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Additional file 1: Table S1. Themes and codes.

Additional file 2: Appendix 2. Interview Topic Guide.

Additional file 3: Appendix 3. Interview schedule for telephone interviews with ambulance staff.

Additional file 1: Appendix 1. Content Analysis Trust Breakdown.

Appendix 4. BMC HSR paper themes and quotes.

Background Historically ambulance care quality and performance has been measured by response times rather than clinical need or effectiveness. This limits the evidence about the effectiveness of the care the ambulance service provides. The Pre-hospital Outcomes for Evidence Based Evaluation (PhOEBE) project is a 5 year research programme which aims to develop new ways of measuring the performance, quality and impact of ambulance service care that better reflect the care provided. Methods We held a 1 day consensus event with a multi-stakeholder group to identify and prioritise which features of ambulance service care are important and worth further development as measures of performance and quality. The day comprised a series of small group discussions to share opinions about measures identified from literature reviews and the opportunity for participants to add their ideas, together with a live vote to help identify and rank measures for further development. Time measures were considered in a separate online questionnaire. The results from the online questionnaire and Consensus Event were fed into a Delphi study. Results 43 participants attended the consensus event, representing a range of participant groups including patient and public, ambulance services, commissioners and policy groups. The top 5 outcome measures prioritised by the participants were: accuracy of dispatch decisions; completeness and accuracy of patient records; accuracy of call taker identification of different conditions or needs (e.g. heart attack, stroke, suitable for nurse advice); pain measurement and symptom relief; and patient experience. From the online survey of time measures the top 5 measures were time of call to time of arrival at scene; time symptoms start (e.g. chest pain) to time of treatment with balloon for heart attack; time taken to answer the emergency call; total time spent on scene; and incident or start of symptoms to calling the ambulance service. Conclusion Using consensus methods we have identified a set of outcome measures that can potentially be used to measure the performance and quality of ambulance service care. Some of these measures fit with existing government targets, such as response times and time taken to answer the emergency call. However, most measures are new ways of measuring ambulance service care and the importance of these measures and methods of measurement will be assessed as part of an on-going Delphi study.

Introduction: Response times have been used as a key quality indicator for emergency ambulance services in the United Kingdom, but criticised for their narrow focus. Consequently, there is a need to consider wider measures of quality. The patient perspective is becoming an increasingly important dimension in pre-hospital outcomes research. To that end, we aimed to investigate patients’ experiences of the 999 ambulance service to understand the processes and outcomes important to them. Methods: We employed a qualitative design, using semi-structured interviews with a purposive sample of people who had recently used a 999 ambulance in the East Midlands region of the UK. We recruited patients of different age, sex, geographical location, and ambulance service response including ‘hear and treat’, ‘see and treat’ and ‘see and convey’. Results: We interviewed 20 service users. Eleven men and nine women participated and twelve were aged 65 years and over. Users valued a quick response when they perceived the call to be an emergency. This was of less value to those who did not perceive their situation as an emergency and irrelevant to ‘hear and treat’ users. All users valued the professional approach and information and advice given by call handlers, crew and first responders, which provided them with reassurance in a worrying situation. ‘See and convey’ users valued a seamless handover to secondary care. Conclusions: Aspects other than response times were important to patients, particularly in situations perceived by patients to be non-emergency. We found it challenging to engage participants to consider quality indicators beyond response times because these were considered to be abstract in comparison with their concrete experiences. The results will be combined with issues identified from systematic reviews and used in a Delphi study to identify candidates for new outcome measures for emergency ambulance services.

Background: The PhOEBE (Pre-hospital Outcomes for Evidence Based Evaluation) project is a 5-year research programme which aims to develop new ways of measuring the performance, quality and impact of ambulance service care. As part of this programme we conducted 2 systematic reviews to identify potential measures and held a consensus event to prioritise these measures. Methods: Actual or potential measures or indicators for assessing ambulance service performance or quality of care were identified from two systematic reviews and categorised as clinical management, operational or patient based measures. Time measures were considered separately. We held a consensus event with participants representing clinicians, ambulance operations, commissioners, policy and academic research. Three small group discussion sessions were held and after each session we used turning point software for participants to electronically vote whether they thought each potential measure was essential, desirable or irrelevant. Results: 42 participants took part and discussed and voted on 52 different measures. They could also add measures. The top 5 ranked operational measures were concerned with completeness and accuracy of records; accuracy of triage; appropriateness of service; ambulance training and ambulance utilisation. Top 5 clinical measures were accuracy of dispatch decisions, accuracy of problem identification, compliance with end of life care plans; patient safety and compliance with protocols. The top 5 patient measures were measurement and relief of pain; patient experience; return of spontaneous circulation; complications from care and survival. Conclusions: Accuracy of different types of decision making and compliance with management protocols predominated as essential with pain management the most important patient measure. Management of end of life care was identified by participants. The electronic voting system which provided instant real time feedback was well received by participants. The next stage is a Delphi survey to further refine these measures and include time interval measures.

Total Electron Content (TEC) of the ionosphere over the Southeast Asian region has been derived from measurements obtained at GPS ground stations of the International GPS Service (IGS) and three GPS ground stations of Vietnam in 2010. This paper presents the results of the study of the TEC variations during four magnetic storms on 4–10 April, 1–9 May, 1–8 August and 10–15 October, 2010. It was found that the structure of the daytime equatorial ionization anomaly (EIA), which consists of two peaks in the vicinity of 10°–15° magnetic latitude. Results are also shown that both peaks are fully developed at around afternoon. The TEC values of peaks on 4–10 April and 10–15 October are higher than on 1–9 May and 1–8 August. During the early stage of the magnetic storms, the EIA expanded poleward with large increases of TEC, which provides evidence of a penetration of the eastward electric field and a strong plasma fountain effect associated with the upward plasma drifts. In the recovery phase, the EIA is significantly reduced; the TEC value decreases and the peaks move equatorward.