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CANDOUR - Issue 7 - December 1999

The newsletter of the ASA/ JCALC Clinical Effectiveness Committee and the ASA Clinical Effectiveness Project

In this issue :

Emergency Care Online - Research into practice

NHS Clinical Governance Support Team

A Guide to Statistics used in Clinical Audit - Part 2

Coming up....

Issue 6 CANDOUR INDEX Issue 8

Emergency Care Online – Research into practice

In the last issue of CANDOUR we described what an electronic mailing list such as Emergency Care Online was, how it worked and what it’s aims were. In this issue we shall show a practical example of spreading best practice through an online list-server. Below are transcripts of a conversation thread regarding the effectiveness of Diazepam.

Subject: Effectiveness of Diazepam

Date: 29/10/99

Time: 05:55

Thought I'd do a quick survey on storage and rotation policy for diazepam
when carried in ambulances/doctor's bags. My interest is not aspects of drug
security, but rather drug potency. This interest was spurred by a recent
article by Gottwald and colleagues, who found a 15% reduction in diazepam
concentration after 210 days when stored at ambient temperatures in
ambulances in San Fransisco. During the same period diazepam stored at 4-8
degrees C had a 7% reduction in concentration. In contrast, Diazepam stored
at a constant 37 degrees C showed a 25% reduction in concentration. The
authors recommend that "when ambient storage temperatures are 30 degrees C
or less, ambulances carrying lorazepam and diazepam should be restocked
every 30 to 60 days. When drug storage temperatures exceed 30 degrees C,
more frequent stocking or refrigeration is required" (p. 333).
Given that in my experience diazepam is only discarded when it reaches its
expiry date, and that ambient vehicle temperatures can be very high during
an Australian summer, I am beginning to develop alternate explanations for
some cases of continuous seizure activity that failed to respond to protocol
doses of diazepam (up to 20 mg for adults).
Any comments?

Gottwald, M.D., Akers, L.C., Liu, P., Orsulak, P.J., Corry, M.D., Bacchetti,
P., Fields, S.M., Lowenstein, D.H. & Alldredge, B.K. (1999). Prehospital
stability of diazepam and lorazepam. American Journal of Emergency Medicine.
17 (4), pp 333-337.

Bill Lord
Lecturer, School of Public Health
Charles Sturt University
Bathurst NSW 2795

Reply to: Effectiveness of Diazepam

Date: 29/10/99

Time: 08:42

Our diazepam is stored at room temperature & is not replaced until expiry.
Perhaps if decay is a well documented phenomenon, the Medicines Control
Agency (UK) should investigate & possibly suggest a sooner expiry date on the
As with medical devices & the MDA, it is imperative to report all adverse
incidents or incidents that may have or be about to cause harm with

medicines to the MCA.

All reports are welcomed & nothing is considered trivial.

Fire & Safety Consultant/Instructor

Reply to: Effectiveness of Diazepam

Date: 30/10/99

Time: 21:28

Re: Loss of potency of diazepam.
We keep our stesolid (diazepam PR) tubes in the fridge at work to stop
this specific problem.


This then led to a discussion about the practicalities of placing refrigerators into ambulances.

What this conversation highlights is the effectiveness of an online mailing list to promote the use of best practice. An academic has highlighted a potential problem brought to light through research and has then asked if this ‘evidence’ has any basis in current practice by requesting feedback. A discussion on the practicalities of the implications of the research can then be conducted, along with issues regarding regulation of the drug’s provision and storage.

Other recent conversation threads have included evidence related to pre-hospital thrombolysis, and again it’s practicalities based on experience; and sharing information about non-diabetic incidents of hypoglycaemia and their causes.

To join in this process of peer review and share your experiences go to http://www.999.org.uk on the internet and register for the Emergency Care Online.

Or write to CANDOUR to share your thoughts and experiences on any of the above subjects and we will publish them in a question and answer format.

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NHS Clinical Governance Support Team

The Department of Health announced the launch of the NHS Clinical Governance Support Team on the 11 August 1999 which would start its’ work during October 1999. The ASA, through the National Clinical Effectiveness Project, became the first affiliated partner of the Support Team to ensure that the issues unique to UK ambulance services relating to clinical governance were given a voice at national level.

Early in October the ASA National Clinical Effectiveness Project Manager and members of the ASA’s Clinical Governance Working Group met with Professor Aidan Halligan, the Director of the NHS Clinical Governance Support Team. The ASA presented Professor Halligan with a copy of the ASA’s Reference Pack on Clinical Governance and exchanged views as to which were the key issues affecting the UK ambulance services.

Professor Halligan was very impressed with the ASA’s Reference pack seeing it as a very useful document. The document itself will soon be published on the NHS website’s clinical governance pages. He stated that he would support the development of clinical governance within the UK ambulance service fully recognising there were unique issues to be resolved which were not apparent in other areas of the NHS.

Key Issues

The key issues to emerge from the discussions were twofold. Firstly, clinical governance strategies must focus on the elimination of all risk, especially at hand-over. Within the NHS as a whole around 90% of errors occur at a hand-over, whether it be from a Doctor to a Nurse or any other form of hand-over.

Secondly, strategies must also focus on the development of the ‘No Blame’ culture. Trusts must ensure that training and procedures are in place to ensure risks minimised. However there has to be a balance struck between accountability and clinical freedom of the practitioner. To solve this issue there has to be an open and honest culture where we can all learn from mistakes.

Role of NHS Clinical Governance Support Team

The NHS Clinical Governance Support Team will aim to get behind the rhetoric and define clinical governance as:

‘a real partnership between patients and healthcare providers - where real can be defined as accountable and trusting - to improve the quality of patient care.’

The main thrust of the Support Team is to develop leadership skills within every NHS Trust across every sector, to facilitate clinical governance from team level.

Professor Halligan opened the invitation to all UK ambulance services. He would like to see at least two frontline staff from each service attend the Support Team’s ‘Learn as you go’ workshops. It is his intention to make the workshop groups as multi-disciplinary as possible.

He would like personnel who would be missed and have the enthusiasm to make change happen.

The Learn as you go’ workshops run over a total period of nine months. There is an initial two day seminar outlining the objectives of the workshops and what is required of the individuals to take back to their Trusts. There are then several recall days over the nine month period. These cover progress made with such things as establishing a baseline of readiness, drawing up a list of recommendations, implementing changes, and measuring against agreed outcomes. The individuals would then be equipped to implement clinical governance successfully within their Trusts.

To sign up for the ‘Learn as you go’ workshop series or for general information about clinical governance or the support team, call the NHS Clinical Governance Support Team Hotline - 0171 210 5629.

The workshops have begun in earnest and already places are being booked. So to ensure your Trust is ready for the changes that clinical governance will bring, show this article to your Trust’s Clinical Governance Lead and call the Hotline now.

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A Guide to Statistics used in Clinical Audit - Part 2

In the last issue of CANDOUR we explored the use of basic descriptive statistics in clinical audit. In Part 2 of this guide we begin to look at statistical techniques used to compare data sets again explaining when they should be used how to interpret the results. This article will not go into how the statistics are calculated, but it will allow you to determine the validity of results published in journals where these comparative statistical tests are frequently used.

The Chi-squared Test is a statistical technique used for testing the independence of two samples. In other words if a change in practice has occurred and you have two sets of results, a sample from before the change and a sample from after the change, you can test to see if there is a significant difference between the two samples. Similarly, it may be that you are comparing two time periods.

This is a very useful technique for analysing clinical audit and questionnaire data. It can be applied to both numeric and non-numeric data. You can also group your data into meaningful categories for analysis. In essence the Chi-squared test compares the observed sample data to an expected distribution of results to see if there is any significant difference.

We can demonstrate this in a simple example. Let us suppose that a clinical audit has been conducted looking at the care received by asthma patients. The results show that crews are not recording the Peak Flow Meter Readings (PFR’s) as often as they should for patients being nebulised. As a consequence the Training School start an educational process to remind crews of the necessity to record PFR’s as a guide to the patients condition and for use in A&E to aid decisions about further treatment. A second clinical audit is then conducted which reveals an increase in the recording of PFR’s.

What we need to know is whether the change is significant enough and can be attributed to a successful education campaign by the Training School or whether it is down to chance. The Chi-squared test will allow us to determine this.

A statistically significant result means that the change between the two sets of results is due to a factor other than chance i.e. a result of an intervening variable e.g. the circulation of educational material on recording of PFR’s. A non-significant result is interpreted as a change which could be down to chance even if an improvement is noted i.e. the educational process was not as successful as anticipated.

In part 3 of this series on basic statistical techniques used in clinical audit we shall look at the Student t-test and how it is used to compare changes in the average values between samples.

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Coming up in the next issue…

As promised we shall have - case reviews outlining problems encountered and lessons learned – an update on clinical governance – an update on the ASA/JCALC Clinical Effectiveness Committee – an overview of a national survey to be conducted by the ASA Clinical Effectiveness Project.

Please write to the CANDOUR editorial team c/o the ASA Clinical Effectiveness Project, Kent Ambulance NHS Trust, Heath Road, Coxheath, Maidstone. Kent ME17 4BG Tel/Fax: 01622 664929 about any of these issues and to contribute to forthcoming editions.

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