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|CANDOUR - Issue 9 - April 2000
The newsletter of the ASA/ JCALC Clinical Effectiveness Committee and the ASA Clinical Effectiveness Programme
In this issue :
Joint ASA/JRCALC Conference 2000 preliminary details
Not Just Another Maternity an update on the work of CESDI and the implications for ambulance services
NICE update on effective clinical practice programmes
Measuring Performance a review of what the Department of Healths quality performance initiatives mean to ambulance services and their staff
New Website www.asancep.org.uk get CANDOUR online
999 EMS Research Forum update for Ambex 2000
Evidence for Change III update on the annual survey of clinical audit
SECS Electronic Patient Record development in Surrey
KEEP YOUR DIARIES OPEN !
Plans are under way for the 4th Joint ASA/JRCALC Conference.
3rd November 2000, Royal College of Physicians (London)
The morning session will highlight the
work of JRCALC.
The conference will have an emphasis on clinical improvement and the promotion of effective clinical practice.
The date and further details will be
circulated as soon as they are confirmed. Details will be
announced immediately on the new website of the
ASA National Clinical Effectiveness Project (see below
and here ) and more details will follow in Issue 10 of
In the last issue of CANDOUR Stephen Hines described an in depth case study where we learnt of the complications which could occur at just another maternity. The case highlighted the risks associated with the management of breech presentations.
At the time of publication the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) held a Focus Group to look into the management of vaginal breech births.
The ASAs National Clinical Effectiveness Project was invited to participate in the review of "Breech Presentation at Onset of Labour A review of 70 intrapartum-related deaths". However, given the experience and knowledge gained by paramedic Stephen Hines, (see above case study), he was chosen to represent the ASA at the Focus Group.
CESDI Focus Group Meeting
Here is Stephens report on the meeting with its implications for all UK ambulance services:
Following discussion of the CESDI reports recommendations the key issues for ambulance services and their staff are to look into the following:
The final report and recommendations from CESDI are due to be published in June/ July 2000. CANDOUR will keep you posted of any developments. Thanks again to Stephen Hines for attending the Focus Group and for writing this summary of events. Please feel free to comment on this article as the ASA will feedback to CESDI in light of the recommendations.
Effective Clinical Practice
The ASA National Clinical Effectiveness Project is set to work closely with NICE as part of its effective clinical practice programme. The programme is a clinical development and support programme involving all the professional associations (e.g. royal medical colleges).
The programme will look to ensure a collaborative network across the NHS is established through NICE to provide NHS staff and patients with ready access to clinical guidelines and audit tools.
The collaboration between NICE and the ASA National Clinical Effectiveness Project will focus future developments around clinical audit and effectiveness on the priorities outlined in the Priorities and Planning Guidance for the NHS (HSC(98)159 & Modernising Health and Social Services: National Priorities Guidance 1999/00 2001/002).
This will mean focus is concentrated upon the targets set in Our Healthier Nation and the National Service Frameworks. Local service delivery will need to improve in these specific areas (e.g. Coronary Heart Disease, Diabetes, Accidents) as a matter of priority. The ASA National Clinical Effectiveness Project working in collaboration with NICE will support and develop local, regional and national clinical audit programmes to measure performance and improve the standards of pre-hospital care provided. The Project will also facilitate a communications strategy to ensure local issues are shared nationally enabling us all to learn from each other. Follow this link to view the ASANCEP Busniess Plan submitted to NICE for 2000-01.
Over the past couple of years the climate for change within the NHS, as set by the Department of Health, is inextricably linked to the QUALITY agenda. Initiatives such as Clinical Governance and Controls Assurance have led to the development of a culture of clinical performance measurement. The previously mentioned effective clinical practice programme being initiated by the National Institute for Clinical Excellence will underpin this evolving culture through the development of evidence based guidelines and clinical audit tools.
Performance is now a key priority for organisations through clinical governance, National Service Frameworks, Health Improvement Plans, Our Healthier Nation targets and control assurance standards to name a few.
It is also a key priority for individuals with the advent of professionalism through state registration and the responsibilities of clinical governance, clinical accountability, lifelong learning and continued professional development.
Much of this does not actually change the way in which you practice with the exception of acting upon the best available evidence for provision of care. What needs to change is the perception that measuring performance is a tool for big brother to wield his big stick.
The table below which is taken from work produced by the NHS Clinical Governance Support Team depicts the weaknesses in the culture.
It shows that it is defensive attitudes with no team-working or little collaboration and poor communication and a general fortress mentality that are to blame for non-improvement in the quality of care provided under clinical governance.
By thinking of the wider picture of how to improve standards of clinical care, the issues surrounding collaboration, team-working and open communication need to be resolved. By working together in an open culture we can all learn from each other, eliminate mistakes and improve performance as individuals and as an organisation.
We can all achieve continuous clinical improvement and improve individual performance with the open support of our organisations. Through communication we can identify, measure, and control any risks learning from any mistakes. Peer review and team-working will benefit individual performance through this learning process. Organisations and individuals alike can learn from untoward incidents, complaints and compliments.
Measuring performance through clinical audit, either individually through self-regulation or as an organisation, means that standards can continually be improved ensuring our practice is evidence based. Research and lifelong learning will also add value to this process of improvement. Individuals will be able to reach their full potential which meets the needs of the patients.
In summary therefore it is as much a responsibility of the individual to measure their own performance as it is the organisations as a whole. Continuos clinical improvement will occur when individuals and organisations work together in an open environment and learn from each other. Everyone makes mistakes but it is the response following the mistake which determines whether the service we provide is to stagnate, through hiding the truth, or thrive through continually learning and improving.
New Website www.asancep.org.uk
Congratulations ! You are already here so you will already know all bout the functions and services of this site. If you would like to see a brief summary follow this link to view the press release officially launching this site - New Website for ASA NCEP
Stop Press! The strengthened working relationship with the National Institute for Clinical Excellence and the launch of the official website of the Ambulance Service Association National Clinical Effectiveness Project will mean both parties have explicit links to each others sites to promote effective clinical practice throughout the NHS. In future, databases of effective clinical practice are likely to be shared across the ASA/NICE partnership interface with links to appropriate and relevant sites of interest (e.g. CHD NSF).
The development of the Project website, and its explicit links to the NICE website, allow for the improved awareness of issues surrounding prehospital care across the whole NHS raising the profile of the ASA and its members staff whilst highlighting effective clinical practice.
In the last issue of Ambulance UK there was a review of the 999 EMS Research Forum from Ambex 1999, which highlighted the history of the Forum and outlined the inaugural programme.
With AMBEX 2000 fast approaching, Helen Snooks (founder of the 999 EMSRF) shares the draft plans for the 999 EMS Research Forum Showcase Theatre that are beginning to take shape.
Sessions will run over the duration of the conference and exhibition and are likely to cover the following issues:
Evidence for Change III A survey of clinical audit in the UK Ambulance Services.
The finishing touches are being put to the latest Evidence for Change survey. Final reports should soon be arriving with your service. For the first time the results of the survey will also be published on the ASA Clinical Effectiveness Project Website (www.asancep.org.uk). Details of last years survey are already available. This years survey has again uncovered some excellent work in improving prehospital care.
Through the regional clinical audit groups which are now in place across the UK, these results can be shared locally, lessons can be learned and collaborative work started to act on this growing evidence base. With Health Improvement Plans and National Service Frameworks being implemented collaborative work is essential to ensure local performance measures are comparable. Again by sharing results and initiatives locally we can all benefit and improve patient care across the board and reduce the variation in treatment and outcome.
SECS Surrey Emergency Care System
As part of the Vision 2010 initiative in West Surrey, Surrey Ambulance Service is exploring ways in which evolving technology can be used to modernise the delivery of emergency medical services. As a result they have developed a collaborative relationship with three suppliers and the University of Surrey to produce a technical solution targeted at the major issues facing the service, specifically, the efficient delivery of good quality care, effective clinical governance and risk management.
The future development of the ambulance service and its ability to achieve government targets will be severely hampered if good quality information is not available where and when it is needed. Clinical governance, and measuring performance in general, is impossible without access to clinical outcome data from hospitals. Also, the move towards professional paramedics delivering some definitive care at scene or home may reduce transfer to hospital by 40% but it will be difficult without an evolving evidence base and effective supervision.
The key is information management, both to provide the right information to crews at the point of delivery of care and to conduct clinical audit in order to improve the quality of care and the efficient delivery of a quality service. SECS Surrey Emergency Care System will aim to provide these information requirements within an integrated IT system covering prehospital care, GP practices and Accident & Emergency.
In the beginning
Several years ago members of Surrey Ambulance Service (SAS) were looking to develop their patient report form (PRF) in order to conduct clinical audit and create a prehospital data set. Part of this process was to develop an electronic database to hold the data set, which could then be interrogated for purposes of clinical audit.
With the support of the Chief Executive, Alan Kennedy, the project team of Andy Deighton, Jeff Jan and Dr Iain McNeil were allowed access to all relevant resources in order to develop the database, driven by the need for accurate, robust, timely and effective information.
At this point Tenax Health Systems, a medically orientated IT company, became involved in the project. Tenax assisted in the development of the database and in 1997 the first trials were held with the software being exhibited at Ambex that year. The system Entriageİ by now was both a clinical audit database and reporting tool and an electronic PRF. One of the first customers for the Tenax system was the RAFs Institute for Health who needed to audit the 300-350 accident and emergency cases managed by the RAFs search and rescue teams each year. This assisted in the development of the audit tool software as previously unasked questions were targeted. The RAF required information which would allow them to change their practice to meet the needs of the patients.
In 1998 Tenax held trials of Entriageİ within SAS. Paramedic Darren Ringshaw was selected to trial both the hardware and software in a live prehospital arena. At this stage the wider implications of the electronic PRF and clinical audit tool were coming to light in conjunction with initiatives such as Clinical Governance and Information for Health (incorporating electronic patient health records). Since 1998 and as Entriageİ has evolved trials have continued at SAS.
Where is SECS now?
During 1999 West Surrey Health Authority provide SAS with £35,000 to develop electronic health records. The concept is that
SECS will not just be an electronic health record system but an integrated information management system enabling the interrogation of operational, clinical and audit data.
The £35,000 has been spent on developing Entriageİ with 3 units situated initially on single response units. Their development has already gone beyond a trial. The Entriageİ units have been field and bench tested. The next phase of the SECS development relating to electronic PRFs is to place Entriageİ with each of the 12 single responders within SAS who will act as field trainers and refining the system ready for full implementation across the Trust.
The future of SECS
The concept is to develop Entriageİ into a fully integrated clinical decision support system. This would allow for treat and refer protocols to be built into the software for safe and effective delivery of care. Virtual cases conference could be held from the patients side between Paramedics, A&E, District Nurses and GPs enabling the most appropriate action to be taken with no unnecessary inconvenience to the patient. This along with the telemetry of clinical information will allow for new ways of working. For example, the transmission of ECGs from the patients side to hospital allows decisions to be made for out-of-hospital thrombolysis.
The software can also incorporate major incident reports and logs for assisting crews refresh their knowledge in such situations. Other educational implications include distance learning with protocols being updated in the emergency vehicle, with crews signing electronically to state they have read and accepted them. The database will become a tool for CPD (continued professional development) and self-regulation through clinical audit.
Surrey Ambulance Service and Tenax Health Systems will continue to update CANDOUR with the ongoing development of Entriageİ. Indeed the clinical audit tool of Entriageİ is already being used by the Isle of Wight Ambulance Service and Lancashire Ambulance Service.
Further details about SECS and Entriageİ are available from:
Dr Iain McNeil, Medical Director, Surrey Ambulance Service NHS Trust, The Horseshoe, Banstead, Surrey. Tel. 01737 353333.
James Ormonde, Managing Director, Tenax Health Systems, Unit 5A, DP House, The Ring, Bracknell, Berkshire RG12 1HB. Tel. 01344 454656.