Some reservations about clinical guidelines

Health informatics and evidence-based medicine - more than a marriage of convenience?

The importance of informatics in healthcare is more than just a consequence of rapid information technology (IT) developments over the last couple of decades. Informatics-related activities are located at the very heart of healthcare and involve biomedical sciences, computer sciences and healthcare policy and management. Evidence based medicine (EBM) may be defined as the explicit and judicious use of current best evidence in making decisions about the care of individual patients. The key principles of EBM - from finding, appraising and using research-based knowledge, to establishing systems for managing medical knowledge and promoting and facilitating evidence-based decisionmaking - have parallel informatics functions. Benson has described these as knowledge browsing, messagingand counting.Health informatics can be described as the very engine room driving EBM. As a consequence of this health informatics is embroiled in an intense social and medical dialogue about the very basis of scientific method, theory and practice of medicine.

Resisting Evidence: The Study of Evidence-Based Medicine as a Contemporary Social Movement

Evidence-based medicine (EBM) emerged relatively recently to describe the explicit process of applying research evidence to medical practice. The movement was high profile, yet not overly successful: many clinicians do not use up-to-date evidence in their everyday work. This article shows how a social movement perspective can be used to analyse the emergence of EBM and shed light on power struggles between segments of the medical profession. It draws on Blumer's (1951) essay on social movements to demonstrate the continued salience of this approach. The article also presents empirical data from a qualitative study of English and American surgeons to illustrate how EBM provides a focus for segmental conflict within medical practice between `art' and `science', `practice' and `evidence'. Together these data and the social movements perspective provide insight into the dynamics of this struggle and help to explain why clinicians continue to resist EBM.

A review of clinical guidelines

Background

Clinical guidelines are increasingly used in patient management but few clinicians are familiar with their origin or appropriate application.

Methods

A Medline search using the terms ‘clinical guidelines’ and ‘practice guidelines’ was conducted. Additional references were sourced by manual searching from the bibliographies of articles located.

Results and conclusion

Clinical guidelines originated in the USA in the early 1980s, initially as a cost containment exercise. Significant improvements in the process and outcomes of care have been demonstrated following their introduction, although the extent of improvement varies considerably. The principles for the development of guidelines are well established but many published guidelines fall short of these basic quality criteria. Guidelines are only one aspect of improving quality and should be used within a wider framework of promoting clinical effectiveness. Understanding their limitations as well as their potential benefits should enable clinicians to have a clearer view of their place in everyday practice.

An evidence and consensus based guideline for the management of a child after a seizure

OBJECTIVE

An evidence and consensus based guideline for the management of the child who presents to hospital having had a seizure. It does not deal with the child who is still seizing. The guideline is intended for use by junior doctors, and was developed for this common problem (5% of all paediatric medical attenders) where variation in practice occurs.

OPTIONS

Assessment, investigations (biochemistry, lumbar puncture, serum anticonvulsant levels, EEG in particular), and/or admission are examined.

OUTCOMES

The guideline aims to direct junior doctors in recognising those children who are at higher risk of serious intracranial pathology including infection, and conversely to recognise those children at low risk who are safe to go home.

EVIDENCE

A systematic review of the literature was performed. Articles were identified using the electronic data bases Medline (from 1966 to June 1998), Embase (from 1980 to June 1998) and Cochrane (to June 1998), and selected if they investigated the specified clinical question. Personal reviews were excluded. Selected articles were appraised, graded, and synthesised qualitatively. Statements of recommendation were made.

CONSENSUS

An anonymous, postal Delphi consensus development was used. A national panel of 30 medical and nursing staff regularly caring for these children were asked to grade their agreement with the statements generated. They were sent the relevant original publications, the appraisals, and literature review. On the second and third rounds they were asked whether they wished to re-grade their agreement in the light of other panellists' responses. Consensus was defined as 83% of panellists agreeing with the statement. Recommendations in brief: For afebrile seizures all children should have their blood pressure recorded, but no other investigations are routine although a seizing or somnolent child should have blood glucose measured; all children under 1 year should be admitted. For seizures with fever, clinical signs indicating the need to treat as meningitis are given. Children should be admitted if they are under 18 months old, have had a complex seizure, or after pretreatment with antibiotics.

VALIDATION

The guideline has undergone implementation and evaluation in a paediatric accident and emergency department, the results of which will be published separately. Only one alteration was made to the guideline as a result of this validation process, which is included here.

Developing benchmark inventories to assess the content of telephone consultations in accident and emergency departments: use of the Delphi technique

The provision of telephone advice to members of the general public from staff based in accident and emergency departments is common practice. However, it is largely conducted on an ad hoc basis without the use of formal guidelines or decision support. The evidence base from which to derive guidelines for the telephone assessment and advice of many common conditions is lacking. This study, using the Delphi technique, was undertaken to develop a number of benchmarks for use as objective measures against which the comprehensiveness of telephone assessments could be tested. Consensus views on the essential and desirable items to be considered for each of 10 presenting complaints was achieved. It is argued that establishing consensus views on clinical topics provides an effective means of developing an evidence base where other sources of evidence are lacking.

An evidence and consensus based guideline for acute diarrhoea management

OBJECTIVE

To develop an evidence and consensus based guideline for the management of the child who presents to hospital with diarrhoea (with or without vomiting), a common problem representing 16% of all paediatric medical attenders at an accident and emergency department. Clinical assessment, investigations (biochemistry and stool culture in particular), admission, and treatment are addressed. The guideline aims to aid junior doctors in recognising children who need admission for observation and treatment and those who may safely go home.

EVIDENCE

A systematic review of the literature was performed. Selected articles were appraised, graded, and synthesised qualitatively. Statements on recommendation were generated.

CONSENSUS

An anonymous, postal Delphi consensus process was used. A panel of 39 selected medical and nursing staff were asked to grade their agreement with the generated statements. They were sent the papers, appraisals, and literature review. On the second and third rounds they were asked to re-grade their agreement in the light of other panelists' responses. Consensus was predefined as 83% of panelists agreeing with the statement.

RECOMMENDATIONS

Clinical signs useful in assessment of level of dehydration were agreed. Admission to a paediatric facility is advised for children who show signs of dehydration. For those with mild to moderate dehydration, estimated deficit is replaced over four hours with oral rehydration solution (glucose based, 200-250 mOsm/l) given "little and often". A nasogastric tube should be used if fluid is refused and normal feeds started following rehydration. Children at high risk of dehydration should be observed to ensure at least maintenance fluid is tolerated. Management of more severe dehydration is detailed. Antidiarrhoeal medication is not indicated.

VALIDATION

The guideline has been successfully implemented and evaluated in a paediatric accident and emergency department.

Development of clinical guidelines for the sedation of children

Young children may be unwilling or unable to cooperate if they are required to remain motionless for a prolonged period of time. In the hospitalized child, investigative procedures perceived as painful or threatening may need the administration of a sedative. Clinical guidelines, within a large teaching hospital NHS trust in the North of England, were implemented in an attempt to reduce the diversity of the practices of healthcare professionals caring for the child requiring sedation. The guidelines were formulated by a multidisciplinary team and, in conjunction with active dissemination strategies, resulted in a change in practice that included: (1) improved communication and cooperation between departments, (2) implementation of starvation times before the administration of a sedative, and (3) the appropriate referrals to a senior paediatrician to seek advice if contraindications to sedation were identified. Audit was integral to the process, facilitating the comparison of actual practice with the standards developed from the guidelines and ensuring a continuous monitoring programme.

Specific issues related to developing, disseminating, and implementing pediatric practice guidelines for physicians, patients, families, and other stakeholders

OBJECTIVE

To describe ways in which medical information should be developed and disseminated, focusing on pediatric practice guidelines as an example of one type of information.

PRINCIPAL FINDINGS

The methodology of guideline development is well known and has been previously reviewed. Guideline development poses problems for many medical specialties, but particularly for pediatrics, because (1) few diseases are prevalent, (2) only limited randomized controlled trials have been conducted with respect to specific diagnostic and therapeutic options, and (3) clinicians often are dealing with patient surrogates--parents--rather than with the actual patient. Patient and family involvement in guideline development and dissemination has been limited and may affect the likelihood that guidelines will be adopted and subsequently improve child health outcomes. The science of dissemination, including guidelines and other information, is poorly developed. Little is known about the most effective ways to ensure that guidelines reach clinicians and are adopted. Finally, the effect of guidelines on child health outcomes is itself uncertain.

RECOMMENDATIONS

(1) Research efforts should focus on guideline dissemination and adoption. (2) The effect of guideline implementation on health outcomes needs to be better understood. (3) Parents should be more involved in guideline dissemination and adoption.

What are hospitals doing about clinical guidelines?

OBJECTIVES

To assess the attitudes of senior hospital staff towards clinical guidelines, and to ascertain the perceived extent and benefits of their local use; to identify those hospitals with current or planned future written strategies for the systematic development of clinical guidelines, and the staff responsible for leading them; and to establish the essential elements of existing strategies, and the methods used to ensure the proper development, dissemination, implementation, and evaluation of local guidelines.

DESIGN

Cross sectional survey.

PARTICIPANTS

Senior staff of 270 acute hospitals in the United Kingdom (response rate 202/270 (75%)) in 1995.

RESULTS

197/199 (99%) of respondents thought that clinical guidelines were a good idea, and 176/196 (90%) were aware of some guideline activity occurring within their hospitals. The most important benefits of local guideline activity were increased healthcare efficiency and effectiveness, greater consistency of treatment, and team building. 174/194 (90%) of respondents were in favour of the development of a readily accessible national repository of evidence-based clinical guidelines. 38/201 (19%) of respondents had a clinical guidelines strategy and a further 91/201 (45%) said that they had plans to develop one in the near future. The need to improve clinical outcomes was most often reported as the reason for developing a strategy. Medical directors most commonly had formal responsibility to lead the strategy, but someone without formal responsibility ran the operation in half the hospitals. Only 18/36 (50%) of strategies gave advice on the development of guidelines; and only a few strategies made explicit statements on which clinical services to target for guideline development, or the methods to be used for their validation and promotion. Some strategies lacked explicit statements on methods to monitor adherence, routine review, and update of guidelines. Internal literature searches (29/31 (94%)), the use of national guidelines (29/32 (91%)), local consensus conferences (28/32 (88%)), and peer group review (21/24 (88%)) were the most popular methods of validation used in hospitals with a strategy. Methods used to promote the dissemination, implementation, and evaluation of clinical guidelines included clinical audit (31/32 (97%)), peer review (25/30 (83%)), continuing education (23/29 (79%)), targeting of opinion leaders (17/26 (65%)), use of structured case notes (14/31 (45%)), patient mediated interventions (9/26 (35%)), and patient specific reminders (8/26 (31%)).

CONCLUSIONS

Most senior hospital staff have a favourable attitude towards clinical guidelines. Most hospitals are undertaking some guideline activity, but few seem to be doing so within a locally agreed hospital wide strategy in which guideline development, dissemination, implementation, and evaluation are systematically considered. Many of the current methods used to validate guidelines locally are inadequate. Evidence-based clinical guidelines should be developed nationally, leaving hospitals to focus their energies on the local adaptation, dissemination, implementation, and evaluation of such guidelines. Only in this way will local guidelines achieve their full potential to improve clinical care and patient outcomes.

Clinical guidelines and their implementation

Within the UK there has been increasing interest in the development and implementation of guidelines, as the emphasis on clinical effectiveness is gathering momentum. This paper outlines some of the practical issues encountered in developing and implementing guidelines, based on experiences within Liverpool. Developing local guidelines can be a lengthy process, but that process is not a waste of time if it means there is more likely to be compliance in the end. Dissemination of guidelines alone is not enough; it needs to be combined with an appropriate implementation strategy. There is a danger of primary care being overloaded with new guidelines; there needs to be a timed strategy for their introduction. More imaginative thought needs to be put into the marketing of new ideas in order to change practice. We need to encourage the ethos amongst healthcare professionals of expecting to have to constantly update knowledge and practice.