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AMBULANCE SERVICE ASSOCIATION
NATIONAL CLINICAL EFFECTIVENESS PROGRAMME

DEVELOPING AND SUPPORTING EFFECTIVE CLINICAL PRACTICE
IN UK AMBULANCE SERVICES

BUSINESS PLAN

April 2000 to March 2001

Submitted to the National Institute for Clinical Excellence

February 2000

Stuart Nicholls, Manager, ASA Clinical Effectiveness Programme &
Special Working Group of the Joint ASA/JRCALC Clinical Effectiveness Committee

Contents

1. Background
2. Existing Functions and Services
3. Agenda until March 2001: Setting the scene

Annex A: Proposed Work Programme 2000/2001
Annex B: Contributions to the Priorities of NHS and the NICE Technology Appraisal & Clinical Guideline Programmes
Annex C: Statement of Commitment

 

1. Background

1.1 The Ambulance Service Association National Clinical Effectiveness Programme (referred to hereafter as either ASANCEP or the Programme) promotes and supports effective clinical practice within all UK public sector ambulance services.

1.2 The original work programme and objectives of the ASANCEP were laid out in the proposal submitted to the NHS Executive (1998) and are steered by the Joint ASA/ JRCALC (Joint Royal Colleges Ambulance Liaison Committee) Clinical Effectiveness Committee. The first Annual Report of the Project was submitted to NICE in May 1999 which outlined the Project’s agenda until March 2000.

1.3 An initial proposed work programme was submitted to NICE in December 1999, but following further instruction in late December 1999 and January/ February 2000 this rewritten proposal reflects the criteria laid down by NICE for effective clinical practice programme business plans.

1.4 The ASANCEP was only initiated in December 1998 and is thus still laying the foundations to fully promote and support effective clinical practice. Without the structures for collating and disseminating information and without a standard data set from which to draw, guidelines and audit tools can not easily be developed.

1.5 The agenda for the Programme during 2000/2001 is outlined within this proposal (Annex A).

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2. Existing Functions and Services: Ambulance Service Association

2.1 Below is a brief description of the existing functions and services provided by the Ambulance Service Association National Clinical Effectiveness Programme, highlighting how those services contribute to improving the quality of care provided by the NHS.

2.2 Facilitate Regional Clinical Audit Groups (across UK)
Promoting collaborative and comparative audit, Sharing effective clinical practice, Future benchmarking exercises (ASANCEP Discussion document summer 1999).

2.3 Evidence for Change
Annual survey of clinical improvement projects within the UK ambulance services.

2.4 Evidence Based Prehospital Standards/ Guidelines
Under development (draft with JRCALC), Reduce variation in clinical practice.

2.5 Minimum Data Set
Minimum data collection requirements for prehospital patient records. Basis for clinical audit tools, allowing for benchmarking, and development of care pathways. Review new technologies which will improve prehospital clinical audit e.g. electronic patient report forms, scanning & data collection, clinical audit tools.

2.6 Guidance on prehospital clinical audit programmes
Assist in implementing clinical audit programmes. Provide guidance on ‘tried and tested’ prehospital audit methodologies.

2.7 Guidance on clinical governance issues
Specific criteria for ambulance services including standardised reports and performance indicators e.g. time to 1st shock for cardiac arrest.

2.8 CANDOUR newsletter
Bi-monthly publication highlighting clinical improvement issues, Sharing effective practice and improving access to information.

2.9 ASANCEP Website (www.asancep.org.uk)
Project publications, Events, CANDOUR on-line, Presentations, Evidence for Change on-line, Links to other prehospital/ health improvement related information. Sharing effective practice and improving access to information.

2.10 Access to health improvement resources
Cochrane Library, Medline, National Research Register, NICE databases.

2.11 Database of prehospital evidence
Research papers, Reviews, Articles, CLIP Index, audit methodologies etc.

2.12 Annual Conferences
Promote work of the ASANCEP at ASA/JRCALC, AMBEX International, NICE and other appropriate conferences as opportunities present themselves.

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3. Agenda for 2000/2001: Setting the scene

3.1 The scope for the ASANCEP over the next twelve months from April 2000 is to support the development of effective clinical practice within all UK ambulance services and continue to promote the Ambulance Service Association as the authoritative voice of the NHS ambulance service.

3.2 The key objective is to develop a communication strategy to ensure that the work of the programme is promoted and supported both within and outside the UK ambulance services. This strategy must also promote the views of all UK ambulance services and allow for feedback both within the ASA itself and with other NHS/ health care organisations.

3.3 The communications strategy manifests itself both explicitly and implicitly within the objectives outlined in the work programme (Annex A). However, the two main components of this strategy are the further development of the regional clinical audit group structure and the implementation of a common minimum data set to allow for the development of national standards/ guidelines and audit tools. Between them these will facilitate the growth of a pre-hospital evidence base and allow for benchmarking of clinical performance between ambulance services using clinical audit.

3.4 Regional clinical audit groups will act as the focus of communication between ambulance services themselves, and to and from the ASA/JRCALC Clinical Effectiveness Committee and the ASANCEP. These will facilitate the development of regional collaborative audits which provide the evidence base for redefining national standards/ guidelines in collaboration with NICE.

3.5 The development of regional and subsequent national audit projects will only be possible when the ASA/JRCALC Minimum Data Set for Patient Information has been implemented by all UK ambulance services. Once implemented, benchmarking clinical performance becomes possible along with the development of clinical indicators specific to ambulance services. These can be developed in conjunction with National Service Frameworks (e.g. time to 1st shock for cardiac arrest) and lead to the progression of integrated pathways of care.

3.6 Communicating these initiatives to all UK ambulance services and obtaining their feedback is of paramount importance to the continued success of the Programme. This is possible through the development of the regional groups, the Programme’s website, the ASA/JRCALC newsletter, conferences/ exhibitions and the implementation of a series of roadshows promoting and supporting the Programme’s initiatives.

3.7 The communications strategy described above is an important mechanism for the continued support and development of clinical audit within the UK’s ambulance services due to its variable history. Clinical audit was developed much later within ambulance services than in other NHS trusts and therefore many services missed out on opportunities for specific audit funding from local and regional health authorities. Even now there are very few services with what can be called audit departments. For many ambulance services clinical audit remains the responsibility of a single manager who often has other responsibilities and priorities.

3.8 Only now with the onset of clinical governance arrangements are quality and clinical audit becoming priorities in their own right. What the ASANCEP must achieve in its objectives is to support and develop systems and processes for the continued growth of clinical audit activity within the UK’s ambulance services. This is the reason why resources are required for the development of the communication strategy to enable the sharing of effective clinical practice, and to promote a national data set (with a code of practice for record keeping and data collection) from which standards/ guidelines and audit tools can be developed.

3.9 Being protocol/ guideline driven the ambulance services are in a good position to take forward the work of NICE through its clinical guidelines programme and to implement the requirements of the NHS Priorities, National Service Frameworks (NSF’s) and work with other NICE clinical guideline and audit programmes. In conjunction with the initiatives outlined in Annex B the ASANCEP will continue to work with JRCALC in the development of national prehospital evidence based standards of care/ guidelines and associated audit tools. As the medical steering body for UK ambulance services JRCALC also has a role in appraising new medical technologies.

3.10 The Programme will also look to use technology to promote such initiatives. Electronic Patient Report Forms (EPRF’s) are the future for prehospital data collection. They can facilitate clinical audit; allow for benchmarking (through common audit tools and inherent performance indicators); allow for the development of electronic health records when implemented in conjunction with hospital information systems; allow for the development of pathways of care. In conjunction with NHS Direct EPRF’s allow for the development of treat and refer protocols which will change the way in which prehospital emergency care and primary care are delivered through electronic clinical decision support systems. The ASANCEP therefore needs to appraise EPRF’s and other relevant technologies as they evolve.

3.11 Updates on the current agenda will be reported regularly to NICE and through the programme’s website and newsletter, with a full summary of the programme in the Annual Report (May 2000). A suggested format in which a quarterly monitoring of progress could be undertaken by NICE would be a series of review meetings against the objectives set down in the Proposed Work Programme for 2000/2001 (Annex A). This would allow for the Programme to develop and adjust its objectives in conjunction with developments in the wider NHS priorities and those of the Technology Appraisal and Clinical Guideline Programmes of NICE (Annex B).

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Annex A: Proposed Work Programme 2000/2001

These objectives are not in any order of priority or significance.

Objective Action Output Performance measure

Target date

Develop further the regional clinical audit group structure
  • Ensure structure is in place with each group having a plan of work including at least one collaborative clinical audit project
  • Monitor and review regional structures in light of mergers
  • Ensure regional group activity is fed back to the ASA/JRCALC Clinical Effectiveness Committee and to the programme’s website
  • Sharing effective practice at a local, regional and national level. Through the Clinical Effectiveness Committee links exist to inform the ASA, JRCALC, NICE, IHCD, BASICS, Ambulance service Medical Directors Forum, education & research groups
  • Terms of reference
  • Project objectives
  • Membership and attendance
  • Group represented on ASA/ JRCALC Clinical Effectiveness Committee
  • Regional pages on website of ASANCEP
  • Mar 2001
  • Mar 2001
  • Ongoing
  • Quarterly meetings
  • Ongoing
Develop a Code of Practice for prehospital record keeping and data collection
  • To ensure Patient Report Forms are completed in a timely and accurate manner highlighting the requirements of professional self-regulation, clinical audit, clinical governance and clinical accountability
  • Promote self-regulation and good clinical record keeping under clinical governance and ‘new’ professionalism
  • Code of Practice for prehospital record keeping and data collection
  • Monitor quality of prehospital data
  • Oct 2000
ASA/JRCALC Minimum Data Set – Review of Compliance
  • Survey all UK ambulance services to ensure the implementation and development of the minimum data set.
  • Review data collection methods for clinical audit
  • Make recommendations for changes felt necessary to the national minimum data set
  • Standard of compliance to minimum data set
  • Review of processes and systems for audit
  • Review data set in light of guidelines/ NSF’s etc.
  • Improve standard of record keeping and ability to audit
  • Monitor quality of prehospital data
  • Promote best of breed system
  • Ensure data set meets needs of ambulance services and wider NHS
  • June 2000
  • Ongoing
  • Ongoing
Objective Action Output Performance measure Target date
Establish an effective communication strategy with interested bodies
  • Establish and maintain a website which informs UK ambulance services and wider NHS
  • Produce editorial on the Project (CANDOUR) for publication in Ambulance UK (the official publication of the ASA)
  • Arrange 4 roadshows for ambulance services around the UK to assist in developing an effective communication strategy
  • Project information, links to NICE, Regional Group activity
  • Initiatives in audit, effectiveness and governance
  • Project initiatives, training sessions, feedback on Programme
  • Sharing effective practice through access to information
  • Sharing effective practice through publication of ‘peer’ newsletter
  • Promote ASANCEP, raise awareness of effective clinical practice programme
  • Mar 2000
  • Ongoing
  • Commence summer 2000
  • Showcase Theatre at Ambex 1-3 July 2000
Develop a rolling programme of audit
  • Conduct regional and national audit projects through a rolling programme.
  • Facilitate benchmarking of clinical performance within UK ambulance services for specific areas of care
  • Review and monitor requirements of NSF’s as they are published
  • One aspect of care will be looked at on an annual basis
  1. Asthma
  2. Diabetes
  3. Epilepsy
  • Standards from NSF’s

e.g. CHD

  • Guidelines and audit tools measuring performance and improving effective clinical practice in each clinical area
  • Benchmark performance

e.g. Time to 1st Shock

  • Initiate first of an annual rolling programme by March 2001
  • As NSF’s published
Maintain databases developed in previous work programme (1999/2000)
  • Update and review databases
  • Link databases to those held at NICE
  • Clinical audit projects, research, events, links to websites
  • Improve access to wider NHS
  • Share effective practice through access to information
  • Improved collaboration with wider NHS
  • Ongoing
  • Ongoing
Develop a clinical audit training package
  • Develop a training package to ensure ambulance staff can acquire the skills to facilitate local and collaborative clinical audit.
  • A rolling programme of training workshops/ roadshows
  • Inform staff of effective clinical practice programmes and performance measures
  • Improve skills and raise awareness
  • Staff aware of effective clinical practice programme’s and implications for practice
  • Change in practice to improve quality
  • June 2000
  • From July 2000
Conduct and disseminate ‘Evidence for Change IV’ - Survey
  • Annual survey of clinical audit and clinical improvement projects within UK ambulance services
  • Index of clinical improvement projects
  • Improve quality of projects and increase collaboration at regional and national levels
  • January 2001
Exhibit at relevant conferences
  • To exhibit and/ or present at appropriate conferences, to raise the profile of both the ASA and the Programme, and inform target audiences of the Programme’s work
  • ASA/JRCALC
  • AMBEX 2000
  • NICE/ CHIMP
  • Share effective practice
  • Learn from experts
  • Establish links with internal and external agencies/ personnel
  • Late 2000
  • 1-3 Jul 2000
  • 29-30 Nov 2000
Develop audit tools around agreed standards
  • Ongoing development of national evidence based standards/ guidelines and audit tools in collaboration with ambulance services and NICE
  • Evidence base reviewed as part of a rolling programme
  • Draft standards currently with JRCALC to be rolled out to UK ambulance services
  • Audit tools developed around standards
  • Audit tools and Index of evidence on website
  • Reduce variation in standards of care and practice
  • Establish and build upon evidence base
  • Benchmarking and national audit tools
  • Improve quality and access to prehospital evidence
  • Spring 2001
  •  
  • Ongoing
  • March 2001
  • Ongoing

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Annex B: Contribution to the Priorities of the NHS, and the NICE Technology Appraisal & Clinical Guidelines Programmes

NHS Lead Priority Definition Objective Ambulance Service impact ASANCEP objective
Waiting Lists and Times To meet the public’s expectations for faster and more convenient access to modern and dependable services by reducing NHS waiting lists and times Pilot the most effective ways of reducing waiting times in Accident and Emergency departments
  • Treat and refer guidelines
  • review of chronic disease management incorporating pathways of care in conjunction with GP’s, District Nurses, Acute and Community health care
  • Development of ‘Practitioner in Emergency Care’
  • New technologies and skills
  • Rolling programme of audit
  1. Asthma
  2. Diabetes
  3. Epilepsy
  • Share effective practice e.g. direct admission to CCU for AMI patients
  • Review new technology e.g. electronic patient report forms, transmission of ECG’s, out-of-hospital thrombolysis
Coronary Heart Disease To reduce the death rate from heart disease and provide high quality, cost-effective and responsive services for the prevention and treatment of coronary heart disease Speedier access to emergency care for those who have a suspected acute heart attack including thrombolytic medication (clotbusters)
  • Prehospital thrombolysis
  • Direct admission to CCU
  • Integrated pathways of care
  • Performance indicators e.g. time to 1st shock, aspirin administration for AMI’s, survival from out-of-hospital cardiac arrest
Mental Health To improve the mental health of the population, and improve treatment and care of those with mental health problems through the provision of high quality, effective and responsive services
  • Review prehospital care
  • Survey of violence and aggression (Royal College of Psychiatrists)
  • Treat and refer guidelines
  • Share effective practice
Primary Care To develop primary and community services, in order to address inequality, improve the quality and convenience of services and increase efficiency.
  • Review prehospital care
  • Treat and refer guidelines
  • review of chronic disease management incorporating pathways of care in conjunction with GP’s, District Nurses, Acute and Community health care
    • Rolling programme of audit
    • Asthma
    • Diabetes (link to NSF in 2001)
    • Epilepsy (link National Sentinel Audit of sudden death)
    Information for Health The purpose of this information strategy is to ensure that information is used to help patients receive the best possible care. The strategy will enable NHS professionals to have the information they need both to provide that care and to play their part in improving the public’s health. The strategy also aims to ensure that patients, carers and the public have the information necessary to make decisions about their own treatment and care, and to influence the shape of health services generally
    • lifelong electronic health records for every person in the country
    • round-the-clock on-line access to patient records and information about best clinical practice, for all NHS clinicians
    • genuinely seamless care for patients through GPs, hospitals and community services
    • the effective use of NHS resources by providing health planners and managers with the information they need.
    • Electronic prehospital patient records
    • Electronic evidence base
    • Facilitate pathways of care
    • Treat and refer guidelines
    • Prehospital thrombolysis
    • Minimum data set
    • Code of Practice for prehospital record keeping and data collection
    • Pilot electronic patient report forms and audit tools (including technologies for transmitting ECG’s for prehospital thrombolysis)
    NICE: National Sentinel Audit Definition Objective Ambulance Service impact ASANCEP objective
    Management of violence in clinical settings (Royal College of Psychiatrists)
    • Review prehospital care
    • Treat and refer guidelines
    • Share effective practice
    Investigation of the circumstances of epilepsy death  
    • Review prehospital care
    • Risk from non-recognised sudden epilepsy death
    • National Epilepsy project
    Falls in the Elderly
    • Review incidence of falls
    • Review prehospital care
    • Treat and refer guidelines
    • Share effective practice
    NICE: Confidential Enquiries Definition Objective Ambulance Service impact ASANCEP objective
    CESDI
    • Review of emergency cases
    • Reduce risks at unplanned births
    • Review prehospital care
    • Treat and refer guidelines
    • Share effective practice
    NICE: Clinical Guidelines Work Programme Definition Objective Ambulance Service impact ASANCEP objective
    Acute Myocardial Infarction  
    • Review prehospital care
    Prehospital thrombolysis
    • Performance indicators from CHD NSF e.g. time to 1st shock
    • Performance indicators from CHD NSF e.g. aspirin administration for AMI
    NICE: Other projects Definition Objective Ambulance Service impact ASANCEP objective
    Central cardiac audit database TBA TBA
    • Out-of –hospital Utstein template for cardiac arrest data collection
    • Prehospital thrombolysis
    • Performance indicators from CHD NSF e.g. time to 1st shock
    Diabetes Pilot Regional Audit TBA TBA
    • Treat and refer guidelines
    • National Diabetes Project
    Acute MI database  
    • Review prehospital care
    • Prehospital thrombolysis
    • Performance indicators from CHD NSF e.g. aspirin administration for AMI

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    Annex C: Statement of Commitment

    This Business Plan has been produced on behalf of the Ambulance Service Association by Stuart Nicholls (National Clinical Effectiveness Programme Manager) and a special working group of the Joint ASA/JRCALC Clinical Effectiveness Committee, and supercedes the initial Proposed Work Programme 2000/2001 submitted to the National Institute for Clinical Excellence in December 1999.

    We the undersigned:

    Make a full commitment to the aims and objectives as described within this Business Plan for the Ambulance Service Association National Clinical Effectiveness Programme,

    and

    understand that the National Institute for Clinical Excellence in it’s role as a Special Health Authority responsible for funding and monitoring NHS effective clinical practice programmes is in a transitional period, and further understand that the plans as described in this document may be subject to change, in review with the Institute, as a new set of arrangements for NHS-supported professional infrastructure emerges.

    Stuart Nicholls
    Manager, ASA National Clinical Effectiveness Programme

    February 2000

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