Towards evidence-based clinical practice guidelines implementation at King Saud University Medical City

Towards implementation of
Evidence-Based Clinical
Practice Guidelines (CPGs)
Dr. Yasser S. Amer
MBBCh, MPed, MHI, CPHQ, FISQua
Quality Management Department
Medical-City Wide CPGs Steering Committee
Research Chair for Evidence-Based Health Care & Knowledge Translation11/2/2016 1

Training Plan Program
Training Program Title :
Towards Implementation of Evidence-Based Clinical Practice
Guidelines
Training Program Duration : Four (4) hours
Targeted Employees : • Department Quality Team Members
• Department CPG Committee Members
• Residents/ Interns
Training Programs Goals : To provide participants with an overview on the state-of-the-art knowledge, skills, and tools on using
evidence-based clinical practice guidelines in daily practice at King Saud University Medical City
Training Program Objectives: At the end of the training program, participants should be able to:
1. Define Evidence-Based Medicine (EBM) and Clinical Practice Guidelines (CPGs).
2. Discuss the rationale and aims for using CPG.
3. Name the stakeholders involved in CPGs.
4. Identify types of CPGs.
5. Recognize standards of trustworthy or high quality CPGs
6. Describe the difference between the (de novo) development versus adaptation of CPGs.
7. Define CPG implementation and recognize different types of CPGs implementation tools.
8. Discuss facilitators and barriers to implementation of CPGs.
9. Memorize CPGs that are applicable in the concerned department of the target audience.
10. Locate and access the CPGs (online and/or offline) that are applicable in the concerned department of the
target audience.
11. Identify which sections to read in the CPG full documents.
12. Recognize the contact person(s) for CPGs in the concerned department of the target audience.
13. Recognize the composition of the CPG program at KSUMC.
14. Appraise CPGs using the AGREE II Instrument.
15. Understand the CPG-related QI/ accreditation standards.
11/2/2016 2

CPGs: Definitions, concepts and standards
11/2/2016 3

Uncertainty!.....Probability!
Sir William Osler (1849 – 1919)
11/2/2016 4

The Epsom Derby, 1821 (oil on canvas) by Theodore Gericault;
Louvre, Paris, France – Slide Courtesy of Prof. Abdelhamid Attia
Importance of Research
People observe what they expect to observe, until shown otherwise
11/2/2016 5

• http://www.youtube.com/watch?v=IEqccPhsqgA&list
=PLSC6ykdWzbjHk4fKrmB94yj11dqfkXF0U
57 years later!
Sallie Gardner (horse) at a Gallop
Eadweard Muybridge in 1878 – 3 seconds silent film, USA
11/2/2016 6

Sallie Gardner (horse) at a Gallop
Eadweard Muybridge in 1878 – 3 seconds silent film, USA
11/2/2016 7

“EBM” - birth of a term
Update of CMAJ series on how to read a
paper
JAMA User guides 1991
authors seek a new term
Clinical epidemiology?
Scientific medicine?
Evidence-based medicine!
Research evidence should guide clinical
practice! Wasn’t it always that way?!
Slide courtesy of Dr. Paul Glasziou
11/2/2016 8

Evidence-Based Medicine (EBM)
Movement: Not new!
• 865–925 Al-Razi (Rhazes)
1st need for experiments, comparisons in clinical studies
• 981–1037 Ibn Sina (Avicenna)
test effect of drugs on humans not animals only
• 1987 David M. Eddy, MD, PhD
‘EB’ in EBCPGs, policies in workshops, manual
• 1992 Gordon Guyatt, MD
‘EBM’ term in JAMA
• 1996 David Sackett, MD
‘EBM’ definition in BMJ
11/2/2016 9

How can we find the research that will improve
the care of our patients?
0
500000
1000000
1500000
2000000
2500000
Biomedical MEDLINE Trials Diagnostic?
MedicalArticlesperYear
5,000?
per day
1,500
per day
95 per
day
MedicalArticlesPerYear
19 of 20
11/2/2016 10

Two Different Approaches to
Evidence-Based Practice
Clinical Practice Guidelines (CPGs)
•“Top-down” approach
• Tell clinicians how to practice
• Favored by health care systems
Evidence-Based Medicine (EBM)
•“Bottom-up” approach
• Teach clinicians how to find answers
• Favored by medical educators
11/2/2016 11
Slide courtesy of Prof. Afaf Ibrahim

11/2/2016 13
Knowledge Translation
Knowledge transfer & exchange
Implementation science/ research
Research utilization
System/ Provider and Quality Improvement
Dissemination & diffusion
Research use
Knowledge transfer & uptake

Definition: (old)
“Systematically developed statements to assist
practitioner and patient decisions about
appropriate health care for specific clinical
circumstances” (IOM 1990)
Clinical Practice Guidelines (CPGs)
1411/2/2016

“Statements that include Recommendations
intended to optimize patient care that are
informed by a Systematic Review of evidence
and an assessment of the benefits and harms of
alternative care options”
(IOM-AHRQ 2011)
11/2/2016 15

Although CPGs have been identified as
tools for improvement of patient
healthcare outcomes, there is an
increasing and often unmanageable
volume of published CPGs that creates
confusion for healthcare providers due
to the variability in the quality of these
CPGs (Altokhais 2016, Greenhalgh 2014)
11/2/2016 16

Evidence Pyramid (Study design)
SR
RCT
Cohort
Case control
Case series
Case report
Expert opinion
I
II
III
IV
A
B
C
LevelsofEvidence
GradesofRecommendations
MA
11/2/2016 17

The proposed new EBM pyramid.
M Hassan Murad et al. Evid Based Med 2016;21:125-127
©2016 by BMJ Publishing Group Ltd
New evidence pyramid
11/2/2016 18

It’s peer-reviewed, therefore it must be OK?
11/2/2016 19

methods
11/2/2016 20
Benefits Risks/
Burden
QoE!

Level
Evidence
(LoE)
Grade
Recomm.
(GoR)
Strength
EVIDENCE PYRAMID11/2/2016 21

What is ‘real EBM’ and how to
achieve it?
11/2/2016 24

What is ‘real EBM’ and how to achieve it? (cont’d)
11/2/2016 25

Relationships between Quality Improvement (QI) and Evidence-Based Medicine (EBM).
Paul Glasziou et al. BMJ Qual Saf 2011;20:i13-i17
Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.11/2/2016 27

HWCPG-ENT-001 (ABRS) 2013
11/2/2016 30

Why
Do we need
CPGs?
11/2/2016 31

Rationale for CPGs
• Worldwide concerns about:-
▫ Unexplained variation/ variability in CP!
▫ Rising healthcare costs!
▫ Exponential growth of health information!
• Aim of CPGs:-
To facilitate more consistent, effective and efficient practice and
improve health outcomes for patients
11/2/2016 32

• Physicians
• Nurses
• Pharmacists
• Technicians
• Technologists
• Decision makers
• Patients
• Public
11/2/2016 34

Types of CPGs
1.Evidence-Based CPGs (evidence-
based methodology)
2.Consensus/ expert-based CPGs
11/2/2016 35
Which type do you think is
better?

Producers Finders
11/2/2016 37

• Specialized (professional) societies
• Healthcare Organizations
• Governmental (National) organizations:
NICE, SIGN, NHMRC, ,etc.
• International organizations
11/2/2016 38

Organization Name
Country
URL
Produc
er
Find
er
Guidelines International Network (G-I-N)
Internatio
nal
http://www.g-i-n.net F
World Health Organization (WHO)
Internatio
nal
http://www.who.int/topics P
National Institute for Health & Care
Excellence (NICE)
UK
http://www.nice.org.uk/page.aspx?o
=ourguidance
P
Scottish Intercollegiate Guidelines Network
(SIGN)
UK
http://www.sign.ac.uk/guidelines/ind
ex.html
P
National Guidelines Clearinghouse (NGC),
AHRQ
USA http://www.guidelines.gov F
EBSCO DynaMed USA dynamed.ebscohost.com/user/login
Institute for Clinical Systems Improvement
(ICSI)
USA http://www.icsi.org/knowledge/ P
F
US National Library of Medicine, National
Institutes of Health (PubMed)
USA
http://www.ncbi.nlm.nih.gov/pubme
d
OR http://www.pubmed.gov
F
Google Scholar USA
https://scholar.google.com/?hl=ar&sa
fe=on
F
11/2/2016 39

CPG Producers: National
Agencies
NICE
National
Institute for
Health &
Clinical
Excellence
www.nice.org.
uk11/2/2016 40

NICE Guidance
 132 CPGs
11/2/2016 41

CPG Producers: National
Agencies
11/2/2016 42
SIGN
Scottish
Intercollegiate
Guidelines Network
www.sign.ac.uk
14 groups

World Health Organization
11/2/2016 43
• WHO guidelines for safe surgery: safe surgery
saves lives (2009)
• Best Practice Guidelines on Emergency Surgical
Care in Disaster Situations (2007)

DynaMed
https://dynamed.ebscohost.com/
11/2/2016 44

CPGs Finders
• National Guidelines Clearinghouse (NGC/
AHRQ)
• Guidelines International Network (G-I-N)
• EBSCO DynaMed
• PubMed/ MedLine
• Google Scholar
11/2/2016 45

AHRQ-NGC
National
Guideline
Clearingho
use
www.guidelines
.gov
11/2/2016 46

Shaikh Bahamdan’s Research Chair for Evidence-
Based Health Care & Knowledge Translation
Member of G-I-N since Oct. 2009
Free access to International CPG Library of G-I-N
http://c.ksu.edu.sa/ebhc
11/2/2016 47

http://c.ksu.edu.sa/ebhc/en
11/2/2016 48

PubMed: US National Library of Medicine,
National Institutes of Health (NIH)
11/2/2016 52

Specialized Societies:
PEDIA AAP
5311/2/2016

PSYCH The Maudsley Hospital
11/2/2016 60

Nursing RNAO
• Toolkit for
implementation
of CPGs
• www.rnao.ca
11/2/2016 63

11/2/2016 66
What makes a trustworthy CPG?

Standards for high quality CPGs
IOM 2011 – G-I-N 2012 – AGREE 2013
11/2/2016 67

Standards for trustworthy CPGs
IOM 2011 G-I-N 2012
1- Establishing Transparency 1- Decision making process. 2- Methods
2- Management of COI 3- COI
3- (GDG) composition 4- GDG composition
4- (CPG – SR) intersection 5- Evidence reviews
5- Assign/ link to (LoE) & (GoR) 6- Rating of E & Rs
6- Articulation of (Rs) 7- CPG Rs (formulation/ wording)
7- External Review 8- Peer review & stakeholder consultation
8- Updating 9- Expiration & updating
10- Scope of CPG
11- Financial support/ sponsoring organization
11/2/2016 68

How to assess of the quality of any CPG ?
11/2/2016 69

23 Items in 6 Domains
USER’S MANUAL page 7
DOMAINS No. of Items
1 Scope & Purpose 3
2 Stakeholder Involvement 3
3 Rigour of Development 8
4 Clarity & Presentation 4
5 Applicability 3
6 Editorial Independence 2
11/2/2016 70

CPG development
methodologies
11/2/2016 71

Read
Adopt
Adapt
Develop
CPGs ?
11/2/2016 73
Slide courtesy of Prof. Nabil Dowidar

CPGs
DEVELOPMENT
(de novo)
vs.
ADAPTATION
11/2/2016 74

Different Options to deal with CPG
11/2/2016 75

Adaptation of CPGs
Is the systematic approach to the endorsement and/or
modification of a guideline(s) produced in one cultural
and organizational setting for application in a different
context. Adaptation may be used as an alternative to
de novo guideline development, e.g., for customizing
(an) existing guideline(s) to suit the local context.
http://www.adapte.org/
http://www.g-i-n.net/
11/2/2016 78

Team - Topic
Total Number of
Health Topics for
CPGs from all
departments
53
11/2/2016 80

Selecting a CPG Topic
 Prevalence of the condition (high volume)
 Patient safety concern (high risk)
 Under-, over-, misuse of intervention(s)
 Burden due to the condition
 Practice variation
 Costs of different practice options
 Likelihood of effectiveness of CPG
 Potential for improving quality of care and/or
outcomes
 Existence of relevant good quality CPGs
11/2/2016 81

KSUMC Protocol for New CPG
11/2/2016 82

Health/ Clinical/ Key Questions
Patient (& disease characteristics)
Intervention(s)
Professionals (Target users)
Outcomes (purpose of the CPGs)
Healthcare settings (& context)
11/2/2016 83
CPG Scope: PIPOH Model

Health Question Tool (modif.)
11/2/2016 84

Inclusion / Exclusion CPGs Selection Criteria (6)
1. Methods of Development: Evidence-Based CPGs: (Detailed
Methodology not Consensus-based CPGs (Expert opinion)
2. Author(s): Organization and Specialized Society not single
authors.
3. Country: International not national CPGs.
4. Date of Publication: range of year of publications: last 5
years or less (e.g. 2011 – 2016) – except if none!
5. Language: English CPGs only
6. Status: only Original source CPG (de novo developed) rather
than adapted CPGs
11/2/2016 90

CPG selection criteria Tool (new)
11/2/2016 91

Producers Finders
11/2/2016 93

How to assess of the quality of any CPG ?
11/2/2016 95

11/2/2016 96
The concept of the
‘LIVING’ CPG

End of Finalization Phase
1. After end of External review
2. CPG Dept. committee submit finalized CPG draft to R & D Unit,
Quality Management Department for review;
3. Submit to CPG Steering Committee for review of adaptation
process methodology and final approval;
4. Congratulations letter to Chairman of department
5. Start dissemination and implementation in relevant
departments;
6. Follow up, clinical auditing & measurement in relevant
departments;
11/2/2016 97

:: Evidence to practice/ knowledge to action cycle ::
CPG Implementation
(CPGI)
Strategies & Tools
11/2/2016 98

CPGI
“The concrete activities and
interventions undertaken to turn
policies into desired results“
Guidelines for clinical practice: from development to use. IOM,
1992
CPGs Practice
11/2/2016 99

CPG “Implementability”
Set of characteristics that
PREDICT the relative ease
of implementation of CPG
recommendations.
Implementability…….BEFORE
implementation
11/2/2016 100

How to Measure Implementability?
Ease and accuracy of translation of
guideline advice into systems that
influence care.
11/2/2016 101

Dissemination &
Implementation
Nothing could be more frustrating
than producing a CPG that is then
ignored by not being disseminated
nor implemented nor updated.
The concept of the ‘LIVING’ CPG
11/2/2016 102

Adapt/ design CPGI Tools
to be made available at the point of care (* MR/ EMR)
Examples
• Clinical Algorithms
• Integrated Care/ Clinical Pathways
• Protocols
• Policies & Procedures
• Chart Documentation/ forms (e.g. Physician Order
Sets: paper vs. CPOE system +/- CDSS)
• Quick Reference Guides/ Physician Guides &
Pocket Guide/Reference Cards (at-a-glance
summary of key recommendations).
• Mobile Apps
10411/2/2016

• Clinical audit criteria (tool)
• Quality/ Performance measures (process, outcome
KPIs)
• Quality Tools (e.g. FMEA)
• Slide Presentation.
• Wall Poster.
• Patient Resources/ Information (HE guides).
• Foreign language Translation (Non-Arabic, Non-
French).
• Implementation Tool Kits (collections of tools and/or
strategies).
• Staff Training/ Competency Material.
CPGI tools (cont’d)
11/2/2016 105

Mobile Apps for
CPGs (mHealth)
11/2/2016 106

MEDICINE/ CARDIOLOGY
Specs detail
Specialty Medicine
Organization American College
of Cardiology
Foundation
Cost Free
System Android
11/2/2016 107

PEDIATRICS
Specs detail
Specialty Pediatrics
Organization Royal Children’s
Hospital,
Melbourne
Cost Free
System Android
11/2/2016 108

General
Specs detail
Specialty Medicine
Organization NICE
Cost Free
System Android
11/2/2016 109

General
Specs detail
Specialty General
Organization SIGN
Cost Free
System Android
11/2/2016 110

NURSING
Specs detail
Specialty Nursing
Organization RNAO
Cost Free
System Android
11/2/2016 111

ORTHOPEDICS
Specs detail
Specialty Medicine
Organization American
Academy of
Orthopedic
Surgeons
Cost Free
System Android
11/2/2016 112

PSYCHIATRY
Specs detail
Specialty Psychiatry
Organization (?)
Cost Paid
System Android
11/2/2016 113

General
Specs detail
Specialty General
Organization Guideline Central
Cost Free/ paid
System Android
11/2/2016 114

NICE Guidance
‘Tools and resources’
• Baseline
assessment
• Clinical audit
• E-learning
module
• Slide set
• Tailored
education
support
• Case scenario
• Commissioning
guide
• Costing
statement
• shared
learning
• ‘Do not do’
recommendati
ons
• Research
recommendati
ons
• Guidance into
practice
11/2/2016 115

CPG implementation strategies/
interventions
11/2/2016 116

CPG implementation
strategies
Dissemination Process (print/ e-/website)
Local Clinical Champions.
Awareness raising/ training activities.
Networking and linking with existing projects
(e.g. CPD/CME activities, Accreditation, etc..).
Patients as champions for change.
Regular M & E (The ‘living’ CPG concept!).
11/2/2016 117

Audit: Manual
• Source of data: paper patient files (before May 2015)
and eSiHi afterwards
• Data collection tools: audit tools included in CPGs
(review)
• Specific clinical audit criteria or KPI formulae
• Data collection
• Data cleansing
• Data analysis
• Graphical representation and reporting the results
11/2/2016 118

Audit: Electronic
• Continue working on eSiHi quality solutions to
generate reports of CPG-based POWERPLANS or
CPOE per diagnosis for CPG (Discern
Analytics©, Power-Insight©,..etc.)
• Ensure inclusion of the identified CPG-based KPIs in
the built of the new Database of the KPI project
11/2/2016 119

“Multi-faceted” are more
effective than single
strategies in CPGI!
11/2/2016 120

Facilitators and Barriers in
CPGI
11/2/2016 121

Facilitators of CPGI
Domain
Positive attitude
Learning through small group interaction
Individual
Leadership support
Champions
Team work collaboration
Organizational
Scientific specialized association support
Inter-organizational collaboration
networks
Environmental
11/2/2016 122

CPG Implementation Failure!
BARRIERS!
Extrinsic to CPG:
provider & care system-related
Intrinsic to CPG: (>Methodology!)
ambiguity – inconsistency - incompleteness
11/2/2016 123

FMEA RESULTS – Major Failure
Modes
Identified potential failure modes in CPGs implementation with the
highest RPN (≥ 80):-
1. Auditing of the CPGs (e.g. data management process).
2. Adaptation process (e.g. AGREE appraisal, Ext. review).
3. Networking with existing projects.
4. Awareness/training activities.
5. Accessible printed & electronic implementation tools
6. Advocates from clinical/ quality champions
12411/2/2016

RESULTS - Actions taken
1. Auditing: Supported by Pedia. CGC, DQT & QMD as a part of
Quality sustainability plan and CPG Program.
2. Adaptation: (e.g. AGREE: 4 appraisers, Review: all
Stakeholders)
3. Networking: (e.g. Dept. QIP, CPD, Accreditation, Research)
4. Awareness/ training activities: Organized regularly.
5. Printed & electronic copies*: Available and accessible to HC
providers at points of care. *eSiHi!
6. Champions: Consultants/ senior practitioners encouraged to
get involved in CPG adaptation/ implementation.
12511/2/2016

11/2/2016 126
CPG Implementation cycle

CPG Implementation cycle
127
FinalCPGApproved+CPGITools+Plan
FormulateImplementation
multidisciplinaryteam
Baseline(Pre-)Auditofcurrent
CP
PilotImplementation
Identifybarriers
Prioritizedisseminationstrategies
andstart
Prioritize1–3keyRsto
implement
Prioritizeimplementation
strategies
Post-implementationM&ERegular
checkpoints(PIPOH-KPI)
Regularreview&updateofpublished
sourceCPG+/-evidence
11/2/2016

Effectiveness of CPGs
implementation interventions
Slide courtesy of Dr. Ulfat Shaikh11/2/2016 129

G-I-N Working Groups (IWG,
PMWG)
11/2/2016 131

The CPG lifecycle at KSUMC: The CPG
Adaptation Program
11/2/2016 132

KSUMC CPG PROGRAM
current status 1437-2016
11/2/2016 133

Clinical Practice Guidelines (CPGs) Program
of King Saud University Hospitals/ Medical City
KSUHs Taskforce Responsible Staff from:
KSUMC-Wide CPG Steering Committee;
Departmental CPG Committees (former CPGs
subcommittees);
Shaikh Bahamdan Research Chair for Evidence-Based
Health Care and Knowledge Translation;
Quality Management Department;
Head of Units & Chairpersons/ Directors of Departments
Top Management & Leadership of College of Medicine
and University Hospitals (Future KSU Medical City)
11/2/2016 134

Guidelines International Network (G-I-N)
www.g-i-n.net
EBHC-KT Chair, King Saud University
Org. Member since 2009
(1st Member from Gulf & 3rd Member from MENA Countries)
Founded in Nov. 2002
11/2/2016 135

HWQPP – Standing orders development,
revision & deletion (2014)
11/2/2016 136

21 KSUMC CPGs Subcommittees
1. Department of Pediatrics
2. Department of Critical Care
3. Department of Psychiatry
4. Primary Care/ Family Medicine Clinics
(Ambulatory Care Services)
5. Department of Pharmacy
6. Department of Emergency Medicine
7. Department of Medicine
8. Department of Orthopedic Surgery
9. Department of Otorhinolaryngology
10. Department of Ophthalmology
11. Department of Cardiac Sciences/ KFCC
(Cardiology – Cardiac Surgery)
12. Department of Surgery
13. Department of Obstetrics & Gynecology
14. Department of Dermatology
15. Department of Anesthesiology
16. Department of Laboratory Medicine &
Pathology
17. Department of Nursing
18. Department of Radiology
19. Health Education Center
20. Department of Rehabilitation Medicine
21. Department of Infection Control
137
New (in progress)
1. Department of Occupational Health & Safety
2. Department of Clinical Nutrition
11/2/2016

11/2/2016
7
10
6
23232
1111
01000000000
0
2
4
6
8
10
12
KSUMC CPGS IN ALL DEPARTMENTS APPROVED BY CGC
(FEB 2015 - JUMADA'I 1436)
# CPGs approved
*Pooling specialties
(reviewers)
138

KSUMC CPGs in Numbers
 KSUMC-Wide CPG Committee Members: 12
 Departments participating in CPG Program: 21
 Health topics identified for CPG projects: 53
 CPG adaptation projects finalized: 33
 CPGs finalized & approved by CPG Committee: 29
 CPGs finalized & implemented: 17
 CPGs uploaded to QM website & relevant desktop in points of
care: 28
 CPGs implemented & audited (data collected): 13
 CPGs implemented & audited (data analyzed): 3
11/2/2016 139

How to access our CPGs
11/2/2016 140

Who is the contact person for EBCPGs
in each clinical department?
 Chairperson & members, CPG Departmental
Committee
 Lead & members, Department Quality Teams
 Department Chairman & Units’ Heads
 Coordinator, CPG Steering Committee:
Dr. Yasser Amer Ext. # 91341, Email: yamer@ksu.edu.sa
 Medical Secretary, CPG Steering Committee
Ms. Dorothy Villena Ext. # 91281, Email: dvillena@ksu.edu.sa
11/2/2016 144

Approved KSUMC Adapted CPGs (cont’d)
11/2/2016 146

How to read the KSUMC CPGs full
documents?
Go to TABLE OF CONTENTS:-
• Preface by authors
• Acknowledgments
• Abbreviations
• Overview material
• Introduction
• Statement of intent
• Scope & Purpose (Health Questions PIPOH)
• Recommendations (Key & details)
• External review & consensus
• Plan for scheduled review & update
• List of funding sources
• Adaptation process methodology
• Implementation considerations & Tools
• References
11/2/2016 147

KSUMC CPG Adaptation Program Deliverables
11/2/2016 148

CPGI
• Start with prioritized with strong evidence.
• Used a planned and structured approach.
• Identify key stakeholders.
• Understand facilitators and barriers.
• Use evidence-based implementation interventions.
• Monitor and evaluate effectiveness.
• Modify and improve your approaches.
• PLAN – DO – STUDY – ACT – ENJOY!
11/2/2016 150Slide courtesy of Dr. Catherine Marshall

11/2/2016 152
With or without Clinical Decision
Support (CDS)

11/2/2016 154
CPOE with Order
Sets =
In eSiHi are called
“POWERPLANS”

6 PowerPlans from Pediatrics CPGs
1. PED Diabetic ketoacidosis CPG
2. PED Severe sepsis/ septic shock CPG
3. PED acute asthma CPG
4. PED acute bronchiolitis CPG
5. PED Fever of known cause in infants 60 days or less
CPG
6. NICU Neonatal Hyperbilirubinemia CPG
11/2/2016 157

5 PowerPlans from Medicine CPGs
1. MED Diabetic Ketoacidosis CPG (adults)
2. MED Gout CPG
3. MED Hypertensive emergencies/urgencies
CPG
4. MED oncology premedication
5. PULM Asthma CPG (adults)
11/2/2016 159

1 from DEM/ ICU CPGs
ED septic shock (adults)
1 from Cardiology (KFCC) CPGs
CARD Heart Failure CPG
11/2/2016 160

1 from Orthopedics CPGs
ORTHO persistent non-
specific Low Back Pain
CPG (adults)
11/2/2016 161

2 from ENT CPGs
1. ENT
Acute Bacterial Rhinosinusitis CP
G (adults)
2. ENT Acute Bacterial Rhinosinusitis
CPG (children)
•
11/2/2016 162

1 from Family Medicine
CPGs
FAM Dyslipidemia CPG
1 from Psychiatry CPGs
PSYCH Bipolar disorder
CPG
11/2/2016 163

Paper Days!
If it’s not documented, you
didn’t do it!
11/2/2016 164

EMR Days!
“eSiHi” days
You documented it . . . . . . . . . Did you (e-)
document it properly? Did you do it?
11/2/2016 165

Anesthesiology (+4)
1. Heart Failure (Adult)
2. Surgical Antibiotic prophylaxis (Adult)
3. Central Vascular Access Device
4. Vancomycin dosing and monitoring (Adult)
11/2/2016 166

Critical Care (ICU) (2+6)
1. Severe Sepsis and Septic Shock (Adult)
2. Venous Thromboembolism Prophylaxis
3. Diabetic ketoacidosis (Adult)
7. Surgical Site Infection Prevention
16711/2/2016

Emergency Medicine: Adult/
Pedia ( +18)1. (Acute) Asthma (Adult)
3. Hypertensive emergencies & urgencies
4. Severe Sepsis and Septic Shock (Adult)
5. Gout (acute gouty arthritis)
8. Surgical Antibiotic prophylaxis (Adult) (NSG
care)
10. Bipolar disorder
11. Persistent non-specific Low back pain (Acute
attack)
1. Acute Asthma exacerbations
(Child)
2. Acute viral Bronchiolitis
3. Diabetic Ketoacidosis (Child)
4. Fever without a source in
infants 60 days or less
5. Neonatal Jaundice
6. Severe Sepsis and Septic Shock
(Child)
7. Status Epilepticus in (Child)
8. Pediatric and neonatal
parenteral nutrition (TPN)
11/2/2016 168

Otorhinolaryngology/ ENT (1 + 2)
1. Acute Bacterial Rhino-sinusitis (Adult/ Child)
11/2/2016 169

Family & Community Medicine
(1+3)
1. Dyslipidemia and prevention of atherosclerosis
2. Gout (acute gouty arthritis/ hyperuricemia)
3. Persistent Non-specific Low Back Pain
4. Asthma
11/2/2016 170

Infection Control (+2)
• Surgical Site Infection Prevention
• Surgical Antibiotic prophylaxis
11/2/2016 171

King Fahad Cardiac Center (2+ 8)
2. Cardiac Artery Bypass Graft Surgery
4. Dyslipidemia
9. Pediatric and neonatal parenteral nutrition (TPN)
11/2/2016 172

Laboratory Medicine &
Pathology
Review 99.99%
CPGs!
11/2/2016 173

Medicine (6 +5)
11/2/2016 174
1. Asthma (Adult)
4. Gout (acute gouty arthritis/ hyperuricemia)
5. Lung Cancer
6. Antiemetics for Chemotherapy-induces nausea & vomiting
8. Dyslipidemia

Nursing (3)
11/2/2016 175
• Surgical Site Infection Prevention
• Central Vascular Access Device
• Extravasation in chemotherapy

Obstetrics & Gynecology (2 +3)
1. Antenatal corticosteroids for fetal maturation
2. Number of Embryos to transfer in IVF
Treatment
11/2/2016 176

Ophthalmology (+2)
• Surgical Antibiotic prophylaxis
(Adult)
• Venous Thromboembolism
Prophylaxis
11/2/2016 177

Orthopedics (1 +3)
11/2/2016 178

Pediatrics (7+2)
11/2/2016 179
1. Acute Asthma exacerbations (Child)
2. Acute viral Bronchiolitis
3. Diabetic Ketoacidosis (Child)
4. Fever without a source in infants 60 days or less
5. Neonatal Jaundice
6. Severe Sepsis and Septic Shock (Child)
7. Status Epilepticus in (Child)
8. Pediatric and neonatal parenteral nutrition (TPN)
9. Acute bacterial rhinosinusitis (Child)

Pharmacy Services (3)
11/2/2016 180
• Vancomycin dosing and monitoring (Adult)
• Pediatric and neonatal parenteral nutrition (TPN)
• Antiemetics for Chemotherapy-induces nausea &
vomiting

Psychiatry (1+ 1?)
1. Bipolar Disorder
11/2/2016 181

Physical/Rehabilitation
Medicine (+1)
2. (?)
11/2/2016 182

Radiology/ Imaging (+4)
1. (Acute) Asthma (Adult) - ?CXR
2. Acute Asthma exacerbations (Child) - ?CXR
3. Acute viral Bronchiolitis - ?CXR
4. Status Epilepticus in (Child) - ?CT/ MRI Brain
5. Acute Bacterial Rhino-sinusitis (Adult/ Child) - ?CT/
MRI PNS
11/2/2016 183

Surgery (1 + 4)
11/2/2016 184
1. Surgical Antibiotic prophylaxis (Adult/
Pedia)
5. Pediatric and neonatal parenteral nutrition
(TPN)

Examples of KSUMC Clinical Practice
Guideline Adaptation
& Implementation Projects
presented and/or published in
national/ international conferences
and/or journals
11/2/2016 185

Lists of publications that resulted from the
program (list is not exclusive)
1. Schünemann HJ, Al-Ansary LA, Forland F, Kersten S, Komulainen J, Kopp IB, et al. Guidelines International Network: Principles for Disclosure of Interests and Management of
Conflicts in Guidelines. Ann Intern Med. 2015;163:548-553. doi:10.7326/M14-1885
2. Mohamed S. From Concept to Bedside: What Pediatricians Should Know about Synthesis of Clinical Practice Guidelines? Iran J Pediatr 2014; 24(5): 557-64
3. Ciocson MAFR, Hernandez MG, Atallah M, Amer YS. Central Vascular Access Device: An Adapted Evidence-Based Clinical Practice Guideline. JAVA 2014; 19(4): 221-37
4. Al-Ansary LA, Tricco AC, Adi Y, Bawazeer G, Perrier L et al. A systematic review of recent clinical practice guidelines on the diagnosis, assessment and management of
hypertension. PLoS One. 2013;8(1):e53744. doi: 10.1371/journal.pone.0053744.
5. Al-Otair HA, Khurshid, Alzeer AH, Venous thromboembolism in a medical intensive care unit the effect of implementing clinical practice guidelines. Saudi Med J 2012; 33 (1):
55-60.
6. Eldawlatly A, Qureshi S, Schumann R. "ROAD MAP" toward establishing clinical practice guidelines for anesthesia in morbidly obese patients undergoing weight loss surgery.
Saudi J Anaesth 2012;6:319-21
7. Wahabi HA, Alzeidan RA. Reasons behind non-adherence of healthcare practitioners to pediatric asthma guidelines in an emergency department in Saudi Arabia. BMC Health
Serv Res 2012; 12: 226 (doi:10.1186/1472-6963-12-226)
8. Wahabi HA, Al-Ansary LA. Innovative teaching methods for capacity building in knowledge translation. BMC Med Educ 2011 Oct 14;11:85 (doi: 10.1186/1472-6920-11-85)
9. Wahabi HA, Alzeidan RA, Fayed AA, Esmaeil SA, Al Aseri ZA. Attitude and practice of the health care professionals towards the clinical practice guidelines in King Khalid
University Hospital in Saudi Arabia. J Eval Clin Pract. 2011 Aug; 17(4):763-7 (doi: 10.1111/j.1365-2753.2011.01694.x.)
10. Wahabi HA, Al-Ansary LA. Great expectations from the chair of evidence-based health care and knowledge translation. Saudi Med J 2009; 30(8): 989-90.
11. Al-Ansary, L. A. and A. Alkhenizan. Towards evidence-based clinical practice guidelines in Saudi Arabia. Saudi Med J 2004; 25(11): 1555-1558.
11/2/2016 186

Conference papers
National and International Conferences:
1. Al-Ansary L. Oral presentation. KSUMC CPG program at the Second wave of CPGs at the Saudi Evidence-Based Healthcare Center, Ministry of Health (2015).
2. Mohamed S et al. Substantial Reduction in Length of Hospital Stay of Patients with Diabetic Ketoacidosis after Implementation of Clinical Practice Guidelines at a University
Hospital in Saudi Arabia at Conference: ENDO 2015: The Endocrine Society's 97th Annual Meeting and Expo, At San Diego, California, USA. March 5-8 2015.
3. Amer YS. Poster. Amer YS, Alswat K, Al-Ansary L, Wahabi HA, Shaikh F. Capacity building for adaptation of clinical practice guidelines at International Forum for Quality and
Safety in Healthcare, IHI/ BMJ. London, UK 2015.
4. Amer YS. Oral presentation. Babiker A, Amer YS, Wahabi H, Alswat K. Failure Mode and Effect Analysis (FMEA) For Implementation of Clinical Practice Guidelines at a
Tertiary Care Teaching Hospital in Saudi Arabia at 32nd International conference of The International Society for Quality in Health Care (ISQua), Doha, Qatar, 4-7 October
2015.
5. Titi M. Oral presentation. Alhabeeb W, Titi M, Rabea N, Amer YS. Adaptation and Implementation of an Evidence-Based Clinical Practice Guideline for Management of Heart
Failure in a University Medical City at the 32nd International conference of The International Society for Quality in Health Care (ISQua), Doha, Qatar, 4-7 October 2015.
6. Ciocson MAFR. Poster. Central Vascular Access Device: An Adapted Evidence-Based Clinical Practice Guideline at International Nursing Conference at KSUHS (2015).
7. Al-Ansary L. Oral Presentation. Al-Ansary L, Amer YS, Fattouh R, Adi Y. Partnering To Transform Clinical Research into Evidence-Based Health Care Guidelines at 10th
International conference of Guidelines International Network 2013, San Francisco, USA. (abstract published in BMJ Quality & Safety 2013).
8. Amer YS. Poster. Abahussain E, Fatani S, Tawariji M, Al-Ansary L, Amer YS. Management of Patients With Bipolar Disorder: An Adapted Clinical Practice Guideline from King
Saud University, King Khalid University Hospital, Clinical Practice Guidelines Committee, College of Medicine and Department of Psychiatry at 10th International conference
of Guidelines International Network, San Francisco, USA (abstract published in BMJ Quality & Safety 2013)
9. Mohamed S. Featured Poster and oral presentation. Development and implementation of Clinical Practice Guidelines in Pediatric Endocrinology: Challenges and
opportunities at ENDO 2013 The Endocrine Society's 95th Annual meeting and Expo, San Francisco June 15-18, 2013.
10. Mohamed S. Poster. Mohamed S et al. Development and implementation of clinical practice guidelines in diabetic ketoacidosis: NICE is also nice in the Middle East at 9th
Joint Meeting of European Society of Paediatric Endocrinologists 19-22 September 2013.
11. Mohamed S. Oral presentation. Development and implementation of Clinical Practice Guidelines in Pediatrics Department, KSUHS: Challenges and opportunities at First
Quality Day Symposium at KSUHS (2013).
12. Hasan G. Oral presentation. Sepsis in PICU: Obstacles for implementation of Sepsis Guidelines at the Saudi Critical Care Society. SCCS, Dammam. (2012). Video:
http://rmsolutions.net/sccs/2012/?q=node/29
13. Hasan G. Oral presentation. Implementation of sepsis and septic shock clinical practice guidelines: overcoming the challenge at 2nd Annual International Conference of the
Saudi Critical Care Society SCCS 2011, Riyadh (2011).
14. Wahabi HA. Oral presentation. From evidence to practice in countries where health policy is not evidence-based (S7) at 7th International conference of the Guidelines
International Network, Chicago, USA, 2010. Link: http://www.g-i-n.net/conference/past-conferences/document-store/g-i-n-conferences/chicago-2010/presentations-
chicago-2010/wahabi-s7.pdf
15. Alzeidan R. Oral presentation. Reasons behind non-adherence to pediatric asthma guidelines in emergency department of King Khalid University (S90) at 7th International
conference of the Guidelines International Network, Chicago, USA, 2010.
11/2/2016 187

What is your role as a HCP in CPGs?
“spread the word”
1) CPG implementers/users:
“Your continuous feedback!”
2) CPG developers/adapters.
3) Improvement research projects.
11/2/2016 189

Towards evidence-based clinical practice guidelines implementation at King Saud University Medical City

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