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CANDOUR - Issue 6 - October 1999

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

In this issue :

ASA Clinical Governance Guidance – Update

Clinical Excellence 99 – Spreading Good Practice

Peer Review on the internet

A Guide to Statistics used in Clinical Audit

Issue 5 CANDOUR INDEX Issue 7

ASA Clinical Governance Guidance – Update

The ASA published its guidance document ‘A proposed strategy for the implementation of clinical governance into the UK ambulance service’ in early September. This was very much a reference pack for UK ambulance services to use in compiling their baseline assessments of capability and capacity for clinical governance as required by the NHS Executive Regional Offices.

However, as of the end of September all UK ambulance services should have completed their baseline assessments. It is the intention of the ASA/JCALC Clinical Effectiveness Committee to produce a second version of the guidance document building on the action plans produced through the above process.

These action plans will be important building blocks as UK ambulance services strive for clinical excellence as required by clinical governance. It is therefore important that they shared openly and honestly so that each Trust and individuals can learn from the experience of others. Indeed clinical governance affects individuals as well as the organisation as a whole and the announcement on 1st September 1999 by the Department of Health launching an NHS wide ‘whistle-blowing’ policy 1 adds further weight to this. Organisations will have to be seen to be achieving the milestones laid down within the action plans otherwise the newly formed Commission for Health Improvement (CHIMP) 2 will be required to enforce its extensive powers to ensure the quality of care provided is of the highest possible standard.

Included below is an example from South Yorkshire Metropolitan Ambulance & Paramedic Service NHS Trust (SYMAS). Noel Wade, Director of Outpatient Services and Chair of SYMAS Clinical Audit Committee, has developed a model which links areas identified through the baseline assessment of capability and capacity for clinical governance to the emerging findings of the National Service Framework (NSF) for Chronic Heart Disease (CHD).

Figure 1. Clinical Governance development areas linked to the NSF on CHD (SYMAS, 1999)











The aims of the model are to:

  1. Develop explicit links with the Clinical Governance development plan and the key areas from the NSF relevant to the ambulance service
  2. Develop an integrated approach to the management of cardiac patients
  3. Improve the quality of pre-hospital care for patients with cardiac related emergencies.

If you wish to share anything from your action plans which may assist other services to develop clinical governance and improve the quality of care provided please forward any relevant information to the ASA National Clinical Effectiveness Project..


  1. HSC 1999/128: The Public Disclosure Act 1998 – Whistleblowing in the NHS (27 August 1999), Department of Health
  2. Commission for Health Improvement (CHIMP). The Commission, which will begin work on November 1st, will work closely with the National Institute for Clinical Excellence (NICE) to ensure high clinical standards across the NHS in England and Wales. As a statutory body, operating at arms length from the NHS and the Department of Health, it will offer an independent guarantee that systems to monitor, assure and improve clinical quality are in place in hospitals, primary care, and community services.

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Clinical Excellence 99 – Spreading Good Practice

Keeping with the theme of sharing best practice the annual conference and exhibition of the National Institute for Clinical Excellence (NICE) will be taking place in Harrogate between December 8th and 9th 1999. This is the UK’s leading event for improving the quality of health care. Keynote speakers include Professor Sir Michael Rawlins, Chairman of NICE and Rt. Hon. Frank Dobson MP, Secretary of State for Health.

The Ambulance Service Association’s National Clinical Effectiveness Project will have a stand at the exhibition promoting the work of the project to a wider audience. The aim will be to raise awareness of clinical effectiveness issues within the UK ambulance services with our colleagues in acute and community NHS Trusts.

Several new initiatives will be launched by the ASA Clinical Effectiveness Project at the exhibition – so do not miss out:

Support the ASA Clinical Effectiveness Project by attending – learn from over 57 sessions covering clinical audit, clinical effectiveness, electronic patient records, guidelines etc. – chat with colleagues from within and outside the ambulance service – participate in the debates – visit over 50 other exhibitors including the Royal Colleges – learn how clinical governance is developing from the people that matter.

Conference Programmes are available from the ASA Clinical Effectiveness Project (address above) or from the organisers Sterling Events Ltd. 62 Hope Street, Liverpool L1 9BZ. Tel. 0151 7098979, Fax. 0151 7090384, email [email protected]

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Peer Review on the internet

The Pre-hospital Immediate Care Online is an electronic mailing list for healthcare providers from all sectors (NHS or military, private or voluntary) to discuss ideas, ask questions and get feedback on the topics relating to pre-hospital care in the United Kingdom. Membership of the list is free but registration is required.

Peer review plays an important role in clinical audit and in reviewing clinical effectiveness. Indeed peer review is a requirement of professional self-regulation. This forum allows all practitioners and other interested parties to perform the educational tasks listed above including peer review.

What is a mailing list?

Mailing lists are a small but important part of the Internet. They use the medium of electronic mail for operation and are, effectively, electronic mailing clubs. Any message sent to a mailing list will be distributed to all members of that list whose e-mail addresses are held centrally on an independent server.

Aims and philosophy

The list promotes discussions of relevance to pre-hospital immediate care within the multi-professional membership. While predominantly aimed at pre-hospital providers in the UK and Ireland it welcomes contributors from all over the world who feel they can contribute positively to the list. Pre-hospital Clinical Case Studies are posted to list periodically which encourage members to offer a diagnosis and method of treatment/disposal. With activate participation from FR's, Nurses, Ambulance personnel and Doctors etc. this enables members to gain insight in the thinking process of each professional group and gives the opportunity to learn from one and other.

To register with Pre-hospital Care Online simply go to http://www.999.org.uk

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A Guide to Statistics used in Clinical Audit

Why do we need to use statistics?

Everyone is afraid of statistics and yet they can be very useful in providing robust evidence where any change is involved. Within clinical audit we are constantly measuring change as we move around the audit cycle and see improvements in patient care and outcome (hopefully!). Statistics provide us with robust tools for measuring this change or measuring current practice against agreed standards. They will tell us whether any change that is evident is due to errors in the sample we are looking at or that the change we have effected has actually had an impact i.e. it is statistically significant.

When are statistics needed?

Statistics can be applied to changes in numbers of procedures and numbers of complications as much as they can to patients responses at given times during a given treatment. For example, we can use them to measure whether there has been a significant increase/ decrease in the number of complications arising from a certain type of procedure.

The key word here is SIGNIFICANT. What we are doing when we carry out any statistical analysis is seeing whether our sample (those patients/interventions we are looking at) behaves in the same way the whole population would. For example, we need to know whether the patients responding to asthma treatment in county x are responding like typical asthma patients across the whole country.

Basic Descriptive Statistics

These include averages (mean, medium and mode), variation (standard deviation) and representation (confidence intervals). Definitions are listed below:

Mean – an average taken as the sum of the values divided by the number of values

Median – the middle number of a set of values

Mode – the most frequently occurring value

Standard deviation – a measure of how widely spread the values are around the mean

Confidence Interval – gives a set of parameters showing how well a sample is representative of the population

Whenever we use a sample (which is most of the time as it is almost impossible to look at everything) it is important that if we are quoting an average figure, especially a mean, then we must also quote the standard deviation and the confidence interval. This is because we can not be certain that our sample is a fair representation of the population as a whole.

An example is given below:

Suppose county x need to know ‘What was the delay from arrival at scene to performing defibrillation?’. If we then looked at 10 patient report forms we might find the following times:

5 mins, 3 mins, 7 mins, 8 mins, 9 mins, 6 mins, 4 mins, 5 mins, 4 mins, 6 mins

Our sample size is 10.

The mean is calculated at 5.7 mins or 5 minutes 42 seconds.

The standard deviation is calculated at 1 minute 53 seconds.

If we decide we want to be 95% sure that this is a fair reflection of defibrillation delays across the country the 95% Confidence Level can then be calculated at 1 minute 10 seconds.

Therefore the 95% Confidence Interval is 4 minutes 32 seconds to 6 minutes 52 seconds inclusive (i.e. the mean +/- the confidence level). We can they say that in county x if we choose any group of patients at random we can be 95% confident that the average delay to defibrillation will be within this interval.

If you have any queries about basic statistics give the ASA Clinical Effectiveness Project a call. Also over the coming issues I shall explain how these values are calculated using Microsoft Excel and share a basic software package developed to undertake statistics within clinical audit.

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