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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 2000preliminary details

Not ‘Just Another Maternity’an update on the work of CESDI and the implications for ambulance services

NICEupdate on effective clinical practice programmes

Measuring Performancea review of what the Department of Health’s quality performance initiatives mean to ambulance services and their staff

New Website – www.asancep.org.ukget CANDOUR online

999 EMS Research Forumupdate for Ambex 2000

Evidence for Change III update on the annual survey of clinical audit

SECSElectronic Patient Record development in Surrey

Issue 8 CANDOUR INDEX Issue 10

Joint ASA/JRCALC Conference 2000


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 afternoon session run jointly with the ASA Clinical Effectiveness Committeee will focus upon the continued commitment to and development of clinical audit and clinical effectiveness by UK ambulance services.

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 CANDOUR.
Follow this link to see details of this and other events related to clinical effectiveness

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Not ‘Just another maternity…’

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 ASA’s 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 Stephen’s report on the meeting with it’s implications for all UK ambulance services:

The meeting started with an introduction to the report, followed by further information on the facts and figures contained in it. The report looks at deaths associated with breech presentation at the onset of labour, in the years 1994 and 1995. Reasons given for inclusion and exclusion were examined - basically the report looks at 70 deaths which were of babies who would normally be expected to survive. It excludes those with developmental abnormalities, and those weighing under 1.5kg.

In the two years covered by the report, there were 873 intrapartum deaths, 70 of which were breech presentations. This is out of 692,292 births (England, Wales & N. Ireland figures), of which 24,941 were breech presentations (17,388 of those were delivered by LSCS, leaving 7,553 vaginal deliveries).

A special presentation was made examining the 14 deaths of one of twins. In each of these cases the other twin did survive. It was generally agreed that twins were a special case, and it was suggested that they be omitted from the final report.

The group then split into two, and discussed first the report, and then recommendations drawn from it.

It was noted that the draft report referred to Paramedics. Since the skill level of the attending ambulance crew could not be verified, and allowing that in 1994 we were still a long way off having paramedics on every vehicle, this was amended to read ambulance staff, possibly with a statement explaining how ambulance and paramedic training has advanced since then.

The recommendations looked initially at assessment.

Intrapartum management:
Any uncertainty about the presenting part should alert the attendant to the possibility of malpresentation. If available, mobile ultrasound should be used to confirm presentation. The consultant should be informed of all breech presentations, and a plan developed. Assessments of labour should be carried out by an experienced practitioner, and adequately documented. It was generally agreed that this should be an obstetrician with at least 2 years in the field, or a midwife with similar post qualification work.
Fetal Surveillance:
All health professionals involved in the conduct of labour should be trained in the use and interpretation of CTG's. (? the practicality of this for us – ambulance staff - maybe limited to understanding what is documented in notes?). Local protocols are required to ensure appropriate assessment.
Training and skills:
Alternative approaches should be considered for gaining experience (other than learning on the job). Structured training should be considered and should include the conduct of a vaginal breech delivery. A review of how to assess the competency of the skill attained should be considered both locally and nationally.
Place of delivery:
It is recognised that hospital delivery is safest for the baby when presenting breech. There should be guidelines for dealing with an undiagnosed breech at home. These should include:
A protocol / strategy to initiate transfer
Procedures for liaison between staff pre-hospital and in the accepting hospital
Training for paramedic staff - ?can we look at including obstetrics in the paramedic hospital placements? Ideally a paramedic should at least see a normal vaginal birth in a secure environment, before being put in a position were they have to manage a malpresentation under less than ideal circumstances.

The group looked at the London Ambulance Service protocols (GP09), and it was generally agreed that these were of a very high standard and well thought out. Can similar guidance be distributed nationally? Is there a uniform policy on when to move, and where to go? It was noted that particularly in London there were problems as to where mothers should be taken - the nearest or where they are booked, (LAS policy is nearest). There is no legal obligation for a hospital to provide a midwife to support an ambulance crew, unless that hospital has an agreement with the mother to give midwifery services. (This was news even to some of the other midwives in the group - apparently the obligation on the health authority is to provide a maternity service - this need not extend to sending midwives out of the hospital.)

All staff involved in the management of a delivery should be capable of at least basic resuscitation, including bag & mask. Inexperienced SHO's should be accompanied by a registrar or higher, until they are competent in neonatal resuscitation. No single person should be put in the position were they are responsible for both mother and neonate - in practice for ambulance services this will mean two ambulance being sent to BBA's. It was noted that there is no uniform policy as to where ambulance staff should take neonates in distress - some hospitals state labour ward, some A&E, some SCBU etc. This is to be looked into.
Quantifying the risk:
It would appear that most of the problems identified were not specific to breech births, and that there may not be the significant risk commonly thought to be associated with them (when full term and normally developed). It was noted however that more breech babies (almost twice the number) than cephalic presentations had required resuscitation. In the majority of cases this was successful.
Intrapartum deaths should be referred to a pathologist with specific expertise, as they are rare, and the pathology is often missed.

Key Messages

Following discussion of the CESDI report’s recommendations the key issues for ambulance services and their staff are to look into the following:

  1. Transfer to hospital protocol & procedure for Undiagnosed Breech Presentations
  2. Procedures for liaison between prehospital/ midwife/ accepting hospital
  3. Protocol & procedure for transfer to booked/ closest hospital
  4. Protocol & procedure for transfer of Neonates in Distress (? labour ward/ A&E/ SCBU)
  5. Include normal vaginal delivery in secure environment as part of hospital placement for ambulance staff.

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.

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National Institute for Clinical Excellence

‘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.

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Measuring Performance

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.

Clinical Governance

Examples of what goes wrong


- Weak Leadership

- Poor Education & Research

- Cliques & Factions


- Poor strategy

- Weak Management Systems

- Poor Communication


- Defensiveness

- Little Collaboration

- Fortress Mentality


- Lack of Skills

- No Team-working

- Motivation

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 organisation’s 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.

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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 it’s 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 it’s members staff whilst highlighting effective clinical practice.

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999 EMS Research Forum

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:

  • Why do research? – exploring the need for evidence in prehospital care and shoeing the benefits of provider involvement.
  • Peer review – presentations of research topics
  • Research skills workshops – including how to read and critically appraise a research paper
  • Cardiac related research – the National Service Framework on Coronary Heart Disease: What difference can it make?
  • A Debate on Category ‘C’ Call management –‘Every 999 caller should get an immediate lights and sirens, paramedic response and should go to A&E unless they refuse’
  • Category C: Where is the evidence? Treat and release/refer protocols, Telephone advice (NHS Direct) and Minor Injury Units
  • Clinical Audit – A training session covering topics such as Planning your audit programme, Acting on evidence, Including health outcomes, the role/impact of NICE and other institutions
  • How do we know where we are going if we don’t know where we are?

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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.

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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 RAF’s Institute for Health who needed to audit the 300-350 accident and emergency cases managed by the RAF’s 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

  • Each ambulance will carry en electronic PRF (Entriageİ) which will include symptom based protocols (developed by the University of Surrey) to guide crews in their management of patients. The electronic PRF will link to vital signs monitors including ECG’s and will record and date time stamp any interventions as they are undertaken. This data will be transmittable to the receiving hospital.
  • Each hospital A&E department will be upgraded to a best of breed A&E software system (HAS Solutions). The HAS system will bring considerable benefits of its own including evidence base at the bedside (developed in partnership with Manchester University).
  • The A&E systems throughout Surrey will all be linked in with the ambulance service to form a Surrey wide emergency medical service network – SECS.

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 PRF’s 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 GP’s 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 ECG’s 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.

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