There are 10 government-regulated ambulance services (paramedic provider services) in Australasia who are members of the Council of Ambulance Authorities (CAA). These CAA-member services each produce clinical practice guidelines (CPGs), which guide the practice of their paramedics. Common to each set of CAA-member CPG is a guideline that addresses cardiac arrest due to ventricular fibrillation and pulseless ventricular tachycardia (pulseless VT/VF). This study sought to answer the question: ‘Are current CAA-member CPGs developed with sufficient methodological rigour to consistently produce guidelines that, according to validated, evidence-based best practices, can be recommended for clinical use?’
This question was addressed by performing a comparison of existing CAA-member CPGs for pulseless VT/VF against the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument. All CPGs were anonymised and sent to each appraiser along with the AGREE II appraisal sheet. Appraisals were conducted independently for each CPG and returned to the lead author for collation. The anonymised results were then shared among all appraisers for consideration and discussion. Appraisers were free to change their appraisal after considering the comments from the other appraisers, and results were then converted into a final percent score for each CPG in accord with the recommended AGREE II instrument methodology. One appraisal question, in addition to the AGREE II criteria was added to each appraisal; the response to this was analysed separately.
Nine CPGs were evaluated according to the AGREE II instrument. The appraisers gave passing marks to only two of the six domains in the AGREE II instrument: Domain 1 – Scope and Purpose (73%), and Domain 4 – Clarity of Presentation (74%). Less than passing marks were awarded for Domain 2 – Stakeholder Involvement (27%). Scores of less than 10% were awarded for Domain 5 – Applicability (8%) and Editorial Independence (1%).
Based on the findings of this paper, the authors conclude that it cannot be assumed that current CAA-member paramedic CPGs are developed with sufficient methodological rigour to consistently produce guidelines that, according to validated, evidence-based best practices can be recommended for clinical use. However, most of the authors agree that the CPGs reviewed could be recommended for clinical use with relatively minor modifications. It would be useful to determine whether end users of the CAA-member CPGs agree on the importance of characteristics of CPGs that the AGREE II instrument appraises.
Nichols M, Peterson K, Alston L. Australian heart disease statistics. Heart Foundation; 2014. Available at: https://heartfoundation.org.au/images/uploads/publications/HeartStats_2014_web.pdf
Heart Foundation. Cardiac arrest. Available at: www.heartfoundation.org.au/your-heart/sudden-cardiac-death [Accessed 22 November 2018].
Dingsdag D. Reliability, sustainability and effectiveness of automated external defibrillators deployed in workplaces and public areas. Journal of Occupational Health and Safety, Australia, New Zealand 2009;25:351-61.
Beck B, Bray J, Cameron P, et al. Regional variation in the characteristics, incidence and outcomes of out-of-hospital cardiac arrest in Australia and New Zealand: results from the Aus-ROC Epistry. Resuscitation 2018;126:49-57. doi:10.1016/j.resuscitation.2018.02.029
The Council of Ambulance Authorities. About the CAA. Available at: www.caa.govt.nz/about_caa/about_the_CAA.htm [Accessed 6 November 2018].
Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical practice guidelines we can trust. Washington, D.C.; 2011. Available at: www.nationalacademies.org/hmd/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx
National Health and Medical Research Council. Australian clinical practice guidelines. Available at: www.clinicalguidelines.gov.au/portal [Accessed 25 March 2019].
Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993;342:1317-22. doi:10.1016/0140-6736(93)92244-N
Worrall G, Chaulk P, Freake D. The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review. CMAJ 1997;156:1705-12.
Thomas L, Cullum N, McColl E, et al. Guidelines in professions allied to medicine. Cochrane Database Syst Rev 1999;(1):CD000349. doi:10.1002/14651858.CD000349
Bahtsevani C, Uden´ G, Willman A. Outcomes of evidence-based clinical practice guidelines: a systematic review. Int J Technol Assess Health Care 2004;20:427-33.
Lugtenberg M, Burgers JS, Westert GP. Effects of evidence-based clinical practice guidelines on quality of care: a systematic review. Qual Saf Health Care 2009;18:385-92. doi:10.1136/qshc.2008.028043
Ebben RH, Vloet LCM, Verhofstad MHJ, et al. Adherence to guidelines and protocols in the prehospital and emergency care setting: a systematic review. Scand J Trauma Resusc Emerg Med 2013;21:9. doi:10.1186/1757-7241-21-9
Kirves H, Skrifvars M. Adherence to resuscitation guidelines during prehospital care of cardiac arrest patients. Eur J Emerg Med 2007;14:75-81.
Fouche PF, Zverinova KM. The Australian Resuscitation Council guideline for managing acute dysrhythmias: an appraisal. The Australasian Journal of Paramedicine 2014;11:1-6.
AGREE Next Steps Consortium. AGREE related publications; 2015. Available at: www.agreetrust.org/resource-centre/agree- related-publications/ [Accessed 25 March 2015].
NHMRC. Procedures and requirements for meeting the 2011 NHMRC standard for clinical practice guidelines, Version 1.1.; 2011.
Ambulance Victoria. Clinical practice guidelines; 2019. Available at: ww.ambulance.vic.gov.au/paramedics/clinical-practice-guidelines/ [Accessed 12 March 2019].
Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ 2010;182:E839-42. doi:10.1503/cmaj.090449
ACT Ambulance Service. CMG 4 – adult cardiac arrest; 2014. Available at: http://cdn.esa.act.gov.au/wp-content/uploads/CMG-4-ADULT-CARDIAC-ARREST.pdf [Accessed 28 August 2014].
Wellington Free Ambulance. Cardiac arrest. Clinical procedures and guidelines; 2014. Available at: www.wfa.org.nz/file/425/Wellington-Free-Ambulance-Clinical-Procedures-Guidelines-December-2014.pdf [Accessed 28 August 2014].
Ambulance Victoria. Cardiac arrest CPG AO201; 2015. Version 5 – 08.06.11. Available at: www.ambulance.vic.gov.au/Media/docs/cpgs-adult-guidelines-705c1a3d-7791-45e1-bb6b-0df2efa120aa-0.pdf [Accessed 28 August 2015].
Gawande AA. The checklist manifesto: how to get things right. Picador, 1st edn. London; 2011.
Roth DL. Crazy from the heat. New York, NY: Hyperion; 1998.
Joint Royal Colleges Ambulance Liaison Committee; 2018. Available at: www.jrcalc.org.uk/ [Accessed 6 November 2018].
National Association of State EMS Officials. National model EMS guidelines. Pediatrics 2015;136(6):e1679. Available at: https://pediatrics.aappublications.org/content/pediatrics/136/6/e1679.full.pdf [Accessed 6 November 2018].