An Analysis of Ambulance Victoria Clinical Practice Guidelines (Essay)

This essay provides an analysis of the Ambulance Victoria Clinical Practice Guidelines (CPGs), specifically focusing on the management of Supraventricular Tachycardia (SVT). It examines the evidence-based recommendations for pre-hospital care, including the use of vagal maneuvers and pharmacological interventions like adenosine and verapamil. The essay discusses the guideline's development, periodic reviews, and adherence to international standards. It also offers recommendations for enhancing the guideline's effectiveness, such as clarifying Valsalva maneuvers, allowing MICA paramedics to use pharmacological agents, and ensuring the availability of 12-lead ECGs. The importance of staff training and education in implementing these changes is also emphasized. The essay highlights the significance of considering various factors, such as patient safety and resource availability, when implementing the suggested recommendations. Furthermore, it underscores the need for a strategic approach to ensure healthcare efficiencies and organizational unity in the implementation process, ultimately aiming to improve patient outcomes.

Running head: ANALYSING AMBULANCE VICTORIA CLINICAL PRACTICE
GUIDELINES
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Analysing Ambulance Victoria Clinical Practice Guidelines
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Analysing Ambulance Victoria Clinical Practice Guidelines
Evidence based Clinical Practice Guidelines (CPGs) are efficient strategies that are used to
enhance patient outcomes by implementing practical recommendations for particular health
disorders (Grimmer, Kredo, Bernhardsson, Machingaidze, Young, & Ochodo, 2016). CPGs
guide health practitioners and policymakers in various aspects of clinical uncertainty through
evidence-based commendations which evaluate the risk-benefit balance and analytically assess
new and old technologies. Ambulance Victoria Clinical Practice Guidelines for Ambulance and
MICA Paramedics is a document developed with procedural rigor by multidisciplinary boards.
This document integrates not just useable outcomes of continuing research, but as well as the
views and experiences of health professionals, needs and priorities within the community, legal
frameworks, cultural heterogeneity, patient’s values and preferences, health system organization,
and available resources and expenditures. These guidelines are replicable, valid, unambiguous,
and easily applicable. This essay focuses on one of the Ambulance Victoria Clinical Practice
Guidelines: CPG A0403 (supraventricular tachycardia).
Supraventricular Tachycardia (SVT) is an ephemeral cardiovascular ailment which affects
around 35 people out of 100 000 people in a given setting per year (Medi, Kalman, & Freedman,
2009). Its common symptoms include shortness of breath, dizziness, chest discomfort, and a
‘racing’ heart (more than 140 heartbeats per minute). Ambulance Victoria Clinical Practice
Guideline recommends two main remedies for treating supraventricular tachycardia disorder in
the critical point, namely vagal maneuvers and pharmacological interventions. Synchronised
cardioversion, used to manage deteriorating and unstable SVT patients is included in the
Australian pre-hospital clinical guidelines (Smith, Taylor, Morgans, & Cameron, 2013). Vagal
maneuvers are used to slow an occurrence of SVT. Simple maneuvers such as Coughing or

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gagging, putting an ice-cold, valsalva, wet towel on the face, and bearing down kindle the vagus
nerve, occasionally leading to decelerated transmission of electrical impulses through the
atrioventricular (AV) nodule of the patient’s heart, thus terminating the arrhythmia (Bibas, Levi,
& Essebag, 2016). CPG A0403 guideline encourages patients to consult their doctors before
trying any vagal maneuvers. Pharmacological interventions result in increase in refractoriness by
weakening normal ion activity through atrioventricular-node cell wall channels (Hillegass &
Sadowsky, 2010). Commonest pharmacological agents for treating SVT include adenosine and
verapamil. The primary goal of pharmacological treatment is to block or abate AV nodal
conduction. There remain some controversies concerning the relative efficiency of verapamil and
adenosine for the treatment of SVT. Adenosine is relatively harmless, efficient and hastily acting
drug for curing SVT (Riaz, Mishra, Hussain, & Sin, 2012). Adenosine is associated with
transitory side effects for example facial reddening, breathlessness in 3.42%, dizziness in 8.04%,
and chest discomforts in 15.26% of subjects, according to the study conducted by Rehan Riaz ,
Jeetendra Mishra, Safqat Hussain, and Lok M Sinha in 2012. Arterial verapamil is linked with
high blood pressure in 9.1% of subjects.
This SVT guideline demonstrates a current usage of the procedure applied to develop and assess
pre-hospital clinical practice in Ambulance Victoria. According to a meta-analysis conducted by
Gavin Smith, both adenosine and verapamil have equal deterioration efficiency (~92%).
Adenosine has a bigger number of transitory side effects, whereas verapamil demonstrates side
effects which are more protracted or need instantaneous intervention ( Gavin, 2014). In the pre-
hospital environment, usage of a pharmacological intervention which offers both secure and
efficient cessation of the arrhythmia is vital. The AV CPG A0403 acknowledges the possibly
substantial side effects of verapamil and thus recommends for addition of aramine (an artificial

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alpha receptor agonist which upsurges peripheral vascular resistance) while treating SVT
patients with blood pressures higher than 100 mmHg systolic (Ambulance Victoria, 2019).
The Ambulance Victoria CPGs are consistently appraised after every three years, so as to
ascertain that Victorian paramedic practice upholds currency with developing or progressing
therapeutic practices and advancements in technology. A core component of the process of
guidelines assessment is an evidence-based approach to the treatment of Supraventricular
Tachycardia and related ailments (Gavin & Kenneally, 2013). The Clinical Practice
Development Committee (CPDC) is left with the responsibility of periodically reviewing whole
AV CPG A0403, to identify new treatments to incorporate into the pre-hospital clinical practices
and make certain commendations to the Medical Advisory Committee (MAC) as requested.
Through this reviews and appraisals, AV CPG A0403 and other guidelines remains effective in
the treatment of their specific ailments. Evaluators are tasked to ensure that the CPGs conform to
the international standards of guidelines so as to generate the greatest evidence-based practices
for the management of various diseases (Alonso-Coello, García, Carrasco, Solà, Qureshi, &
Burgers , 2011). Even though development of pre-hospital AV CPG A0403 is frequently faced
by lack of field-specific evidence, expert consensus and in-hospital studies are greatly depended
on for decision-making and this allows for combination of all available components to make sure
that the AV CPG A0403 is of the highest possible standard.
Despite the noted effectiveness of the CPG A0403 (supraventricular tachycardia) thus far, it is
prudent to recommend for some changes in the entire guideline. Gavin in his study found out that
change is vital in most of the CPGs particularly AV CPG A0403 since it is unsafe for paramedics
to perform at the absence of a physician though he did not substantiate his rationale with proper
evidence. However, change is vital in this particular guideline in order to enhance its

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applicability and effectiveness. To start with, the Valsalva Manoeuvres should be defined and
expanded clearly such that all Ambulance Victoria paramedics can use them especially when the
patient is “stable” as demarcated by a systolic blood pressure of exceeding 100mm Hg
(Ambulance Victoria, 2019). In addition, Mobile Intensive Care (MICA) paramedics ought to be
allowed to utilize pharmacological agents (verapamil and adenosine) for treatment of both stable
and unstable Supraventricular Tachycardia especially when no relapse to the Valsalva
manoeuvre is noticed. This Pharmacological intervention is supposed to integrate adenosine
(6mg IV adenosine, 12mg IV adenosine, and then 12mg IV adenosine till relapse or maximum
total dosage). Besides, synchronized cardioversion ought to stay unaltered (75 Joules biphasic
increased to 150 Joules for ensuing shocks), and be set aside for Mobile Intensive Care
paramedics only. Also, every Supraventricular Tachycardia patient is supposed to have a 12-lead
Electrocardiogram conducted where available before treatment unless quickly worsening. Where
not available, a 3-lead Electrocardiogram strip ought to be noted down. In case there is no
relapse to the optimum dosage of adenosine, indicative management and hurried transport to a
health center should take place. What is more, usage of adenosine and Valsalva Manoeuvre
ought to be contraindicated for atrial flutter and atrial fibrillation identified on electrocardiogram.
Aramine (metaraminol bitartrate) and verapamil should be removed from Ambulance Victoria
practice, apart from Adult Retrieval Victoria and Air Ambulance Victoria.
The effectiveness of this change can be measured with ease. Within a given period post change
(for instance one year), an assessment process separate from the ordinary clinical audit process
can be carried out to make sure that the SVT CPG is both effective and suitable. In case any
issues occur before the actual assessment, they can be identified by a different clinical audit
process and quicken prompt evaluation of the SVT CPG. Substantial subject matters influencing

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the safety of patients or paramedics cause instant referral to the Sentinel Events Committee or
Mobile Intensive Care for speedy examination and action as part of the continuing quality
appraisal integrated into the procedure.
In attempt to ensure a successful implementation of the aforementioned recommendations, a
clinician should know precisely what is that it is trying to attain and how it intends to attain it.
Though with similar purpose of managing SVT, different health practitioners will have different
options for the actions they can take for a successful application of SVT CPG. Not all
recommendations are going to work as expected, either, thus it is prudent to address and consider
each one taking into account what it that the practitioners want to achieve. Needless to say, this
is another phase which calls for comprehensive information analysis and collection in order to
come up with solutions that are going to work best in managing SVT. Determining the available
options necessitates a bit of brainstorming and research and hence the clinicians applying the
recommended SVT CPG should look at the details of the patient and intended outcomes as well
as the available and needed resources (Kredo & Bernhardsson, 2016). After that, they should
weigh each option vigilantly and put into consideration various factors which can impact a
certain action’s efficiency. Some factors such lack of proper skills, time, and cost can affect the
goals of the Ambulance Victoria CPG since they directly affect the actions taken and methods
used to manage SVT. If there are so many factors working against a given recommendation, then
it will most possibly have high chances of failing- and probably lead to additional health
challenges on the SVT patient. As a result, it might be necessary to consider back-up clinical
actions, just in case, on top of the suggested recommendations.
Change is a multifaceted process and change is not easily comprehended by all healthcare givers
throughout all levels of the organization (Aaron & Henry, 2014). Therefore, for the pre-hospital

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clinical practice guideline recommendations to be implemented properly, practitioners should
establish a strategic direction meant to enhance healthcare efficiencies, organizational unity,
skills and capabilities of all parties involved in the implementation process. In healthcare, the
importance of staff education and training cannot be underestimated (Gesme, Towle, &
Wiseman, 2010). So, senior practitioners in the attempt to execute the suggested
recommendations should initiate strategic learning programs at various levels of the healthcare
center. All staffs should be assessed of their individual need for education and training on the
revised SVT CPG and its intricacies. After the assessment, they should be provided with
consistence education and training so as to develop the general understanding of the new SVT
guidelines. With continued education and training there will be increased hospital reputations,
patient outcomes, professional morale, and more motivated and better skilled staff (Bhatnagar &
Srivastava, 2012). Empowering clinical staffs through training and education will allow them to
follow the SVT CPG with much ease. It is also worth noting that change comes along with cost.
Organizations are needed to allocate money, time, and manpower resources for them to attain
successful execution of the CPGs recommendations. Some of the possible costs associated with
change implementation in a healthcare setting include training and educating, maintenance,
restructuring, resources, and communication (Antwi & Kale, 2014).
This essay is focusing on one of the Ambulance Victoria Clinical Practice Guidelines (CPGs)
namely CPG A0403 (AV SVT CPG) that is used to manage patients suffering from
Supraventricular tachycardia (SVT). Ambulance Victoria recommends two main treatments for
SVT disorder namely vagal maneuvers and pharmacological interventions. Vagal maneuvers are
utilized to slow an occurrence of this disorder while adenosine and verapamil are used as
pharmacological agents for treating it. AV calls for periodical assessment of these guidelines to

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ensure its practices are up to date with tremendous changes taking place in the healthcare sector
such as advancements in technology. The assessors are also required to ensure that the CPGs
conform to the international standards of guidelines so as to produce the greatest evidence-based
practices for the management of various diseases. This essay has also provided some
recommendations on the changes that can be done in the CPGs especially SVT guidelines to
enhance their efficiency and applicability. As noted, change is good if it achieves its required
goals and most importantly if it enhances patient outcome and experiences. AV requires senior
practitioners to integrate recommendations like these ones in their guidelines strategically to
ensure they achieve their intended purpose. This essay emphasizes that staff training and
education is an essential component of the change implementation process. Knowledgeable and
skilled clinicians will most likely follow the recommended guidelines prudently and accomplish
the primary goal of Ambulance Victoria Clinical Practice Guidelines (CPGs).

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