1. The JRCALC Clinical Guidelines Dr Iain McNeil Medical Director, Surrey Ambulance Service Associate Medical Director, Kent Ambulance Service

2. JRCALC guidelines • The need • History • Where we are now • The short term future • The medium term future • The long term future Only those who do nothing make no mistakes JRCALC

3. The need • Public expectations • Clinical Governance • Clinical Audit • benchmarking • Risk Management • Educational base • Evidence base Only those who do nothing make no mistakes JRCALC

4. History • IHCD training manuals • Individual service guidelines • Staffordshire guidelines • Joint review of “Carney protocols” • ASA/JRCALC effectiveness committee • Department of Health • JRCALC endorsement Only those who do nothing make no mistakes JRCALC

5. Where we are now • “Carney protocols” now ‘Medical Directors Guidelines’ • NO claim to be perfect!! • Reviewed by JRCALC experts • Endorsed as “interim” • Ready for use in number of services • Agreed starting point for future work Only those who do nothing make no mistakes JRCALC

6. We MUST overcome prejudices To have a future Only those who do nothing make no mistakes JRCALC

7. The short term future • National Association of Air Ambulance Services (NAAAS) • IHCD • Medical Directors Group • Meeting December to establish commonality with NAAAS • Merge NAAAS and JRCALC evidence bases Only those who do nothing make no mistakes JRCALC

8. The medium term future • Merge JRCALC work with NAAAS • Publish on web and CD • Develop audit processes with ASANCEP • Develop evidence base where it is absent • Update in light of evidence • Go through ECC weighting process Only those who do nothing make no mistakes JRCALC

9. The ECC process • Agree start point • Gather evidence • Determine level of evidence * • Critically evaluate quality of evidence • Summarise the evidence • Determine class of recommendation * • Draft guideline Only those who do nothing make no mistakes

10. Levels of evidence • Level 1 Randomized clinical trials or meta- analyses of multiple clinical trials with substantial treatment effects • Level 2 Randomized clinical trials with smaller or less significant treatment effects • Level 3 Prospective, controlled, non-randomized, cohort studies • Level 4 Historic, non-randomized, cohort or case- control studies AHA-ECC, Levels of evidence 1998 Only those who do nothing make no mistakes

11. Levels of evidence • Level 5Case series: patients compiled in serial fashion, lacking a control group • Level 6Animal studies or mechanical model studies • Level 7Extrapolations from existing data collected for other purposes, theoretical analyses • Level 8Rational conjecture (common sense); common practices accepted before evidence-based guidelines AHA-ECC, Levels of evidence 1998 Only those who do nothing make no mistakes

12. Class of evidence • Class I • excellent evidence: always acceptable • Class II a • good - very good: considered best practice by majority • Class II b • fair to good:considered acceptable alternative by majority Only those who do nothing make no mistakes

13. Class of evidence • Indeterminate • insufficient evidence or preliminary research evidence • Class III • Harmful, Unacceptable Only those who do nothing make no mistakes

14. The long term future • Secure funding for evidence base work • Secure funding for ASANCEP • Develop national audit facility • Develop co-ordinated national R&D facility Only those who do nothing make no mistakes JRCALC

15. Summary • Interim guidelines are ready • Evidence base must be developed • Work must be funded • We must work together to secure a safe future • We must share! Only those who do nothing make no mistakes JRCALC

16. Any questions? Only those who do nothing make no mistakes JRCALC