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CANDOUR - Issue 17 - August 2001

The newsletter of the Joint ASA/JRCALC Clinical Effectiveness Committee and the ASA National Clinical Effectiveness Programme

In this Issue:

Issue 16 CANDOUR INDEX Next Issue October 2001

Clinical Guidelines for Ambulance Services - past, present and future

Medical Director Surrey Ambulance Service NHS Trust & Associate Medical Director Kent Ambulance NHS Trust
Chairman, Clinical Guidelines Group, Joint Royal Colleges Ambulance Liaison Committee

Dr Iain McNeil. MIMMS, PHEC instructor, Founder member of the Faculty PHC RCS Ed, Fellow of FPHCRCS (Ed), is the Medical Director of Surrey Ambulance Service NHS Trust. He graduated from Dundee University in 1981 and, after training as a GP in North Wales, spent 15 years working as a GP in West Sussex and as a BASICS Doctor in Sussex and Surrey. He is the founding Chairman of Sussex and Surrey Immediate Care Scheme (SIMCAS) and the Immediate Past Chairman of BASICS. As well as being a Member of JRCALC he is also Chair of the JRCALC Guidelines Committee and Vice-Chair of the Joint ASA/JRCALC Clinical Effectiveness Committee. Dr McNeil is also Associate Medical Director at Kent Ambulance Service NHS Trust and a Member of the Fire Service Search and Rescue Team which was deployed last summer to assist in the aftermath of the earthquake in Turkey.

The Imperative

In early 2000 the BBC aired a "Panorama" programme on operational and clinical standards in Britain's ambulance services. Whilst in my view the message that was delivered was unnecessarily sensationalised by highlighting a small number of apparently poorly handled cases, there was no doubt that things had to change. The key message being that clinical standards and practices were hugely variable across Britain and that this "post-code lottery" of care was wholly inappropriate and must stop. The programme caused great anger and embarrassment amongst ambulance services but the basic message could not be ignored.

Additionally 'clinical governance' and, of course, the patient require all health care providers, regardless of status, to deliver best practice at all times. To do this, care should be delivered using evidence based clinical guidelines, and that care should be audited against a clearly defined standard. But where were the evidence-based guidelines, and what was the standard? It was clear that many ambulance trusts had developed a set of clinical guidelines and variable standards for use within their own service but there was no conformity and neighbouring services often had widely differing guidelines and practices.

In May 2000 The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) were given a clear direction by the Department of Health, to resolve this problem and produce a set of guidelines for use by all ambulance trusts in England - by October 2000.

The Background

In 1996, Dr Chris Carney then Medical Director of Staffordshire Ambulance Service NHS Trust wrote and produced a comprehensive set of clinical guidelines in pre-hospital care for paramedics and technicians. These were at the time widely acclaimed by many services both at home and abroad, yet strangely no one else adopted their use.

In 1999, Dr Carney, now Chief Executive of Bedfordshire and Hertfordshire Ambulance Service NHS Trust, in conjunction with Dr John Scott, Medical Director at East Anglia Ambulance Service and Dr Iain McNeil, Medical Director of Surrey and also of Kent Ambulance Services began a systematic review and rewrite of the "Carney Protocols" for use within their own respective services. There was a clear need to revise the original guidelines as they were now somewhat out of date and the work commenced during 1999 in earnest with considerable input from training and audit staff from each of the above services.

The work continued throughout the year and into 2000 with the services "gifting" the time of staff and the Medical Directors. The work used the original guidelines as a basis and was updated in line with whatever evidence could be gleaned from journals and texts. There was very little published evidence in many areas. Where there was no evidence a consensus was agreed between the contributors, all experienced in current UK pre-hospital practice and education.

Local becomes National

In May 2000 the group were approached by JRCALC who requested that the work so far undertaken be shared with JRCALC in order that it may be taken forward to inform the national agenda that had been set. This was readily agreed to and the National Clinical Guidelines for Ambulance Services began to take shape.

Dr Iain McNeil was tasked by JRCALC to lead an expanded group, with representatives from many other services and a number of recognised experts in pre-hospital care. As a result the JRCALC guidelines sub-group was formed and began work on developing the "Carney Protocols" into a fully evidence based piece of work - a huge undertaking.

The group met in May 2000, scoped the work, and agreed the format upon which the evidence was to be reviewed. At the same time as JRCALC began work the Welsh Ambulance Service began a funded project to develop a number of evidence based guidelines for Wales. This work, under the supervision of Malcolm Woollard of the Welsh Ambulance Service had done much work on the academic basis of evidence analysis and thus the Welsh Ambulance Service team was invited to join with the JRCALC team to ensure conformity across England and Wales.

The new expanded group began a review of the work already done and by September 2000 were able to present a set of draft guidelines that were agreed to represent a reasonable and fair standard that could be applied by all ambulance services in England and Wales. These guidelines were then presented to JRCALC for consideration by the experts in the various fields - trauma, paediatrics, obstetrics and medicine. A number of additions and suggestions were offered and were incorporated into the final version.

At the same time guidelines for the soon to be agreed "new drugs" were added to the guidelines. This was a complication that had not been anticipated and resulted in considerable extra work to the main body of the text as well as the drug guidelines. Another complication was the impending introduction of the UK Resuscitation Guidelines, however a decision was made to publish the first version of the guidelines without those changes being incorporated.

In November 2000 JRCALC launched the guidelines at its annual conference at the Royal College of Physicians and thus the National Clinical Guidelines for Ambulance Services were born.

The guidelines have been published on the internet at www.jrcalc.org.uk. A Number of services have now formally adopted the guidelines for use within their services and some have gone to print and issued them to their operational staff.

Further Developments

It is wholly accepted that the current version of the guidelines is not perfect. It is also accepted that the evidence upon which they are based is variable, with much being based on consensus opinion - but at least it is a common starting point. As a result the guidelines team has continued to work to develop them. This is a massive task and is out with the ability of individuals, or groups, working on their own in their spare time and thus JRCALC is seeking financial support in order to employ research assistants with academic support to continue with the systematic reviews of the literature where possible and to support the development of the consensus opinion where the evidence does not exist. This funding has not yet been secured, but is imperative to the safe future of clinical care within the ambulance services in England and Wales.

The guidelines group has continued to meet and has held a number of two-day meetings to iron-out the snags in the current guidelines and also to further develop the guidelines. This work will be on-going and will result in updates to the guidelines being published at regular intervals. The guidelines are thus a "living document" and will be improved in light of developing evidence and research in the future.

The membership of the guidelines group has been expanded to included all the Medical Directors of ambulance services within the UK and has also incorporated some members of another working group who have been very busy developing standards for use on the air ambulances in the Midlands. Furthermore the IHCD have become involved with the project to ensure that training manuals and educational material reflect the content of the National Guidelines. Thus all the known groups who might have influenced the development of clinical guidelines on the national arena are now working under the JRCALC banner to a common end.

In the meantime some support has been gained through a development project run by Surrey Ambulance Service, the Defense Evaluation and Research Authority (DERA) and Professor Lt. Col Tim Hodgetts of the Royal Army Medical Corp. This project is looking to develop computer based software for use by ambulance staff and medical
staff in military circles. This software must be based upon best evidence if it to be acceptable to Surrey Ambulance Service and the military and thus DERA have agreed to fund a project for approximately one year to do as much as it can to ensure the evidence base is as robust as possible. This work is being undertaken by a Research Assistant, Ian Todd (a lawyer and paramedic) under the academic supervision of Dr Matthew Cooke, Director of the Emergency Medicine Research Group at the University of Warwick. The work whilst primarily aimed at the software project will be made available to JRCALC for use in the national arena and has already proved useful in informing the national agenda.

Additional support has been provided from the ASA Clinical Effectiveness Manager, Stuart Nicholls, who is responsible for secretarial matters and maintaining the guidelines on the JRCALC website (www.jrcalc.org.uk). Thus the momentum is being continued for the present.

The Future

It is expected that the guidelines be welcomed for use by all ambulance trusts within England and Wales, enabling them to deliver, for the first time ever, a common standard of care for all patients regardless of location.

It is agreed that such a stance can only be supported if further developments are made to ensure that standards are current and appropriate and this will be done. In the event that ambulance services identify a problem with the content of the published guidelines they should communicate with the Chairman of the JRCALC Guidelines
Committee (Dr Iain McNeil). Additionally if as a result of research, audit or literature reviews ambulance services identify areas of care that should be reviewed or developed then equally that too should be put to the guidelines committee through its Chairman. Those suggestions will then be assessed and any subsequently agreed changes can then be disseminated to all ambulance services through a common pathway.

The guidelines are not intended to stifle research and development (R&D), but clearly if R&D was done in a co-ordinated fashion through JRCALC then the benefits would be spread much wider much faster. It would also ensure that services do not go down a route of research that has proven fruitless in the past.

Clinical Governance requires the adoption of best practice and any service that decides to "go it alone" may be exposed to considerable scrutiny if a problem arises and the JRCALC position is not being followed. I would therefore counsel against the use of patient group directives in an attempt to circumvent the current guidelines, unless part of a specific research project that can in due course inform the national view.

JRCALC will continue to examine developments in clinical care and if necessary will recommend additions to, or deletions from the guidelines, of clinical practices and drugs. All drugs used by ambulance staff should be endorsed for use by the Medicines Control Agency (MCA) on the Prescription Only Medicines (POMs) exemption list to allow services to use them. JRCALC will continue to review the list and when necessary make applications for additional drugs to be made available.

The committee intends to publish routine changes in January of each year and services will be advised of those changes through the JRCALC website and direct communication. In the event of a large change in other established guidelines (e.g. changes to the UK Resuscitation Council Guidelines) these will be issued as interim updates as required, without waiting for a January release. In the unlikely event that there is an urgent need to rapidly move away from current practice then the committee will contact all ambulance services as quickly as possible to advise them of the problem.

The guidelines group will also soon publish a summary of its work programme so that ambulance services are aware of those areas that might change in the coming year.

The Key to Success

The guidelines will only work if ambulance services all work together and support not only the concept but also, ultimately, their universal adoption.

The guidelines will only work if the JRCALC committee can continue to develop them and keep them current and this depends on an enormous amount of laborious review and research. For that process to be successful adequate funding must be provided to ensure timely progress.

We must accept that the ambulance services deserve the best guidance available, and to date that has been provided as a labour of love by a group of enthusiastic volunteers, many of whom having no direct links with ambulance services. This must be change, the National Health Service should not rely entirely on this goodwill and arrangements must be formalised and properly funded. JRCALC has approached the Department of Health for support but at the time of writing no financial support has been forthcoming.

If that can happen we can continue to develop pre-hospital practice so British ambulance services will then be able to rightfully stand alongside the other high performance services across the world.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

In summary the process for developing the guidelines is as follows:

1. Communicate all problems with the guidelines through the Chair of the JRCALC-CGC
2. Results of research, clinical audit or literature reviews which services feel impact upon existing guidelines, or require the development of new guidelines, again should be channelled through the Chair of the JRCALC-CGC
3. The JRCALC-CGC will assess any reviews and make any agreed changes subsequently, with the appropriate ratification of the full JRCALC committee
4. All changes will be disseminated to all ambulance services through the JRCALC-CGC

Useful contacts:

Dr Iain McNeil – Chair JRCALC-CGC - [email protected]
Ian Todd – Research Assistant - [email protected]
Stuart Nicholls – Manager ASA NCEP - [email protected]

General - [email protected]

Website - www.jrcalc.org.uk

Please inform us of any results from clinical audit or research – these will be held in a database and be made available via the website – www.asancep.org.uk

Timetable of developments
The current timetable for the guideline development programme under the supervision of the JRCALC-CGC is as follows:

All of the JRCALC guidelines are currently being reviewed/ evidence based
The 3rd JRCALC-CGC consensus meeting to make any additional changes will be held 13th and 14th September 2001
These changes will be presented to the full JRCALC Committee on 1st November 2001
“Version 2”/ “2002” JRCALC Clinical Guidelines will be published and disseminated to ambulance services in January 2002.

Pocket Books
Another of the current projects being undertaken is the development of a “pocket” version of the guidelines using diagrammatic algorithms for use by paramedics. These will hopefully be ready for publication in the next six months or so.

Regular updates will be posted to the JRCALC website at www.jrcalc.org.uk

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Quality must come first - pledge

A landmark statement pledging to put quality first in the NHS has been agreed by the Government and the medical professions.
It is the first time doctors and ministers have agreed a statement on how standards of care will be raised in the NHS.
It argues that medicine is not a perfect science and even the best people can make mistakes. But it sets out a shared commitment to minimise errors, to learn from mistakes and to make improvements in clinical quality the cornerstone of reform in the NHS.
The report follows growing concerns after a number of recent medical scandals and the fear that a handful of problem doctors may be tainting the reputation of the whole medical profession.
Health secretary Alan Milburn said: "The NHS is full of good doctors, not bad ones. Together doctors, NHS staff and the Government are leading a quiet revolution to raise standards of care in the health service."
The statement sets out a seven-point pledge, one of which will be to take every opportunity to involve patients and their representatives in decisions about their care and in the planning and design of services

The document can be viewed at the following website:


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A Case Study – Critical Incident and Risk Management

The following case studies has been reproduced from the website of the NHS Clinical Governance Support Team – www.cgsupport.org - with kind permission of NHS CGST and the ambulance service concerned.

It provides an example of clinical governance at work in producing a no-blame culture. Please contribute examples from your local service to both the NCGST or to the ASANCEP
Email: [email protected]

Example 1:

Setting: Ambulance Service
Keywords: Demonstrating cultural change; no-blame environment; systems awareness; improving safety
The event:
A Paramedic, working alone in the back of an ambulance gave a single dose of nubain (analgesia). He later needed to give another dose, and accidentally gave narcan (analgesia reversal). He recognised his mistake, there was no harm done to the patient, he gave the appropriate analgesia, reported the incident to the A&E Consultant and then to the Training Officer.

What used to happen next:
The drug box is instantly removed ‘for examination’
The Paramedic is not allowed to practice – he is demoted to ‘technician’
There is an investigation of the incident
The Paramedic attends a disciplinary hearing
He receives a ‘warning letter’ which is copied to his personal file
If he ‘offends’ again in the next 12 months he is sacked
Realising the above the Paramedic claims he dropped the narcan
The incident is not reported

What actually happened:
The Paramedic reported the incident to the training officer (a delegate)
The Paramedic finished his shift
The Training Officer met him after the shift, and talked through what had happened
The paramedic satisfied the Training Officer of his understanding of correct procedure, and his ability to practice safely
The Training Officer submitted a report which identified a system flaw – the nubain and narcan are stored next to each other in the drug box, in identical vials. The only difference between them is in the colour of the label
The Training Officer arranged immediately for the narcan to be removed from all drug boxes, and for it to be stored in a separate, clearly marked container
The incident was recorded on the Paramedic’s Training File
Key benefits:
Improved patient safety
Incident reporting encouraged
Staff feel valued and supported – not criticised and blamed
There is added impetus for the cultural change which must underpin quality improvement initiatives

Example 2:

Setting: Ambulance Service
Keywords: Improving patient care; making systems patient focused; challenging existing rules
The event:
A Paramedic was called to attend an 8 year old child who had fallen from a tree and fractured his femur. The child was too distressed to use Entonox (inhaled analgesia) and faced a ’15 minute carry’ to the ambulance. The paramedic gave a dose of nubain calculated for the child knowing that the protocol in operation forbade administration of nubain to children under the age of 14. He reported the incident on return to the station.

What happened next:
The Training Officer reviewed the case
The dose correct for age had been given
A report has been sent to the Steering Committee suggesting that paramedics be allowed to administer drugs to children under the age of 14 in accordance with pharmaceutical licensing regulations
The incident was recorded on the Paramedic’s Training File

Key benefits:
Improved patient service
Systems become ‘patient centred’
Systems to address problems are developed
Staff are encouraged to report incidents
Staff feel supported when events call for sensible, calculated, but new decisions

All correspondence for CANDOUR should be directed to:

Stuart Nicholls, Manager, National Clinical Effectiveness Programme
Ambulance Service Association, Friars House, 157-168 Blackfriars Road,
London SE1 8EU. Tel: 020 7928 9620 Fax: 020 7928 9502
Email: [email protected]

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Lessons for clinical audit from the Bristol Royal Infirmary Inquiry


Below is an extract from the final report available on the above website that highlights the lessons to be learned in the use of clinical audit as the central tool for improving the quality of care received by patients.

These statements are equally applicable to the NHS ambulance services and their staff as ‘clinical practitioners’.

Clinical audit and reflective practice

Clinical audit, the process whereby healthcare professionals reflect on and improve their and the team’s clinical practice is fundamental to improving the quality of care received by patients. The NHS is already committed to the notion that participation in clinical audit will be compulsory. It is essential, therefore, that those entering the healthcare professions are given a good grounding in the basic skills of clinical audit: what it is; how it should be conducted; what is meant by team-based audit; how to understand and interpret data; how to use published material and evidence of effective practice; how to use national standards and guidance; how to understand the nature of error and mistakes; and how to learn from them. We see this as an area that cries out for a common core curriculum for the professions. If we expect multiprofessional team-based clinical audit, it makes no sense at all to educate nurses, doctors and other healthcare professionals about clinical audit along separate lines.
Equally, those already in practice should be able, as part of their continuing
professional development, to gain access to further training in clinical audit, and there must be opportunities for clinical teams, who carry out shared audit, to train together.

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