The JRCALC Clinical Guidelines Dr Iain McNeil Medical Director, Surrey Ambulance Service Associate...

The JRCALC Clinical The JRCALC Clinical GuidelinesGuidelines

Dr Iain McNeilDr Iain McNeilMedical Director, Surrey Ambulance ServiceMedical Director, Surrey Ambulance Service

Associate Medical Director, Kent Ambulance Associate Medical Director, Kent Ambulance ServiceService

Only those who do nothing make no mistakes

JRCALC guidelinesJRCALC guidelines

The needThe need HistoryHistory Where we are nowWhere we are now The short term futureThe short term future The medium term futureThe medium term future The long term futureThe long term future

JRCALC


The needThe need Public expectationsPublic expectations Clinical GovernanceClinical Governance

– Clinical AuditClinical Audit benchmarkingbenchmarking

– Risk ManagementRisk Management– Educational baseEducational base

Evidence baseEvidence base

JRCALC


HistoryHistory

IHCD training manualsIHCD training manuals Individual service guidelinesIndividual service guidelines Staffordshire guidelinesStaffordshire guidelines Joint review of “Carney protocols”Joint review of “Carney protocols” ASA/JRCALC effectiveness committeeASA/JRCALC effectiveness committee Department of HealthDepartment of Health JRCALC endorsementJRCALC endorsement

JRCALC


Where we are nowWhere we are now

““Carney protocols” now ‘Medical Carney protocols” now ‘Medical Directors Guidelines’Directors Guidelines’

NONO claim to be perfect!! claim to be perfect!! Reviewed by JRCALC expertsReviewed by JRCALC experts Endorsed as “interim”Endorsed as “interim” Ready for use in number of servicesReady for use in number of services Agreed starting point for future workAgreed starting point for future work

JRCALC


We MUST We MUST overcomovercom

e e prejudiceprejudice

ss

JRCALC

To have a future


The short term futureThe short term future National Association of Air National Association of Air

Ambulance Services (NAAAS)Ambulance Services (NAAAS) IHCDIHCD Medical Directors GroupMedical Directors Group Meeting December to establish Meeting December to establish

commonality with NAAAScommonality with NAAAS Merge NAAAS and JRCALC evidence Merge NAAAS and JRCALC evidence

basesbases

JRCALC


The medium term future The medium term future

Merge JRCALC work with NAAASMerge JRCALC work with NAAAS Publish on web and CDPublish on web and CD Develop audit processes with Develop audit processes with

ASANCEPASANCEP Develop evidence base where it is Develop evidence base where it is

absentabsent Update in light of evidenceUpdate in light of evidence Go through ECC weighting processGo through ECC weighting process

JRCALC


The ECC processThe ECC process

Agree start pointAgree start point Gather evidence Gather evidence Determine level of evidence *Determine level of evidence * Critically evaluate quality of evidenceCritically evaluate quality of evidence Summarise the evidenceSummarise the evidence Determine class of recommendation *Determine class of recommendation * Draft guidelineDraft guideline


Levels of evidenceLevels of evidence

Level 1Level 1 Randomized clinical trials or meta-Randomized clinical trials or meta-analyses of multiple clinical trials analyses of multiple clinical trials

with with substantial treatment effectssubstantial treatment effects Level 2Level 2 Randomized clinical trials with Randomized clinical trials with

smaller or smaller or less significant treatment less significant treatment effectseffects

Level 3Level 3 ProspectiveProspective, controlled, non-, controlled, non-randomized, randomized, cohort studiescohort studies

Level 4Level 4 HistoricHistoric, non-randomized, cohort or , non-randomized, cohort or case-case- control studiescontrol studies

AHA-ECC, Levels of evidence 1998


Levels of evidenceLevels of evidence Level 5Level 5 Case series:Case series: patients compiled in serial patients compiled in serial

fashion, lacking a control groupfashion, lacking a control group Level 6Level 6 Animal studies or mechanical model Animal studies or mechanical model

studiesstudies Level 7Level 7 Extrapolations from existing data Extrapolations from existing data

collected collected for other purposes, theoretical analysesfor other purposes, theoretical analyses

Level 8Level 8 Rational conjecture (common sense); Rational conjecture (common sense); common practices accepted before common practices accepted before evidence-based guidelines evidence-based guidelines

AHA-ECC, Levels of evidence 1998AHA-ECC, Levels of evidence 1998


Class of evidenceClass of evidence Class IClass I

– excellent evidence: always acceptableexcellent evidence: always acceptable Class II aClass II a

– good - very good: considered best good - very good: considered best practice by majority practice by majority

Class II bClass II b– fair to good:considered acceptable fair to good:considered acceptable

alternative by majorityalternative by majority


Class of evidenceClass of evidence

IndeterminateIndeterminate– insufficient evidence or preliminary insufficient evidence or preliminary

research evidenceresearch evidence Class IIIClass III

– Harmful, Unacceptable Harmful, Unacceptable


The long term futureThe long term future

Secure funding for Secure funding for evidence base workevidence base work

Secure funding for Secure funding for ASANCEPASANCEP

Develop national Develop national audit facilityaudit facility

Develop co-Develop co-ordinated national ordinated national R&D facilityR&D facility

JRCALC


SummarySummary Interim guidelines are Interim guidelines are

readyready Evidence base must Evidence base must

be developedbe developed Work must be fundedWork must be funded We must work We must work

together to secure a together to secure a safe future safe future

We must share!We must share!

JRCALC


Any questions?Any questions?

JRCALC

The JRCALC Clinical Guidelines Dr Iain McNeil Medical Director, Surrey Ambulance Service Associate...

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