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CANDOUR - Issue 10 - June 2000

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

In this issue :

Development of National Clinical Guidelines for Ambulance Services – the latest from the ASA/JRCALC Clinical Effectiveness Committee

Clinical Audit Database for Coronary Heart Disease – developed by the ASA to meet the requirements of the National Service Framework

ASA/JRCALC Conference – 3rd November 2000

Book Review - "Research Methods and Statistics in Health Care"

Scottish Ambulance Service - Clinical Performance: A Pilot Study

Northern & Yorkshire Patient Report Form – towards a regional PRF

Issue 8 CANDOUR INDEX Issue 11

 

Development of National Clinical Guidelines for Ambulance Services

It has long been recognised that there is a need for a set of national clinical guidelines for ambulance services. Panorama’s ‘Casualties’ programme highlighted this issue but, aside from its’ unfair criticism, the drive towards national clinical guidelines and away from ‘postcode prescribing’ has been a priority of the NHS for several years now.

The most recent example is the National Service Framework (NSF) for Coronary Heart Disease. The table below shows the milestones and goal of the NSF for ambulance services:

Heart Attack

(AMI & ACS)

Coronary Heart Disease National Service Framework - Milestone

Action being taken

October 2000

  • The ambulance service has an effective means for setting service clinical standards for common conditions
  • The ambulance service has a systematic approach to determining whether agreed clinical standards are being met
  • Work initiated by the JRCALC sub-committee in collaboration with the ASA/JRCALC Clinical Effectiveness Committee and the ASA National Clinical Effectiveness Programme, and linked to NICE
  • National clinical audit undertaken through the ASA National Clinical Effectiveness Programme

April 2001

  • The ambulance service has an agreed service-wide protocol for the management of suspected AMI
  • Standard/ guideline developed by the JRCALC sub-committee in collaboration with others (see above)

April 2002

  • The ambulance service has clinical audit data no more than 12 months old that describe the relevant items listed in the AMI chapter (of the NSF)
  • National clinical audit tools, projects and performance indicators developed by the ASA National Clinical Effectiveness Programme in conjunction with NICE

NSF Goal

Every ambulance service should offer complete and correct packages of audited effective interventions to all people assessed as having a suspected AMI, demonstrated by clinical audit data no more than 12 months old
  • A complete clinical audit package developed by the ASA National Clinical Effectiveness Programme based on the JRCALC guideline for AMI allowing for benchmarking of performance

Initiatives such as clinical audit, clinical effectiveness and clinical governance have all been put in place for two reasons. Firstly to improve the quality of care provided within the NHS and secondly to reduce variation in treatment and outcome for patients. Clinical governance now means that every individual within the NHS is accountable for clinical quality with Chief Executives accountable for sustaining continual clinical quality improvement within their Trusts. One of the elements to clinical governance is the sharing of best practice to reduce variation in care and outcome, to learn from each other and to improve the quality of care we all provide as individuals and as organisations.

Indeed the ASA is very much part of the NHS Effective Clinical Practice Programme through the ASA’s National Clinical Effectiveness Programme, which supports clinical audit, clinical effectiveness and the development of clinical guidelines in collaboration with the National Institute for Clinical Excellence (NICE). One of the key objectives of NICE is the development of national guidelines across the NHS working in partnership with the medical professions.

At the last meeting of the Joint ASA/JRCALC Clinical Effectiveness Committee it was reported that JRCALC have established a sub-committee to co-ordinate the development of a set of national clinical guidelines for use by UK Ambulance Services. This sub-committee will be working jointly with the ASA/ JRCALC Clinical Effectiveness Committee and the ASA National Clinical Effectiveness Programme to ensure links are established and maintained with UK ambulance services, the professional bodies (ASA & JRCALC) and with NICE. The sub-committee is representative of the skills required to develop a set of national clinical guidelines including academics, researchers, clinicians and ambulance service personnel.

Initially work will be based upon the guidelines developed by Dr Iain McNeil, Dr John Scott and Dr Chris Carney amongst others which have already been submitted to JRCALC in draft form. Thanks must go to all those involved, from Bedfordshire & Hertfordshire Ambulance & Paramedic Ambulance Service NHS Trust (especially Lesley Cave and her team), Surrey Ambulance Service NHS Trust and East Anglia Ambulance Service NHS Trust, who contributed to this initial work which very much lays the foundations from which subsequent guidelines will be drawn,

The sub-committee will also co-ordinate their work with that of the Welsh Ambulance Service NHS Trust who have secured a grant from the Clinical Effectiveness Support Unit (CESU – the Welsh NICE) to develop twenty four prehospital clinical guidelines over the next three years. This will enable resources to be pooled and will avoid any unnecessary duplication of work. All the guidelines produced will be clinically effective with research being undertaken where necessary to bridge any gaps in the evidence base.

This in an exciting initiative which will undoubtedly improve the quality of prehospital care provided by the UK’s ambulance services and reduce variation in patient treatment and outcome. As the guidelines are developed updates and news will be published here in CANDOUR and also on the website http://www.asancep.org.uk in the new guidelines section.

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Clinical Audit Database for Coronary Heart Disease

When the National Service Framework for Coronary Heart Disease was finally published in March 2000, it outlined a set of clinical audits which are to be undertaken on an annual basis by ambulance services. The milestones and goal of the NSF were described in the previous article showing the action being taken. In summary by October 2000 the ambulance service is expected to have adopted a systematic approach to determining whether agreed clinical standards for AMI are being met. This means the implementation of clinical audit techniques to measure adherence to and the effectiveness of prehospital standards for AMI.

The table below describes all the annual clinical audits to be undertaken within the CHD NSF :

National Service Framework – Coronary Heart Disease - Clinical Audit
 
BOLD – annual clinical audit
Non-bold – clinical audit once routine information available
 
  1. % Category A calls to emergency services attended within 8 minutes of a call for professional help by a trained individual with a defibrillator
  • number and % of patients eligible for thrombolysis arriving at hospital within 30 minutes of call for professional help (‘call to door’ time)
  • number and % of patients eligible for thrombolysis receiving it within 20 minutes of arrival at hospital (‘door to needle time’)
  • number and % of patients eligible for thrombolysis receiving it within 60 minutes of call for professional help (‘call to needle time’)
  • number and % of adult patients with out-of-hospital, non-traumatic cardiac arrest who reach hospital alive and survive to leave hospital
  • number and % of patients with suspected AMI, given at least 300 mg aspirin within 60 minutes of call for professional help
  • the number and age-sex standardised proportion of people with AMI admitted to an NHS Trust who die within 30 days of admission
  • the number and age-sex standardised proportion of people age 35 to 75 vii years in a PCG/PCT, HA area with a diagnosis of AMI who die within 30 days of their infarct
  • number and % of patients discharged from hospital with a diagnosis of acute myocardial infarction:
  • a) prescribed aspirin
    b) prescribed beta blocker
    c) prescribed ACE inhibitor
    d) prescribed statin
    e) documentation of assessment of left ventricular function in discharge

    communication to the general practitioner

    f) documentation of arrangements for cardiac rehabilitation in discharge

    communication to the general practitioner

    g) documentation of results/arrangements for assessing need for revascularisation.

    The objective of the ASA National Clinical Effectiveness Programme (ASANCEP) is to support the development of clinical audit and as part of the contract with NICE for 2000/2001 the ASA are required to initiate benchmarking of performance for ‘Time to 1st shock’ by March 2001.

    In order to achieve these objectives and work towards the clinical audit requirements listed above the ASANCEP has been able to purchase a bespoke clinical audit database for coronary heart disease on behalf of every ambulance service.

    Tenax Health Systems Limited in collaboration with the ASANCEP have developed a clinical audit database which will record and report on all the data required by the CHD NSF and more. This will allow performance in every ambulance service to be truly and effectively compared with other services and will allow for national clinical audits around CHD. For example, we will for the first time be able to get an accurate picture of aspirin administration rates with all data bias removed, the effectiveness of ‘fast-tracking’ systems can be examined allowing for the sharing of effective clinical practice and improving the quality of care provided for AMI patients across the UK.

    The clinical audit database is flexible enough to allow for existing data sources to be ‘downloaded’ to avoid duplication, but is robust enough to ensure the definitions and data collection methods used are identical in each setting to allow true comparisons to be made without any disclaimers covering the quality of the data.

    Each ambulance service will receive a free copy of the clinical audit database courtesy of the ASANCEP who will continue to develop and support the software with Tenax Health Systems Limited. The adoption of technology which reports on clinical audit data against the CHD NSF and allows for benchmarking of performance is central to the process of clinical governance in improving the quality of patient care. This applies as much to individuals as to the performance of the organisation as a whole, and it is hoped that as the software is developed over the coming months it will be able to audit individual performance as well as the performance of the organisation against the National Service Framework.

    For more information about the clinical audit database contact either of the following:

    Stuart Nicholls, Manager, ASA National Clinical Effectiveness Programme c/o Kent Ambulance NHS Trust, Heath Road, Coxheath, Maidstone, Kent. ME17 4BG Tel/Fax: 01622 664929, email: [email protected], web: http://www.asancep.org.uk
    or
    James Ormonde, Managing Director, Tenax Health Systems Limited, Unit 3 The Ring, Bracknell, Berks. RG12 1AX. Tel: 01344 454656, Fax: 01344 310660 web: http://www.TenaxHealthSystems.com

    Alternatively visit Tenax Health Systems Limited at AMBEX 2000 - Stand Q38.

    Click here for more details about the CHD Database

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    Joint ASA/JRCALC Conference 2000


    The fourth conference of the
    Joint ASA/JRCALC Clinical Effectiveness Committee.

    3 November 2000
    Royal College of Physicians (London) Conference Centre

    • The morning session will highlight the work of JRCALC

    • The afternoon session run jointly with the ASA Clinical Effectiveness Committee and will focus upon the continued commitment to and development of clinical audit and clinical effectiveness by UK ambulance services.

    The conference will have an emphasis on clinical improvement and the promotion of

    ‘Effective Clinical Practice’

    Further details will be circulated as soon as they are confirmed.
    Details will be announced on the website

    http://www.asancep.org.uk

    and more details will follow in CANDOUR.

    Stuart Nicholls, Manager, ASA National Clinical Effectiveness Programme
    c/o Kent Ambulance NHS Trust, Heath Road, Coxheath, Maidstone, Kent. ME17 4BG
    Tel/Fax: 01622 664929 Email: [email protected]

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    BOOK REVIEW

    "Research Methods and Statistics in Health Care"

    Norma G. Reid and Jennifer R.P. Boore
    Edward Arnold Publishers
    London, Melbourne, Auckland
    ISBN 0-7131-4522-6
    (130pp paperback).

    It is not often that one comes across texts relating to research methods and statistics that are non-taxing and welcoming to the newcomer to these fields. "Research Methods and Statistics in Health Care" by Norma Reid and Jennifer Boore helps to bridge this gap and provides a text which is clear, concise and easy to follow and which does so with a clinical emphasis.

    Although written for the practising nurse this book is suitable for other health care professions and may prove useful to the ambulance technician or paramedic wishing to undertake an area of research or to analyse the results of clinical audit from a ‘scientific’ perspective. It begins by addressing the role and usefulness of research methods and statistics within the health care professions followed by an introduction to research methods and a step-by-step account of basic statistical techniques, and concludes with practical examples illustrating the value of these techniques and methods.

    Given the increasing emphasis on clinical audit and the importance of research and evidence-based practice in today’s society and the significance of Clinical Governance, this text should go far in assisting those who wish to embark on this pursuit and in assisting them in their acquisition of skills to enhance their professional performance and ultimately to improve the quality of their patient care.

    Presented in a handy portable size "Research Methods and Statistics in Health Care" is likely to appeal not only to those undertaking clinical audit as part of their main clinical role but also to those undertaking courses of further study including those based within the higher education establishment. It is written in a user-friendly format which touches on many of the key issues without covering them in great depth but leads the way to further exploration and study.

    The wide range of contents in this book, including the steps involved in the research process, ethical considerations, research techniques, the approach to describing and summarising data and the importance of testing hypotheses, render it a useful adjunct to anyone wishing to become involved in clinical research, clinical audit or clinical trials.

    Reviewed by Rose Ann O’Shea, Senior Lecturer, Department of Nursing and Paramedic Sciences, University of Hertfordshire. February 2000.

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    Scottish Ambulance Service - Clinical Performance: A Pilot Study


    This pilot study originated within the National Audit Office's Value-For-Money Study of the Scottish Ambulance Service. A small part of the study had the aim of examining the issue: 'within existing resources, what scope is there to improve quality and increase the clinical effectiveness of patient care?'. The study is a case-note audit intended to support this aim.

    All emergency and urgent records from Command and Control Systems covering Scotland were sampled for a one-week period covering 26/11/97 to 03/12/97. Patient Report Forms for the same period were cross-referenced and analysed by experienced Operational Officers. This involved 10,033 patient-journeys, made up of 5,540 emergency and 4,491 urgent (or short-term planned) patient-journeys.


    Characteristics of the incidents, times, patients, injuries and treatments were taken for inclusion into a purpose built database. An external company was commissioned to produce a total of 86 tables from 560 database queries. Dr Fiona Gailey, NAO, and Robin Lawrenson, SAS directed the process toward the report, with the latter being responsible for the production of the report and the text within.

    In the overview of the service, titled "A case-note audit of patient report forms. Are the Service making the most of existing patient and clinical information?", the following sub-objectives were identified:

    1. Identifying completion rates of patient report forms across the Service
    2. Quantify the completeness and quality of information being recorded
    3. Provide further insight into patient demand
    4. Describe and quantify A&E crew healthcare activities
    5. Pilot the capture of additional information, which is of interest to the NAO in the short term, and to the Service in the longer term (including information about severity of condition and clinical condition)
    6. Pilot the use of hospital A&E information to gauge severity of patient condition and also to monitor the time ambulance patients wait in A&E departments
    7. Pilot the use of record linkage with routine hospital inpatient data in order to provide a measure of health care outcome for the Service

    In order to achieve these objectives the following aspects were audited :

    • PRF compliance
    • Frequency of calls
    • Response times
    • On-scene times
    • Pre-hospital times
    • At-hospital times
    • Incident severity
    • Patient mobility
    • Patient age-groups
    • Number of incidents with actions
    • Response times for marker conditions
    • Pre-hospital times against severity
    • Number of incidents by marker conditions
    • Number attended by GP/Flying Squad/Midwife by marker conditions
    • Number of incidents by crew type
    • Number of incidents by type
    • Clinical skills performed


    It is intended the report will form a basis for discussion aimed at improving clinical efficiency, especially in those areas within, both internally and with Service stakeholders.

    For more details about this unique and commendable pilot study please contact Robin Lawrenson, National Clinical Audit Manager, Scottish Ambulance Service, 4 Maitland Street, Glasgow. G4 OHX. Tel: 0141 353 6001 Fax: 0141 353 6359

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    Northern & Yorkshire Patient Report Form

    Tees, East & North Yorkshire Ambulance Service NHS Trust (TENYAS) together with North East Ambulance Service NHS Trust (NEAS) are working jointly on a collaborative Patient Report Form (PRF).

    Since the merger of the three services in TENYAS there was a need for a single PRF to allow for trust-wide audit. NEAS use the same scanning system as TENYAS and have donated the design of their PRF to be used jointly with TENYAS.

    This will allow for cross-Trust comparison of clinical audit data including collaborative projects. It is hoped that other services in the region will be interested in this initiative and lead to the development of a region-wide PRF.

    Similarly, within the Welsh Ambulance Service NHS Trust the former PRF’s of the constituent parts are being discarded and a national PRF is being introduced. Who knows, maybe this collaborative work is the shape of things to come in light of mergers and closer working arrangements with our neighbours ? Will other regions follow suit ? What odds for a National PRF ?

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