Post on 30-Dec-2015
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