Pre-hospital care comes in many guises and is one of the most exciting areas of current medical practice. Increased demands are being placed on the teams who provide this vital service, and its development is an important factor in delivering better patient care.
This editorial is to introduce these consensus documents and to describe the on-going process that the Royal College of Surgeons of Edinburgh Faculty of Pre-hospital Care (RCSEd FPHC) is utilising to improve the evidence base for pre-hospital practice.
Being part of a pre-hospital team
In the pre-hospital context the response teams are doing all they can to save lives. A terrifying ordeal or horrific accident comes without warning at any time of the day or night. With lives at risk, the rescue and pre-hospital care teams need to work fast and in harmony with each other. Everyone has to be clear about their role, with multi-agency teams working seamlessly together. Each situation is unique and may present real dangers; not just for the patient but also for the medics. Blending of services within health and social care allows for the provision of meaningful governance with timely and appropriate interventions throughout the patient pathway. To enable this, many of the processes need to be well thought through and described beforehand, allowing all to work through the same methodology towards a common goal. The consensus process is one tool in the decision-support process. The development of these guidelines needs to follow a transparent system to result in the best evidence-supported practice that is auditable and accountable, balances risk and benefit in most circumstances and remains financially viable.
These areas of practice need to work with and further develop other regulation and guidance, e.g. the paramedic curriculum and soon to be competency framework, JRCALC, etc.
Therefore, the way forward will need to deliver the ‘best for most’. There requires a pragmatic approach trying to overcome prejudice along with personal and traditional preferences, organisational agendas and semantics. Such models would require systems that are appropriately resourced, resilient and adaptable. At the end of the day, we should be striving for the best clinical care and quality assurance, without any significant geographical variation in the quality and level of care, using finite resources in the most cost-effective way. Appropriately trained pre-hospital clinicians should work within a well thought-out and structured integrated governance framework, alongside effective leadership and technology aimed at providing resilient and high-level guidance, decision support and triage.
The FPHC in conjunction with key and leading stakeholders produces systematically developed guidelines to assist pre-hospital emergency care practitioners to deliver a high standard of care. They are designed to assimilate, evaluate and then introduce changes to clinical practice based on the contemporary and evolving evidence base where available. Quality assurance is maintained by a systematic literature review, consultation and transparent peer review. The process allows for updates if there are any essential changes and each topic to be revisited after a set period of time.
The consensus guidelines aim to educate healthcare professionals and assist in agreeing appropriate management. They should be regarded as an aid to clinical judgement and not to replace it.
Looking to the future, however, there are issues as to how we develop systems to improve these services, save more lives, value our colleagues, operate more safely and work more efficiently: rather than simply continuing based on current expertise available, a better way forward, might be to continue to develop the systems that support the wider body of pre-hospital practitioners and allow them to progress both their technical and non-technical skills. The consensus process is a small step towards this. However, we do need all those involved and in particular the paramedic profession, to increase the amount of meaningful research that will help support, change and develop clinical practice.
Therefore, to conclude, in all forms, pre-hospital care is an exciting area of medicine. Increased demands are being placed upon it. It forms an integral part in the development of numerous patient pathways and systems, including trauma, unscheduled and social care. Furthermore, it has a developing, ongoing evidence base that cannot always be extrapolated from in-hospital care. There have been marked developments in the systems that enable both safe and effective delivery of care in this context, but this is often based on anecdotal areas of practice. Improving the care and support of the people who deliver the pre-hospital services and further development of an evidence base, should be a priority and will lead to even better care of the casualties, patients, staff and colleagues.
‘We do need all those involved and in particular the paramedic profession, to increase the amount of meaningful research that will help support, change and develop clinical practice’
‘Ten good soldiers wisely led will beat a hundred without a head’ Euripides 480–406 BC.