Clinical Practice Guidelines By Dr. Hanan Said Ali

Objectives  Define clinical guidelines.  Identify topic of a clinical guideline.  Enumerate the purpose of using Clinical Practice Guideline.  Identify the characteristics of effective guidelines.  Describe how to Prioritize topic areas for guideline development.  Identify how are guidelines developed and Patient involvement.  List benefits and disbenefits of clinical guidelines.

Clinical Practice Guidelines Clinical guidelines Are ‘systematically developed statements to assist practitioner decisions about appropriate health care for specific clinical circumstances’.

Clinical Practice Guidelines  Topic of a clinical guidelines  A condition such as asthma or angina;  A symptom such as extravasations.  A clinical procedure such as urinary catheter care.

Clinical Practice Guidelines Why we can be use Clinical Practice Guideline ?  To reduce inappropriate variations in practice.  To promote the delivery of high- quality, evidence-based health care.  To provide a mechanism by which health care professionals can be made answer for clinical activities.

Characteristics of Effective Guidelines  Attribute : Explanation  Validity : It lead to the predicted improvements in health  Cost- effectiveness: Improvements in health care should be at acceptable costs  Reproducibility : Given the same evidence, another guideline development group would produce similar recommendation

Characteristics of Effective Guidelines Cont.  Reliability : Given the same clinical circumstances another health professional would apply the recommendations in a similar fashion.  Representative development :  All key disciplines and interests contribute to guideline development

characteristics of Effective Guidelines Cont.  Clinical applicability: The target population is in accordance with the evidence  Clinical flexibility : Guidelines identify exceptions and indicate how patient preferences are to be incorporated into decision making.  Clarity: It use precise definitions, unambiguous language and user- friendly format.

characteristics of Effective Guidelines Cont.  Meticulous documentation : Guidelines record participants, assumptions and methods and link recommendations to the available evidence  Scheduled review : Guidelines state when and they are to be reviewed.  Utilisation review : Guidelines indicate ways in which adherence to recommendations can be sensibly monitored.

characteristics of Effective Guidelines Cont.  Ensuring that guidelines meet these criteria is a resource- intensive task in terms of cost and the time and skills required in its development and in ensuring they remain up to date.  The process from start of guideline development to publication take up to 24 months, depending on the volume of relevant literature on the topic, the amount of feed back received during the consultation phase and the time constraints of the guideline development group.

National or Local Guideline Development  While locally developed (‘internal’) guidelines may need fewer resources and may be more likely to be adopted into clinical practice because of local ownership.  An alternative is the development of guidelines at regional/ national level and subsequent modification to suit local circumstances.

Prioritizing Topic Areas for Guideline Development  Situations where there is evidence of excessive morbidity, disability or mortality.  Conditions for which available treatment offers the potential for improvement in any of the above.  Those where there is evidence of wide variation in practice.  Conditions that are resource intensive either because they are high cost or high volume.

Prioritizing Topic Areas for Guideline Development Cont.  Situations involving cross- boundary issues, as inter-professional working or the need for joint working between primary and secondary care.  Conditions where effective treatment is proven and can reduce mortality and morbidity.  Iatrogenic diseases/ interventions where significant cost or risk is involved.

How are Guidelines Developed?  Selection of guideline topic.  Composition of the guideline development group.  Defining the scope of the guideline.  Systematic literature review.  Formation of recommendations.  Consultation and peer review.  Presentation and dissemination.  Local implementation.  Audit and review.

What are the Skills Required in Guideline Development Group Members?  Clinical expertise ( nursing, physiotherapy).  Other specialist expertise ( health economics, research methods).  Practical understanding of the problems faced in the delivery of care.  Critical appraisal skills.

Patient involvement in guideline development  Patient involvement in guideline development should be no exception.  Patient’s knowledge, understanding and experience of their illness makes them ideally placed to contribute, particularly in areas where guideline developments is difficult because of lack of evidence.

Patient involvement in guideline development Cont. Title Role  Client Presents their own views  Member of client Presents the group’s views group  Client advocate Presents knowledge of clients views

Patient involvement in guideline development Cont. It may be beneficial for the advocate (who is not a patient) to have:  Abroad knowledge of the subject of the guideline.  A knowledge of clients’ experiences of coping with the symptom or condition.  An awareness of client’s feelings and problems.  An understanding of clients’ needs.  Training in communication or counseling skills.

Patient involvement in guideline development Cont.  Once the group has been established, the scope of the guideline is defined.  A number of key clinical questions are identified.  Broad topic, for example the management of patients receiving chemotherapy, will take longer to develop and be more labour intensive than a topic that focuses on a single aspect of care such as mouth care in children with cancer

Patient involvement in guideline development Cont.  Next. A detailed literature search is conducted to look for evidence from research studies about the appropriateness and effectiveness of different clinical management strategies.  Next. The evidence is considered by the guideline development group and recommendation are formulated.

Patient involvement in guideline development Cont.  Finally. The guideline is tested by asking professional not involved in guideline development to review it for clarity, internal consistency and acceptability.  All guidelines should be reviewed after a specified time period to make sure they are updated to take into account new knowledge.

Consensus Guidelines  Participants write down their views on topic in question.  Each participant, in turn, contributes one idea to the facilitator, who records it on a flip chart.  Similar suggestions are grouped together where appropriate. There is group discussion to clarify and evaluate each idea.

Consensus Guidelines Cont.  Each participant privately ranks each idea.  The ranking is tabulated and presented.  The overall ranking is discussed and re-ranked.  Final rankings are tabulated and results fed back to participants.

Appraising Published Guidelines  Rigour of development.  Context and content.  Application

Stages of Introducing the Guideline into Practice  Dissemination Stage: The method by which the guidelines are made available to potential users, publication in professional journals and sending the guideline to targeted individuals as well as educational intervention.

Stages of Introducing the Guideline into Practice Cont.  Implementation Stage: Is a means of ensuring that users subsequently act upon the recommendations. Implementation strategies try to ensure that users adopt and apply guidelines to which they have access.

Evaluating the effectiveness of Clinical Guidelines  Evaluation examined whether clinical guidelines are effective in changing the behavior of nurses and other professions, change in some process of care, measuring outcomes, in addition to evaluation of dissemination and implementation.

Benefits and Disbenefits of Clinical Guidelines Benefits of Clinical Guidelines  Ensure safe practice.  Improve consistency of care in different parts of the country / settings of care.  Build parity of knowledge amongst staff.  Allow for individual patient variation.

Benefits and Disbenefits of Clinical Guidelines Benefits of Clinical Guidelines Cont.  Make it more likely that clients receive correct treatment.  Raise client expectations about types and standards of care they might expect to receive.  Provide more information for clients about what they expect from the health care system.

Benefits and Disbenefits of Clinical Guidelines Cont. Disbenefits of Clinical Guidelines  Stifle (Limit) individual clinical judgment.  De-skill professionals by reducing their capacity to think for themselves.  Limit quality of care by restricting care/ treatment options.  Introduce practice which could be ineffective or dangerous.  Lack local relevance.