Clinical Guidelines

'Guidelines' are systematically developed statements designed to assist practitioner and patients on decisions about appropriate health care for specific clinical circumstances’ (Field and Lohr 1992).

The term guideline is now very common and is used within numerous setting e.g. government, education, transport, retail, health care etc. However there is still some confusion as to what a guideline is. The Oxford Dictionary defines the word guideline as :

A general rule, principle, or piece of advice

And that is exactly what clinical guidelines are, they are tools for implementing best evidence into clinical practice and it must be remembered that they are “tools not rules”  However  it is important to understand that within health care ‘clinical guidelines’ differ from guidance, standards and protocols in that they are:

“a series of systematic statements (derived from the best available evidence) and designed to guide the practitioner and patient to make informed decisions about health care for specific clinical circumstances”. (Field MJ & Lohr KN (eds). 1992): Guidelines for clinical practice. From development to use. Washington DC: National Academy Press.

It is a good idea to recognise the difference between other terms associated with delivery of effective health care.

For Example:

Guidance is normally provided to aid decision making in a specific and or general area which is normally derived from expert opinion and not necessarily based on evaluation of current research.

Standards are single or multiple statements that specify the type of care a patient should receive.  A standard may or may not be research based whilst a guideline will always be derived from the best research evidence available.

Protocols provide a specific framework with specific criteria for providing an aspect of patient care. Unlike a guideline they are less flexible and may or may not be based on the best research evidence.

Guidelines are playing an increasing role in setting standards of care in the UK. Well-developed guidelines provide clear, concise statements of best practice that are based on critically evaluated primary research studies or systematic reviews.  They are used to provide standards from which audit criteria can be derived. Although not legally binding (in the UK) they are frequently cited in courts of law as providing standards for practice which should be followed in the majority of cases, although good guidelines should also state exceptions to the case (Eccles 2001).

Clinical guidelines – are recommendations for the care of individuals by healthcare professions, which are based on the best available evidence. They aim to offer the level of care which is acceptable.  Good clinical guidelines are where possible based on the results of systematic reviews to underpin recommendations made about care/treatment/interventions.  Basing clinical decisions on a single research study may be misleading due to inadequate sample sizes which are unable to detect clinically important differences between.

Clinical guidelines are recommendations for care of a particular condition that have been developed by a multidisciplinary team and based on the best available evidence and expert opinion where necessary.  The aim is to improve the quality of care delivered and patient outcomes (National Institute for Clinical Excellence 2001b). They can provide evidence-based information on key clinical decisions relating to making a diagnosis; estimating prognosis; assessing relevant outcomes including the benefits, risks, and costs of alternative treatments; and finally, weighing up the various consequences of different treatment options (Eccles et al 2001).

Sometimes the findings or main recommendations from a guideline will be available in a flow diagram or algorithm which identifies the key decisions and important outcomes for patients.

What is the purpose of a clinical practice guideline?

The purpose of a clinical practice guideline is:

To provide practitioners with an evidence-based guide to practice;

To improve patient care; and

To assist practitioners and patients to make decisions about care and treatment.

Individual clinicians may use guidelines:

To answer specific clinical questions arising out of their day-to-day practice;

As an information source for continuing professional education;

To provide an overview of the management of a condition or the use of an intervention; and

As instruments for self-assessment or peer review to learn about gaps in performance (Feder et al. 1999).

The guideline should have audit review criteria derived from the guideline recommendations which you could implement in practice to measure your performance against best practice.

Clinical Guidelines are developed by National Guideline Developers, often bodies like NICE, SIGN and RCN will ask health professionals and members  to submit topics for guideline development and this involves 4-5 stages.

Stages

Tasks

Resources Needed

Stage 01

Initial scoping of topic

Identify the patient groups and for which type of patients the guideline will be most useful

Consider all potential forms of treatment

Confirm what the guideline will and will not cover (inclusion and exclusion criteria)

Develop search strategy and carry out literature search

Guideline developer methodologist

Guideline development group.

Health information specialist

Access to extensive library databases.

Stage 02

Retrieval and appraisal of evidence

Sifting and obtaining relevant papers

Critical appraisal and extraction of relevant data

Assimilation of evidence e.g. meta-analysis (Insert def into glossary)

Assess patient views

Guideline developer methodologists

Statistician

Health economist

Stage 03

Synthesis of evidence

Synthesis, summarising and grading of evidence

Consensus agreement of findings

Guideline developer methodologist

Guideline development group

Stage 04

Presentation of findings

Development of report and recommendations

Peer review – external clinical assessor and methodologist review

Guideline developer methodologist

Guideline development group

External assessors

Stage 05

Implementation

Review current practice and identify priorities for change

Consider potential barriers to implementation

Choose techniques for implementing guideline

Guideline development group

 Implementation group

Eccles M, Freemantle N, Mason J. 2nd edition 2001: Using systematic reviews in clinical guideline development.  In Egger M, Davey Smith G, Altman DG (eds) Systematic reviews in health care.  Meta-analysis in context: British Medical Journal Books

Feder G, Eccles M, Grol R, Griffiths C, Grimshaw J. 1999: Using clinical guidelines. British Medical Journal 318,728-730 .

© Yana Richens 2004 | Credits