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CANDOUR - Issue 8 - February 2000

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

In this issue :

ASA Clinical Governance Newsletter

Clinical Governance on the internet

Local initiatives to share nationally

What you should know about clinical governance

Evidence for Change III - A survey of clinical improvement projects

Clinical Excellence 99 - conference report

A Guide to Statistics in clinical audit - Part 3

Reviews of published materials

Case History - 'Just another Maternity'

Issue 7 CANDOUR INDEX Issue 9


ASA Clinical Governance Newsletter

To keep everyone up to date with the latest clinical governance information the ASA will shortly be producing a newsletter specifically to deal with these issues. This will enable CANDOUR to concentrate on clinical improvement issues and ensure those who need to know about clinical governance initiatives are kept informed. The newsletter will outline the latest developments and preview additions to the ASA Clinical Governance Reference Pack.

In order to be successful and to maintain the momentum of change relating to clinical governance issues it is vitally important that ambulance services contribute details of their local initiatives to promote the sharing of good practice and to offer support and advice to others. Again send your contributions to the ASA National Clinical Effectiveness Project (NCEP). Contact details are given below.

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Clinical Governance on the internet

The ASA Clinical Governance Reference Pack is now available on the internet. As part of the NHSWeb site on clinical governance, the Reference Pack now informs the wider NHS about how clinical governance is being adopted in the UK ambulance service. The internet address for the main NHS clinical governance site is as follows (this can only be accessed as part of the NHSWeb): http://nww.doh.nhsweb.nhs.uk/nhs/clingov.htm

Also, the ASA NCEP will soon have its own web site where the Clinical Governance Reference Pack will be available to everyone. The site will also have all the back editions of CANDOUR, the newsletter of the ASA/JCALC Clinical Effectiveness Committee, and all other publications and presentations produced by the ASA NCEP. As soon as the site is launched details will be sent to all UK ambulance services.

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Local initiatives to share nationally

One of the main objectives of the ASA Clinical Governance Reference Pack was to promote sharing of information and good practice to ensure ambulance services do not have to ‘reinvent the wheel’. The ambulance services of the Northern & Yorkshire NHSE Region have adopted this ethos. They are currently working to produce a joint template for reporting clinical governance at Trust Board level and for Trust Annual Reports. Two main themes have been established:

  • How do you know quality of care has been improved?
  • How have patients benefited?

Both of these lend themselves to the development of a set of ambulance service indicators for quality of care provided. When shared nationally these indicators could allow for clinical performance benchmarking between all UK ambulance services.They have also agreed, through the regional ASA Council, to share (confidentially) their baseline assessments of capacity and capability to ensure variations in practice across the region are reduced and that lessons can be learned.

The ASA NCEP will act to ensure these issues are raised at a national level. This will allow the co-ordination of developments and the dissemination of relevant information to all interested parties.

Let the ASA NCEP know of any local initiatives which have wider national implications or will allow for a co-ordinated approach to clinical governance.

Stuart Nicholls - National Clinical Effectiveness Project Manager, Ambulance Service Association, c/o Kent Ambulance NHS Trust, Heath Road, Coxheath, Maidstone. Kent ME17 4BG, Tel/Fax: 01622 664929 Email: [email protected]

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What you should know about clinical governance

This is an information leaflet produced by Scriptographic Publications Ltd. It is aimed at front-line staff to give them an understanding of how clinical governance affects them in their every day work and their role in quality improvement. It is an easy read with plenty of cartoon illustrations. The main headings dealt with in the 15 page leaflet include:

  • What is clinical governance?
  • Why should I learn about it?
  • Quality improvement is a key part of clinical governance.
  • Clinical governance can help improve performance.
  • Clinical governance may involve new ways of thinking.
  • You play a key role.
  • Learn to be an effective team player.
  • Open communication is vital for team success.
  • Work actively with your patients and clients.
  • Continue your professional development.
  • Clinical governance helps ensure quality care.

More details about this leaflet are available from the ASA NCEP (see contact details above)

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Evidence for Change III – A survey of clinical improvement projects in the UK ambulance services during 1999.

We’ve reached that time of year again. It’s time review what we’ve all accomplished in the last twelve months to improve the quality of care provided to patients. As with the previous two Evidence for Change surveys the ASA National Clinical Effectiveness Project will be collating details of clinical audit projects, research and any other clinical effectiveness initiatives to have been undertaken during 1999.

Progress of the survey will be reported in the next issue of CANDOUR with a summary of the results to follow once they are published in the Spring.

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Clinical Excellence ’99 -

The first annual conference and exhibition of the National Institute for Clinical Excellence (NICE).

NICE held its first annual conference and exhibition in Harrogate on 8-9 December 1999. As the conference title suggests the theme was the promotion of clinically excellent practice within the NHS. It is the largest NHS conference with over 2000 delegates, underlining the importance of the quality agenda.

The ASA were represented through an exhibition stand highlighting the work of the National Clinical Effectiveness Project. The exhibition proved a successful forum to promote the work of UK ambulance services to a wider audience within the NHS.

Congratulations must go to London Ambulance Service NHS Trust who collected a top prize at the exhibition for their poster presentations which covered the following topics:

  • Collection of information about cardiac arrest outcomes by UK ambulance services: use of the internationally agreed ‘Utstein’ dataset
  • Improving emergency asthma care by ambulance crews in London: measuring the effects of evidence based changes to treatment protocols and training
  • The use of routine ambulance data in managing pre-hospital cardiac arrest

This is an excellent achievement raising the profile of not just LAS but the whole UK ambulance service. The LAS posters were chosen from around 200 poster entries at the exhibition to take one of the top three prizes.

Early Warning

Next year NICE will be joining forces with CHIMP (the Commission for Health Improvement) for the annual conference and exhibition. The joint NICE/CHIMP Conference is to be held in Harrogate at the International Exhibition Centre on 29th and 30th November 2000.

The ASA NCEP will be present again with a stand highlighting the work of all UK ambulance services. We would encourage a greater level of interest and participation from UK ambulance service staff both in terms of submissions for poster presentations and numbers of delegates.

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A Guide to Statistics used in Clinical Audit - Part 3

In the last issue of CANDOUR we explored statistical techniques used to compare data sets explaining when they should be used how to interpret the results. We continue this theme with the Student t-test. 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 Student t-test is a comparative statistic used to test whether two samples are likely to have come from the same underlying populations that have the same mean (average). It is therefore useful for comparing the means between different samples e.g. samples from different time periods or differing patient sub-groups etc.

An example would be where a study on the effectiveness of Nalbuphine Hydrochloride measured the average (mean) dose of drug given to different patient groups. The measures would show the mean dose of drug required to obtain a moderate relief from pain for samples of both trauma and medical patients. The mean doses given could then be compared using the Student t-test to determine whether trauma patients require a larger/ similar/ smaller average dose of Nalbuphine to obtain moderate pain relief than that required by medical patients. If statistically significant differences were found it would suggest trauma and medical patients require different considerations when it comes to pain relief. This may in turn with enough robust evidence lead to the development of drug protocols targeted at specific patient groups. The advantage of this would be the individual patient concerned would be receiving the most clinically effective dose of pain relief.

Let us suppose that the study showed that trauma patients require on average a larger dose of pain relief than medical patients. The Student t-test would then be used to determine whether this difference in means is statistically significant. If there is no significant difference it is interpreted that the samples of trauma and medical patients come from the same underlying population and must therefore be treated in the same manner. If there is a significant difference it can be interpreted that the samples of trauma and medical patients come from different underlying populations, and consideration could be given to treating the patient groups in differing manners. A protocol for pain relief amongst trauma patients would suggest using larger doses of Nalbuphine to control pain whilst a separate protocol for medical pain relief would suggest using smaller doses to the levels suggested by the evidence in the survey.

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Reviews of published materials.

The aim of this section is to raise the awareness of those practicing in the pre-hospital care environment of selected published texts and materials and to provide a brief, comprehensive review of each.

It is hoped that by providing such reviews and synopses of materials, practitioners will be afforded the opportunity to remain updated with the expanding databases on the pre-hospital care and stabilisation of patients and the issues which they raise. It is further hoped that this will assist those who are interested or who are actively involved in undertaking audit, research or development activities in these areas by highlighting additional sources where data and information may be gained, or where opportunities for networking and benchmarking may arise.

It should be noted that these reviews are subjective and reflect the views of the reviewer only. Further comment on the reviews presented are welcomed and, indeed, encouraged. While the reviewer and members of the editorial panel may be contacted in this regard it is recommended that for further details of these materials, readers refer directly to the text in question or approach either the authors or the publishers directly.

Book Review 1 - Churchill’s Pocketbook of Pre-Hospital Care, Matthew Cooke 1999

Book Review 2 - Emergency Care - A Textbook for Paramedics, Ian Greaves, Tim Hodgetts & Keith Porter

Churchill’s Pocketbook of Pre-Hospital Care, 1st Edition, 1999

Matthew Cooke

Churchill Livingstone Publishers ISBN: 0-443-05987-X

The market for texts relating to pre-hospital care is rapidly increasing and incorporates a wide range of practitioners ranging from first-responders and first-aiders through to experienced ambulance, nursing and medical staff who practice on a regular basis.

This text, Churchill’s Pocketbook of Pre-Hospital Care, which is written by Dr. Matthew Cooke is aimed primarily at doctors, ambulance paramedics and technicians, nurses and those involved in the rescue services but is also intended to be of benefit to others practicing pre-hospital care. Described as a pocketbook, it offers many attractive features including its size, its use as a quick reference guide, its layout and presentation and its general appeal as being user-friendly. The use of language is clear and concise avoiding the use of jargon where possible and the adoption of a style of writing which is easy to understand render this text beneficial for a wide range of practitioners.

Divided into a number of short concise sections, Churchill’s Pocketbook of Pre-Hospital Care sets out to provide a resume of key actions and activities which may require to be carried out on scene and to act as an aide-memoire for those procedures which require to be carried out an infrequent basis. Aimed at balancing the urgency of treatment with the limitations of the pre-hospital environment it also attempts to provide a framework outlining the principles of pre-hospital care and emphasising the importance of time as an essential concept.

On balance, Churchill’s Pocketbook of Pre-Hospital will prove to be a useful adjunct in assisting the decision-making process, in particular when treating the patient or when responding to an incident.

Reviewed by Rose Ann O’Shea, Senior Lecturer, Dept. of Nursing and Paramedic, Sciences, University of Hertfordshire - October 1999

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Emergency Care - A Textbook for Paramedics

Ian Greaves, Tim Hodgetts & Keith Porter

W.B. Saunders Publishing Company ISBN: 0-7020-1975-5

This widely acclaimed textbook which covers all aspects of the practice of pre-hospital care for the paramedic is the first comprehensive British text for paramedics based on British practice. The arrival of Emergency Care - A Textbook for Paramedics on the market comes at an optimal time and goes some way to fill the gap in the body of scientific information on which ambulance care is based.

This comprehensive textbook which is co-edited by three leading and well established pre-hospital clinicians affords this text credibility among practitioners and teachers from all disciplines involved in pre-hospital care. Contributions from a wide range of authors, the majority of which are doctors, provide variety and value for money and start to build on the multidisciplinary fabric of pre-hospital care. With the introduction of degree courses for paramedics this text is particularly welcome in beginning the process of assisting paramedics in achieving greater underpinning knowledge and an enhanced evidence base for their practice.

Written in a user-friendly style with numerous illustrations and photographs Emergency Care - A textbook for paramedics is a valuable resource for all those working in the pre-hospital arena. Each chapter is written by a clinician with experience of working in the pre-hospital environment, with material contained within the chapters ranging from resuscitation, paediatrics and trauma to care of elderly and ethics and law. Key learning points presented in designated boxes highlight essential points and direct the reader to the salient noteworthy points. Designed to be used as a reference tool as well as a definitive text in its own right this book is a welcome addition to the growing body of information pertaining to pre-hospital care. Perhaps future editions will include a greater contribution from paramedic and nursing colleagues in addition to those from their medical counterparts.

Reviewed by Rose Ann O’Shea, Senior Lecturer, Dept. of Nursing and Paramedic Sciences, University of Hertfordshire - November 1999.

Thanks to Rose Ann for taking the time to review these two books. If you have read these texts or any others we would like to hear from you.

We would like to see reviews conducted by those who use the texts. If you would like to submit a review of a book you have found useful and/ or interesting please write in. When writing a review please bear in mind the following:

Author - credibility, an authority to write on this subject?, Style of writing and use of language, Research base of text, Length, Value for money, Practical and practical usefulness?, Benefit as a revision aid for examinations in pre-hospital care, Competition and competing texts, Content and organisation of material, Relevance, Topical?, Size of book, User friendly, Conclusion.

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Case History / Review

By Stephen Hines

Just another maternity…


In 1998 the LAS were called to attend 16,567 obstetric calls. On average in a 12 hour shift in London each ambulance crew will attend one maternity call. This accounts for approximately 4% of the total workload. The vast majority of these are patients in early labour with most simply requiring transport to hospital (LAS Management Information Bulletin APPENDIX 1). This article describes one such obstetric call where the expertise of the ambulance crews was put to the test.

A 38 year old woman (para 1+0) with a confirmed twin pregnancy of 28 weeks gestation went into labour and called the ambulance service complaining of a massive PV bleed. On arrival the attending ambulance crew (technician and paramedic) found the mother having given birth to one blue, lifeless baby. Resuscitation of this neonate was successful with crews following protocols laid down by the London Ambulance Service (LAS) (Treatment protocol 09). Ambulance control supported the crew in providing three additional vehicles and an Emergency Obstetric Unit (EOU) who arrived within 15 minutes of the original call. Effective teamwork between all concerned enabled optimal care to be given to the mother and the first twin while the second baby was being delivered. The second twin was a breach presentation and also required full resuscitation. The mother was distressed and had lost a significant amount of blood. Rapid transportation of both mother and infants was made possible by the provision of the additional vehicles and enabled ongoing assessment of each to be continued until arrival at hospital. Although no invasive paramedic skills were used in caring for these patients pre-hospitally, effective clinical decisions were made and high quality care provided drawing on the knowledge and experience of the team as a whole. This article highlights the importance of adequate resources and knowledge of local services, the need for effective communication, familiarity with equipment and protocols, the need to treat each call seriously and the need to obtain a full patient history.

The issues

Ambulance control played a key role in co-ordinating the provision of adequate resources in this situation. In particular the deployment of three additional vehicles allowed the mother and each child to be transported separately and enabled optimal care to be delivered to each. Had this not been the case a shortage of personnel and equipment would have rapidly become a problem. While this action may easily be justified it must be recognised that the deployment of this number of vehicles inevitably left a shortfall of cover in the area. Some will argue that it is inappropriate to separate a new-born from its mother but in this case it was the only way to provide quality care for each.

Knowledge of local services facilitated the speedy dispatch of an Emergency Obstetric Unit (EOU) to the scene. Having the additional expertise of a midwife and an obstetrician immediately to hand was reassuring to both mother and crew. Decisions have to be made regarding whether it is appropriate to wait for help or to transport immediately; this can only be done effectively with accurate and up-to-date knowledge of the facilities and help which are available.

Communication is widely accepted as being an essential part of every clinician’s work and is vital to effective teamwork (Greaves & Porter 1997). In the pre-hospital environment communication is facilitated through the use of the vehicle main radio set, hand-portable radios, fixed line telephones and where available the use of the crew’s personal mobile telephones. In this situation the use of a mobile telephone enabled ongoing communication between ambulance control and the crew and avoided the crew having to leave the patient to make use of the vehicular communication system. It also avoided interfering with the dispatch of other emergency vehicles in the area. In areas where radio reception is poor it is often the case that mobile telephones provide a more effective and reliable method of communication.

Greaves and Porter (1997) state that "Pre-hospital care requires teamwork and good teamwork demands good communication" (p7). The ultimate aim of pre-hospital teamwork is for practitioners to have an understanding of each others’ roles and responsibilities and to work together towards achieving a common goal. This also requires a recognition of the skills, abilities and attributes of each team member resulting in greater collective knowledge and experience.

Obstetric care is only a small part of paramedic training in the current syllabus (IHCD 1991). The additional help of the Emergency Obstetric Unit in this situation brought additional experience and confidence above that of the practising paramedic and meant that every eventuality could be dealt with calmly and confidently by those experienced in this field.

While recognising the benefits of effective teamwork it is also important to be aware of the disadvantages associated with poor teamwork and poor communication. These may be a consequence of competition between and within disciplines, a lack of co-ordination of the activities of team members and some practitioners working beyond their level of competence rather than asking for help.

Familiarity with equipment and protocols is essential in all areas of ambulance work (Operational Instruction G1004). Paediatric and neonatal resuscitation are key examples as these are skills which are used relatively infrequently (Dolphin 19**). It is widely accepted that ‘children are not small adults’ (Dolphin 19**) and require to be treated individually in response to their needs. Knowledge of these protocols is therefore of particular importance. In the case history presented familiarity with these protocols created confidence in the practitioners attending, reduced time spent thinking about the actions to take and increased the speed with which the protocols were followed. Equipment posed a problem in so far as there was insufficient supplies to resuscitate two neonates and one adult simultaneously should this have been required. This problem was overcome by the crew’s familiarity with the equipment rendering them able to identify the need for and request specific items of equipment from other vehicles, and by their ability to adapt and to be flexible with available resources. In view of these equipment issues the crew felt justified in having additional vehicles deployed, an action which is supported by LAS Control Instruction 004.

In order to ensure familiarity with protocols and equipment each ambulance technician and paramedic is required to attend one post-proficiency course each year (Personnel Policy Manual 1999). This course includes an update on recent protocol changes (such as those from the European Resuscitation Council or the British Thoracic Society) and requires staff to demonstrate practical knowledge and understanding of protocols using simulated patient exercises. Examples of such protocols include basic life support (BLS), advanced life support (ALS), patient assessment, interventions related to the trauma patient and methods of extrication.

In addition, paramedics are required to recertify every 3 years with the emphasis on endotracheal intubation, intravenous cannulation and extended treatment guidelines.

This case highlighted in particular the need to treat each obstetric call seriously and emphasised the fact that there is no place for complacency within prehospital care or health care generally. In practice the view is often held that obstetric calls are not taken seriously, perhaps due to the volume of calls and the number of patients who require no clinical input from ambulance personnel. Some also believe that these patients use the ambulance service solely as a means of transport. Statistics from the LAS (Management Information Bulletin) indicate that the vast majority of these patients are in early labour. Routine care of these patients includes obtaining a history, monitoring their vital signs, providing reassurance and being prepared to recognise and deal with complications. However, in view of the small percentage (4%) who develop complications pre-hospitally or on route, particularly when compared with the volume of calls, this results in ambulance staff being less familiar and less confident in how to deal with them. It is hoped that this issue will be addressed by the increased emphasis on obstetrics and obstetric care within the revised paramedic training syllabus.

"Obtaining a medical history is a core skill for any health-care professional" (p.71, Greaves & Porter 1997). This applies to each obstetric call just as it applies to all calls received and is a process which commences with the call taker in ambulance control to ensure early dispatch of appropriate additional resources rather than waiting for a crew report. This avoids unnecessary and potentially serious delays and is an important aspect of patient care. In the case of obstetric patients the history may be obtained from the mother and a quick review of her obstetric notes. On occasions it may also be possible to obtain this information from the GP if available.

Accurate documentation of all findings and interventions on the Patient Report Form is essential to provide all those involved in the patient’s care with relevant information and to ensure continuity of care. Not only is this an important aspect of seamless care but is also provides a baseline for future audit and research and a platform upon which to discuss present and future practices.

Conclusion and recommendations

In conclusion, this case highlighted the importance of knowing the facilities, resources and services which are available, the inherent benefits in knowing the personnel involved and the importance of understanding each others’ roles and responsibilities and how these contribute to effective teamwork. It also emphasised the importance of effective teamwork and communication, the need to be familiar with equipment and protocols and the benefits of post-proficiency courses and recertification, the inherent need to avoid complacency with obstetric calls and to take each call seriously, and the need to obtain a full patient history.

Recommendations for future clinical audits or research into this field may address the use of emergency ambulances for routine maternity cases allowing the targetting of paramedic crews to actual or potential obstetric emergencies. This may mean involving maternity departments in making the decision whether a blue light response of an emergency ambulance is the most appropriate for a patient in the early stages of labour.

"Just another maternity .............. but three lives saved!


LAS Management Information Bulletin

LAS Treatment Protocol 09 ‘Resuscitation of a baby at birth’.

‘Emergency Care - A textbook for paramedics’ Greaves I, Hodgetts T and Porter K, WB Saunders Publishing Co, London 1997

IHCD Ambulance Service Paramedic Training Manual, Bristol 1991

LAS Operational Instruction GI/004 ‘Vehicle checks and inventory’.

Dolphin - ‘Paediatrics for paramedics’

LAS Control Instruction CI/004 ‘Maternity cases and obstetric emergencies’

LAS Personnel Policy Manual 1999


Thanks to Stephen Hines for submitting this case study, and to Rose Ann O’Shea for her advice on the content and style. If you have any comments on this article or wish to submit a case history of your own please write to Stuart Nicholls, Manager, ASA National Clinical Effectiveness Project. C/O Kent Ambulance NHS Trust, Heath Road, Coxheath, Maidstone, Kent. ME17 4BG.

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