guidelines

1. Writing and implementation of
guidelines, story in between
and practical advices
Prof. Dr. Jens Meier
Clinic for Anesthesiology and Critical Care Medicine
Kepler University Linz

2. Which care do we want to deliver?
patient
satisfaction
high medical
and nursing
quality
economical
and effective
optimized
processes

3. The standard of care in transfusion

4. Which care do we want to deliver?
patient
satisfaction
high medical
and nursing
quality
economical
and effective
optimized
processes
Do you achieve this
in PBM?

5. Overconfidence
Are you an above average lover?
> 75 % yes
< 25 % no

6. Are there any differences?

7. The situation in my country
Gombotz, Transfusion, 2007

8. Knowledge transfer
Gombotz, Transfusion, 2014
Center
before PBM implementation
after PBM implementation

9. Transfusion policy is like...

10. What creates this diversity?

11. 9 types of procedural
nonadeherence
• No perception of relevant information (input)
• Misperception of information (pattern matching)
• Procedural design (input, interpretation)
• Procedural experience/training (long-term memory)
• Cultural aspects (influencing factors)
• Personality aspects/attitudes (influencing factors)
• Situational factors (influencing factors)
• Decision-making heuristics (decision making)
• awareness and attention management

12. Types of violations
• routine violations: common practice becoming group norm
• optimizing violations: challenge when rules are too
restrictive
• situational violations: dictated by immediate environment
• exceptional violations: unusual or unfamiliar circumstances

13. Individualism?
I know better?

14. There is urgency for a guideline

15. Why do we need guidelines?
• Overwhelming amount of the literature
• Inadequacy of textbooks
• Difficulty synthesizing evidence and
translating into practice

16. What makes a good guideline?
• Valid
• Reproducible
• Cost-effective
• Representative / multidisciplinary
• Clinically applicable
• Flexible
• Clear
• Reviewable
• Amenable to clinical audit

17. How are evidence-based
guidelines developed?
• Identifying and refining the subject area of a guideline
• Running guideline development groups
• Identifying and assessing the evidence
• Translating evidence into a clinical practice guideline
• Reviewing and updating guidelines

18. The WHO way for guideline
development

19. The WHO way of a guideline

20. Who should write a guideline?
Professor Practitioner
• lots of theoretical knowledge
• well known
• trustable
• knows nothing about daily practice
• sponsored by industry
• good theoretical knowledge
• often unknown
• trustable ?
• knows everything about daily practice
• does not know the whole story
• sponsored by industry

21. The WHO way of a guideline

22. What is a PICO question?

23. What is a PICO question?
among elderly patients
does restrictive transfusion
versus liberal transfusion
affect mortality

24. What is a PICO question?
among elderly patients
does restrictive transfusion
versus liberal transfusion
affect mortality
among patients > 85 years
does Hb>11 g/dl
versus Hb<11g/dl
affect morbidity

25. The WHO way of a guideline

26. Grading the results

27. The WHO way of a guideline

28. Knowledge transfer

29. Knowledge transfer

30. Knowledge transfer

31. What are the typical steps of
guideline development
• Convert the need for info into an answerable
question
• Track down the best evidence
• Critically appraise that evidence
• Integrate the appraisal with one’s clinical
expertise and the individual patient

32. Critique for the guideline
process
• De-emphasizes patient values
• Doesn’t account for individual
variation
• Devalues clinical judgment
• Leads to therapeutic nihilism

33. Conclusions