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CANDOUR - Issue 16 - June 2001

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

In this Issue:

Issue 15 CANDOUR INDEX Next Issue August 2001

Focus on Scotland

The following articles have been reproduced with the kind permission of the Scottish Ambulance Service from their national newsletter RESPONSE, and in particular the CERBERUS section whose focus is clinical audit and clinical effectiveness.

DIVISIONAL QUALITY CIRCLES - local people delivering local solutions to local problems

The Service programme for the rollout of clinical effectiveness across the Service relies heavily on the formation of 6 DQCs to cover the whole country. The main purpose of these groups is to ensure that the standards of each department (A/E, Non-Emergency, Operations Rooms, Operational support) are monitored, problem areas highlighted, and solutions sought and tested. The main terms of reference include:

  • Monitoring and reviewing the effectiveness of patient care
  • Clinical Corrective and Preventative action
  • Clinical Audit
  • Ensuring awareness of updates to procedures, equipment, training issues.
  • Commendation/complaints monitoring
  • Exception reporting
  • Achievement of quality standards

Reports from this group may include matters related to finance, staffing arrangements and future development planning affecting provision of core services within the division.

The membership of such groups includes-

  • Divisional and Assistant Divisional Managers
  • Divisional Officers and Training Officer
  • Accident/Emergency (LAP/T, Technician, Paramedic) representatives
  • NES representatives
  • ORA representatives
  • Staff side representatives
  • Admin/Clerical representatives
  • GP reps
  • Hospital (a/E consultant, nursing) reps
  • Patient/public reps
  • National co-ordinator
  • Workshops reps.
  • Other relevant expertise as required

The first group to start was South East Division, in March this year. After the first two meetings the group is getting to grips with the concepts involved in quality and clinical effectiveness – no mean feat in itself. Formal clinical standards are being evaluated, and systems being developed and assessed which should help us all to deliver `the goods` as effectively as possible.
During the rest of this year, these groups will be set up in each division.


The first issue of Cerberus looked at the levels of PRF completion across the Service, and briefly outlined plans to improve these. It is pleasing to note that recent studies have reported a significant rise in PRF completion, and this will be reported once a National figure is determined.

This issue looks at the standard, accuracy and quality – compliance – of PRF information.

The accepted format to assess this is to use three parameters-

Level 1 – All relevant data (+/- one field) could be gathered, and was logical.
Level 2 – More than one field could not be completed due to missing or illogical data.
Level 3 – The absence of data was so great that it was necessary to estimate the patient`s condition and any treatment given.

PRF compliance was first assessed nationally using data from Dec. 1997

Percentage of Incidents with Quality of PRF completion

Source – SAS Clinical Performance Pilot Study, June 1999 (data Dec.`97)

This data was collected ensuring that the benefit of any doubt (eg proximity to hospital) was always given to those completing the form.

The most recent data collected on this subject comes from South West division, who wisely used exactly the same parameters as the above table. This means that the two sets of figures can be compared, and trends examined (although it is accepted that the latter are not National figures).
The South West PRF Audit, taking data from June 2000, recorded compliance as –

Level 1 – 11% overall
Level 2 – 50% overall
Level 3 – 27% overall
(n= 249)

If these figures are correlated against the results from the earlier work, it can be seen that

Level 3 (poor standard) has reduced by 7.6%
Level 2 (satisfactory) has increased by 12.2%
Level 1 (very good) has reduced by 16%

As well as the standard of PRF completion, the South West study looked at completion-rates. This showed a 30% increase in completion since the last National study.
Although this result does not necessarily reflect across the whole Service, other local initiatives have suggested similar results.
How do we interpret this data ? It is clear that major effort has resulted in clear improvements in PRF standards - and congratulations go to all involved. When set alongside the level of PRF completion overall, numerous trends can be seen, but this seems clear –
As a Service, we are improving our clinical data, yet we are not as yet delivering a high enough percentage of PRF to hospitals, and the information on them is too often incomplete.
It is important that all of us involved in Accident /Emergency patient care, at whatever level, play our part in putting this right. As previously reported, numerous systems are being assessed to help us become more clinically effective. There is no doubt, however, that personal and group professionalism, from every one of us, will continue to be the most important factors involved.


After the success of last year`s baseline audit into asthma patients in Glasgow (which recommended the adoption of new guidelines) a second, larger study has commenced. This second study, being carried out by Paramedics from Glasgow East Station, involves the use of Peak-flow meters for mild and moderate asthma, and a percentage being noted for expected respiratory flowrates. These patients will then be followed through the Glasgow Royal Infirmary to determine outcomes.
The purpose of this study is to find out if our traditional handling of these patients is effective, and to see if any other treatments (including drugs, hence becoming a Paramedic study) could be offered. Case studies will be held monthly by a team led by Dr Russell from GRI.


This study started during May `98, with the original intention of discovering the pain-levels of hip-fractured patients within Fife. It was decided to expand this to look at all our patients, to determine which treatments work best for which conditions, and how often they are applied.
5,000 patients transported by ambulance from within Fife (March-October `99) were `pain-scored` on arrival at scene and at hospital. Karen Stuart, a Cowdenbeath Paramedic, provided the data-input and verification of data. Staff at Queen Margaret Hospital, Dunfermline, pain- scored a small number of patients for further verification.
Although the report is yet to be signed off by all involved, a number of important areas can be highlighted. The specific findings included:
Entonox reduced pain in every recorded case.

The most painful conditions were;
Back pain
Chest pain
Abdominal pain
Children`s injuries
Hip injury
Leg injury

The greatest pain reduction associated with scene-removal techniques was seen in (greatest first):
Spinal board
Carry chair
No equipment used

41.58% of all patients had no pain on collection, compared with 43.68% on arrival at hospital. This equates to a complete cessation of pain in 105 patients.
Journey times greater than 20 minutes showed a very slight increase in pain (that is, a decrease in pain reduction).
The main conclusions from the study include;
Every group of patients, across every level of pain, enjoyed overall reduction in pain during ambulance treatment/transport.
All patients showing any degree of discomfort benefit when removed from the scene supine, and transported by stretcher.
Patients showing levels of pain greater than `discomfort` should be offered Entonox (contra-indications permitting). Those in severe pain should be offered Nubain where possible.
Nubain has the greatest single effect in pain reduction. Dosage should be titrated to the patients’ condition, as low dosages (5mg) can be very beneficial.
GTN is an excellent pain-relief in chest pain, yet often overlooked. It should be used with aspirin (unless contra-indicated) and high-flow oxygen.
There should never be an acceptance that pain needs to be endured without attempts to reduce it. Certain patients (e.g. hip-injury, abdominal pain) are not receiving sufficient pain-relief. The service needs to work with clinicians to correct these anomalies.
Immobilisation/supporting devices (splints, blankets, etc) should be considered more often, as they reduce pain considerably.
Almost 60% of all emergency/urgent patients were in some degree of pain. It is clear that the reduction of pain is a major concern in pre-hospital care.
Many thanks are due to the accident/emergency staff of Fife for their enthusiastic involvement in this important work.


Continuing on from the snapshot of PRF performance, below is a chart showing average on-scene times for emergency incidents from across the sub-divisions (seven-day period).

Time On Scene Statistics for Emergency Incidents By Health Board

Source – NAO/SAS Clinical Performance Study 1999

As can be seen, there are significant differences across the Service. It has been shown in numerous studies that, in trauma at least, longer on-scene times can be deleterious to the patients condition. While there is no suggestion that proper stabilisation should not be part of treatment, it would seem wise to determine and eliminate unnecessary delays at scene.
Why is the variance so high? Are we practising different systems in different places, causing some areas to spend longer on scene than others. What delays could be avoided that would not affect patient care? Should a maximum time be suggested, or is it more important to highlight the effects of different treatments versus the time they take to practise? Are there any simple causes that could be dealt with quickly?

If you have any comments regarding clinical audit/effectiveness within the Scottish Ambulance Service, please direct them to -
Robin Lawrenson
National Clinical Audit Manager
Range Road
Motherwell ML1 2JE

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Focus on Wales

There has been much work done in recent times within the Welsh Ambulance Service NHS Trust to promote clinical audit, effectiveness and research co-ordinated through the Pre-hospital Emergency Research Unit (PERU).

The unit has recently published several key papers which are listed below:

Developing a research capability in the Welsh Ambulance Service
(Woollard, M., Pitt, K., Leaves, S., Charters, K., Bottell, J., Donnelly, P. Learning the alphabeta: Developing a Research Capability in the Welsh Ambulance Service. Pre-hospital Immediate Care. 2000;4:100-101. Reproduced with the permission of BMJ Publishing Group.)

Emergency Medical Services
(Guppy, L., Woollard, M. Emergency Ambulance Services: Performance Management And Review. Pre-hospital Immediate Care. 2000;4:40-45. Reproduced with the permission of BMJ Publishing Group.)

Difficult intubation protocol: use of the endotracheal tube introducer (gum-elastic bougie)

Should Paramedics 'Bougie' on down?
(Pitt, K., Woollard, M. Should paramedics bougie on down? Pre-hospital Immediate Care. 2000;4:68-70. Reproduced with the permission of BMJ Publishing Group.)

Prehospital care five years hence
(Woollard, M., Ellis, D. Pre-hospital care five years hence. Pre-hospital Immediate Care. 1999;3:102-107. Reproduced with the permission of BMJ Publishing Group.)

All of these papers are available to view on the website (http://www.asancep.org.uk) by kind permission of the BMJ Publishing Group. They remain copyrighted and must not be reproduced without the permission of the authors.

For further information about clinical audit, effectiveness and research in the Welsh Ambulance Service NHS Trust please contact.

Malcolm Woollard
Executive Officer
Pre-hospital Emergency Research Unit (PERU)
Lansdowne Hospital
Sanatorium Road
Tel: 02920 233651 ext. 2930
Fax: 02920 237930

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National Clinical Audit (including the NSF - CHD)

The following extract from a circular distributed by Professor Douglas Chamberlain, Chairman of JRCALC outlines the staged implementation of the national clinical audit required by the Medicines Controls Agency following the licensing of the 'new' paramedic drugs in November 2000.
The JRCALC database.
After much discussion this is now based on a database that was pioneered by SEACAG (South East Ambulance Clinical Audit Group). Our audit will be run in conjunction with the Clinical Effectiveness and Evaluation Unit (CEEU) at the Royal College of Physicians and will link (where appropriate) with hospital data so that we have information on patients from the time they encounter the ambulance service to hospital discharge. This will be introduced progressively because we do not underestimate the complexity of the task. The stages that we planned are as follows:-

Stage 1 (To be implemented immediately) Ambulance Trusts will be asked to provide the JRCALC/ASA National Clinical Effectiveness Programme (NCEP) with information on all patients who have been treated with thrombolysis, opiates, or benzyl penicillin (for meningococcal septicaemia). Until Trusts have the database and can export information electronically it will be necessary to do this using the appropriate section of the database in hard copy. (Details of the precise procedure will be distributed by the ASA NCEP to all ambulance services).

Stage 2 (To be implemented as soon as possible) The CEEU at the RCP will send to Ambulance Trusts data on patients who have received thrombolysis and who are recorded as having travelled by ambulance. The data will give the various time intervals that have been recorded; time of onset of symptoms; first call for help; arrival of ambulance; delivery to hospital. This information will already have been collected by the Ambulance Trust for all their patients, but it may be helpful for them to receive the data specifically for patients who have received thrombolysis in hospital.

Stage 3 (To be implemented at a date to be decided after consultation with Trusts) Trusts will be asked to provide to the JRCALC/ASA NCEP all patients with presumed cardiac pain for whom thrombolysis was considered, whether or not it was administered. We will be particularly interested in the reasons why thrombolysis was not eventually given pre-hospital.

Stage 4 (To be implemented at a date to be decided after consultation with Trusts) Trusts will be asked to provide information on all cases of cardiac arrest for whom resuscitation was attempted.

Stage 5 (To be implemented at a date to be decided - at least a year from now - after consultation with Trusts). Trusts will be asked to provide data on all patients with chest pain thought to be cardiac in origin. We recognise that this stage may present appreciable logistical difficulties because of the numbers involved.

Douglas Chamberlain
URL: http://www.jrcalc.org.uk
Email: [email protected]

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ASA NCEP relocates to ASA HQ London
If you have any comments or wish to contribute to CANDOUR please forward any information to:

Stuart Nicholls
Programme Manager
Ambulance Service Association
National Clinical Effectiveness Programme
2nd Floor, Friars House
157-168 Blackfriars Road
London SE1 8EU
Email: [email protected]

Tel: 020 7928 9620 Fax: 020 7928 9502

Please note that the Ambulance Service Association National Clinical Effectiveness Programme (ASA NCEP) has relocated to the ASA's main offices in London.

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