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A Survey of U.K. Ambulance Services

on behalf of the Joint ASA/JCALC Clinical Effectiveness Committee

Evidence for Change II

Clinical Audit Activity 1998

Completed Survey

June 1999

Designed by : Stuart Nicholls - ASA Clinical Effectiveness Project Manager

Evidence for Change II

A National Survey of Clinical Audit in UK Ambulance Services

CONTENTS

Survey Objectives Results Part 1 Discussion Parts 1&2 References
Background Results Part 2 Discussion Part 3 Action Plan
Method Results Part 3 Recommendations Appendices

A – Future Initiatives for Clinical Governance

B – Role of ASA Project & ASA/JCALC Committee

C – Index of Projects

D – Project Details

Evidence for Change II

A National Survey of Clinical Audit in UK Ambulance Services

Survey Objectives

The survey was designed to 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.

Background

Given the cessation of the National Statistical Audit of Paramedic Skills it was a recommendation of the ASA/JCALC Clinical Effectiveness Committee that there should be an annual survey of audit activity with UK ambulance services. This has become more pertinent given the forthcoming reporting and arrangements for clinical governance. This survey therefore follows on from the original ‘Evidence for Change’ survey 1 conducted by the Northern & Yorkshire Regional Ambulance Clinical Audit Project in 1998, by concentrating on clinical audit and clinical effectiveness activity within the last year ( 1st January to 31st December 1998 inclusive).

As you will also know the Department of Health have recently funded the post of ASA Clinical Effectiveness Project Manager. This survey will form a baseline of information from which a more specific strategy can be developed which is in touch with current ambulance and audit/ effectiveness issues.

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Method

The survey was designed under the auspices of the ASA/JCALC Clinical Effectiveness Committee and acknowledges the earlier work of the Northern & Yorkshire Regional Project.

There were three sections to the survey which are outlined below :

Part 1 - Background information on structures and processes of audit activity

Part 2 - Future Initiatives in the development of clinical audit/ effectiveness & governance

Part 3 - Audit Activity 1st January 1998 to 31st December 1998 including outcomes

The draft report of the survey was presented to the ASA/JCALC Clinical Effectiveness Committee at their meeting in March 1999.

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Evidence for Change II : Part 1 - Background Information

Number of services surveyed : 43 Completed : 39 Response : 91%

  1. Funding received for clinical audit by U.K. ambulance services by year.
Year

1996/97

1997/98

1998/99

Funded

19

21

25

Not Funded

20

18

14

  1. Ambulance Service Clinical Audit Groups Yes 26 (67%) No 13
  1. a) In-house clinical audit training Yes 10 (26%) No 29
  1. b) Interested in courses and/ or workshops tailored to the ambulance service Yes 30 (77%) No 3
  2. Clinical audit projects completed in the last year conducted in collaboration with the following agencies :
  • Other ambulance services 13 (33%)
  • Hospital Trusts 23 (59%)
  • Health Authorities 11 (28%)
  • GP groups 8 (21%)
  • Other agencies 10 (26%)
  1. Future clinical audit programmes linked with local Health Improvement Programmes Yes 23 (59%) No 16
  1. Single lead person within local Health Authority/Authorities who is responsible for ambulance clinical audit issues Yes 27 (69%) No 12
  2. a) Annual report of clinical audit activity Yes 21 (54%) No 18
  1. b) Annual report submitted to the National Centre for Clinical Audit (NCCA) Yes 8 (21%) No 31

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Evidence for Change II : Part 2 - Future Initiatives

  1. Initiatives taken locally in response to arrangements for clinical governance

Appendix A provides the list of comments regarding arrangements being planned for clinical governance from around the UK ambulance services. The main points are covered in the discussion following this summary of the findings.

  1. Issues which you feel should be addressed either by the National Clinical Effectiveness Project and/or directly by the ASA/JCALC Clinical Effectiveness Committee

Appendix B lists the issues raised by the responding UK ambulance services regarding the roles of both the ASA/JCALC Clinical Effectiveness Committee and the National ASA Clinical Effectiveness Project. Again, the main points are covered in the discussion following this summary of the findings.

The survey asked for particular attention to be given to the areas listed in the table below. It can be seen there is strong backing for each topic but especially the progression Regional Clinical Audit Groups and the development of national evidence based protocols/ standards.

Specific areas of interest

  • Develop Regional Groups 27 (69%)
  • Education programmes 22 (56%)
  • National Projects 22 (56%)
  • Communication 22 (56%)
  • Develop evidence based protocols/ standards 30 (77%)

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Evidence for Change II : Part 3 – Completed Audit Projects

1st January 1998 to 31st December 1998 inclusive

Responses to the Evidence for Change II survey were returned from 39 services, representing 91% of the total number questioned.

Of these 24 (62%) services supplied details of at least one completed audit project.

Indeed a total of 72 projects were collated as a result of the survey.

In a small number of additional cases it was noted that although no audit projects had been completed during the period of this survey there were a number of projects which were either on-going or being planned but no further details were supplied.

Appendix C provides an Index of Projects submitted as part of this survey.

Appendix D provides the Project Details in greater depth for each project.

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Discussion

Parts 1&2 – Progress in UK ambulance service clinical audit

As well as the findings from this survey, comparisons will be drawn with the National Baseline Questionnaire 2 which looked at the progress made with the implementation of clinical audit within UK ambulance services in 1996.

Funding arrangements for clinical audit within the UK ambulance services are steadily improving although more needs to be done. Given that the new era of clinical governance is upon us all and there is an overt requirement to implement a robust clinical audit programme, ambulance services need to obtain funds to ensure they are fully prepared to undertake the work that clinical governance implies.

There has been an increase in the number of services with a clinical audit group, growing from 21 services in 1996 to 26 services in 1998.

There has been an increase in collaboration since 1996 from 68% to 72% in 1998 of services working with other health care sectors/ organisations. There is however plenty of room for improving the levels of collaboration. The retrieval of outcome data from hospitals is of paramount importance for a successful ambulance service clinical audit programme, and this study has shown that 59% of services have worked with hospital trusts. It was also indicated that 59% of service’s clinical audit programmes were linked to local Health Improvement Plans (HImP’s) 3. With the development of HImP’s and National Service Frameworks (NSF’s) 3 , and the continued pursuit of clinical outcome data, it is expected there will be future increases in the level of collaboration between ambulance services and other health care organisations.

What is of more concern, especially following recent publications from the Department of Health 3,4 , is that the level of collaboration between ambulance services themselves is relatively low. Only one third of services reported to be working with other ambulance trusts. Collaboration is essential if national ambulance service clinical audit projects are to be developed, an initiative in which 56% of respondents were interested.

It is interesting to note that the amount of in-service clinical audit training being undertaken has not changed between 1996 and 1998. There are still only 10 services which organise training for their staff. What this survey has indicated though, is the large interest in the development of courses/ workshops/ training packages tailored to ambulance services. Indeed, 77% of respondents expressed an interest in initiatives such as these. Also, in part 2 of the survey (p. 5) 56% of services wanted to see the ASA Clinical Effectiveness Project co-ordinate audit education and training programmes.

Previously 18 services had produced an annual report of clinical audit activity but now the figure stands at 21 services. However, this still only represents 54% of the ambulance services whom responded to the survey. Each trust’s annual report from 1999/2000 will be obliged to report on clinical governance, a component of which is clinical audit, so there is plenty of work to be done to ensure each trust complies to this requirement.

Despite the previous survey 1 encouraging submission of audit projects to the National Centre for Clinical Audit (NCCA), it was reported that only 21% of respondents actually submitted their clinical audits during 1998. The project summaries collated by this survey will be submitted to the NCCA and be added to their database of Clinical Improvement Projects (CLIP). Also, the ASA Clinical Effectiveness Project will actively promote stronger links with both the NCCA and the National Institute of Clinical Excellence (NICE).

Many of the issues raised in Part 2 of the survey (p. 5) are objectives of the ASA Clinical Effectiveness Project. Indeed several initiatives are already underway in response to the expressed demand as explained below and in the following action plan.

69% of services wanted to see the development of regional clinical audit groups. Given that many of those services who did not express an explicit interest are already part of either of the two existing regional groups (Northern & Yorkshire Regional Ambulance Clinical Audit Group, and South East Ambulance Clinical Audit Group), this translates to around 90% of services either being part of, or wishing to be part of a regional clinical audit group. A proposal for a regional clinical audit group structure has been submitted to the ASA/JCALC Clinical Effectiveness Committee for ratification. Hopefully this structure covering the whole of the UK should be implemented during the summer of 1999.

Many services wanted to see better communication between ambulance services and the ASA, especially the ASA/JCALC Clinical Effectiveness Committee. The latter committee oversees the Candour newsletter in Ambulance UK (Official publication of the ASA) and co-ordinates the annual ASA/JCALC clinical audit conference. Improved communication will be facilitated through the ASA Clinical Effectiveness Project, it’s website, project information, and the development of regional clinical audit groups, who will be represented on the ASA/JCALC Clinical Effectiveness Committee.

The most popular initiative supported by 77% of respondents, was to see the development of evidence based protocols/ standards. Again, the ASA/JCALC Clinical Effectiveness Committee are acting in this area. Beds. & Herts. Ambulance and Paramedic Service NHS Trust are currently updating and producing evidence based pre-hospital care standards. Given that the production of an evidence base is a continual and on-going process, the ASA/JCALC Clinical Effectiveness Committee have stated that these standards can be used by other services should they wish.

Clinical Governance Initiatives are being undertaken by the vast majority of services and fit with the guidance issued in March 1999 4 . Appendix A outlines the work currently being done in this area. The ASA itself will shortly be issuing guidance on the implementation of clinical governance specific to ambulance services.

Similarly, the issues raised in Appendix B will be addressed by the both the ASA Clinical Effectiveness Project and the joint ASA/JCALC Clinical Effectiveness Committee. Indeed many initiatives are already underway as can be seen in the following recommendations and action plan.

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Part 3 – Clinical Audit Projects

Project Work

A total of 72 clinical audit projects have been collated as part of this survey, with 24 of the 39 services who responded returning at least one project. It was also noted that a number of additional projects were being undertaken but their results were unable to be presented in this survey. Appendices C and D index and summarise the completed projects respectively.

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Recommendations

  1. There should be an annual review of clinical audit activity within UK ambulance services.
  2. Co-ordination of HimP’s and NSF’s to develop national projects e.g. CHD, Diabetes etc. in conjunction with the development of common standards/ protocols and the minimum data set for patient report forms.
  3. Identification of and response to specific training needs for clinical effectiveness/ governance.
  4. Identification of and response to communication needs for ambulance services in terms of clinical effectiveness/ governance.

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Action Plan

Action Plan Component (s) Information Due
Communication ASA Clinical Effectiveness Project Leaflet

Newsletter – Candour – Ambulance UK

Website – http://www.ambex.co.uk

Conference – Clinical Governance & Effectiveness – creating the link 20 May 1999

02-99

on-going

05-99

20-05-99

Regional Clinical Audit Groups Proposal to ASA/JCALC Clinical Effectiveness Committee – includes structure and basis for terms of reference

Summer 99

Evidence Based Protocols/ Standards ‘Carney’ protocols/ standards of patient care

Minimum Data Set

National Institute of Clinical Excellence

Summer 99

Summer 99

Summer 99

Clinical Governance ASA Guidance Document – implementing clinical governance in UK ambulance services

Summer 99

National Ambulance Audit Projects Links with existing projects - NSF’s, HimP’s, PAF’s etc.

Autumn 99

References

  1. Evidence for Change: A survey of UK ambulance services, C Meehan, Dr B Ennis, & F Goulding, Northern & Yorkshire Regional Clinical Ambulance Clinical Audit Project, August 1998.
  2. Results of National Baseline Questionnaire, L Gomershall & K Marshall, Northern & Yorkshire Regional Ambulance Clinical Audit Project, November 1996.
  3. A First Class Service, Department of Health, January 1998.
  4. Clinical Governance, Department of Health, March 1999.

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