Shared learning database

South Western Ambulance Service NHS Foundation Trust
Published date:
February 2013

The planned coming together of the South Western Ambulance Service NHS Foundation Trust and the Great Western Ambulance Service on the 1st February 2013 provided an opportunity to harmonise and advance clinical practice. The effective implementation of NICE guidelines was central to the process to ensure that patients receive the highest standards of pre-hospital care.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

During 2012 the South Western Ambulance Service NHS Foundation Trust began the process of acquiring the Great Western Ambulance Service. The new organisation which covers a fifth of the landmass of England launched on the 1st February 2013, serving a population of 5.3 million. Almost 4,000 staff work across 120 operational sites, utilising over 600 ambulance vehicles. Previous ambulance service mergers have used the approach of harmonising care over the first 1-2 years. However, the Trust felt that it was vitally important that all patients received the same high standard of care from day one.

The aim of the project was to ensure the all patients received the same high standard of care from day one of the new organisation, across the South West.

The objectives were to:
- Review all aspects of clinical practice across both organisations.
- Adopt the best clinical practice from both organisations.
- Ensure full implementation of NICE and other national guidance.
- Develop concise evidence based guidelines for pre-hospital clinicians.
- Deliver guidance to staff using multiple methods of communication.
- Establish educational requirements
- Establish evaluation processes

Reasons for implementing your project

Each year thousands of research papers, national guidelines and recommendations are published. The Trust's senior clinical team work to review the latest evidence, to ensure that when an opportunity arises to enhance the care patients receive, clinicians are supported to implement the changes at the earliest opportunity. Although the clinical practice of ambulance clinicians is supported by nationally published JRCALC guidelines, much of the care is still determined by individual Trusts.

The Trust had robust processes for reviewing and implementing NICE guidelines; the challenge was that the full guidelines were in a format which was often not practical to implement into frontline practice. The application of guidelines is often difficult, as the pre-hospital environment presents unique challenges. For example, although all patients aged over 65 who sustain a head injury should be admitted to hospital, many refuse and it is sometimes challenging to differentiate between a scalp laceration and a true head injury. Guidelines were required to provide support to staff when the full application of NICE guidance was not possible.

One of the most significant challenges was to harmonise clinical practice. Both Trusts had previously used a system of Clinical Notices to disseminate NICE guidelines to staff. Staff found it difficult to keep up with over 30 updates a year and it was virtually impossible to memorise the detail of many of the guidelines. The detail within some NICE guidelines presented the greatest challenge. For example the safe application of the paediatric fever traffic light system requires clinicians to memorise 46 criteria. Staff feedback was that the current was no longer fit for purpose.

It was clear that a radically new approach was needed to ensure that ambulance clinicians on the frontline had access to the key clinical information they needed. The Trust contacted other UK ambulance services to establish if a solution had already been found, but all were in the same position. It was apparent that the implementation of a standard, concise and easy to access resource written by ambulance clinicians, for ambulance clinicians would result in a range of benefits. Benefits included the availability of guidance out in the field, raising the profile of evidence based practice, improving the implementation of guidance and most importantly improving care.

How did you implement the project

The senior clinical teams worked together to review over 450 internal clinical document published over the previous six years. The baseline assessment identified 24 areas where further guidance was required. Guideline development was allocated to a team of six senior paramedics, with the remit of combing the best clinical practice form both organisations with the latest evidence base. The guidelines had to be easy to read, concise and provide practical support to ambulance clinicians of all grades.

The inclusion of NICE guidance was central to the project, with nine guidelines being dedicated to their implementation (CG4, 36, 47, 84, 95, 102, 109, 127, 134 and TA122). 24 pre-hospital focused guidelines were developed and extensively proof read before publication. The challenge was to provide resources in an easily accessible practical format. During December 2012 all ambulance clinicians were issued with their own clinical guidelines folder. IT solutions were also used extensively to enhance access to the documents. Within Devon and Cornwall guidelines were available on ruggedised laptops, with officers obtaining access through the Trusts Incident Command iPad App. Documents were also available to view on the Trusts intranet and internet sites. Staff were encouraged to download the documents onto their smartphones.

During January staff had chance to review the guidelines, to ensure that they could be fully implemented by all clinicians from the 1st February. The implementation was supported by the senior clinical team spending a week in the field providing information sessions at 11 main ambulance stations. The ability for staff working remotely across 120 sites to access rapid advice and clarification was identified as a key challenge. A dedicated email group was established, with a guarantee that all emails would receive a response within 24 hours, 7 days a week. An on-call rota was used to answer late night and weekend questions; in reality the majority received a response within 1-2 hours. Face to face support was also provided by a member of the senior clinical team within each area. Following a training needs analysis, additional education will be delivered to staff during 2013-14 to ensure that the guidelines are fully embedded into practice. The time implications of the project were absorbed within normal capacity, with the only non-recurrent cost of £33,000 resulting from the publication of 3,600 clinical guideline folders.

Key findings

Throughout the year the Trust evaluate the quality of care being delivered to patients. Key elements are evaluated on a monthly basis, through the submission of the national Ambulance Quality Indicators. The completion of clinical audits further reviews a range of topics in greater detail.

On a daily basis the senior clinical team review incident reports which have been received concerning patient care, to ensure that trends are identified and actions are taken to reduce emerging risks. Nine clinical sub-groups covering topics from sepsis to resuscitation meet regularly to review emerging issue in-depth and drive forward care. Serious incidents are also comprehensively investigated and chaired by a senior clinical to maximise the learning potential. As part of the guideline development process, incident reports regarding the application of guidelines, and relevant serious incidents were reviewed. The process identified areas where further clarification would reduce the clinical risk and provide staff were further support, which were included within the new guidelines.

The successful implementation of the guidelines will be monitored through 2013-14 using a combination of clinical audit, incident report review and analysis of serious incidents. Analysis of the serious incidents reviewed over the past year demonstrated that had the new clinical guidelines been available and applied at the time of the incident, all applicable cases would have been avoided. It is hoped that the project will further improve patient safety, and further decrease the number of serious incidents.

Key learning points

The project demonstrated how bringing together clinical expertise from two organisation with a focus on delivering evidence based care, resulted in patients from across the South West not only receiving the same level of care from day one, but care that has been enhanced across the board. Relevant NICE guidance is now firmly embedded across the organisation, and the profile of NICE resources locally has been increased. The project demonstrated the advantage of aiming for harmonised clinical care from day one, when previous ambulance mergers have used the approach of harmonising care over the first 1-2 years. The use of multiple implementation methods has also contributed to the success of the project, which took just six months from start to completion. Producing such a significant change to the clinical practice of so many clinicians across a large area presents a range of challenges; effective communication being the most important. The project highlighted the important of swift accessible advice to support the implementation of new guidance. A summary of clinical implications document was published with the guidelines, to enable staff to identify the practical changes to their practice in a concise four page document. A frequently asked questions page was also updated on a weekly basis.

Overall, the project demonstrates that whilst many national guidelines are already out within clinical practice, the mere presence of a guideline does not necessarily lead to its full implementation. Clinicians need resources that enable the use of the multitude of guidance available in the fast paced clinical environment, where referral to further internet resources or text books are simply not an option.

In terms of learning points, the project demonstrates that the review of national guidance and synthesise into concise publications is extremely time consuming, with adequate resources in terms of clinician time, proof reading, IT and finance being required.

Contact details

Adrian South
Deputy Clinical Director
South Western Ambulance Service NHS Foundation Trust

Is the example industry-sponsored in any way?