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CANDOUR - Issue 13 - December 2000

The newsletter of the Joint ASA/JRCALC Clinical Effectiveness Committee and the ASA National Clinical Effectiveness Programme

In this Issue:

National Prehospital Clinical Guidelines - Launched at JRCALC Conference

JRCALC.ORG.UK - the new website for JRCALC

Coronary Heart Disease National Clinical Audit

Spinal Injury Immobilisation

Issue 12 CANDOUR INDEX Issue 14

NATIONAL PREHOSPITAL CLINICAL GUIDELINES
FOR UK AMBULANCE SERVICES

At the Annual Conference of the Joint Royal Colleges Ambulance Liaison Committee held on Friday 3rd November 2000, Dr Iain McNeil, Chairman of the JRCALC Clinical Guidelines Sub-Committee launched the first set of national prehospital clinical guidelines for use in UK ambulance services.

Dr Iain McNeil, chairman of the `guidelines’ sub-committee presented new national clinical guidelines that had been revised and endorsed by JRCALC for use in the UK’s ambulance services. These are available now on the JRCALC web site http://www.jrcalc.org.uk

He reminded the audience that the public rightly expects the same high standard of pre-hospital care wherever and whenever they might need it and that it has to be recognised that there is currently little standardisation, ability to benchmark, or define best practice. There is also a general lack of research in pre-hospital care and very little evidence to support many current practices. With the development of clinical governance and risk management these deficiencies were important managerially as well as clinically and whilst programmes like Panorama may have been unduly critical they did highlight a very real deficiency.

Much has already been done to produce training manuals and local guidelines, but JRCALC firmly believe that national guidelines are now essential and was asked by the Department of Health to help develop a standard approach. Building on the extensive work already carried out by Drs Carney, Scott and others, these new guidelines are not claimed to be perfect, but rather a good start at producing a living document which belongs to the ambulance service. A greater degree of standardisation is clearly desirable, but at present these guidelines can only be advisory and Ambulance Paramedic Steering Committees or Medical Directors may choose to deviate from them at a local level. However, clinical governance would suggest a need to explain deviations and it would be helpful if Services shared the reasons behind any change. We must seek to overcome local prejudices and the whole intention is to maintain and refine the guidelines, develop a scientific and rigorous evidence base and produce practical and measurable clinical standards supported by audit tools and programmes. As such, Dr McNeil would particularly welcome feedback, comments and suggestions.

He also emphasised that producing and maintaining evidence- based guidelines was a time consuming, lengthy, expensive and continuous process - akin to painting the Forth bridge. For the future, solely relying on the good will and commitment of a small number of volunteers is not a practical approach, to do the job properly will take investment. Initial funding had been secured from the Ministry of Defence, which is also interested in areas of this work. But to develop the guidelines and supporting audit programmes ambulance services and the Department of Health, JRCALC and the ASA must now accept the need for investment to produce better patient care. In summary Dr McNeil emphasised that the interim guidelines are now ready, the evidence base is still to be developed, that task requires funding and there is a need to work better together in order to improve standards and practice.

As well as appearing now on the JRCALC website the national clinical guidelines will soon be available for download from the National electronic Library for Health within the Emergency Care virtual branch library. Dr Matthew Cooke a member of the JRCALC Clinical Guidelines Sub-Committee is developing the Emergency Care virtual branch library of the NeLH.

NeLH: Emergency Care Virtual Branch Library - http://www.nelh.nhs.uk

The aims of the work to be completed in 2000/2001:

  • To have a preliminary site for the NELH-EC by November 2000, to launch at NELH meeting in Newcastle
  • To obtain opinion of users on the format and content of an emergency care branch

The scope of the work that will be completed:

  • Consultation with potential users on their needs, expectations and desired content
  • The site to include search facilities for emergency care guidelines, links to appropriate texts and sites, search tools to medical literature.
  • It will also include access to databases such as the national poisons information and drug information databases.
  • Database of guidelines will be started with three levels of information - rapid view guidelines for clinical support, full guidelines for background information and referencing/search for latest information.

Other news from the Conference:

A complete summary of the Annual JRCALC Conference 3rd November is available at the JRCALC website along with copies of the presentations made. http://www.jrcalc.org.uk

  1. Drawing up the New National Guidelines - the process (Dr Iain McNeil, JRCALC)
  2. "National Clinical Guidelines from paper to best practice" (Graham Brown, Westcountry AS)
  3. Collecting the right data from the right forms at the right time (Stuart Nicholls, ASA NCEP)
  4. "What does the ambulance service need from JRCALC in the new millenium?" (Barry Johns, President ASA)
  5. A rapid ambulance protocol for acute stroke (Gary Ford, University of Newcastle upon Tyne)
  6. Pre-Hospital Thrombolysis in Sweden (Dr Lars Engerstrom, Falun Central Hospital, Sweden)
  7. Pre-Hospital Thrombolysis in the UK - looking ahead (Professor Richard Vincent)

There are also 2 dates for your diaries:

12th March 2001 - JRCALC are holding a conference to look at the practicalities of prehospital thrombolysis and progress made to date.

2nd November 2001 - Annual JRCALC Conference

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JRCALC.ORG.UK - The new website for JRCALC

The new website of the Joint Royal Colleges Ambulance Liaison Committee was launched in September 2000. It gives a brief history and background to JRCALC and includes:

- Membership details of the main JRCALC Committee
- Details of JRCALC Sub-Committees
- Details of the JRCALC Guidelines and development programmes
- Details of the JRCALC Conference including a summary of the day, copies of the presentations made, and future dates
- News and views from JRCALC
- Synopses of JRCALC meetings
- Links to individual Royal College websites

Check it out now at - http://www.jrcalc.org.uk

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CORONARY HEART DISEASE NATIONAL SERVICE FRAMEWORK
NATIONAL CLINICAL AUDIT IN THE UK AMBULANCE SERVICE

In October 2000 representatives from JRCALC and the ASA met again with the Royal College of Physicians to push forward the prehospital clinical audit database developed in conjunction with the ASA National Clinical Effectiveness Programme and Tenax Health Systems Limited.

CHEST - Coronary Heart Evaluation of Symptoms and Treatment - as it has provisionally be called will collect the data required to undertake the clinical audits as stated in the NSF.

The Royal College of Physicians acting as the driving force behind the CHD NSF Working Group on behalf of the Department of Health have developed a national in-hospital audit of acute myocardial infarction (MINAP). This will collect information on delays to treatment including thrombolytic therapy.

The MINAP database will also be linked to the Central Cardiac Audit Database (CCAD) where 'live and online' outcome data can be sourced and analysed.

The Royal College of Physicians were excited by the development of a prehospital clinical audit database which would provide robust prehospital data and by linking to MINAP and CCAD ambulance services will be able to obtain accurate outcome data, with all parties fulfilling the requirements of the CHD NSF.

JRCALC have also stated that the Medicines Commission and the Medicines Controls Agency require that ambulance services audit the administration of drugs provided under the POM's list. This has become a mandatory requirement with the new drug licences issued on 16 November 2000 which includes Streptakinase, a thrombolytic agent.

It means that all ambulance services proceeding with prehospital thrombolysis will be required to audit the treatment of appropriate patients. JRCALC require that such audit is coordinated nationally through the National Clinical Effectiveness Programme with data being collected via the CHD NSF clinical audit database (CHEST).

The CHEST database will be piloted amongst several ambulance services throughout December 2000 and January 2001. As from 1st April 2001 all UK ambulance service will be required to collect clinical audit data on myocardial infarct patients. These clinical audits will again be coordinated by the ASA NCEP.

CHEST will be given free of charge to all UK ambulance services including initial installation and training. Other systems for data collection can be developed separately but JRCALC, the ASA and the Royal College of Physicians will require that any other databases are vetted to ensure compatibility. It is vitally important that the data sets and definitions match and that data can be transferred between the various databases (CHEST, MINAP and CCAD).

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Spinal Injury Immobilisation: Is current practice best for the patient?
Stephen Hines, Paramedic, London

Paramedic education suffers from a gulf between theory and practice. Use of reflection enables the practitioner to link what they are doing and why. Practitioners are encouraged to look at the scientific evidence base to practice, and possibly to challenge it.

This article focuses on the use of reflective practice techniques to examine current practice, in the care of the patient with a spinal injury, and challenges whether this is indeed best practice. Included is an examination of studies in the UK and abroad, looking in particular at cervical spine immobilisation.

If we follow protocols laid down by most ambulance services, the occupants of any vehicle involved in an impact at speeds above 30mph should be treated as having a spinal injury. In reality, with modern car safety equipment, such as pre-tensioning seatbelts and airbags, many car occupants are out of the vehicle prior to the arrival of the emergency services. Of those that are injured, some will show no clinical signs of injury, but will risk further damage and possible paralysis if an unstable fracture of the spine is left unsupported.

New technicians are taught to follow protocols without deviation. If an injury is suspected, then it must be treated by following an approved course of action. On the face of it, this would appear common sense. An ambulance service cannot allow staff to treat patients as they see fit; clinical guidelines must be drawn up following an evidence base.

The reflective practitioner, however, may often question whether they are truly giving the best treatment. By identifying particular feelings and looking at theoretical concepts, it may be that they can develop alternative solutions, which might be appropriate for future actions, and hence change the guidelines.

Looking at the road traffic accident scenario, staff are taught to immobilise patients using a semi-rigid collar and an extrication device. The patient should then be moved on either a trauma board or a scoop stretcher, utilising body straps, head blocks and tape to fully immobilise the body.

Most ambulance staff are taught apocryphal stories similar to that of the old lady who crashed into a tree and was OK until she turned her head to say hello to the ambulance crew…

Examples of such secondary trauma are rare. It is very difficult to show if an injury was the result of the original accident or from subsequent movement. Hauswald et al (1998) looked at patients with spinal injury who were taken to two hospitals over a five-year period. They concluded that ‘Out of hospital immobilisation has little or no effect on neurological outcome in patients with blunt spinal injuries’. This is supported by Brosius (2000) who failed to find one single documented case of iatrogenic cord injury as a result of failure to collar.

It is difficult to say ‘do not immobilise’. In today’s litigious society we must look at treating every potential injury. We must also look at the problems associated with cervical immobilisation as currently taught. These include:

  • Incorrect sizing of collars, resulting in poor stabilisation or hyperextension of the neck.
  • Discomfort
  • Raised intracranial pressure (ICP)
  • Other injuries
  • Fear
  • Non compliant patients
  • Clothing

The issue about sizing is partly one of education and partly a manufacturing problem. The use of six sizes of collars does not always allow a good fit. It is in recognition of this that most manufacturers are now making adjustable collars, some in two pieces, to enable more accurate sizing. It should never be accepted that the ‘no neck’ collar will fit all patients.

There have been several recent studies on the deleterious effects of cervical collars and trauma boards. Nursing literature, for example, is replete with examples of decubitus ulcers occurring within as little as an hour of immobilisation. Chan (1994) demonstrated, by immobilising healthy volunteers, that the immobilisation is uncomfortable, and may itself cause occipital and lumbar pain. It must therefore be considered that the patient immobilised as a precaution on scene, being initially pain and symptom free, who later complains of pain, is not justifying the treatment. It may be that the pain is a result of that treatment.

More worrying was Kolb’s research (1999) showing that cervical collars have a modest effect on increasing ICP. This supports earlier work by Davies et al (1996), which showed a mean rise of 4.5mmHg in ICP after application of a cervical collar. This rise may be very significant, especially in the treatment of head injuries.

Other injuries may complicate the treatment of c-spine injuries. Staff are taught that if they put a collar on, then the patient must lie flat. So what should be done with the patient with a suspected neck injury who suffers from cardiac failure, or who has a significant chest injury? Do we lay them flat or sit them up? Is it acceptable to have a collar fitted to a patient transported in the sitting position?

Dealing with fear will play a part in the treatment of any casualty. Many patients will not want the discomfort of a collar, and may fight it off. This is common in head injured patients and children. Their management is often a test of interpersonal skills.

Non-compliance is a problem with any treatment. The rules on informed consent apply to the treatment of spinal injuries as they do to any treatment. It is not acceptable to tell a patient that they must wear a collar. Instead the paramedic should explain the pros and cons of such an intervention. If the patient refuses the treatment this should be documented and, ideally, witnessed.

Clothing is also often a problem when fitting collars. In particular motorcyclists and horse riders, in acknowledging that they are at an increased risk of injury in an accident, are wearing reinforced spine protection. Where this extends to neck level it can make the fitting of a collar difficult of impossible. It is not unheard of for paramedics or hospital staff to sit a patient up to remove clothing, before laying them down a fitting a collar! Of course some patients will not allow you to cut clothing. It they do not suspect an injury they will rarely let you damage several hundred pounds worth of clothing ‘just in case’!

What are the alternatives? To do nothing would risk the practitioner being accused of causing or aggravating an injury. This is a course of action that could prove costly in court. The manufacturers of the collars will always be on hand to provide statistics of how vital they are.

The evidence is conflicting. Almost all the texts say that any suspected spinal injury should be immobilised by use of a collar. The inclusion criterion for suspecting a neck injury includes head injuries. Yet when we look at new research it is becoming apparent that the collar may raise ICP and therefore be contraindicated.

Should patients with chest injuries or ailments sit up or lie flat? If the former, is it acceptable for them to be sitting up whilst wearing a collar? In the case of a car driver, is this not the position we often find them?

The patient who has spent money on expensive protective clothing to protect themselves from injury in an accident risks secondary injury from the removal of the same. How can this be acceptable?

Unfortunately the same patient cannot be treated twice for the same injury. It is hard to show that one form of treatment is better than another. Trials such as Hauswald et al (1998) cannot be relied on, as they do not demonstrate that injuries are related to transport, extrication or to the initial accident. Hauswald’s study looked solely at transportation. The period of greatest theoretical risk is during the extrication or initial movement of the patient.

Current research seems to be in favour of moving away from the mandatory use of collars. Immobilisation using only headblocks and straps is perhaps indicated. To remove the collar completely from protocols will be difficult, however, and further debate is needed.

It is recommended that a further study of the treatment of patients with suspected spinal injury be undertaken. This would need to look at the reasons for applying (or not applying) a collar, any difficulties with putting it on, and how they were dealt with. Whether or not the collar was correctly sized, other associated injuries and the damage done (to person or property) by fitting the collar. Finally, it must look at what percentage of patients treated pre-hospitally for spinal injuries actually have them.

It would be useful to audit the sizing and fitting of collars, and to examine the length of time that patients are left wearing collars or on a spinal board following an accident.

References:

  1. BROSIUS, J. (2000) Cervical collars Paramedicine.com Announcement List www.paramedicine.com 23/5/00
  2. CHAN, D. (1994) ‘The effect of spinal immobilization on healthy volunteers’ Ann Emerg Med 1994 Jan; 23(1):48 – 51
  3. DAVIES, G; DEAKIN, C; & WILSON A. (1996) ‘The effect of a rigid collar on intracranial pressure’ Injury 27: 647 – 649
  4. KOLB, JC. Cervical collar-induced changes in intracranial pressure’ Am J Emerg Med 1999 March; 17(2): 135 – 137
  5. HAUSWALD, M; ONG, G; TANDBERG, G; & OMAR, Z. (1998) ‘Out of hospital spinal immobilisation: Its effect on neurologic injury’ Acad Emerg Med 1998 March; 5(3): 214 – 219

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