Evidence for ‘excellence in care’ 4/15/2017 9:26 PM 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 © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

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

4/15/2017 9:26 PM 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) © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

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

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

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’

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

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

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

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

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 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

Results Six-phase model ‘Medical effectiveness research’ evidence Generate locally relevant knowledge Seek and synthesise evidence Decision-making: discuss and agree Construct or amend protocol Implement Evaluate Results Six-phase model ‘Medical effectiveness research’ evidence ‘Local’ evidence

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

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

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

Next steps 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 states Standardisation of prehospital care Relies upon ‘network’ of reviewers with appropriate skills Consider contributing to Canadian database