Defib
95. AED
96. EMS CPR
97. Time circulation returned
98. Result (ROSC)
99. Other cardiac treatment
100. Head/chin lift/tilt
101. Jaw thrust
102. Oropharyn- geal airway
103. Nasopharyn -geal airway
104. Suction
105. Manual clearance
106. Failed attempt (cannulation)
107. By whom (cannulation)
108. Flow rate
109. Site
110. Peripheral circulation in tact
111. Intraosseous needle
112. By whom
113. Spontaneous circulation
114. Recognised at scene (death)
115. By whom
116. Confirmed by Dr
117. Name
118. Hand over to whom
119. signature
120. date of call
121. vehicle location at time of call
122. hospital dept.
123. pain
124. fatality
125. severity
126. PMH not known
127. Signs & symptoms
128. Other (PMH)
129. Aspirated
130. Normal (breathing)
131. Suspect
132. Buccal mucosa
133. Echymoses
134. TRTS
135. BLS
136. ALS
137. bi/Uni -phasic
138. time respiration returned
139. time CPR stopped
140. time onset of chest pain
141. other device
142. BVMR
143. Pocket mask
144. LMA/Combi tube
145. Ventialtor settings
146. Total volume given
147. Size
148. Vacuum mattress
149. Inflatable splint
150. Frac straps
151. Sam splints
152. Cricothyrotomy
153. Needle thoraco-centesis
154. Second priority code defined by crew
155. Spontaneous respiration
156. AVPU/GCS
157. Time (hand-over)
158. Position (hand-over)
159. Disposition of property

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