Clinical Guidelines From Paper into Practice

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Clinical Guidelines From Paper into Practice

• Graham Brown
• Clinical Effectiveness Manager
• Westcountry Ambulance Services NHS Trust

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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?
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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
Of unknown effect - not in research setting or in
poor quality research
Do more good than harm
Of unknown effect, but in good quality research
programme
(Muir Gray 1997)
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Present distribution of healthcare interventions
Do more harm than good
Of unknown effect - not in research setting or in
poor quality research
Do more good than harm
Of unknown effect, but in good quality research
programme
(Muir Gray 1997)
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Current Position

• Trusts receive medical advice from
• IHCD
• Paramedic and Technician and training manuals
• JRCALC
• recognition of death
• Anaphylaxis
• LMA
• Local medical practitioners
• LAPSC
• Medical adviser/director

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CONSENSUS EVIDENCE
RESEARCH
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(Hawksworth 1998)
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(Hawksworth 1998)
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Management of Cardiac Chest Pain
Trust A Trust B Trust C Trust D
Aspirin ? ? ? ?
Oxygen ? ? ? ?
GTN ? ? ? ?
Opioid ? ? ? ?
Anti-emetic ? ? ? ?
12 lead ECG ? ? ? ?
Admit AE ? ? ? ?
Admit CCU ? ? ? ?
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Guidelines vary in effectiveness

• BLS and ALS
• Asthma
• AMI

• European Resuscitation Council
• British Thoracic Society
• British Heart Foundation Working Group

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Major determinants of guideline effectiveness

1. Political commitment
2. Chief Executive commitment
3. Guideline credibility and validity
4. Acceptability to practitioners
5. Changes in practice achieved
6. Health gain achieved

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April 2001
8 minutes
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DoH
CEO
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Determinants of guideline effectiveness

• Political commitment
• Chief Executive commitment
• Guideline credibility and validity
• Acceptability to practitioners
• Changes in practice achieved
• Health gain achieved

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Guideline credibility and validity

• 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

• NEGATIVES
• Top down
• Control tool
• Curb flexibility/initiative
• Not-invented-here

• POSITIVES
• 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

• TACTICAL (crews)
• Simple format
• Clear layout
• Rationale explained
• Targeted education
• Reinforcement
• Monitoring
• Feedback
• Realistic timescales

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Measuring health gain

• Monitoring evaluation
• 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...

• 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
• NO
• UNSURE

• 16
• 10
• 7

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Services Willing to Adopt JRCALC National
Guidelines

• Yes 30
• Unsure 3
• (3 dependent on evidence base)

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