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Clinical Guidelines From Paper into Practice

Clinical Guidelines From Paper into Practice. Graham Brown Clinical Effectiveness Manager Westcountry Ambulance Services NHS Trust. £345,000 damages for surgery nightmare. Parents in child organs protest. Monday, 17 January, 2000 Ambulance services 'falling short'.

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Clinical Guidelines From Paper into Practice

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  1. Clinical Guidelines From Paper into Practice Graham Brown Clinical Effectiveness Manager Westcountry Ambulance Services NHS Trust Towards a Unified Approach

  2. £345,000 damages for surgery nightmare Parents in child organs protest Towards a Unified Approach

  3. 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.” Towards a Unified Approach

  4. Guidelines vs. Protocols? Towards a Unified Approach

  5. Clinical guidelines ‘Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances’ Field & Lohr 1990 Towards a Unified Approach

  6. Protocol ‘Standard procedure laid down to be followed step by step’ IHCD paramedic manual 1993 Towards a Unified Approach

  7. Evidence based practice Only 10-20% of physician interventions are supported by objective evidence (Cochrane 1976; White 1976) Towards a Unified Approach

  8. 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) Towards a Unified Approach

  9. 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) Towards a Unified Approach

  10. 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 Towards a Unified Approach

  11. Towards a Unified Approach

  12. CONSENSUSEVIDENCE RESEARCH Towards a Unified Approach

  13. (Hawksworth 1998) Towards a Unified Approach

  14. (Hawksworth 1998) Towards a Unified Approach

  15. Management of Cardiac Chest Pain Towards a Unified Approach

  16. European Resuscitation Council British Thoracic Society British Heart Foundation Working Group BLS and ALS Asthma AMI Guidelines vary in effectiveness Towards a Unified Approach

  17. Major determinants of guideline effectiveness • Political commitment • Chief Executive commitment • Guideline credibility and validity • Acceptability to practitioners • Changes in practice achieved • Health gain achieved Towards a Unified Approach

  18. April 2001 8 minutes Towards a Unified Approach

  19. DoH CEO Towards a Unified Approach

  20. Determinants of guideline effectiveness • Political commitment • Chief Executive commitment • Guideline credibility and validity • Acceptability to practitioners • Changes in practice achieved • Health gain achieved Towards a Unified Approach

  21. 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 Towards a Unified Approach

  22. 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) Acceptability to practitioners Resistance hard to detect and overcome Towards a Unified Approach

  23. 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 Achieving changes in practice Towards a Unified Approach

  24. Measuring health gain • Monitoring & evaluation • Compliance vs outcomes • Integrated care pathways • Interface audits – primary/secondary care • Audit component of clinical governance framework • Exception reporting Towards a Unified Approach

  25. 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 Towards a Unified Approach

  26. YES NO UNSURE 16 10 7 Capacity to Develop Evidence Based Guidelines Towards a Unified Approach

  27. Services Willing to Adopt JRCALC National Guidelines Yes 30 Unsure3 (3 dependent on evidence base) Towards a Unified Approach

  28. Towards a Unified Approach

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