Question: I have heard the term "best practice" used quite often in the past little while. I was wondering if you could elaborate on the means of "best practice", and if the SWORBHP guidelines can be considered "best practice"?
If not, where would one look to ensure they are using the "best practice"? For example, in recent studies, best practice may not be to administer oxygen to each and every patient, however the BLS states that we should administer oxygen to each patient.
Thanks for the excellent question. Best practice (and this is our interpretation) would be an ideal state whereupon the clinical practice of medicine is based entirely upon the most current medical literature/evidence/consensus guidelines which then translates into optimal patient care.
As for your question as to whether the SWORBHP guidelines could be considered best practice, that is difficult to answer.
Best practice would be an ideal state that not only refers to the documents and directives that are created, but also the actual clinical care delivered by the health care provider.
As you know, the SWORBHP does not really have guidelines that are our own: while we do have our own policies and procedures, we are mandated to follow the Ontario MOHLTC Basic Life Support Patient Care Standards (BLS-PCS) and the Ontario MOHLTC Advanced Life Support Patient Care Standards (ALS-PCS).
The medical directors at SWORBHP work very hard with our provincial Base Hospital colleagues, the Ontario Association of Paramedic Chiefs (OAPC) as well as the MOHLTC to ensure that both of these sets of standards reflect current medical literature. That being said, changes to both of these sets of standards take time: something we have discussed at length previously on this forum and others.
With that background, to answer your questions: Best practice not only involves the consensus of the most up to date medical literature, it also involves your clinical care so we all have a role to play in delivering best practice.
The BLS-PCS and the ALS-PCS are constantly receiving updates and recommendations for change by the BH Physicians and the OAPC based upon emerging new evidence. Unfortunately it takes time to change and release these documents and train paramedics to reflect the latest recommendations in the medical literature: it is a never ending process.
As to where one would look for best practice, literature searches can be performed using any number of online search engines scanning various medical journals for the published medical literature. Consensus guidelines can also be a very useful source of information as can some of the free online medical literature distributed over social media sites.
Finally, as for the question related to oxygen delivery: this is an excellent example. In February 2011, the Ontario Base Hospital MOHLTC Medical Advisory Committee (OBHG MAC) formally reviewed the current BLS PCS Oxygen Utilization Standard which in essence advocates for high flow oxygen €Žfor a large variety of conditions: but to be clear, not each and every patient as you assert.
The MAC again at the May 2011 meeting reviewed further literature and specifically the British Medical Journal by Austin et al: "Effect of high flow oxygen on mortality in COPD patients in prehospital setting" BMJ 2010;341:c5462
This paper showed that the mortality in the high flow oxygen group was 9% vs 4% €Žin the titrated oxygen group within their study population.
One of the challenges in adopting an oxygen titration protocol is one needs oxygen saturation monitors which up until 2015 still were not on the mandatory minimum equipment list despite the MAC€Ž having formally endorsed these for years.
Oxygen delivery is not a delegated act and in theory, the OAPC and the MOHLTC have responsibility for the BLS-PCS. Similarly, equipment purchases such as oxygen saturation monitors are also beyond the purview of the Base Hospital and the responsibility of the OAPC and the MOHLTC.
At the May 2011 as well as at the Sept 2011 OBHG MAC meetings, revisions to the BLS PCS were proposed, edited, discussed, and finally by the Dec 2011 meeting the OBHG MAC made a motion to the MOHLTC to change the BLS PCS and that titrated oxygen €Žbe incorporated into the BLS PCS.
As of today, this change (along with numerous other similar changes reflective of best practice) have yet to be released in a new version of the BLS-PCS.