Clinical Guidelines From Paper into Practice Graham Brown Clinical Effectiveness Manager Westcountry Ambulance Services NHS Trust Towards a Unified Approach

£345,000 damages for surgery nightmare Parents in child organs protest Towards a Unified Approach JRCALC 2000

Towards a Unified Approach Monday, 17 January, 2000 Ambulance services 'falling short' Panorama reveals how treatments available for trauma patients vary widely depending on where their accident takes place “Each of the UK's 36 ambulance trusts has its own treatment instructions but… there are wide discrepancies among the trusts.” Towards a Unified Approach JRCALC 2000

Guidelines vs. Protocols? Towards a Unified Approach JRCALC 2000

Towards a Unified Approach Clinical guidelines ‘Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances’ Field & Lohr 1990 Towards a Unified Approach JRCALC 2000

Towards a Unified Approach Protocol ‘Standard procedure laid down to be followed step by step’ IHCD paramedic manual 1993 Towards a Unified Approach JRCALC 2000

Evidence based practice Only 10-20% of physician interventions are supported by objective evidence (Cochrane 1976; White 1976) Towards a Unified Approach JRCALC 2000

Towards a Unified Approach Present distribution of healthcare interventions Do more harm than good Of unknown effect - not in research setting or in poor quality research Do more good than harm Of unknown effect, but in good quality research programme (Muir Gray; 1997) Towards a Unified Approach JRCALC 2000

Towards a Unified Approach Present distribution of healthcare interventions Do more harm than good Of unknown effect - not in research setting or in poor quality research Do more good than harm Of unknown effect, but in good quality research programme (Muir Gray; 1997) Towards a Unified Approach JRCALC 2000

Towards a Unified Approach Current Position Trusts receive medical advice from IHCD Paramedic and Technician and training manuals JRCALC recognition of death Anaphylaxis LMA Local medical practitioners LAPSC Medical adviser/director Towards a Unified Approach JRCALC 2000

Towards a Unified Approach JRCALC 2000

Towards a Unified Approach CONSENSUS EVIDENCE RESEARCH Towards a Unified Approach JRCALC 2000

Towards a Unified Approach (Hawksworth 1998) Towards a Unified Approach JRCALC 2000

Towards a Unified Approach (Hawksworth 1998) Towards a Unified Approach JRCALC 2000

Management of Cardiac Chest Pain Trust A Trust B Trust C Trust D Aspirin   Oxygen GTN Opioid Anti-emetic 12 lead ECG Admit A&E Admit CCU Towards a Unified Approach JRCALC 2000

Guidelines vary in effectiveness BLS and ALS Asthma AMI European Resuscitation Council British Thoracic Society British Heart Foundation Working Group Towards a Unified Approach JRCALC 2000

Major determinants of guideline effectiveness Political commitment Chief Executive commitment Guideline credibility and validity Acceptability to practitioners Changes in practice achieved Health gain achieved Towards a Unified Approach JRCALC 2000

Towards a Unified Approach April 2001 8 minutes Towards a Unified Approach JRCALC 2000

Towards a Unified Approach DoH CEO Towards a Unified Approach JRCALC 2000

Determinants of guideline effectiveness Political commitment Chief Executive commitment Guideline credibility and validity Acceptability to practitioners Changes in practice achieved Health gain achieved Towards a Unified Approach JRCALC 2000

Guideline credibility and validity Vital if services are to adopt Use/adapt pertinent existing guidelines Development group credentials Involvement and support of eminent bodies Evaluation in practice Must be suitable for prehospital setting Towards a Unified Approach JRCALC 2000

Acceptability to practitioners NEGATIVES Top down Control tool Curb flexibility/initiative Not-invented-here POSITIVES Building ownership Local adaptations Inclusive development Consultation Pilot/test Effective dissemination Incentives (sanctions) Resistance hard to detect and overcome Towards a Unified Approach JRCALC 2000

Achieving changes in practice STRATEGIC (managers) Clinical governance Sound underpinning evidence base Litigation Dissemination strategy TACTICAL (crews) Simple format Clear layout Rationale explained Targeted education Reinforcement Monitoring Feedback Realistic timescales Towards a Unified Approach JRCALC 2000

Towards a Unified Approach Measuring health gain Monitoring & evaluation Compliance vs outcomes Integrated care pathways Interface audits – primary/secondary care Audit component of clinical governance framework Exception reporting Towards a Unified Approach JRCALC 2000

Towards a Unified Approach In summary... Rigorous guideline development resources/skills targeted at relevant topics regular review communication and consultation Total commitment to implementation ambulance service managers & advisory bodies Local ownership Monitoring of implementation and outcomes Towards a Unified Approach JRCALC 2000

Capacity to Develop Evidence Based Guidelines YES NO UNSURE 16 10 7 Towards a Unified Approach JRCALC 2000

Services Willing to Adopt JRCALC National Guidelines Yes 30 Unsure 3 (3 dependent on evidence base) Towards a Unified Approach JRCALC 2000

Towards a Unified Approach JRCALC 2000