Evidence for ‘excellence in care’

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

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

4. Current process • ‘Protocols’ define clinical practice for NSW Ambulance clinicians: • Informed using ‘ad hoc’ processes • Uncertainty around alternative, more appropriate processes to guide development • Difficulties in accessing and appraising literature (time / skills)

5. Current process • Review of ‘Medical Director’ role: • Changes to scope of practice • Principles of evidence-based practice (EBP) used in wider health since 1990s

6. Method Two-step process: • 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

7. Method Literature reviews 1)Prehospital literature • Medline and CINAHL • 2000 to May 2012 • Prehospital studies • Included information on processes or frameworks for protocol or guideline development/review • Additional grey literature search ‘Google’

8. Method Literature reviews 2) Wider health EBP literature • Initial search n = > 58,000 articles • Used ‘snow ball’ approach • Previous 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

9. Results • Prehospital Review • Seven studies fulfilled criteria • Three really useful (2 x USA, 1 x Canada)

10. Results • What is ‘evidence’? • Medical effectiveness research evidence • “generated through a prescribed set of processes and procedures recognized as scientific” • context-free guidance for ideal situation • Colloquial evidence • views and expertise of stakeholders • Social-science research evidence • context-sensitive guidance - geographic or resource constraints, organisational feasibility, patient needs, costs • determines what is actuallypossible Lomas J, et al. Conceptualizing and combining evidence for health system guidance. Final report. Ontario, Canada: Canadian Health Services Research Foundation; 2005. ‘Local’ evidence

11. 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

12. Results • 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

13. 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)

14. Results 2. Stakeholder discussions (Consensus Meetings): • Draft report: • What EBP is and isn’t / what constitutes ‘evidence’? • Case for change • Methods • Proposed six-phase model • Required organisational resources • Draft report to stakeholders and Executive Director, Clinical Governance – review and amendments • Second draft version to Clinical Governance Committee - final review and amendments • Final report – CE approval March 2013

15. Results Six-phase model ‘Medical effectiveness research’ evidence ‘Local’ evidence

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

17. Current implementation status • ‘Research Officer: Protocols and Practice’ • Newly created ‘knowledge broker’ position • Collaboration 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 managers • Database construction and maintenance

18. Evidence for ‘excellence in care’ smuecke@ambulance.nsw.gov.au

19. Next steps • Database of appraised prehospitalresearch studies to: • Consider development of guidelines at a national level, with adaptions by state services into locally applicable protocols • Eliminate duplication of effort between states • Standardisation of prehospital care • Relies upon ‘network’ of reviewers with appropriate skills • Consider contributing to Canadian database