Utility, Development, and Practice: The Learning Curve of Clinical Practice Guidelines

By Kelly Walkovich, MD, and Valerie Castle, MD

As pediatric oncologists, we are accustomed with working within the boundaries of extensive patient care protocols. In fact, the backbone of success in pediatric cancer treatment is largely due to strict adherence to and cooperation with protocol-driven care. But although many clinicians are familiar with protocol-driven care, they’re often hesitant, if not downright resistant, to adopt clinical practice guidelines (CPGs) for general care.

So why create CPGs? We believe they help us to meet multiple goals:

  • to provide evidence-based, expert-opinion sourced patient care that is current, reliable, and institution-appropriate
  • to educate the nurses, residents, fellows, and faculty who make up the patient care team
  • to unify care practices and minimize parental and staff confusion/disgruntlement
  • to improve efficiencies and reduce costs where possible
  • to improve quality and maximize safe care practices
  • to establish a reliable platform for high-quality clinical research.

In short, the CPGs are designed to enhance better patient care, better education, better patient satisfaction, and better clinical research.

To develop a successful CPG, it’s important first to identify needs for guidelines that resonate with clinicians, such as common clinical entities or, at the other end of the spectrum, rare clinical scenarios that require emergent care. Needs might be created by unnecessary practitioner difference or complex care scenarios involving multiple services and/or team members. Needs also can emerge in recognized system flaws (often triggered by “near misses” or unintended outcomes) or opportunities for cost-effectiveness.

After identifying a need, take these steps to ensure the success of the CPG and avoid common roadblocks:

Involve all stakeholders, particularly the non-physician staff such as pharmacy, nurses, clerks, and specialty lab directors. Their input invariably improves the product and allows for efficiencies and cost containment that providers may not always appreciate.

Identify a lead editor/author who will serve as the champion for each CPG, and who is responsible for coordinating meetings, facilitating discussion, and drafting or updating the actual CPG document.

Use a standardized CPG template; this can greatly expedite the writing process and improve content quality.

Have the entire primary clinical group review and update the CPGs; after all, they will be using the document to guide care and implementation.

Educate all staff — nurses, residents, clerks, fellows, faculty, pharmacists, and so forth — who will be involved in providing care according to the guidelines,  as well as patients and families affected by changes in care practice. This is a critical step in successful implementation.

In 2010, C. S. Mott Children’s Hospital at the University of Michigan Health System embarked on a new strategic plan that included the following commitment from all service lines and providers:

Research evidence will guide our care; without evidence we support clinical trial development. In the absence of evidence, our practitioners will practice best available and economically appropriate care, according to internally agreed-upon practice standards.

And the charge was simply put:

Each service line and specialty will develop clinical practice guidelines for the disease states of the patients they serve. Through the adoption of these CPGs, unnecessary practice differences will be eliminated.

To date, we have developed more than 180 clinical care guidelines, a number of which address major medical problems that cross service disciplines, for example: Care of Indwelling Catheters, Management of Fever in Immunocompromised Hosts, and Safe Use of Contrast Medium in Patients with Impaired Renal Function, to name just a few.  Our current efforts are focused on evaluating practice deviations from care guidelines and barriers to effective implementation.

Although early in our process, we have learned that CPGs survive scrutiny and prove useful when end-user acceptance is secured early; the CPG addresses high-risk care decision making; the document is easily accessible online with concise, practical, and current information; and, through service collaboration, helps to relieve non-medical barriers to care. We believe the development of clinical practice guidelines will grow as providers, trainees, staff, and health system leadership experience CPGs as a mechanism to foster care collaboration and improve care outcomes; and will embrace CPGs as vehicles for quality improvement efforts and clinical research opportunities.

—Valerie P. Castle, MD, is Ravitz Professor of Pediatrics, Professor and Chair, Department of Pediatrics and Communicable Diseases, and Pediatrician-in-Chief, C. S. Mott Children’s Hospital University of Michigan Health System. She can be reached at vcastle@med.umich.edu.

—Kelly Walkovich, MD, is a pediatric oncologist/hematologist at C. S. Mott Children’s Hospital. She can be reached at kwalkovi@med.umich.edu.

0 thoughts on “Utility, Development, and Practice: The Learning Curve of Clinical Practice Guidelines

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