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CANDOUR - ISSUE 11 - August 2000

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

In this issue:

Westcountry Ambulance Service Launch New Degree in Emergency Care

SYMAS & NHS Clinical Governance Support Team Programme – first hand experience of the programme

How long does it take to perform procedures on scene? – abstract from Prehospital Immediate Care Journal

ASA/JRCALC Track Thrombolysis Developments – details of future collaborative work

Evidence for Change III – preliminary results of the annual survey

‘An organisation with a memory’ – looking at adverse event reporting

Issue 10 CANDOUR INDEX Issue 12


The national debate on the future development of NHS Paramedics is well under way and it seems certain that higher education opportunities will be an essential component. Already, degree level courses specifically designed for Paramedics are offered by several universities in the UK and elsewhere. However, the strength of multidisciplinary education is the focus for a new course currently being developed in a partnership between Westcountry Ambulance Service and the University' of Plymouth’s Institute of Health Studies.

A Bachelor of Science honours degree in Emergency Care will commence in September and will offer a groundbreaking educational opportunity for paramedics and registered nurses. The project has the support of the Cornwall and South Devon Education Purchasing Consortium, which has agreed to fund the first two cohorts of up to ten students. Following accreditation of prior experience and learning, students on each cohort will take the equivalent of the final year of the course over two years part time.

In 1997, WAS and the University joined forces with Derriford Hospital Accident & Emergency Department to pioneer a multi-disciplinary approach to emergency care education with their Multi-disciplinary Immediate Care Course (MICC). Six Westcountry paramedics and three nurses successfully completed the six-month programme, proving that there are common elements in both professions that can be addressed by joint education initiatives.

Each of the first two cohorts for the new degree will comprise four experienced paramedics and four registered nurses currently involved in A&E or ICU duties. As well as extensive clinical development, which includes a number of clinical placements, the course will incorporate modules in research and professional issues (legal aspects of care, ethics, etc) and a teaching/mentoring component.

After the two cohorts have been evaluated in 2002, the full three year full time course may be open to other NHS and non-NHS students.

Further information is available from Graham Brown, Clinical Effectiveness Manager, Westcountry Ambulance Service NHS Trust, Abbey Court, Eagle Way, Exeter, EX2 7HY. Tel. 01392 261500.

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South Yorkshire Metropolitan Ambulance Service (NHS Trust)

Clinical Governance Development Program

South Yorkshire Metropolitan Ambulance Service is one of the first Services in the country to be involved with the Clinical Governance Development Program run by the NHS Clinical Governance Support Team. Based in Leicester, the program is a nine month review and development process within an the NHS and aims to equip candidates with practical understanding to develop patient care in the context of a listening, learning organisation. Within the program are five learning days which cover all aspects of introducing change and demonstrating the difference.

Mick Keyworth an Operational Manager and Kevan Whitehouse a Work Based Trainer Assessor have now completed the third leaning day and have been involved within their own organisation with a review of Clinical Aspects of Emergency Care.

The review is in progress and includes measuring current practice and gaining support for change. Staff interviews revealed many positive topics for improvement and staff workshops are due to commence in August.

This program, supported by a Project Manager from the Support Team, has helped Mick and Kevan to develop the skills and understanding, which will take SYMAS through a ‘review’ process. It has also helped them to gain agreement on recommendations for change and implementation.

This is a excellent program and will enhance the Services ability to develop clinical governance and to lead clinical progress.

For further information please contact Mick or Kevan via SYMAS Training and Development Centre 01302 327021 or contact NHS Clinical Governance Support Group on Leicester 0116 261 9064.

If your service is involved in the NHS Clinical Governance Support Team Programme let us know your experiences and how it is changing service delivery and improving clinical quality in your area. Send details to Stuart Nicholls, Manager, ASA National Clinical Effectiveness Programme, c/o Kent Ambulance NHS Trust, Heath Road, Coxheath, Maidstone, Kent, ME17 4BG. Tel. 01622 664929.

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Occasionally, CANDOUR will reproduce an abstract or full paper concerning a topical research subject. In this issue…

How long does it take to perform procedures on scene?

Barrett B, Guly HR;.Pre-hospital Immediate Care 2000; 4: 25-29

This paper was published following a one year research project carried out in Devon by Paramedic Supervisor Barry Barrett of Westcountry Ambulance Service and Dr Henry Guly, A&E Consultant at Derriford Hospital, Plymouth.

The project was funded by a research grant from the Joint Royal Colleges Ambulance Liaison Committee (JRCALC).

To investigate the time taken for individual assessments, basic and advanced skills. An understanding of the time it takes to perform assessments and treatments will allow those who provide pre-hospital care to write protocols for the ambulance with real knowledge of the amount of time that procedures can consume.

This was a prospective study. A paramedic supervisor acting as a research assistant travelled on emergency ambulances as a third person to collect data and details of procedures performed on scene. The time taken to perform assessments, treatments, and extended skills was recorded by a stopwatch. Cardiac patients were studied in more detail in an attempt to determine why the additional on scene time in patients who had an intravenous cannula sited is considerably longer than the time it takes to site the cannula.

The median times taken to perform specific parts of the patient assessment ranged from 0.6 to 3.1 minutes. The median times taken to perform specific parts of the basic treatments ranged from 1.0 to 4.4 minutes. The median time from arrival at scene to the first shock was 1.9 minutes. The median access time was 0.4 minutes and the median time arriving at the patient to the completion of the first shock was 1.4 minutes. The median time for a successful cannulation was 3.2 minutes. The median time to perform a successful endotracheal intubation was 1.8 minutes.

Accurate assessment of a patient is important but it is also important to avoid delays in the pre-hospital setting. This study gives an indication of the time it takes to perform procedures at scene. Ambulance training should ensure that paramedics can perform procedures quickly and that they are efficient in their use of on scene time.

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Administration of Thrombolysis by Ambulance Paramedics

The ASA and JRCALC are set to work collaboratively on a database which will log developments within UK ambulance services as they move towards pre-hospital thrombolysis for acute myocardial infarction.

This will build on the questionnaire recently circulated by Professor Douglas Chamberlain which looked at current and future plans for pre-hospital thrombolysis. Local initiatives will be fed into the database to ensure the ASA and JRCALC are aware of all the thrombolysis developments.

More details will follow in future issues of CANDOUR.

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Evidence for Change III

This is the third annual survey of clinical improvement initiatives within the UK’s ambulance services. It covers work undertaken during the period 1st January 1999 to 31st December 1999 inclusive.

The survey was written , distributed and collated by the ASA National Clinical Effectiveness Programme on behalf of the Joint ASA/JRCALC Clinical Effectiveness Committee.

Below are the preliminary results of the survey. The full and final results will be published in a separate report to be distributed to all UK ambulance services. It will also be available to download on the website of the ASA National Clinical Effectiveness Programme http://www.asancep.org.uk

55% of ambulance services still do not receive any external funding for their clinical audit and clinical effectiveness functions.
Funding for clinical audit activity remains a problem for most ambulance services.

30% collaborated with other ambulance services
59% collaborated with local hospitals
26% collaborated with Health Authorities
15% collaborated with local GP’s
15% collaborated with other organisations (e.g. academic/ research etc.)

There is still much improvement to be had in the level of collaboration especially between ambulance services and in working with local hospitals to obtain valuable outcome data. Where funding is a problem, increased collaboration can help address resource and workload issues.

74% of ambulance services have planned clinical audits in conjunction with local Health Improvement Programmes or National Service Frameworks. Much of this work is based around the Coronary Heart Disease Framework, which was finally published in March 2000 but had been pre-empted by the emerging findings report of November 1999.

Sharing Information & Advice
78% of ambulance services currently produce an annual report of clinical audit activity.
59% of ambulance services produce a newsletter or bulletin covering the issues of clinical audit and clinical governance.

It is important that local initiatives are fed through to both the regional clinical audit groups and to the main ASA/JRCALC Clinical Effectiveness Committee. Similarly, it is important information is shared through media such as this CANDOUR newsletter and the website of the ASA National Clinical Effectiveness Programme.

71% of ambulance services now employ a medical director/ adviser.
Stronger links will be established between the ASA, JRACLC and the national ambulance service medical advisers group to ensure clinical issues are discussed collaboratively.

Other Issues
The Evidence for Change III survey also dealt with initiatives surrounding clinical governance and those issues you wished to be raised with the ASA/JRCALC Clinical Effectiveness Committee.

Details of Projects
Over 70 individual clinical improvement projects were submitted as part of the survey. This exceeded the total for the previous year despite several ambulance service mergers.

Again the full details will be available as part of the final report and are to be accessible via the website (http://www.asancep.org.uk).

The topics covered ranged from documentation of patient records to patient satisfaction, hypoglycaemia to cardiac arrest, burns to asthma, pulse oximetry to PTS pressure sores, A&E admission protocols to minor injuries units.

By far the most covered topics were those surrounding the coronary heart disease framework. The results and methods will be compared to see where work is being duplicated, where collaboration could easily take place, where lessons can be learned and shared with others undertaking similar work etc.

The ASA/JRCALC Clinical Effectiveness Committee will use the results of the Evidence for Change III Survey:

  • to ensure the ASA National Clinical Effectiveness Programme continues to act as a resource for all UK ambulance services looking for advice on clinical audit and related issues.
  • to ensure all UK ambulance services learn the lessons of others and do not have to ‘re-invent the wheel’ by co-ordinating the collation of local initiatives through the ASA National Clinical Effectiveness Programme.
  • to ensure ambulance services use the same methods when tackling similar issues to ensure data and results can be compared.
  • to promote collaborative working.

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‘An organisation with a memory’

The Department of Health recently published the above document which looks at the development of a national adverse events database.

It was agreed that the ASA/JRCALC Committee would monitor national developments following this report and would look to establish a complimentary national ambulance service adverse events database along the lines of the MDA bulletins to be reported through CANDOUR/ Ambulance UK and the website.

The ASA National Clinical Effectiveness Programme would act as the fulcrum of any such mechanism, collating details of adverse events from all UK ambulance services and disseminating the lessons learned again to all UK ambulance services. The Programme has links to both JRCALC and the Medical Advisor/Director Groups (The latter through Dr Chris Carney who asked the ASA/JRCALC Clinical Effectiveness Committee to look at adverse event reporting issues).

Tees, East & North Yorkshire Ambulance Service NHS Trust offered to table this proposal at the annual meeting of ambulance service risk managers which was held at AMBEX in July 2000, and would report back at the next Committee meeting in September 2000.

Once we have a clearer picture of the way forward it would be useful to for ambulance service Chief Executives to share their own experiences of adverse events through such a database.

Full details of the DoH publication ‘An organisation with a memory’ can be found on the internet at http://www.doh.gov.uk/orgmemreport/index.htm

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