Transcript Clinical guideline - JRCALC - Joint Royal Colleges Service

Clinical Guidelines
From Paper into Practice
Graham Brown
Clinical Effectiveness Manager
Westcountry Ambulance Services NHS Trust
Towards a Unified Approach
£345,000 damages
for surgery nightmare
Parents in child organs protest
JRCALC 2000
Towards a Unified Approach
Monday, 17 January, 2000
Ambulance services 'falling short'
Panorama reveals how treatments available
for trauma patients vary widely depending on
where their accident takes place
“Each of the UK's 36
ambulance trusts has its
own treatment instructions
but… there are wide
discrepancies among the
trusts.”
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Guidelines vs. Protocols?
JRCALC 2000
Towards a Unified Approach
Clinical guidelines
‘Systematically developed
statements to assist practitioner and
patient decisions about appropriate
health care for specific clinical
circumstances’
Field & Lohr 1990
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Protocol
‘Standard procedure laid down to
be followed step by step’
IHCD paramedic manual 1993
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Evidence based practice
Only 10-20% of physician
interventions are supported by
objective evidence
(Cochrane 1976; White 1976)
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Present distribution of healthcare
interventions
Do more
harm than
good
Do more
good
than
harm
(Muir Gray; 1997)
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Of
unknown
effect, but
in good
quality
research
programme
Of unknown
effect - not in
research
setting or in
poor quality
research
Towards a Unified Approach
Present distribution of healthcare
interventions
Do more
harm than
good
Do more
good
than
harm
(Muir Gray; 1997)
JRCALC 2000
Of
unknown
effect, but
in good
quality
research
programme
Of unknown
effect - not in
research
setting or in
poor quality
research
Towards a Unified Approach
Current Position
Trusts receive medical advice from
o
o
o
o
o
o
IHCD
Paramedic and Technician and training manuals
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o recognition of death
o Anaphylaxis
o LMA
Local medical practitioners
LAPSC
Medical adviser/director
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BASIS FOR AMBULANCE TRUST PRACTICE
Local medical
opinion
12%
Inc EB guidelines
49%
IHCD +/- Local
medical opinion
39%
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CONSENSUS
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RESEARCH
EVIDENCE
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NALOXONE - FIRST IV DOSE
14
12
A
m
b
u
l
a
n
c
e
s
e
r
v
i
c
e
s
10
8
6
4
2
0
200
400
800
1200
Microgrammes
(Hawksworth 1998)
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MAXIMUM NALOXONE DOSE
12
10
A
m
b
u
l
a
n
c
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s
e
r
v
i
c
e
s
8
6
4
2
0
800
1200
1600
2400
10000
Microgrammes
(Hawksworth 1998)
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Management of Cardiac Chest Pain
Aspirin
Oxygen
GTN
Opioid
Anti-emetic
12 lead ECG
Admit A&E
Admit CCU
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Trust A
Trust B
Trust C
Trust D
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Towards a Unified Approach
Guidelines vary in effectiveness
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European Resuscitation BLS and ALS
Council
Asthma
British Thoracic
Society
British Heart
AMI
Foundation Working
Group
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Major determinants of guideline
effectiveness
1.
2.
3.
4.
5.
6.
Political commitment
Chief Executive commitment
Guideline credibility and validity
Acceptability to practitioners
Changes in practice achieved
Health gain achieved
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8 minutes
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DoH
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CEO
Towards a Unified Approach
Determinants of guideline
effectiveness
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Political commitment
Chief Executive commitment
Guideline credibility and validity
Acceptability to practitioners
Changes in practice achieved
Health gain achieved
JRCALC 2000
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Guideline credibility and validity
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Vital if services are to adopt
Use/adapt pertinent existing guidelines
Development group credentials
Involvement and support of eminent bodies
Evaluation in practice
Must be suitable for prehospital setting
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Acceptability to practitioners
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NEGATIVES
Top down
Control tool
Curb flexibility/initiative
Not-invented-here
POSITIVES
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Building ownership
Local adaptations
Inclusive development
Consultation
Pilot/test
Effective dissemination
Incentives (sanctions)
Resistance hard to detect and overcome
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Achieving changes in practice
STRATEGIC (managers)
 Clinical governance
 Sound underpinning
evidence base
 Litigation
 Dissemination strategy
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TACTICAL (crews)
Simple format
Clear layout
Rationale explained
Targeted education
Reinforcement
Monitoring
Feedback
Realistic timescales
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Measuring health gain
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Monitoring & evaluation
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Compliance vs outcomes
Integrated care pathways
Interface audits – primary/secondary care
Audit component of clinical governance
framework
Exception reporting
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In summary...
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Rigorous guideline development
 resources/skills
 targeted at relevant topics
 regular review
 communication and consultation
Total commitment to implementation
 ambulance service managers & advisory
bodies
Local ownership
Monitoring of implementation and outcomes
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Capacity to Develop Evidence Based
Guidelines
YES
16
NO
10
UNSURE
7
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Services Willing to Adopt JRCALC
National Guidelines
Yes
Unsure
30
3
(3 dependent on evidence base)
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JRCALC 2000
Towards a Unified Approach