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CANDOUR - Issue 14 - February 2001

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

In this Issue:

Issue 13 CANDOUR INDEX Issue 15

National Clinical Guidelines - progress to date

Since the launch of the JRCALC National Clinical Guidelines at the Annual JRCALC Conference in November 2000, as reported in Issue 13 of CANDOUR, significant progress has been made in the continuing development of evidence based clinical practice for ambulance services.

A two-day meeting was held between JRCALC's Clinical Guidelines Sub-Committee and representatives from BASMED (British Ambulance Service Medical Directors Group) in early December 2000.

Introduction - Dr Iain McNeil, Chair JRCALC-CGC

The principal aim of the meeting was to synthesise the JRCALC guidelines, the IHCD paramedic handbook and the guidelines developed by the County Air Ambulance Group.

Delegates were split into groups to achieve the following:

A consensus view would be sought about the guidelines
Key performance indicators would be identified
Audit standards would be developed around the guidelines

The work from this meeting would then help to inform the priorities for work to be undertaken using the funding received from DERA (Defence Evaluation and Research Agency) to evidence base the guidelines. This work is to be overseen by Dr Matthew Cooke at Warwickshire University and as such Dr Cooke facilitated the two-day meeting.

Background - Professor Douglas Chamberlain, Chair JRCALC

Professor Chamberlain thanked everyone for attending this important and ground-breaking meeting. JRCALC had been slow to develop guidelines since their inception in the early 1990's. Three or four guidelines had been developed by JRCALC but following the 'Panorama' programme in January 2000 there had been considerable political pressure from Ministers and the Department of Health to develop comprehensive clinical guidelines for ambulance services.

JRCALC had been aware of the work undertaken initially by Dr Chris Carney whilst at Staffordshire Ambulance Service which during 2000 was being updated by Dr Carney, Dr McNeil and Dr John Scott. These 'Medical Directors' guidelines were adopted by JRCALC in November 2000.

They have subsequently been submitted to the Department of Health and the Minister. As they stand they are the definitive set of current guidelines for ambulance services. Professor Chamberlain emphasised that the continued work to evidence base, update and revise these guidelines must be co-ordinated through the JRCALC-CGC using a properly defined mechanism to be discussed during the two day meeting.

Professor Chamberlain also emphasised the requirement, indeed mandate, from the Medicines Commission for central national audit, especially of the 'new' prehospital drugs (e.g. streptakinase, benzyl penicillin, morphine sulphate) on the POM's list. There would also be a requirement to co-ordinate audit and consider guidelines for drugs used under Patient Group Directions.

'Evidence Based Medicine' - Dr Kevin Mackway-Jones, Medical Director, GMAS

Dr Mackway Jones started by stating the actual current practice is not EBM - evidence based medicine - but in fact FBM - faith based medicine and as such any change or progress is right and good.

He defined EBM as: "the integration of best research evidence with clinical expertise and patient value" (EMB Journal).

Best research evidence is not necessarily Cochrane reviews or RCT's (Random Control Trials) but could be from a dozen case reviews or consensus opinion. Consensus opinion, even if defined as best evidence causes controversy but how can we achieve it?

1. Define 3 part question for guideline:

IN [patient group]

2. Search the evidence using a defined and recorded (auditable) strategy
3. Appraise the evidence critically
4. Define the clinical bottom line

Where evidence is sparse or not sound the process towards EMB was summarised as: 'evidence driven - consensus creep'

In summarising Dr Mackway-Jones asked the delegates to challenge everything they read, to appraise guidelines in terms of who produced them (stakeholders, authors, positions, interests etc.), sources of information/evidence (defined search strategy) and the explicit grading of the evidence.

Where consensus was achieved the guidelines could be produced into 'standard operating procedures' and audit tools and in terms of further evidence basing those guidelines where agreement has been made would appear lower down the list of priority for development than those where differences on opinion still exist.

The ECC Process - Kath Charters, Research Assistant, Welsh Ambulance Service

The ECC (Emergency Cardiac Care) Process for developing a guideline template has been used in Wales to evidence base the guidelines currently being developed. The template provides a framework of how to look at the 3 part research question.

Important issues were raised as Ms Charters went through an example using the ECC template.

  • Adequate time must be given to conducting the literature search.
  • Must look at the balance of risk against evidence, which may be dependent on how the original question is asked (i.e. different emphases on parts of the question)
  • There may be different ways of attributing the class of recommendation
  • Is the ECC process applicable to other areas of care
  • Given most evidence is hospital based, the time critical nature of prehospital care must be considered (i.e. delay from diagnosis to treatment and at what time should treatment be given, is it time critical?)

Setting the Agenda - Dr Matthew Cooke, University of Warwick

Dr Cooke outlined the agenda for two days in terms of progressing the JRCALC guidelines and synthesising the air ambulance guidelines and the IHCD paramedic manual. He began by stating the broad stages through which the guidelines would evolve before becoming fully evidence based:

First stage - JRCALC guidelines submitted to Ministers and Department of Health who will be asked to support the ongoing work of evidence basing existing guidelines, developing new guidelines and developing audit tools based on the guidelines.

Second stage - Co-ordination of the JRCALC guidelines, air ambulance guidelines and the IHCD manual through a process of consensus.

Third stage - To initiate the evidence basing of the consensus guidelines using the funding secured from DERA. Work would be co-ordinated with the evidence based guideline project in the Welsh Ambulance Service. The ongoing process will eventually lead to the full set of guidelines being evidence based.

The remaining sessions on day one of the meeting followed guidance given in the HTA (Health Technology Assessment) paper on consensus groups.

At the start of day two consensus was gained on the major issues highlighted from day one. This included revising the list of core skills for paramedics, deciding on those guidelines where consensus was agreed, those guidelines which required further evidence but would not be changed until this was available and those guidelines where an interim consensus was gained but further evidence was required.

The second session on day two concentrated on the development of core audit standards. These are briefly outlined below and will be worked up into full audits through the ASA National Clinical Effectiveness Programme:

Use of morphine
Needle Crico/Thoraco
On-scene time for non-entrapped patients
Airway management of patients with a GCS <8
Vascula access in burns cases
NSF audits
AMI audit including Streptakinase
Respiratory assessment
Oxygen (conditions including O/D, CVA, Fits, Trauma, COPD, AMI)
Benzyl Penicillin
Paediatric airway (under 12's)
Needle Chest Decompression
Intraosseous infusion

Summary of meeting - Dr Iain McNeil, Chair JRCALC-CGC

Dr McNeil thanked everyone for their contribution especially Dr Cooke for facilitating the sessions.

Important progress had been made in beginning the process of evidence basing prehospital guidelines through the synthesis of the JRCALC guidelines, air ambulance guidelines and the IHCD manual. Many major changes had been made to the guidelines through the consensus process and a number of audit standards had been defined.

The process for updating and revising the guidelines was outlined.

The JRCALC guidelines as they now stand will be circulated immediately to all ambulance services via their medical directors (or Chief Executive). They are now also available in pdf format (Adobe Acrobat Reader). The pdf version will be added to the JRCALC website and be copied on CD-ROM to all ambulance services. The pdf versions will also be published on the Virtual Emergency Care Branch of the National Electronic Library for Health.

Dr Cooke would collate the changes made during the course of the meeting. It is envisages that this first set of updates would be circulated following the second consensus meeting in early March 2001.

Any changes, alterations, new evidence and questions etc. must come through Dr McNeil as Chair of the JRCALC-CGC. It was envisaged that subsequent updates following the evidence base work completed by the Welsh Ambulance Service and/or University of Warwick would be issued six monthly.

Updated guidelines would be flagged up on the JRCALC website whilst revisions as part of the consensus process would be circulated with changes highlighted via the BASMED discussion group.

The objective would be to have one end product of JRCALC/ BASMED endorsed prehospital clinical guidelines but it was recognised that in the interim there would probably be two sets albeit of consensus guidelines. It would probably take 18 months to reach the single end product.

Intellectual Property Right (IPR) is held by JRCALC although through the evidence basing process this would be between JRCALC and DERA/ University of Warwick. Once the process is complete the guidelines would become public property given the appropriate acknowledgement.

Important to note

Two-way process

It is important to note that the development of national prehospital clinical guidelines is very much a two way process. If individual ambulance services feel that their local guidelines are more effective/ evidence based than those stated in the JRCALC guidelines, then they are invited to submit their guideline with the supporting evidence to the JRCALC Clinical Guidelines Sub-Committee through Dr Iain McNeil (Medical Director, Surrey Ambulance Service NHS Trust). The JRCALC-CGC will then review the guideline and decide on any changes to the existing JRCALC guideline.

Timetable of developments

Following this first meeting to arrive at consensus between the JRCALC and air ambulance guidelines and the IHCD paramedic training manual there will be a second consensus meeting in early March 2001.

Version 2 of the JRCALC Guidelines will be published in early April 2001. Any updates and/or changes will be highlighted to ensure it is clear which guidance has been amended.

As the evidence based guidelines are developed in Wales and Warwickshire, or through research by individual ambulance services, these will also be added to the updated JRCALC guidelines.

The guidelines will be issued on a six-monthly basis on specified dates to ensure there is continuity in their evolution.

Any updates will be notified on the JRCALC website (http://www.jrcalc.org.uk) where the definitive set will always be available.

If you have any questions surrounding the development of the JRCALC Clinical Guidelines please feel free to contact Dr Iain McNeil, Medical Director, Surrey Ambulance Service NHS Trust, Headquarters, The Horseshoes, Banstead, Surrey. SM7 2AS.

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Joint Royal Colleges Ambulance Liaison Committee
National Conference

Pre-hospital thrombolysis- putting the plans into practice.

At the Royal College of Physicians of London.
Monday 12th March 2001

09.30 Registration and Coffee
10.00 The story so far - Professor Douglas Chamberlain Chair JRCALC
10.45 Reteplase for real - practical experience in Staffordshire - Dr Anton van Dellen
11.15 Using reteplase - Dr Tracey Cooper East Midlands Ambulance Service
11.45 Coffee
12.00 Managing acute coronary syndromes in Essex - Dr Judith Fisher Essex Ambulance Service
12.30 Forum Session 1
13.00 Lunch
Paramedic identification of patients suitable for thrombolysis - Karen Pitt Pre-hospital Emergency Research Unit, University of Wales
14.05 View from the front line - Paul Bastow Lancashire Ambulance service
14.25 Putting together a training course for thrombolysis - Dave Whitmore Westcountry Ambulance Service
14.45 The JRCALC/ASA thrombolysis audit and how it will work - Stuart Nicholls Manager National Clinical Effectiveness Programme, ASA
15.05 Tea
15.25 Technical aspects - fax modems, telemetry, pumps etc. - Speaker to be confirmed
15.45 Forum Session 2
16.15 Closing comments and summary

Booking enquiries should be directed to Peter Plume, JRCALC Administrative Assistant, Royal College of Physicians, 11 St Andrews Place, Regents Park, London. NW1 4LE
Tel: 020 7935 1174 Fax: 020 7847 5218 Email: [email protected]

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Future Funding Arrangements - ASA NCEP

Sam Jones, Chairman of the Joint ASA/JRCALC Clinical Effectiveness Committee, reported that a meeting of all the ASA Committee Chairs had given their full support to the continued work of the ASA National Clinical Effectiveness Programme (ASANCEP). They recognised the value of the work completed to date and recognised that the work around clinical audit and guidelines must continue with the full support of the ASA.

Given the need to secure at least a short term future the ASA has agreed to support the ASA NCEP. JRCALC have also 'bought-in' to the Programme for 2001/2002. JRCALC have an obligation with the Medicines Commission/ Medicines Controls Agency to conduct national clinical audit of the new drugs issued for use by paramedics. Such national audit will be co-ordinated on behalf of JRCALC through the ASA NCEP.

JRCALC and the ASA are still actively negotiating with the DoH to secure longer-term security and funding for the development of national prehospital guidelines and audit to be facilitated by the ASA NCEP.

The Clinical Effectiveness Committee decided that continued pressure by the ASA and JRCALC should be applied to NICE to ensure prehospital issues find their way onto future NICE work programmes for guidelines and audit. It was felt that a national steer is essential as funding in general is fragmented leading to local variation. Examples were given covering implementation monies for the CHD NSF. Initiatives such as the joint work between JRCALC, ASA and the Royal College of Physicians to produce a database for the CHD NSF and AMI which would close the audit loop are important in raising the profile of prehospital inclusion in national audits. Indeed the Manager of the ASA NCEP is to work with the RCP in a much closer capacity in future, sharing resources with the Clinical Effectiveness Evaluation Unit and working on other national projects such as a national audit of cardiac resuscitation.

Formal and/or informal agreements have been made with the following Royal Colleges to ensure a prehospital issues are raised through the NICE 'collaborating centres' for future guideline and audit developments: Physicians, Surgeons, Anaesthetists and General Practitioners. JRCALC will also be more active in promoting prehospital issues amongst its representative professions.

Given the new structure and working relationships of the ASA NCEP, the next issue of CANDOUR will outline the new objectives and resources available through the ASA NCEP for the UK's ambulance services.

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NHS Clinical Governance Support Team

The NHS Clinical Governance Support Team (NHS CGST) held a meeting in mid-November 2000 specifically for the ambulance services on their development programme. Being the first professional body to contact and meet with the NHS CGST it was only appropriate that the ambulance service were the first part of the NHS to have a day specifically dedicated to their development. Normally the development teams are deliberately multi-professional to encourage an understanding of different parts of the NHS.

Six of the seven ambulance services on the NHS CGST programme were present to share ideas and initiatives about the implementation of clinical governance. Examples of some of the projects being undertaken are listed below:

SYMAS - Minor Injuries Units, Oxygen therapy, Fast-track for CVA patients, Aspirin, CHD NSF
TENYAS - Clinical Risk, key stakeholder involvement, staff interviews
Lancashire - Joint review of A&E and NHS Direct services
Gloucestershire - Work Based Training, Critical Incident reporting, Patient surveys, AMI audit
Lincolnshire - Review of drug therapies, Communication, Aspirin audit & patient survey
Twoshires - Continuing Professional Development points as part of Work Based Training, reviews of 12-lead ECG, drugs, resource deployment, equipment, communication, CHD NSF, Integrated Care Pathways

The programme runs until August 2001 if other services wish to participate. The NHS CGST will then become part of the NHS Modernisation Agency. Details are available from Stuart Nicholls at the ASA NCEP.

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