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CANDOUR - Issue 2 - February 1999

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

In this issue :

ASA Clinical Effectiveness Project

Evidence for Change II - A National Survey of Clinical Audit in UK Ambulance Services

South East Ambulance Clinical Audit Group (SEACAG)

Pre-hospital Management of Asthma (Re-audit ) - Kent Ambulance NHS Trust


Issue 1 CANDOUR INDEX Issue 3

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ASA Clinical Effectiveness Project

Funding for the project was secured from the Department of Health following the success of the Northern & Yorkshire Regional Clinical Audit Project in promoting collaborative ambulance audit and through the production of national surveys (e.g. Evidence for Change).

The aim of the ASA Project is to develop strategies for the co-ordination of clinical effectiveness throughout the U.K. ambulance services.

The main objectives are as follows :

  1. To provide guidance and support to the development and implementation of clinical effectiveness education programmes
  2. To ensure the progression of clinical effectiveness within the U.K ambulance services through consultation and collaboration with local and national bodies
  3. To identify and agree national priorities for clinical effectiveness regimes
  4. To participate in the development of multi-disciplinary care-pathways to ensure and integrated approach.
  5. To contribute to the development and production of communication tools to serve the above objectives

The project will act as a resource for use by all U.K ambulance services providing advice on clinical effectiveness issues including clinical governance. National initiatives will aim to promote clinical effectiveness with the project acting as a link between the ASA/JCALC Clinical Effectiveness Committee, all U.K Ambulance services, the National Institute for Clinical Excellence (NICE) and other relevant bodies or organisations.

To achieve the above aims it is intended to promote collaboration through increased communication and the development of regional groups to discuss and promote clinical audit and effectiveness. Good examples where such systems already exist include the Northern & Yorkshire Regional Ambulance Clinical Audit Group (from which the national project developed) and the South East Ambulance Clinical Audit Group (SEACAG) which is discussed in more detail later in this edition.

The project is currently developing its own internet web-site to further enable communication between U.K ambulance services. It is envisaged the web-site will contain the following items :

  • Details or examples of clinical audit/ effectiveness projects
  • Links to other services or relevant organisations (e.g. www.ambex.co.uk; [email protected]; www.ncca.org.uk)
  • Details of Candour
  • The latest conference information
  • Details of relevant events/ publications etc.
  • Details of audit tools/ templates etc.
  • ASA/JCALC Clinical Effectiveness Committee - meet the members ,minutes
  • An area for discussing the latest developments

Should you have any ideas on what should go on this web-site or wish to volunteer your expertise in developing such sites please contact either the Project Manager Stuart Nicholls (see details below) or e-mail in the first instance [email protected]

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Evidence for Change II - A National Survey of Clinical Audit in UK Ambulance Services

Given the cessation of the National Statistical Audit of Paramedic Skills it was a pre-requisite of the IHCD that there should be an annual survey of audit activity with UK ambulance services. This has become more pertinent given the forthcoming reporting arrangements for clinical governance. This survey will therefore follow on from the original ‘Evidence for Change’ survey conducted by the Northern & Yorkshire Regional Ambulance Clinical Audit Project, by concentrating on clinical audit and clinical effectiveness activity within the last year (1998).

The data gathered will inform the ASA/ JCALC Clinical Effectiveness Committee and the Department of Health of the current situation regarding clinical audit and clinical effectiveness within the U.K. Ambulance services. Its’ three sections concentrate on background information on structures and processes of audit activity, future initiatives in the development of clinical audit/ effectiveness, and audit activity 1st January 1998 to 31st December 1998 including outcomes.

A reminder that responses should be returned to the Project Manager by 19th February 1999. By completing the questionnaire you will be directly affecting how the National Clinical Effectiveness Project can help you. By stating what you require from the project priorities can be set against your needs.

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South East Ambulance Clinical Audit Group (SEACAG)

SEACAG was formed in 1995 as a forum through which ambulance services could exchange ideas and results from audit projects. The member services include Essex, Sussex, Surrey, Beds & Herts, Two Shires, Kent, London, Royal Berkshire and East Anglia.

The group established some terms of reference which have subsequently been updated to reflect developments both inside and outside of the group :

  • To provide a forum for the promotion of clinical audit/ effectiveness in the prehospital setting
  • To provide a regional voice at national level
  • To provide information regarding effective patient outcome results
  • To challenge the effectiveness of current work through clinical audit
  • To contribute to the education of members, both in specialist topics and in audit methodology, drawing expertise via invited speakers
  • To share information

General meetings are held every two to three months to discuss the business of the group with specific and additional project meetings held as and when appropriate.

Typically a general meeting will cover the latest developments in clinical audit and effectiveness, the groups’ regional representative will report on the latest information coming from the ASA/JCLAC Clinical Effectiveness Committee, and each service will share ideas and thoughts on current audit projects to assist in establishing best practice.

The group has developed over the years and during 1997 conducted its first collaborative audit looking at the pre-hospital care provided to hypoglycaemic patients across the region. Through comparison of the differing treatment regimens, in place amongst the seven services who participated in the joint audit, the group and the project’s specialist advisory panel were able to formulate and recommend a regional treatment protocol for the prehospital management of hypoglycaemic patients which was evidence based. Indeed several services subsequently changed their protocols as a result.

SEACAG are currently planning a collaborative audit of cardiac arrest outcomes using the Utstein reporting template.

SEACAG is a good example of ambulance services coming together voluntarily and without funding but with common objectives to share information, learn from each other and establish best practice. Through the groups collaborative and comparative audit projects the aim is to establish a regional evidence base from which sound clinical decisions can be recommended.

It is hoped more regional groups can be developed such that regional evidence can be shared nationally. Indeed together with the Northern & Yorkshire Regional Ambulance Clinical Audit Group there are very positive foundations to build from.

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Pre-hospital Management of Asthma (Re-audit ) - Kent Ambulance NHS Trust


To re-audit the pre-hospital care given to asthmatics with special attention given to :

  • increased rates of recording peak flow readings
  • increased rates of recording levels of oxygen saturation
  • Oxygen therapy given to patients with saturation levels below 96%
  • Outcome measures from A&E treatment


A retrospective study of patients presenting with asthma as the primary condition during September 1997. Patients were audited against the relevant standards of care.


In total there were 175 incidences of asthma attended by Kent Ambulance NHS Trust during the audit period. This compares to 181 patients in the audit of 1996.

The two group of patients in the two audits were found to be the same in terms of age and sex distribution. Also the number of patients conveyed to hospital was not different between the two audits.

  • Using chi-square analysis there has been a highly significant increase (p<0.0001) in the number of peak flow readings recorded between the two audits. All recorded incidence of peak flow readings increased from 14% in 1996 to 34% during this audit.
  • The rate of recording oxygen saturation levels increased from 77% to 82% between the two audits. Also the number of cases where two readings had been recorded increased from 31% to 35%.
  • Despite the recommendations of the 1996 audit the number of patients with below 96% oxygen saturation who did not receive oxygen therapy increased between the two studies from 2% in 1996 to 7% in 1997. This proved to be a significant difference (p<0.05).
  • Contrary to the greater level of intervention resulting from increased recording of peak flow rates there was no significant difference in either the distribution or average time spent at scene or the average total length of the incident from the time of call to arrival at hospital.
  • 90% of patients were taken to A&E with 42% being admitted to hospital. 59% of patients taken to A&E required nebulisation. This includes 12% whom had not been nebulised in the pre-hospital phase.
  • Patterns of treatment and outcome were established for different groups of patients - those not conveyed, those taken to A&E then discharged, and those taken to A&E then admitted.


  • To re-audit once new protocols under discussion by the Paramedic Steering Committee for increased adult dosage nebulised salbutamol have been agreed.
  • The re-audit to include data on the time spent in A&E for patients conveyed to hospital.

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