The Emergency Services Foundation Scholarship Scheme ... · Report by Paul Jennings – 2006...

The Emergency Services Foundation Scholarship Scheme

Report by – Paul Jennings – 2006 Scholarship Recipient

Ambulance Service Clinical Effectiveness and Audit in the United Kingdom

Clinical Effectiveness and Audit in the United Kingdom

Report by Paul Jennings – 2006 Scholarship Recipient Page 2

TABLE OF CONTENTS 1 INTRODUCTION ........................................................................ 3

1.1 Acknowledgements .......................................................................................... 4 2 EXECUTIVE SUMMARY................................................................. 4 3 STUDY TOUR PROGRAM .............................................................. 5 4 STUDY TOUR OBJECTIVES............................................................ 6

4.1 Investigate ‘Clinical Effectiveness’ process and measures of clinical performance.................................................................................................................. 6 4.2 Investigate incident identification and reporting methods...................... 7 4.3 Examine research activities and the methods employed to disseminate findings........................................................................................................................... 8 4.4 Attend the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) - Annual Conference .................................................................................. 8

5 CONCLUSIONS ......................................................................... 9 6 RECOMMENDATIONS .................................................................. 9 APPENDIX 1 - STUDY TOUR ITINERARY .................................................10 APPENDIX 2 – MAP OF LONDON ..........................................................11 APPENDIX 3 – PROGRESS OF RECOMMENDATIONS.....................................12 APPENDIX 4 – TABLE OF ABBREVIATIONS...............................................13



1 INTRODUCTION There is scant literature relating to audit, adverse events and incident reporting in the pre-hospital environment. The Victorian Ambulance Service (ASV), comprising both Rural Ambulance Victoria and Metropolitan Ambulance Service had limited formal error monitoring procedures in place. In 2005, only sporadic, random audit of all patient care records existed, and the audit procedure varied considerably across the State. In 2006 RAV commenced a project designed to identify optimal methods to identify and monitor critical incidents and errors. This project employed several ‘Quality Assurance’ type principles in an effort gauge the true prevalence of errors in our emergency service, with a view of ultimately implementing policies and procedures to reduce the occurrence or mitigate the effect of these incidents. This report is the result of a fifteen day study tour to the London, England to study different approaches to clinical effectiveness monitoring, critical incident identification and audit processes. The specific objectives of the tour were to:

• Investigate ‘Clinical Effectiveness’ process and measures of clinical performance

• Investigate incident identification and reporting methods • Examine research activities and the methods employed to disseminate

findings • Attend the Joint Royal Colleges Ambulance Liaison Committee (JRCALC)

- Annual Conference

The UK was chosen because of the similarities to the Victorian Prehospital system and because of their developed Clinical Effectiveness programs and specific prehospital audit expertise.



1.1 Acknowledgements Many people helped to make this study tour a success, but particular thanks are due to Mr Tony Walker, General Manager Clinical Effectiveness, Rural Ambulance Victoria, for his support of the tour and assistance with logistical considerations. My employer, Rural Ambulance Victoria has and continues to be very supportive of the professional development of staff through this and other scholarships as they arise. I gratefully acknowledge the assistance of Mr Mark Cooke, Clinical Effectiveness Program Manager, Ambulance Services Association, who acted as tour host, organised the majority of my itinerary, and assisted with accommodation and access to a mobile phone (which came in very handy). Mr Richard Lee, Ambulance Operations Manager and Mr Phil Grieve, Paramedic Team Leader also ensured that my visits flowed seamlessly and provided transport and contacts as required. For the opportunity to undertake this study tour I acknowledge the valued support of the Emergency Services Foundation, for without their assistance this study tour would not have been possible. Finally, this trip would not have been possible without the support and understanding of my wife, Natasha. Thank you.

2 EXECUTIVE SUMMARY This project involved visits to prehospital care providers (predominately the London Ambulance Service) and related agencies in the UK. The aim of the project was to investigate current clinical effectiveness processes, incident monitoring and performance reporting methods. A wide variety of approaches were observed for incident monitoring and performance reporting. Similar challenges are encountered by ambulance services in the UK as are facing Victorian Ambulance services, such as the pending retirement of large numbers of experienced personnel, workload pressures on paramedics and the high costs of training programs. The author would be pleased to elaborate on any aspects of this report for ambulance services or other interested parties.



3 STUDY TOUR PROGRAM The study tour took place over 15 days from Sunday 26th November until Sunday 10th December 2006. Date (2006) Visit Location Sunday 26th November Arrive London, UK Monday 27th November Ambulance Services Association HQ Central London

• Meet with Mr Mark Cooke, Manager Clinical Effectiveness Program manager

Tuesday 28th November Joint Royal College Ambulance Liaison Committee (JRCALC) Conference

Wednesday 29th November

London Ambulance Service • Meet with Mr Richard Lee, Ambulance Operations

Manager – Wimbledon and Battersea • Attend District clinical manager meeting

Thursday 30th November London Ambulance Service – Battersea Ambulance • On road with Battersea ambulance crew

Friday 1st December London Ambulance Service – Control Room

• Tour of Control Room and Incident Management facilities

• Meet with ePCR Data Manager Saturday 2nd December At Leisure Sunday 3rd December At Leisure Monday 4th December London Ambulance Service – Battersea Education and

Development College • Basic Ambulance Attendant Assessments

Tuesday 5th December London Ambulance Service – Battersea Education and Development College

• Paramedic Skills update Wednesday 6th December London Ambulance Service – Extended Care Paramedic

(ECP) • On road with Extended Care Paramedic • Visit of trust ‘Walk in’ Centers

Thursday 7th December London Air Ambulance • Death and Disability Conference

Friday 8th December London Air Ambulance • Day Shift - Professional Development Day – Skills

Review • Evening shift - On road with LAA crew

Saturday 9th December At Leisure Sunday 10th December Depart London for home



4 STUDY TOUR OBJECTIVES Prior to embarking on this study tour I developed four clear objectives. These were: 1. Investigate ‘Clinical Effectiveness’ process and measures of clinical

performance 2. Investigate incident identification and reporting methods 3. Examine research activities and the methods employed to disseminate

findings 4. Attend the Joint Royal Colleges Ambulance Liaison Committee (JRCALC)

- Annual Conference 4.1 Investigate ‘Clinical Effectiveness’ process and measures of clinical

performance The UK has a relatively sophisticated suite of clinical monitoring instruments as a result of a dedicated ‘Clinical Effectiveness’ Committee. In 1995 the Ambulance Service Association (ASA) and Joint Royal Colleges Ambulance Liaison Committee (JRCALC) formed a Joint ASA/JRCALC Clinical Effectiveness Committee to promote the highest quality pre-hospital care through clinical audit, education programs, and evidence based practice. In 1998 the ASA/JRCALC Clinical Effectiveness Committee made a successful bid to the Department of Health to fund the Ambulance Service Association National Clinical Effectiveness Program as an 18 month project as part of the 'Core Audit Program'. The program has now been embedded within the UK Ambulance Service, and receives ongoing funding by the Department of Health. The process of Clinical Practice Guideline (CPG) development is remarkably similar to that within the Victorian prehospital setting; a multidisciplinary committee identifies best practice using evidence based medicine literature review principles and then seeks expert opinion. JRCALC, the committee responsible for the governance of clinical practice within the UK then produce a set of detailed CPGs. The manner in which the key changes are disseminated to operational staff is by a summary document know as the ‘Report of Key Changes’ which is easy to read and would be a useful adjunct to the material currently developed within our services. Recommendation 1: Adopt a similarly formatted document as the ‘Report of Key Changes’ for dissemination of key CPG changes in ASV. The ASA and LAS collaborate with a number of registries and databases which provide them with a powerful information base from which to conduct various



audits and interrogate for trends. The following registries are directly related (to varying degrees) to the clinical business activities of LAS:

• LAS Cardiac Arrest Registry • Central Cardiac Audit Database (CCAD) • Myocardial Infarction National Audit Project (MINAP) • Prehospital Thrombolysis Register

One of the information fields collected by the MINAP that would be a useful comparator in ASV would be the reporting of ‘Aspirin administration’ for patients who are suspected to be suffering from a cardiac event. This would enable the ongoing monitoring of universally accepted clinical practice and allow benchmarking against other ambulance services both national and international. Recommendation 2: Implement the collection and reporting of ‘Aspirin administration’ for presumed acute coronary syndromes in RAV. Another example of key evidence / information dissemination is the ASAs use of information posters. The ASA develop posters relating to key topics and distribute these to all operation centers for display. During the study tour it was plain to see that this medium was embraced by prehospital staff as evidenced by their prominent display. Staff believed the posters had an important role in the dissemination of key information. The posters addressed topical issues such as; recognition and emergency management of suspected stroke, and management of patients suffering capsicum spray contamination. Recommendation 3: Adopt a poster medium for dissemination of key information / evidence in ASV. 4.2 Investigate incident identification and reporting methods Incident identification and reporting methods seem consistent across nations; the LAS use similar, ad hoc identification and reporting practices. Patient Care Record clinical audit procedures are similar to that of ASV and form the primary mode of incident / error identification. The London Air Ambulance utilise a proactive process of case review during bimonthly ‘Death and Disability Conferences’. These multidisciplinary conferences rely upon peer review and promote ‘no blame’ in depth reviews of high risk cases. Cases that are identified through routine audit to have potential errors or management processes that could have been performed differently are selected for review, and all personnel involved in the case present their ‘part’. Personnel including call takers, pilots, observers, doctors and paramedics are involved and describe the case and any issues in a temporal manner. Following this the crews peers ask questions and critique decisions,



and finally the senior clinician (usually the Medical Retrievalist) summarises any lessons learnt. What was particularly interesting about these case reviews was the ‘no blame’ and supportive environment that was maintained throughout; the sole purpose was to identify any system related problems and to allow the audience to learn from the attending crew’s experience. Another interesting aspect of this conference was that the vast majority of attendees were attending in their own time! Very few of the registrants were paid yet there would be 40 to 50 people regularly attending the meetings. Recommendation 4: Implement a similar ‘case review conference’ to discuss high risk cases in ASV. 4.3 Examine research activities and the methods employed to disseminate findings The London Ambulance Service have collaborated in a number of research projects including cardiac arrest outcomes research, specificity of emergency dispatch systems and extensions to the scope of paramedic practice. An area where they perform particularly well is the dissemination of research findings across their organisation. One strategy that the LAS use very effectively is the Research Bulletin. This document is distributed to all staff branches to be displayed on branch pin boards and coffee tables. The bulletin is informative, well read and respected. Recommendation 5: Implement a ‘bulletin’ type document to disseminate research outcomes and contemporary evidence in an easy to understand format in RAV. Having spoken with a number of LAS and ASV staff it is clear that prehospital care providers are becoming increasingly interested research findings, and the evidentiary basis for contemporary practice. Disseminating such information requires a number of different mediums. The LAS ‘Bulletin’, as a hardcopy medium effectively serves a purpose, however a number of people (interestingly in both the UK and Australia) indicated that they would prefer similar information to be available in a web based form. Recommendation 6: Implement a ‘web based’ portal to disseminate research outcomes and contemporary evidence in an easy to understand format in RAV. 4.4 Attend the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) - Annual Conference The JRCALC Conference was an excellent opportunity for networking and transference of UK practices to Victoria. The conference program was very



relevant to contemporary prehospital care and the majority of presentations were directly related to the study tour objectives.

5 CONCLUSIONS

Overall this study tour was worthwhile and provided the author with many insights into the various ways a like ambulance service (LAS) incorporated their quality systems and performance measures into their service. The LAS faced many of the same challenges faced by Victorian Ambulance services, and were in various stages of managing issues around incident identification and performance monitoring and reporting.

6 RECOMMENDATIONS

As a result of this study the author recommends that Ambulance Service Victoria: 1. Adopt a similarly formatted document as the ‘Report of Key Changes’ for

dissemination of key CPG changes in ASV. 2. Implement the collection and reporting of ‘Aspirin administration’ for

presumed acute coronary syndromes in RAV. 3. Adopt a poster medium for dissemination of key information / evidence in

ASV. 4. Implement a ‘case review conference’ to discuss high risk cases in ASV. 5. Implement a ‘bulletin’ type document to disseminate research outcomes and

contemporary evidence in an easy to understand format in RAV. 6. Implement a ‘web based’ portal to disseminate research outcomes and

contemporary evidence in an easy to understand format in RAV.



APPENDIX 1 - STUDY TOUR ITINERARY

2006 Sunday 26th November At Leisure Monday 27th November Mark Cooke at ASA HQ Central London Tuesday 28th November JRCALC Conference Wednesday 29th November Richard Lee Orientation Battersea Ambulance Thursday 30th November On Road Battersea Ambulance Friday 1st December LAS Control Centre Saturday 2nd December At Leisure Sunday 3rd December At Leisure Monday 4th December LAS Education and Development College Tuesday 5th December LAS Education and Development College Wednesday 6th December ECP Ride along Thursday 7th December London Air Ambulance – Death and Disability

Conference Friday 8th December London Air Ambulance Saturday 9th December At Leisure Sunday 10th December Flight London - Melbourne



APPENDIX 2 – MAP OF LONDON

2007 Google – Map data 2007 NAVTEQ™



APPENDIX 3 – PROGRESS OF RECOMMENDATIONS

Recommendation Progress 1. Adopt a similarly formatted document as the ‘Report of Key Changes’ for dissemination of key CPG changes in ASV

Partially Complete

2. Implement the collection and reporting of ‘Aspirin administration’ for presumed acute coronary syndromes in RAV

In Progress

3. Adopt a poster medium for dissemination of key information / evidence in ASV

In Progress

4. Implement a ‘case review conference’ to discuss high risk cases in ASV

In Progress

5. Implement a ‘bulletin’ type document to disseminate research outcomes and contemporary evidence in an easy to understand format in RAV

Complete

6. Implement a ‘web based’ portal to disseminate research outcomes and contemporary evidence in an easy to understand format in RAV

Partially Complete



APPENDIX 4 – TABLE OF ABBREVIATIONS

ASA Ambulance Services Association ASV Ambulance Service Victoria

CCAD Central Cardiac Audit Database CPG Clinical Practice Guidelines ECP Extended Care Paramedic ePCR Electronic Patient Care Record ESF Emergency Services Foundation HQ Headquarters

JRCALC Joint Royal College Ambulance Liaison Committee LAA London Air Ambulance LAS London Ambulance Service MAS Metropolitan Ambulance Service

MINAP Myocardial Infarction National Audit Project PCR Patient Care Record RAV Rural Ambulance Victoria UK United Kingdom

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