title: Development of key performance indicators for prehospital emergency care.
abstract: BACKGROUND
  Key performance indicators (KPIs) are used to monitor and evaluate critical areas of clinical and support functions that influence patient outcome. Traditional prehospital emergency care performance monitoring has focused solely on response time metrics. The landscape of emergency care delivery in Ireland is in the process of significant national reconfiguration. The development of KPIs is therefore considered one of the key priorities in prehospital research.
  
  
  OBJECTIVE
  The aim of this study was to develop a suite of KPIs for prehospital emergency care in Ireland.
  
  
  METHODS
  A systematic literature review of prehospital care performance measurement was undertaken followed by a three-round Delphi consensus process facilitated by a broad-based multidisciplinary group of panellists. The consensus process was conducted between June 2012 and October 2013. Each candidate indicator on the Delphi survey questionnaire was rated using a 5-point Likert-type rating scale. Agreement was defined as at least 70% of responders rating an indicator as 'agree' or 'strongly agree' on the rating scale. Data were analysed using descriptive statistics. Sensitivity of the ratings was examined for robustness by bootstrapping the original sample.
  
  
  RESULTS
  Of the 78 citations identified by the systematic review, 5 relevant publications were used to select candidate indicators for the Delphi round 1 questionnaire. Response rates in Delphi rounds 1 and 2 were 89% and 83%, respectively. Following the consensus development conference, 101 KPIs reached consensus. Based on the Donabedian framework for quality-of-care indicators, 7 of the KPIs which reached agreement were structure KPIs, 74 were process KPIs and 20 were outcome KPIs. The highest ranked indicator was a process KPI ('Direct transport of ST-elevation myocardial infarction patients to a primary percutaneous intervention (PCI)-capable facility for ECG to PCI time <90 min').
  
  
  CONCLUSIONS
  Improving the quality of prehospital care requires the development and implementation of performance measurement using scientifically valid and reliable KPIs. Employing a Delphi panel of key multidisciplinary Emergency Medical Service stakeholders, it was feasible to develop a suite of 101 KPIs for performance monitoring of prehospital emergency care in Ireland. This suite of KPIs may contribute to a framework for achieving safer, better care in the prehospital environment.
authors.affiliation: Paediatric Emergency Research Unit (PERU), National Children's Research Centre, Dublin, Ireland.
authors.forename: Adrian
authors.initials: A
authors.lastname: Murphy
authors.affiliation: Division of Population Health Sciences, Emergency Care Research Unit (ECRU), Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland Department of Emergency Medicine, Beaumont Hospital, Dublin, Ireland.
authors.forename: Abel
authors.initials: A
authors.lastname: Wakai
authors.affiliation: Department of Mathematics and Statistics, University of Limerick, Limerick, Ireland.
authors.forename: Cathal
authors.initials: C
authors.lastname: Walsh
authors.affiliation: National Ambulance, Abu Dhabi, UAE.
authors.forename: Fergal
authors.identifier: http://orcid.org/0000-0002-7644-5781
authors.initials: F
authors.lastname: Cummins
authors.affiliation: Paediatric Emergency Research Unit (PERU), National Children's Research Centre, Dublin, Ireland School of Medicine, University College Cork, Cork, Ireland.
authors.forename: Ronan
authors.initials: R
authors.lastname: O'Sullivan
mesh_terms: D032921:Consensus; D003697:Delphi Technique; D004632:Emergency Medical Services / Q000592:standards*; D006801:Humans; D007494:Ireland; D019984:Quality Indicators, Health Care / Q000592:standards*
keywords: emergency ambulance systems; performance improvement; prehospital care