Clinical Practice

Guidelines
Definition of CPGs

 The standard definition of Clinical practice guidelines (CPGs) is that of

Field and Lohr [1990]:

"systematically developed statements to assist

practitioners and patient decisions about
appropriate health care for specific circumstances".
 An Integrated Care Pathways ICP determines locally agreed
multidisciplinary and multi-agency practice, based on
guidelines and evidence where available for a specific
patient/client group. It forms all or part of the clinical record,
documents the care given, and facilitates the evaluation of
outcomes for continuous quality improvement.
What are Clinical Practice Guidelines?

‘’Clinical practice guidelines are systematically developed

statements to assist practitioner and patient decisions about
appropriate health care for specific clinical circumstances"
(Institute of Medicine, 1990).

 They define the role of specific diagnostic and treatment

modalities in the diagnosis and management of patients.

 The statements contain recommendations that are based on

evidence from a accurate systematic review and synthesis of the
published medical literature.
introduction

 Guidelines are designed to support the decision-making processes in patient

care . The content of a guideline is based on a systematic review of clinical
evidence - the main source for evidence-based care.
 The movement towards evidence-based healthcare has been gaining ground
quickly over the past few years, motivated by clinicians, politicians and
management concerned about quality, reliability and costs.
 CPGs, based on standardised best practice, have been shown to be capable
of supporting improvements in quality and consistency in healthcare. Many
have been developed, though the process is time- and resource-consuming.
 Many have been distributed, though largely in the relatively difficult to use
format of narrative text. As yet they have not had a major impact on
medical practice, but their importance is growing.
Purpose of CPGs

 To describe appropriate care based on the best available

scientific evidence and broad compromise;
 To reduce inappropriate variation in practice;
 To provide a more rational basis for referral;
 To provide a focus for continuing education;
 To promote efficient use of resources;
 To Act as focus for quality control, including audit;
 To highlight shortcomings of existing literature and suggest
appropriate future research.
Need for CPGs

 CPGs offer recommendations for care and are

prescriptive in nature, helping the practitioner
determine the appropriateness of selected
interventions.
 Official statement or policies for proper care .
 CPGs could be EBP based or non- EBP based.
 CPGs may be referred to as practice parameters,
practice policies and appropriateness criteria.
Computerised guidelines

 Computerised guidelines encode evidence-based recommendations for and can

automatically generate recommendations about what medical procedures to
perform adapted for an individual patient.
 Computerised guidelines offer benefits over and above those offered by paper-
based guidelines:
 They offer a readily accessible reference, providing selective access to guideline
knowledge.
 They help disclose errors in the content of a guideline;
 They help improve the clarity of a guideline, e.g. in decision criteria and clinical
recommendations;
 They help offer better descriptions of patient states;
 They can automatically propose timely, patient-specific decision support and
reminders.
Guidelines and protocols

 Clinical protocols can be seen as more specific than guidelines,

defined in greater detail. Protocols provide "a comprehensive
set of rigid criteria outlining the management steps for a single
clinical condition or aspects of organisation""
CPG for Radiography of the Ankle and Foot. (Ottawa
Ankle Rule )

Ankle X-ray series is required only if there is pain

in the malleolar Zone and any one of the following:
1. 1.Bone tenderness along the distal 6cm of the
posterior edge of the fibula or tip of the lateral
malleolus.
2. 2.Bone tenderness along the distal 6cm of the
posterior edge of the tibia or tip of the medial
malleolus.
3. 3.Inability to bear weight for four steps, both
immediately and in the emergency department.
Algorithms

 Algorithms are “Written guidelines to stepwise evaluation and

management strategies that require observations to be made,
decisions to be considered, and actions to be taken”.
(Hadorn,McCormick,&Diokno,1992)
 Algorithms are simply CPGs arranged in a decision-tree
format.
 A list of well-defined instructions for
completing a task.
Example

This is an algorithm that

tries to figure out why the
lamp doesn't turn on and
tries to fix it using the steps.
Flowcharts are often used
to represent algorithms
graphically.
Algorithms

Algorithm= Logic + control

Clinical Pathways
 Integrated Care Pathways (ICPs) provide a pattern for multi-
disciplinary care that is evidence-based and co-ordinated.
 An ICP determines locally agreed multidisciplinary and multi-
agency practice, based on guidelines and evidence where
available for a specific patient/client group. It forms all or part
of the clinical record, documents the care given, and facilitates
the evaluation of outcomes for continuous quality
improvement.
Sue Overill, Journal of Integrated Care (1998) 2, 93-98
 An ICP will plot the best sequence and timing of interventions
by clinicians, nurses, other professionals and agencies for the
best patient outcome.  ICPs can be developed nationally and
locally.   The development of a pathway is based on:
 evidence of good practice
 patient experience
 professional experience and judgement
 Once an integrated care pathway has been put in place for a
procedure or condition it can act as an explicit standard for the
delivery of patient care that can be monitored, streamlined and
improved.  Successful implementation of an ICP depends on
the.
 development of ICPs as part of an organisational quality
improvement process
 collaboration of patients and professionals in the development of
the ICP
 support and facilitation given to staff involved
 careful selection of ICP topics
 evidence-base or professional agreement for the ICP
 agreed goals and outcomes
 collection and analysis of variations from the ICP
 completion and use of the ICP by all staff involved.
 Defining characteristics of care pathways include:


(i) A clear statement of the goals and key elements of care based on evidence, best
practice, and patients’ expectations and their characteristics;

(ii) the facilitation of the communication among the team members and with patients and
families;

(iii) the coordination of the care process by coordinating the roles and sequencing the
activities of the multidisciplinary care team, patients and their relatives;

(iv) the documentation, monitoring, and evaluation of variances and outcomes; and

(v) the identification of the appropriate resources.

 The aim of a care pathway is to enhance
the quality of care across the continuum
by improving risk-adjusted patient
outcomes, promoting patient safety,
increasing patient satisfaction, and
optimizing the use of resources.
 Clinical Pathways were introduced in the early 1990s in the UK and
the USA, and are being increasingly used throughout the developed
world. Clinical Pathways are structured, multidisplinary plans of care
designed to support the implementation of clinical guidelines and
protocols.
 They are designed to support clinical management, clinical and non-
clinical resource management, clinical audit and also financial
management.
 They provide detailed guidance for each stage in the management of
a patient (treatments, interventions etc. ....) with a specific condition
over a given time period, and include progress and outcomes details.
Component of Clinical pathways

 Clinical Pathways have four main components

(Hill, 1994, Hill 1998):
 a timeline,
 the categories of care or activities and their
interventions,
 intermediate and long term outcome criteria,
 the variance record (to allow deviations to be
documented and analysed).
 Benefits of ICP

 Support the introduction of evidence-based medicine and use of clinical

guidelines
 Support clinical effectiveness, risk management and clinical audit
 Improve multidisciplinary communication, teamwork and care planning
 Can support continuity and co-ordination of care across different clinical
disciplines and sectors;
 Provide explicit and well-defined standards for care;
 Help reduce variations in patient care (by promoting standardisation);
 Help improve clinical outcomes;
 Help improve and even reduce patient documentation
 Support training;
 Optimise the management of resources;
Benefits of ICP

 Can help ensure quality of care and provide a means of continuous quality improvement;
 Support the implementation of continuous clinical audit in clinical practice
 Support the use of guidelines in clinical practice;
 Help empower patients;
 Help manage clinical risk;
 Help improve communications between different care sectors;
 broadcast accepted standards of care;
 Provide a baseline for future initiatives;
 Not narrow: don't override clinical judgement;
 Expected to help reduce risk;
 Expected to help reduce costs by shortening hospital stays
Pathway Development Teams

 Assemble multidisciplinary teams.

 Define clinical problems and current practice.
 Conduct literature search
 Describe and classify research according to levels of evidence.
 Formulate guideline recommendations
 Link guidelines to form clinical pathways.
Issues - potential problems and barriers to the introduction
of ICPs

 May appear to discourage personalised care

 Risk increasing litigation
 Don't respond well to unexpected changes in a patient's condition
 Suit standard conditions better than unusual or unpredictable ones
 Require commitment from staff and establishement of an adequate
organisational structure
 Problems of introduction of new technology
 May take time to be accepted in the workplace
 Need to ensure variance and outcomes are properly recorded,
audited and acted upon.
 CPGs, Algorithms, and Clinical Pathways Comparison.

CPGs& Algorithms: Clinical pathways

 Focus on identifying best clinical option. Focus on operationalizing options.
 Useful across clinical Settings, apply  Setting/institution specific; tailored to fit local
generally. conditions.
 May or may not be provider specific.  Require multi or trans-disciplinary approach
based on evidence.
 Based on evidence, expert opinion or
consensus  Produced by a multidisciplinary team.
https://blogs.bmj.com/bjsm/2018/08/31/how-physiotherapists-can-contribute-to-decision-making-a-proposal-for-a-pt-
treatment-pathway-for-knee-osteoarthritis/