see also: [[Quality improvement]] see: [Dunn Clinical Practice Guidelines](x-devonthink-item://B6D1C23E-7AD5-4413-8EDA-907787FA8088) [NHMRC principles for guideline development](http://www.nhmrc.gov.au) # pros/cons of clinical practice guidelines **pros** - translate current evidence into usable, accessible practice guideline - synthesises a large amount of information - ideally results in improved standard of care - identifies interventions of proven efficacy and discourages use of ineffective interventions - sets a standard for practice - supports quality improvement activities - identifies areas with poor evidence to direct further research **limitations** - variable quality - clinical decision rules with variable impact (10% are shown to be superior to normal practice, 30% inferior to unstandardised practice) - variable governance for guideline committee membership or process - may not be based on standard criteria - may not be subject to independent review (in contrast to research) - evidence base for recommendations may be incomplete - may mislead or existence of a guideline can be misinterpreted as evidence - may not apply to certain patient demographics - may not consider associated issues - cost-effectiveness - medico-legal - patient preferences - available resources - guidelines between various organisations may conflict - acceptance of guideline may not be universal - conflict of interest - by guideline authors eg financial or intellectual conflict - note that 80% of leaders of professional medical organisations in the USA have financial ties to industry - need regular review, process to allow early reviews if new evidence # NHMRC principles for guideline development - process should focus on outcomes - based on best available evidence and include statement on strength of recommendations - evidence can be graded according to its level, quality, relevance, and strength - multi-disciplinary process of guideline development - flexible and adaptable to varying local conditions - consider resources and economic appraisal - implementation and impact of guidelines should be evaluated - updated regularly - # write a guideline for X in 7 steps 1. Identify and meet with stakeholders -- senior ED medical and nursing staff 2. Research/Benchmark/lit review  3. Write draft policy with appropriate committee 4. Circulate amongst wider staff group for feedback/incorporate improvements identified 5. officially ratify and publish on guideline library 6. Education about policy 7. audit and review efficacy # how to develop a protocol? 1. identify need and define the problem and benefit 2. complete project initiation proposal 3. establish a project team and steering committee 4. research and gather information 1. review existing guidelines 2. conduct lit search and professional body guidelines 3. audit current practice 5. benchmark with other EDs 1. assemble stakeholders (eg FACEms, nurses, management) 6. desired content 7. define how auditing occurs 8. develop draft 9. circulate to stakeholders for review 10. implement and education 11. evaluate and adjust (QI PDSA cycle) # Example, stroke guideline: 1. Title - Thrombolysis for acute CVA 2. Target audience -ED Triage and staff / Internal Medicine /ICU / Radiology Immediate actions for patients with suspected stroke 3. Inform ED senior / Focused history and examination /Proceed to urgent CT Brain /Order routine lab tests, ECG, CXR 4. Instructions / Checklist paperwork for nursing staff and medical team to document process – BP observation important 5. Detailed Examination including - NIHSS score - Disability assessment – Modified Rankin score 6. Inclusion criteria - Clinically suspected CVA - Less than 4.5 hours - Age >18 7. Exclusion criteria - ICH / recent stroke / MI / Trauma /GI bleeding. Pt improving dramatically / Very large CVA on CT or clinically very severe symptoms Abnormal INR or platelets 8. Assess Bleeding risk 9. Discussion with Neurology / ICU / Stroke Team 10. Consent process - with patient / family – risks of bleeding 11. Drug specific information tPA (0.9mg/kg, 10% bolus dose, then infusion)– dose / route of 12. Disposition – ICU / stroke team. 13. References – stroke guidelines, Australian Stroke Foundation Addenda – NIHSS score 14. Signatories – ED director / Stroke team / ICU 15. Review date