Dr Sandy Muecke - Director, Research Ms Nada Curac - Project Officer Ms Darryn Binks - Manager, Clinical Professional Development excellence in care.

Evidence for ‘excellence in care’Dr Sandy Muecke - Director, Research

Ms Nada Curac - Project OfficerMs Darryn Binks - Manager, Clinical Professional Development

excellence in care

To describe the processes and frameworks used to develop an evidence-based model to underpin clinical policy decision-making practices in NSW Ambulance.

Aim

Current process

‘Protocols’ define clinical practice for NSW Ambulance clinicians:

Informed using ‘ad hoc’ processesUncertainty around alternative, more appropriate processes to guide developmentDifficulties in accessing and appraising literature (time / skills)

Review of ‘Medical Director’ role:Changes to scope of practicePrinciples of evidence-based practice (EBP) used in wider health since 1990s

Current process

Two-step process:1. Reviews of the academic and grey literature:

To inform a model

2. Stakeholder discussions (Consensus Meetings):To assess organisational acceptability / feasibility of any proposed EBP model

Method

Literature reviews1) Prehospital literature

Medline and CINAHL2000 to May 2012Prehospital studiesIncluded information on processes or frameworks for protocol or guideline development/review

Additional grey literature search ‘Google’

Method

Literature reviews2) Wider health EBP literature

Initial search n = > 58,000 articlesUsed ‘snow ball’ approachPrevious work with Professor John Lavis‘SUPPORT Tools’ series: Lavis, Oxman et al 2009 (Health Research Policy & Systems journal)

Other useful studies identified through secondary reference search

Method

Prehospital Review

Seven studies fulfilled criteriaThree really useful (2 x USA, 1 x Canada)

Results

Database searches Medline (n = 947), CINHAL (n= 591):

human subjects, English language, abstracts available Search results combined (n = 1538)

585 duplicates removed

934 records excluded

Full text articles excluded (n = 13)

Reasons: - Not in pre-hospital setting (n = 4) - Not about protocol development (n = 9)

Articles screened on basis of title and abstract (n = 954)

Additional records identified through

Google search (n = 1)

Full text articles assessed for eligibility (n = 20)

Articles included in the review (n = 7)

Medical effectiveness research evidence “generated through a prescribed set of processes and procedures recognized as scientific”context-free guidance for ideal situation

Colloquial evidenceviews and expertise of stakeholders

Social-science research evidencecontext-sensitive guidance - geographic or resource constraints, organisational feasibility, patient needs, costsdetermines what is actually possible

Lomas J, et al. Conceptualizing and combining evidence for health system guidance. Final report. Ontario, Canada: Canadian Health Services Research Foundation; 2005.

ResultsWhat is ‘evidence’?

‘Local’ evidence

Results

From Oxman et al. SUPPORT tools for evidence-informed health policymaking (STP) 1: What is evidence-informed policymaking? Health Research Policy and Systems 2009;7 Figure 1, page 4

Organisational issues:

Success dependant on committed leadership and provision of purposive human and structural resources

Common problems include “lack of organizational arrangements”

Success evasive when unfunded, unstructured grassroots efforts

EBP processes not well understood within ambulance services

Guideline construction is a lengthy “painstaking” process

Results

Process issues

Evidence-informed health policymaking should be systematic and transparent

Consider construction of a database of appraised prehospital research evidence (Dalhousie University, Nova Scotia, Canada)

Research evidence is not the only type of information needed to inform the judgements necessary for policy decision making

Clinical evidence can inform, but never replace, individual clinical expertise

A step-wise set of processes described in published papers (prehospital and wider health literature)

Results

2. Stakeholder discussions (Consensus Meetings):Draft report:

What EBP is and isn’t / what constitutes ‘evidence’?Case for changeMethods Proposed six-phase modelRequired organisational resources

Draft report to stakeholders and Executive Director, Clinical Governance – review and amendmentsSecond draft version to Clinical Governance Committee - final review and amendmentsFinal report – CE approval March 2013

Results

ResultsGenerate locally

relevant knowledge

Seek and synthesise evidence

Decision-making: discuss and agree

Construct or amend protocol

Implement

Evaluate

Six-phase model ‘Medical effectiveness research’ evidence

‘Local’ evidence

Used EBP processes to construct a systematic and transparent clinical policy decision-making model for NSW Ambulance

Summary

‘Research Officer: Protocols and Practice’Newly created ‘knowledge broker’ positionCollaboration with Senior Staff Specialist, Protocol Committee, Director of Research

Literature reviews (in line with protocol updates)Critical appraisal, ‘levels of evidence’, ‘class of recommendation’ Convene stakeholder meetings (‘policy dialogues’)Synthesis: ‘research summaries’, ‘policy briefs’Support NSW Ambulance project managersDatabase construction and maintenance

Current implementation status

Evidence for ‘excellence in care’

[email protected]

Database of appraised prehospital research studies to:

Consider development of guidelines at a national level, with adaptions by state services into locally applicable protocols

Eliminate duplication of effort between statesStandardisation of prehospital care

Relies upon ‘network’ of reviewers with appropriate skills Consider contributing to Canadian database

Next steps