• Led by East Midlands Ambulance Service NHS Trust, in collaboration with the University of Lincoln.
  • Working across all Ambulance trusts in England.
  • Aimed to improve services for people with heart attack and stroke by improving the reliability of care delivered by ambulance clinicians.
  • Used care bundles and a Quality Improvement (QI) collaborative approach.

The UK death rate from coronary heart disease and stroke is high. Ambulance services are well placed to deliver pre-hospital care to improve patients’ chances of recovery.

This project aimed to improve the reliability of care delivered by ambulance clinicians to patients presenting with acute myocardial infarction (AMI) and stroke across all ambulance trusts in England.

It did this using a care-bundle approach to ensure that every patient receives each element of optimal care. It also spread Quality Improvement methods throughout ambulance services and developed Patient Reported Outcome Measures and Patient Reported Experience Measures for AMI and stroke.

Key findings

  • Significant improvements were achieved in the majority of trusts for both stroke and AMI care bundles.
  • Overall performance for the AMI care bundle increased in England from 43% to 79% and for stroke from 83% to 96%
  • Technical knowledge and relational skills in ambulance staff together enhanced patient experience.


  • Pressures of time and conflicting demands and connectivity between different staff groups.
  • Some QI innovations could not be adopted due to budgetary constraints.
  • Achieving and then sustaining engagement of all ambulance trusts nationally.
  • The stroke care bundle was easier to deliver than the AMI bundle since it had fewer elements.

Who was involved?

The project was led by the East Midlands Ambulance Service NHS Trust in collaboration with the University of Lincoln. It was supported by the National Ambulance Clinical Audit Steering Group.

The team was led by Professor A Niroshan Siriwardena, Associate Clinical Director at the East Midlands Ambulance Service NHS Trust and Professor in Primary Care at the University of Lincoln, and Anne Spaight, Head of Clinical Governance, Audit and Research at East Midlands Ambulance Service.

Supporting dissemination

This project was given further support through a Spreading Improvement grant to help disseminate learning and maximise the impact of the approach across the health service at a local, regional or national level.

Funding was used to spread quality improvement (QI) knowledge and skills to a wider proportion of health care staff, and to disseminate knowledge from the Ambulance Services Cardiovascular Quality Initiative (ASCQI) to a range of key stakeholders, opinion leaders and decision-makers.

A QI e-learning resource and a web-based toolkit were developed to help spread QI learning more widely.

Four QI webinars were filmed and made available on the project.

A series of local workshops were conducted in nine participation ambulance services to allow the sharing of information and techniques learned during ASCQUI to bring about improvement.  Project leads from each trust selected an aspect of clinical care that required improvement in the service. Eight of the nine trusts have now introduced their QI interventions.

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