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CANDOUR - Issue 5 - August 1999

The newsletter of the ASA/ JCALC Clinical Effectiveness Committee and the ASA Clinical Effectiveness Project

In this issue :

Spotlight on ASA Clinical Effectiveness Project

ASA Guidance on Clinical Governance

Clinical Governance & Effectiveness – Creating the link

Your Views Count

Deliberate Self Harm Audit - Two Shires Ambulance Service NHS Trust

Issue 4 CANDOUR INDEX Issue 6

Spotlight on ASA Clinical Effectiveness Project

Evidence for Change II - A survey of clinical audit within UK ambulance services (1st January to 31st December 1998 inclusive)

Back in issue 2 of Candour Stuart Nicholls outlined the aims and objectives of the second Evidence for Change Survey. Here he presents the results of the survey published in June 1999.

43 ambulance services were surveyed with 39 (91%) posting a response.

The largest single success of the survey came from the 24 services (62%) who provided details of at least one clinical audit project. Indeed a total of 72 individual projects were collated within the survey identifying the tremendous work currently being done within the UK ambulance service to improve the quality of patient care. Improvements in pre-hospital care are often overlooked but this survey shows there is a great deal of valuable work being done upon which all UK ambulance services can build.

Details of the 72 projects were published with the full survey report and can be obtained from the ASA Clinical Effectiveness Project. The database will also be passed to the National Centre for Clinical Audit (NCCA) as part of the National Institute for Clinical Excellence (NICE) to promote the work of ambulance services in this area.

These projects will also be highlighted in Spotlight in future editions of Candour.

There has been a gradual increase in the number of services receiving funding for clinical audit over the 3 years since 1996. The awareness of the need to audit clinical practice is mirrored in the increase in clinical audit groups within ambulance services which grew from 21 in 1996 to 26 in 1998.

Only 26% of ambulance services provide in-house training for clinical audit, although 77% expressed an interest in courses/ workshops. It will be an objective of the ASA Clinical Effectiveness Project to promote clinical audit training within UK ambulance services.

Table 1. Clinical audit projects completed in collaboration with :

Other ambulance services 33%

Hospital Trusts 59%

Health Authorities 28%

GP groups 21%

Other agencies 26%

Looking at the first two lines of Table 1 it is encouraging that almost 60% of services work closely with their neighbouring hospital trusts in the collection of outcome data. Indeed 59% have planned future clinical audit programmes to link with local Health Improvement Programmes. It is however, disappointing that only one third admitted to collaborating with other ambulance services. The ASA Clinical Effectiveness Project will seek to improve this through a structure of regional clinical audit groups.

 Table 2. Specific areas of interest for future initiatives.

Develop Regional Groups 69%

Education programmes 56%

National Projects 56%

Communication 56%

Develop evidence based protocols/ standards 77%

Table 2 shows the support for regional clinical audit groups, and other developments to be co-ordinated through the ASA Clinical Effectiveness Project. Indeed given that several services are already part of one of the two existing regional clinical audit groups the support for this initiative is well above 90%.

The other issue which was raised by a significant number of respondents to the survey was that of providing guidance on clinical governance specific to ambulance services. The ASA Executive has also recognised the need for such guidance and is currently working on a document (See article later in this issue of Candour).

Copies of the full report, details of individual projects or contact details for specific projects are available from the ASA Clinical Effectiveness Project Manager

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ASA Guidance on Clinical Governance

At the October 1998 meeting of the ASA Executive, it was agreed that a group should be formed to produce a guidance document on clinical governance for the members of the ASA.

Following the outcome of several initiatives, the first meeting of this group was held on 4 June 1999. It was recognised there was a need for the co-ordination of initiatives regarding clinical governance, with a focus on the provision of education and information materials for use by all UK ambulance services. Once this initial guidance document has been produced it will be maintained through the joint ASA/JCALC Clinical Effectiveness Committee to avoid duplication and centralise on-going work.

Work is currently underway to produce a reference pack of all relevant documents, presentations and other information. The reference pack will be published and circulated to all UK ambulance services in late August 1999 in time for the deadline of baseline assessments set by the NHSE for September 1999.

The pack will include amongst other items:

  • a glossary of the key terms – without the rhetoric
  • a list and examples of relevant documentation and literature
  • a directory of those involved with clinical governance in UK ambulance services and NHSE Regional Offices
  • a compendium of ambulance service clinical governance committee terms of reference.

All the contents of the pack will also be available on disk for ease of use, and will held centrally by the ASA Clinical Effectiveness Project, which will continually update and maintain the reference material in light of further developments. It is hoped to place the pack on the official ASA website as well.

The initial reference pack will be very much version one of an on-going development. As further guidance is issued or initiatives are undertaken and shared, subsequent versions will assist in answering any new questions posed. It will be an interactive document with ambulance services feeding in to its resources as well as from them.

So if you have anything of interest you wish to share with others relating to clinical governance or any of its components, please feel free to contribute to the evolving reference pack by contacting the ASA Clinical Effectiveness Project Manager

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Clinical Governance & Effectiveness – Creating the link

The joint ASA/JCALC conference on Clinical Governance & Effectiveness – creating the link was held on 20 May 1999 at the Commonwealth Institute, London.

Despite the high profile of clinical governance and the undoubted impact it will have upon us all, there was disappointing support for this very valuable day. Many services and individuals had expressed interest in a day specifically applying the principles and components of clinical governance to the ambulance service.

The 80 or so attendees however did get a very informative and constructive set of presentations taking each of the components of clinical governance in turn and applying them to the ambulance service setting.

Professor Douglas Chamberlain of JCALC introduced the morning session and gave a thought provoking keynote address describing a vision of ambulance service provision within a culture of clinical excellence. Whatever the future holds, Professor Chamberlain emphasised the requirement of continued and further education for ambulance staff to enhance clinical decision-making in the prehospital field.

Dr John Scott (East Anglia Ambulance Service NHS Trust) then outlined the need for a comprehensive risk management strategy within clinical governance, stressing the importance of a NO BLAME culture within ambulance services to ensure all adverse events are reported and acted upon.

The role of the joint ASA/JCALC Clinical Effectiveness Committee was described by its Chair, Mr Paul McCormick, who explained how links to the National Institute for Clinical Excellence (NICE) would be forged over the coming months.

Alan Howson (IHCD) summarised the links between clinical governance and training, development and education within ambulance services as a system of continuous improvement which will act at all levels within an organisation from clinical guidelines to research and organisational structures.

The issues surrounding complaints and litigation were explained succinctly in plain English by John Evans, a partner with Beachcroft Wansboroughs Solicitors. This again proved to be a very thought provoking presentation offering a great deal of insight into how legal perspectives may change under clinical governance with the introduction of NICE and the Commission for Health Improvement.

The final session before lunch was given by Patricia Oakley, Director of Practice Made Perfect Ltd. Ms Oakley showed how all the components of clinical governance (training & education, audit & effectiveness, complaints & risk management) along with human resource and information strategies fit together. The presentation also highlighted the significance of an organisational approach to clinical governance and a shift in organisational culture to sharing of best practice. All of these will then bring effective organisations, effective staff and effective clinical practice together.

The President of the ASA, David Griffiths, introduced the afternoon session which highlighted projects funded by JCALC and the Department of Health.

Judy Duck presented an approach to increasing survival from cardiac arrest through the First Responder scheme run by Essex Ambulance NHS Trust. She described how community volunteers are trained to use automated defibrillators and are then deployed when an ambulance may be some distance away.

The role of the ASA National Clinical Effectiveness Project Manager – a Mission Impossible? – was then described by Stuart Nicholls. He showed how the objectives of the project in promoting clinically effective practice fit with and compliment clinical governance. He stressed that clinically effective practice was definitely possible within a culture of communication and collaboration.

Tony Hayward from Welsh Ambulance Service NHS Trust presented the results of a project which was developing Care Pathways for specific patient groups.

The afternoon was rounded off by Dr Henry Guly (A&E Consultant, Derriford Hospital, Plymouth) who showed what influences on-scene times. He outlined several research projects in this area drawing attention to various interesting findings which prompt further questions into the effectiveness of pre-hospital care and its future development.

  Complete copies of all the presentations are available from the ASA Clinical Effectiveness Project upon request.

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Your Views Count

We are always looking at ways to ensure Candour remains an informative and useful newsletter, providing information on all issues concerning the improvement in pre-hospital patient care. The editorial panel have come up with a few ideas to make Candour a more valuable resource. Please feel free to comment on any of these or indeed on anything within Candour – Your Views Count – If Candour can promote open debate then it can only be of benefit to all.

Case Review

Review of interesting incidents and their outcome, highlighting lessons learned and good practice.

Self Assessment

Multiple choice questions (with answers) to see if you would approach an incident in the same way as others. Both of these assist in continued education, training and development.

Literature Review

Review all the literature on a specific topic highlighting trends for best practice, recommending action and showing how clinical audit can be used to compare your practice with the evidence.

‘From the Journals’

Identify the most recent research findings and provide a summary in plain, understandable language. Making the evidence more accessible.

Book reviews

Again, reviewing the evidence.

Your views and opinions are extremely valuable in the development of the above as informative, educational and debate provoking sections of the newsletter. So if you have any questions surrounding recent research or new training please contribute.

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Two Shires Ambulance NHS Trust – Clinical Audit of the Quality of Care Provided to Patients who have Deliberately Self-Harmed.

Background to the audit – A significant proportion of 999 calls are to patients who have deliberately self-harmed. It was felt by the Clinical Audit Committee that these patient’s, for various reasons, may not be receiving the highest level of care.

Objectives - To measure the number of patients presenting with deliberate self-harm. To assess whether the Two Shires Clinical Standards1 were being adhered to and if they met the patients needs. Also to bench mark the standard of care being provided to these patients, against that provided to other categories of patient and so develop and implement recommendations for action.

Methods - All patients, who presented with a chief complaint of Deliberate Self-Harm, over a three-month period, were included in the clinical audit. Data was collected from the Patient Report Forms and compared to the Trusts standards. In addition, the level of basic care, including observations, was collated and compared to that found in all previous audits, irrespective of patient group. The audit also included patients who had refused to travel to hospital.

Analysis and Interpretation – The results from the data showed;

  • There was no specific standard, or pro-active pre-hospital treatment for the care of patients who have overdosed, which led to..
  • A poor adherence to basic treatments and observations, but only when compared to similar groups of patients.
  • A lack of documentation on the Patient Report Form.
  • No standard procedure when a patient refuses to travel.
  • That the majority of overdose cases involve substances, which appear on the BMA’s Highly Dangerous Drugs List 2
  • With such a variety of over-the-counter, prescribed and illicit drugs available it is impossible for crews to keep upto date with their effects, and appropriate treatment.

Change Management

  • Evidence base standard of care for overdose which falls within the Dangerous Drugs List.
  • Up-to-date information on drugs, identified by brand and ‘street’ name provided to crews via NHS Direct.
  • Use of Activated Charcoal, for the treatment of patients overdosing on substances from the Dangerous Drugs List, given by the LAPSC.
  • Post Audit Education pack issues surrounding Mental Health, toxicology, specific treatment regimes and reinforce the need to always provide the highest level of care to patients, this includes the recording of a full set of observations, and that any exceptions must be documented.
  • For patients who, despite the crews advice, still refuse to travel the service still has a duty of care and must ensure that, through Control, the patients GP is informed of the situation.

Key Lessons

That clear clinical standards were not in place for the treatment of patients which have overdosed.

That crews need up-to-date, on-scene, information on the consequences of specific drugs, and drug combinations.

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