Background In India, prehospital care is still in its fledging state. There are a lot of gaps in research, prehospital care consensus, notification, and evaluation needed for trauma care and for the acutely ill patient. India does not have a centralized body that provides guidelines for the training and operation of Emergency Medical Services (EMS). Emergency Medical Services are fragmented and in many places limited to scoop and run. There is no consensus and very little literature on how to approach an acutely ill patient during transport by emergency responders. This Quality Improvement study tries to make critical care bundles of specific life-threatening emergencies to be trained to a cohort of EMS staff of government-run ambulance services through dialectic lectures, handouts, continuing medical education and video lectures.

Primary Objective: To improve the percentage of compliance with the critical steps of prehospital care provided by Government-run, manned ambulances presenting to the AIIMS Emergency Department with life-threatening illnesses which include chest pain, shortness of breath, major trauma, stroke, seizure, and unresponsiveness with absent pulse.

Secondary Objectives: 1. Improving the percentage of handovers by the prehospital care providers to the receiving medicalstaff in the hospital 2. Improving the pre-hospital notification rates for the above-mentioned critical illnesses. 3. Increasing the percentage of resuscitation done during the transport of patients end route. 4. Formulating a standardized training program for prehospital care providers.

Study Design: Quality Improvement study

Place of study: Triage of Department of Emergency Medicine AIIMS New Delhi, and

Department of Emergency Medicine, JPNTC New Delhi.

Study time period: April 2023 to July 2023 – Pre-intervention Phase. August 2023 to November 2023 – Intervention phase. December 2023 to March 2024 – Post intervention phase

Inclusion Criteria: Patients that can be triaged red, brought by the government CATS ambulance services under the broad subheadings of life-threatening trauma, chest pain, altered mental status, stroke, seizures, code blue and breathing difficulty.

Exclusion criteria: Patients brought to the EMD by non government, private ambulance services.

Patient arriving by their own vehicle to the emergency department.

Yellow category patient as decided by the Triage office.

Sample Size: 100 visits to be captured per condition, divided into preintervention, intervention and post intervention. Based on WHO operational manual considering 4 to 5 CATS ( Centralised Accident and Trauma Services ) ambulance visits /12 hrs a day in medical emergencies and 3to 4 visits for trauma. Non probability sampling used.Tools used (for data collection) - Questionnaires, focussed group discussions, non structured interviews.Statistical scales used - Run charts, Driver diagrams, Pareto charts, Process maps, Fish Bone Analysis, pictorial representations and tables.

Observations and Results During training we had focussed group discussions and non formal interviews taken with 180 participants and we were able to identify the bottle necks in the system. We used the fish bone diagram to analyse our problems and defined it as people, place, process and policy issues. Non confident with equipment knowledge and use( 82%),difficulty in emergency recognition( 100%),absent pre-hospital notification( 100%),CPR challenges( 72%) and drug administration challenges (74%).47% of the respondents had only 1 training since joining the force. 24% of them had never attended training workshops. This is evidenced with 100% respondents asking for training programmes. They weren’t familiar with the BLS algorithm.

Prior to training their confidence levels for recognising and managing chest pain, altered sensorium or trauma was 35% to 40% but post test showed 75 % to 80% results. The pretest mean was 6 , the post test mean was 9, again a 50% rise.Run charts for breathlessness showed encouraging reports, the preintervention compliance median was zero %, In the intervention arm, full compliance percentage was 60.7%, post intervention it was about 33%.

Statistically significant results were obtained. Altered sensorium compliance from a zero % preintervention median , it improved to an 91.6% partial compliance but the post intervention data were falling and stabilised at 31%.The preintervention trauma compliance and partial compliance was zero percentage .Once intervention begins the full compliance mean become 33% although it was not sustainable and in the post intervention phase it again reached zero median percentage. The partial compliance median however was 50 % post intervention phase also, which was statistically significant.

Conclusions This study is a first of its kind and manner to evaluate a Government run ambulance service, looking at multiple process indicators and also tries to improve the system.

The people, policy , process and place bottlenecks were identified extensively through this study.Training through videos, classes, scenarios, simulations brought about significant improvement in the standard of care and they were statistically significant and also sustainable. This study opens the gates for more such studies in the field of prehospital care in Indian settings to improve the fragmented systems already in vogue.