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How to create an evidence- based guideline Eric Finlay January 2008.

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1 How to create an evidence- based guideline Eric Finlay January 2008

2 EBM Guidelines Choosing a topic Developing a question Finding the evidence Evaluating the evidence Write the guideline Implement the guideline

3 EBM Guideline Why?Where?What?How?

4 Why?

5 What the RCPCH says 1 Clinical guidelines are increasingly being developed in order to help improve the health outcomes for patients and to help reduce unacceptable variations in clinical practice. However, guidelines can only be effective if they are developed to the highest standards and are based upon the best available evidence. Clinical guidelines must also be seen to be of value to clinicians so that they are implemented in everyday clinical practice.

6 Choose a topic Remember creating a guideline is resource-intensive and time-consuming Perceived need? What is to be gained by the guideline? What is the scope of the guideline?

7 Measure current practice Knowing what is currently happening is very useful Audit Survey Monkey Talk to your stakeholders

8 Where? Not a problem here-BAPN

9 Organisation analysis ‘The culture and politics of many organisations constrain the degree of transformation and change in which they can successfully engage’ Morgan 1989 Organisations are well integrated entities within which everybody works harmoniously together- the reality is very different’ J Hayes 2002 ‘My Arse’ Ricky Tomlinson 2008 To change an organisation you must first understand it!

10 What?

11 What the RCPCH says 2 Appropriate, efficient and cost effective healthcare Important part of clinical governance Rigorously developed Transparent method Careful planning

12 Searching the medical databases Get your question right Know where to look Know your synonyms Chunking Save your search strings

13 That all important question What do you want the search to answer? PICO(T) The question then forms the structure of your search.

14 Finding the evidence Your question should lead you Know your databases The more databases searched the more sensitive the search

15 Know your synonyms Increase the number of search terms increase your search sensitivity Look at Cochrane search strings for synonyms

16 Databases Medline/PubmedCinahlEmbaseAMED Biomed Central CochraneDH-DataBNIPsyche-infoLISAEmeraldERICBEIHMIC

17 Chunking Join all your (P) synonyms with OR Join all your (I) synonyms with OR Join all your (C) synonyms with OR Join all your (O) synonyms with OR Now P AND I AND C AND O That’s chunking

18 Example of synonyms (haemodialysis catheter) OR (tesio-cath) OR (central venous dialysis catheter) OR (vascular access) OR (vascular access) OR (central venous catheter) OR (central- venous catheter) OR (francis catheter) OR (vascath) OR (permcath) OR (haemodialysis venous catheter) OR (central venous line) OR ('central venous line') OR (dialysis catheter*)

19 Watch out Only add in limits at the end if despite chunking you still have hundreds of pages MESHCochrane Save your searches-my NCBI Avoid NOT

20 Critical Appraisal CASP tools Look for flaws- written and omissions Can you use it? Is it applicable and transferable?

21 Write the guideline Be concrete, unambiguous and use specific terms. Key recommendations Audit criteria Algorithms/pathways Short version/comprehensive version Educational packages

22 How?

23 Implementation The hardest part Find out where the stakeholders stand Find out where the stakeholders stand Actively for, passive, active against What are the resistive forces How can these resistive forces be undermined Strategic planning Strategic planning Best to erode resistance rather than push harder

24 Organisational Analysis SWOT Strengths, weaknesses, opportunities and threats Strengths, weaknesses, opportunities and threatsPESTELI Political, economic, sociological, technological, ecological, legislative and industry Political, economic, sociological, technological, ecological, legislative and industryForce-field Driving forces against resistive forces Driving forces against resistive forces The Seven S’s Strategy, structure, system, staff, style, shared validity and skills Strategy, structure, system, staff, style, shared validity and skills

25 Peer review and Updating All guidelines will be reviewed by the Clinical Standards Committee Must be up-to-date to be useful Set and update date based on frequency of relevant publications in the preceding year.

26 In Conclusion This is effectively a systematic review without the statistical analysis. Choose something that interests you as well as is clinically relevant. Choose a small subject, or a small portion of a larger one. Set yourself deadlines for each of the stages.

27 Finally is your best friend.


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