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

2. £345,000 damages for surgery nightmare Parents in child organs protest
Towards a Unified Approach
JRCALC 2000

3. 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

4. Guidelines vs. Protocols?
Towards a Unified Approach
JRCALC 2000

5. 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

6. 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

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

8. 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

9. 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

10. 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

11. Towards a Unified Approach
JRCALC 2000

12. Towards a Unified Approach
CONSENSUS EVIDENCE
RESEARCH
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JRCALC 2000

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

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

15. 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

16. 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

17. 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

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

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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

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

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

28. Towards a Unified Approach
JRCALC 2000