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Brown, G. (2000). Developing effective clinical practice guidelines for ambulance services. Pre-Hospital Immediate Care, 4, 136–140.  (not available online)

This is obviously an older article but it’s a great overview of some of the issues surrounding developing guidelines for paramedics.  The author points out that there (was) some fairly extreme variation in clinical practice by UK medics (e.g. the maximum dose of naloxone varied between 800 and 10,000 mcg!).

The focus of the article are four main issues that the author goes on to examine in separate sections.

1. The credibility and validity of the guidelines:
   1. drawing from existing guidelines increases credibility and decreases work
   2. soliciting buy-in from opinion leaders is important
   3. proving health gains supports credibility
2. User acceptance of guidelines:
   1. parochialism and resistance to curbing autonomy and flexibility are common concerns in regards to guidelines that need to be addressed, including end-users and explicitly addressing their concerns is important.
3. The amount of change in clinical practice they produce:
   1. Guidelines may be ignored by managers if they are predicted to require additional costs, equipment or training resources.
   2. The author makes an important point about what sort of immunity guidelines may grant.  Noting:Presently, however, it is unclear whether adherence to guidelines confers immunity from liability or if non-adherence increases the likelihood of being found negligent if a patient suffers harm as a result because, in English law, guidelines carry little weight.  They are considered ‘hearsay’ evidence because, unlike an expert witness, they cannot be examined and cross examined.  However, it is worth noting that in the United States, legally validated guidelines  have been used as a complete defence in a malpractice claim”.
      I’ve contacted Michael Eburn from the Australian Emergency Law blog to ask him his impression of the Australian context in regards to the above.
      
   3. The author quotes another study which lists 3 essential components which result in improved acceptance of guidelines:
      1. explicit identification of the major decisions relevant to patients
      2. collation of valid evidence
      3. concise presentation of the evidence (ensuring that they are easy to use)
   4. He also quotes a different author who describes three components which encourage uptake:
      1. a simple algorithm of steps to follow
      2. an explanation of the content of the algorithm
      3. a detailed summary of the underpinning evidence
4. The health gain that those changes produce:
   1. The author suggests that comparison with national benchmarks is of higher quality than retrospective evaluation of outcomes before introduction of the new CPGs, although this is obviously more complex and requires greater cooperation with external agencies (to determine eventual outcome).
   2. The author also suggests that all paramedic paperwork have a section dedicated for possible explanations of why care deviated from the CPGs.

The final section of the paper points out the amount of expertise that is required to translate research into clinical practice (something I’m getting an appreciation of!) and the tremendous amount of time and resources it requires, and suggests that these requirements are far beyond the resources of ambulance services.

For comparisons sake, I know in South Australia they did a trial project of producing one robustly evidence-based CPG (it was really good) and it took approximately 250 staff hours.  Australasian ambulance services have about 100 CPGs (on average) which means that it would take about 25,000 hours to write a comprehensive, complete set of highly researched CPGs.  Multiply that by whatever you pay your paramedics on overtime (let’s just say $50 an hour), and that’s a budget of at least $1.25 million – not including any support staff work or hiring a PhD to oversee the project.  I can tell you, none of the CAA members have the resources to do that.

Writing appropriate, best-practice CPGs will necessarily have to be a voluntary collaborative effort of many people.