Towards a Unified Approach

Clinical Guidelines From Paper into Practice

Graham BrownClinical Effectiveness Manager

Westcountry Ambulance Services NHS Trust

JRCALC 2000 Towards a Unified Approach

£345,000 damages for surgery nightmare

Parents in child organs protest

JRCALC 2000 Towards a Unified Approach

Monday, 17 January, 2000

Ambulance services 'falling short'

Panorama reveals how treatments available for trauma patients vary widely depending on where their

accident takes place

“Each of the UK's 36 ambulance trusts has its own treatment instructions but… there are wide discrepancies among the trusts.”

JRCALC 2000 Towards a Unified Approach

Guidelines vs. Protocols?

JRCALC 2000 Towards a Unified Approach

Clinical guidelines

‘Systematically developed statements to assist practitioner and patient decisions about appropriate

health care for specific clinical circumstances’

Field & Lohr 1990

JRCALC 2000 Towards a Unified Approach

Protocol

‘Standard procedure laid down to be followed step by step’

IHCD paramedic manual 1993

JRCALC 2000 Towards a Unified Approach

Evidence based practice

Only 10-20% of physician interventions are supported by

objective evidence

(Cochrane 1976; White 1976)

JRCALC 2000 Towards a Unified Approach

Of unknown effect - not in research setting or in poor quality research

Do more harm than

good

Do more good than harm

Of unknown effect, but

in good quality

research programme

Present distribution of healthcare interventions

(Muir Gray; 1997)

JRCALC 2000 Towards a Unified Approach

Of unknown effect - not in research setting or in poor quality research

Do more harm than

good

Do more good than harm

Of unknown effect, but

in good quality

research programme

Present distribution of healthcare interventions

(Muir Gray; 1997)

JRCALC 2000 Towards a Unified Approach

Current PositionTrusts receive medical advice fromo IHCDo Paramedic and Technician and training manualso JRCALC

o recognition of deatho Anaphylaxiso LMA

o Local medical practitionerso LAPSC o Medical adviser/director

JRCALC 2000 Towards a Unified Approach

BASIS FOR AMBULANCE TRUST PRACTICE

IHCD +/- Local medical opinion

39%

Local medical opinion12%

Inc EB guidelines49%

JRCALC 2000 Towards a Unified Approach

CONSENSUS EVIDENCERESEARCH

JRCALC 2000 Towards a Unified Approach

NALOXONE - FIRST IV DOSE

0

2

4

6

8

10

12

14

200 400 800 1200

Microgrammes

Ambulance

services

(Hawksworth 1998)

JRCALC 2000 Towards a Unified Approach

MAXIMUM NALOXONE DOSE

0

2

4

6

8

10

12

800 1200 1600 2400 10000

Microgrammes

Ambulance

services

(Hawksworth 1998)

JRCALC 2000 Towards a Unified Approach

Management of Cardiac Chest PainTrust A Trust B Trust C Trust D

Aspirin Oxygen GTN Opioid Anti-emetic 12 lead ECG Admit A&E Admit CCU

JRCALC 2000 Towards a Unified Approach

Guidelines vary in effectiveness

European Resuscitation Council

British Thoracic Society

British Heart Foundation Working Group

BLS and ALS

Asthma

AMI

JRCALC 2000 Towards a Unified Approach

Major determinants of guideline effectiveness

1. Political commitment

2. Chief Executive commitment3. Guideline credibility and validity

4. Acceptability to practitioners

5. Changes in practice achieved

6. Health gain achieved

JRCALC 2000 Towards a Unified Approach

8 minutes

JRCALC 2000 Towards a Unified Approach

DoH

CEO

JRCALC 2000 Towards a Unified Approach

Determinants of guideline effectiveness

Political commitment Chief Executive commitment Guideline credibility and validity Acceptability to practitioners Changes in practice achieved Health gain achieved

JRCALC 2000 Towards a Unified Approach

Guideline credibility and validity

Vital if services are to adopt Use/adapt pertinent existing guidelines Development group credentials Involvement and support of eminent bodies Evaluation in practice Must be suitable for prehospital setting

JRCALC 2000 Towards a Unified Approach

Acceptability to practitioners

NEGATIVES Top down Control tool Curb flexibility/initiative Not-invented-here

POSITIVES Building ownership Local adaptations Inclusive development Consultation Pilot/test Effective dissemination Incentives (sanctions)

Resistance hard to detect and overcome

JRCALC 2000 Towards a Unified Approach

Achieving changes in practice

STRATEGIC (managers) Clinical governance Sound underpinning

evidence base Litigation Dissemination strategy

TACTICAL (crews) Simple format Clear layout Rationale explained Targeted education Reinforcement Monitoring Feedback Realistic timescales

JRCALC 2000 Towards a Unified Approach

Measuring health gain

Monitoring & evaluation Compliance vs outcomes Integrated care pathways Interface audits – primary/secondary care Audit component of clinical governance

framework Exception reporting

JRCALC 2000 Towards a Unified Approach

In summary... Rigorous guideline development

resources/skills targeted at relevant topics regular review communication and consultation

Total commitment to implementation ambulance service managers & advisory

bodies Local ownership Monitoring of implementation and outcomes

JRCALC 2000 Towards a Unified Approach

Capacity to Develop Evidence Based Guidelines

YES

NO

UNSURE

16

10

7

JRCALC 2000 Towards a Unified Approach

Services Willing to Adopt JRCALC National Guidelines

Yes 30

Unsure 3

(3 dependent on evidence base)

JRCALC 2000 Towards a Unified Approach