This session was conducted as a part of the 6th Resident Professional Development Course titled "Evidence-Based Medicine" in 9th SEPT 2015 at College of Medicine, King Saud University

1. Towards EBCPGs
Implementation
for Physicians
Dr. Yasser S. Amer
MBBCh, MPed, MHCI, CPHQ
Coordinator, KSUMC-Wide CPG Steering Committee
Coordinator, Research & Development, Quality Management Dept.
9/9/2015 1
6th Residents Professional Development Course
College of Medicine, King Saud University

2. ‫ـيم‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ح‬‫الر‬‫ـن‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫م‬‫الرح‬‫هللا‬ ‫ـم‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫س‬‫ب‬
In the name of Allah. Most Gracious, Most Merciful
9/9/2015 2

3. Learning objectives
• CPG Definitions & concepts
• How to scout for EBCPGs?
• How to appraise CPGs (standards)?
• Develop or adapt CPGs?
• CPG implementation?
• KSUMC CPG program
• How to access and use KSUMC CPGs ?
• What is your role as a physician?
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4. 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
4
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5. The Georg Ebers Papyrus.
Found in Egypt in the 1870s,
the Ebers Papyrus contains
prescriptions written in
hieroglyphics for
more than 700 remedies,
including this one for an acute
asthma attack.
From: University of Leipzig
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6. The EBM Triad
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7. Definition: (old)
“Systematically developed statements to assist
practitioner and patient decisions about appropriate
health care for specific clinical circumstances”
(IOM 1990)
Increasing international interest in the development
& implementation of CPGs!
Clinical Practice Guidelines (CPGs)
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8. CPGs Definition (New)
“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”
Committee on Standards for
Developing Trustworthy
CPGs (IOM-AHRQ 2011)
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9. Why
Do we need CPGs?
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10. Rationale for CPGs
• Worldwide concerns about:-
▫ Unexplained variation/ variability in clinical practice
▫ 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
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11. Who
Needs CPGs?
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12. •Physicians
•Nurses
•Pharmacists
•Decision makers
•Patients
•Public
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13. How
Do we react to CPGs?
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14. Read
Adopt
Adapt
Develop
CPGs ?
9/9/2015 14

15. Different Options to deal with CPG
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16. 9/9/2015 16

17. 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.
9/9/2015 17

18. 189/9/2015

19. Types of CPGs
The Role of CPGs in Health Care Reform (Rosoff AJ 1994)
CPGs are basically of two types:-
1. Quality-enhancing CPGs are primarily intended to
improve medical outcomes, often by increasing the
amount of care given.
2. Cost-reducing CPGs are oriented toward cutting costs,
generally, by limiting the amount of care given.
http://www.upenn.edu/ldi/issuebrief1_2.html
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20. Types of CPGs (cont’d)
1.Evidence-Based CPGs (evidence-
based methodology)
2.Consensus/ expert-based CPGs
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Which type do you think is better?

21. The EBM Triad
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22. EVIDENCE PYRAMID ?
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23. Evidence Pyramid
SR
RCT
Cohort
Case control
Case series
Case report
Expert opinion
I
II
III
IV
A
B
C
LevelsofEvidence
GradesofRecommendations
MA
9/9/2015 23

24. 9/9/2015 24

25. Producers Finders
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26. • Specialized (professional) societies
• Healthcare Organizations
• Governmental (National) organizations: NICE, SIGN,
NHMRC, ,etc.
• International organizations
9/9/2015 26

27. Organization Name
Country
URL Producer Finder FREE PAID
Guidelines International Network
(G-I-N)
Int’l http://www.g-i-n.net F √ √
World Health Organization (WHO) Int’l http://www.who.int/topics P √
National Institute for Health
& Clinical Excellence (NICE)
UK
http://www.nice.org.uk/page.aspx?o=ourguidanc
e
P √ √
Scottish Intercollegiate Guidelines Network (SIGN) Scotland http://www.sign.ac.uk/guidelines/index.html P √
New Zealand Guideline Group (NZGG) NZ http://www.nzgg.org.nz P √
Registered Nurses Association of Ontario (RNAO) Canada http://www.rnao.org P √
National Guidelines Clearinghouse (NGC) USA http://www.guidelines.gov F √
US National Library of Medicine, National
Institutes of Health (PubMed)
USA
http://www.ncbi.nlm.nih.gov/pubmed
OR http://www.pubmed.gov
F
√
(Abstra
cts)
√
(Full
Text
)
Institute for Clinical Systems Improvement (ICSI) USA http://www.icsi.org/knowledge/ P √
9/9/2015 27

28. CPG Producers:
National Agencies
NICE
National Institute
for Health & Clinical
Excellence
www.nice.org.uk
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29. NICE Guidance
> 132 CPGs
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30. SIGN
Scottish
Intercollegiate
Guidelines
Network
www.sign.ac.uk
> 12 CPGs
CPG Producers: National Agencies
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31. N.H.M.R.C.
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32. WHO
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33. Societies: PEDIA AAP
339/9/2015

34. MED ACP
349/9/2015

35. FM/PC AAFP
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36. SURG RCS
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37. SURG BPGS
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38. OBS-GYNE RCOG
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39. CARDIO ESC
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40. PSYCH The Maudsley Hospital
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41. PSYCH APA
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42. ORTHO AAOS
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43. 9/9/2015 43

44. AHRQ-NGC
National
Guideline
Clearinghouse
www.guidelines.gov
> 408 CPGs9/9/2015 44

45. 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
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46. http://c.ksu.edu.sa/ebhc/en
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47. 9/9/2015 47

48. http://ebhc.ksu.edu.sa/gin/index.html
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49. 9/9/2015 49

50. 9/9/2015 50

51. EBSCO DynaMed & DynaMed Plus
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52. Guideline Central
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53. PubMed
US National Library of Medicine
National Institutes of Health
(NIH)
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54. Standards for high quality CPGs
IOM 2011 – G-I-N 2012
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55. IOM 2011: 8 Standards for Developing
Trustworthy CPGs
1. Establishing transparency.
2. Management of conflict of interest (COI).
3. GDG composition.
4. CPG – SR intersection.
5. Establishing [E] foundations for and rating strength of [Rs]. (i.e. E – Rs
link)
6. Articulation of [Rs].
7. External review.
8. Updating.
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56. Date of download: 8/19/2014
From: Guidelines International Network: Toward International Standards for
Clinical Practice Guidelines
Ann Intern Med. 2012;156(7):525-531. doi:10.7326/0003-4819-156-7-201204030-00009
Copyright © American College of Physicians. All rights reserved.9/9/2015 56

57. 1
2
3
4
5
6
7
8
9
10
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58. How to assess of the quality of any CPG ?
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59. Assess CPG quality
AGREE II
Instrument• 23 items in 6 domains
• 7 point response scale
• 6 Domain scores
• Overall assessment &
recommendations for use 599/9/2015

60. 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
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61. DOMAIN 1. SCOPE AND PURPOSE
1. Objective(s)
2. Health Question(s)
3. Target population
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62. 4. Guideline group
5. Patient preference
6. Target users
DOMAIN 2. STAKEHOLDER INVOLVEMENT
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63. 7. Systematic methods for E search
8. Selection Criteria of E
9. Strengths & Limitations of E
10. Methods of Rs formulation
11. Benefits , side effect and risks in Rs
12. Evidence Links (Gs of Rs – LoE)
13. External Review
14. Update Procedure
DOMAIN 3. RIGOUR OF DEVELOPMENT
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64. DOMAIN 4. CLARITY OF PRESENTATION
15. Rs are specific
16. Options for management
17. Recommendation identifiable
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65. DOMAIN 5. APPLICABILITY
18. Facilitators & barriers
19. Tools
20. Resource implications
21. Monitoring /audit criteria
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66. DOMAIN 6. EDITORIAL INDEPENDENCE
22. Funding body
23. Competing interests
9/9/2015 66

67. CPG Implementation
“The concrete activities and interventions
undertaken to turn policies into desired
results“
Guidelines for clinical practice: from development to use. IOM, 1992
CPGs Practice
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68. Implementation research
is the scientific study of methods to promote the
systematic uptake of proven clinical treatments,
practices, organizational, and management interventions
into routine practice, and hence to improve health.
In this context, it includes the study of influences on
patient, healthcare professional, and organizational
behavior in either healthcare or population settings.
http://www.nlm.nih.gov/hsrinfo/implementation_science.html
9/9/2015 68

69. Implementation science
It is the study of methods to promote the
integration of research findings and evidence into
healthcare policy and practice.
It seeks to understand the behavior of healthcare professionals and other
stakeholders as a key variable in the sustainable uptake, adoption, and
implementation of evidence-based interventions.
As a newly emerging field, the definition of implementation science and the type of
research it encompasses may vary according [to] setting and sponsor. However, the
intent of implementation science and related research is to investigate and address
major bottlenecks (e.g. social, behavioral, economic, management) that impede
effective implementation, test new approaches to improve health programming, as
well as determine a causal relationship between the intervention and its impact.
http://www.nlm.nih.gov/hsrinfo/implementation_science.html
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70. Dissemination
Is the purposive distribution of information and
intervention materials to a specific public
health or clinical practice audience.
The intent is to spread information and the associated evidence-based
interventions. Research on dissemination addresses how information
about health promotion and care interventions is created, packaged,
transmitted, and interpreted among a variety of important stakeholder
groups.
http://www.nlm.nih.gov/hsrinfo/implementation_science.html
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71. CPG Implementability
Set of characteristics that PREDICT the relative
ease of implementation of CPG
recommendations.
Implementability is an abstract concept related to several factors, including
intrinsic factors that are specific to the CPG itself and under control of the
CPG development group and extrinsic factors that are often specific to the
intended healthcare settings and context of implementation.
Implementability…….BEFORE implementation
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72. CPG implementation Strategies (SIGN)
 Dissemination Process (print/ e-/website).
 Local Clinical Champions.
 Awareness raising/ training activities.
 Regular M & E (Auditing) (The ‘living’ CPG concept!).
 Networking and linking with existing projects (e.g. Dept.
Clinical Rounds, CPD/CME activities, Accreditation, etc..).
 Patients as champions for change.
729/9/2015

73. CPG implementation Tools
available at the point of care (* MR)
Examples
1.Clinical Algorithm
2.Integrated Care/ Clinical Pathways
3.Protocol and/ or Policy & Procedure
4.Chart Documentation/ forms (e.g. Physician Order Sets: eSIHI
CPOE PowerPlans)
5.Quick Reference Guides/ Physician Guides & Pocket
Guide/Reference Cards (at-a-glance summary of key
recommendations 5 or 1-2 pages).
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74. 1.Clinical audit criteria (tool)
2.Quality (outcome/performance) measures
3.Slide Presentation.
4.Wall Poster.
5.Patient Resources/ Information (health education
guides).
6.Foreign language Translation (Non-English, Non-Arabic).
7.Implementation Tool Kits (collections of tools and/or
strategies).
8.Staff Training/ Competency Material.
CPG implementation tools (cont’d)
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75. Mobile Apps
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76. CPG Implementation Failure….WHY?
Extrinsic to CPG:
provider & care system-related
Intrinsic to CPG:
ambiguity – inconsistency - incompleteness
9/9/2015 76

77. Barriers (Physician adherence to CPGs)*
I – KNOWLEDGE:-
• Lack of familiarity and/or Awareness
II – ATTITUDES:-
• Lack of agreement with specific CPGs
• Lack of agreement with CPGs in general
• Lack of outcome expectancy
• Lack of self-efficacy
• Lack of motivation/ inertia of previous practice
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78. Barriers (cont’d)
III – BEHAVIOR:-
• External factors (e.g. patient factors, care
system factors)
• Internal factors (CPG factors)
• Environmental factors
9/9/2015 78
*Enhancing the Use of Clinical Guidelines: A Social Norms Perspective
The McDonnell Norms Group 2006

79. Individual
 Positive attitude
 Learning through small
group interaction
Environmental
• Professional
association/society support
• Inter-organizational
collaboration networks
Facilitators
Organizational
• Leadership support
• Champions
• Team work
collaboration
9/9/2015 79

80. KSUMC CPG PROGRAM
current status 2015 - 1436
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81. Clinical Practice Guidelines (CPGs) Program of King Saud
University Medical City
KSUMC CPG Program Partners:-
KSUMC-Wide CPGs Steering Committee;
Clinical Departments (20 CPGs Depart.
Committees);
Research Chair for Evidence-Based Health Care
and Knowledge Translation;
Quality Management Department; DQTs
Top Management & Leadership of KSU College
of Medicine and KSU Medical City
IMPLEMENT
QIP
ADAPT
Methods
9/9/2015 81

82. 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
9/9/2015 82

83. 23 KSUMC CPGs Subcommittees
1. Department of Pediatrics (7)
2. Department of Critical Care (
3. Department of Psychiatry
4. Primary Care/ Family Medicine Clinics
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
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
22. Department of Occupational Health & Safety
23. Department of Clinical Nutrition
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84. Health/ Clinical/ Key Questions
Patient (& disease characteristics)
Intervention(s)
Professionals (Target users)
Outcomes (purpose of the CPGs)
Healthcare settings (& context)
9/9/2015 84
CPG Scope: PIPOH Model

85. Level
Evidence
(LoE)
Grade
Recomm.
(GoR)
Strength
EVIDENCE PYRAMID9/9/2015 85

86. CPG-ICU-002 (VTE) 2013
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87. HWCPG-ENT-001 (ABRS) 2013
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88. How to access the KSUMC CPGs?
• PAPER
1. CPG Binder (full document)
2. Forms (Implementation tools)
3. Algorithm Booklet
• ELECTRONIC
Online:
1. QMD website (KSU email)
2. Icity website (KSU email)
3. G-I-N website (EBHCKT)
Offline: (intranet)
Desktop Icon
PARADIGM
SHIFT: eSiHi
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89. CPG Binder in the Wards
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90. FORMS
(algorithms, pathways, physician orders)
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91. The Clinical Algorithm Booklet
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Coloured clinical algorithms
of
four Pedia. CPGs:-
.1Acute asthma
.2DKA
.3N. Jaundice
.4FUS

92. Desktop Icon
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93. Desktop Icon
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94. How to access CPGs on Intranet City (ICity)
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95. QMD Website
http://medicinequality.ksu.edu.sa/
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96. 9/9/2015 96

97. 9/9/2015 97

98. 9/9/2015 98

99. 9/9/2015 99

100. Ped. DKA
9/9/2015 100
18 CPOE
/28 CPGs

101. Acute asthma
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102. EMR & CPGs
• EMRs (or EHRs) & CPGs are being
incorporated into routine medical practice
• Synergism exist between EHRs & CPGs
9/9/2015 102

103. Paper Days!
If it’s not documented, you didn’t do it!
9/9/2015 103

104. EMR Days!
“eSiHi” days
You documented it . . . . . . . . .
Did you do it?
9/9/2015 104

105. KSUMC CPG PROGRAM IN NUMBERS
 KSUMC-Wide CPG Steering Committee Members: 12
 Departments participating in CPG Program: 20
 Health topics identified for CPGs’ projects: 53
 CPG adaptation projects finalized: 33
 CPGs finalized & approved by CPG Steering Committee:
28
 CPGs finalized & implemented: 10
 CPGs uploaded to ICity, QMD websites & desktops at points of care:
28
 CPGs implemented & audited (data collected): 8
 CPGs implemented & audited (data analyzed): 5
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106. Who is the contact person for EBCPGs in each
clinical department?
Chairperson, CPG Departmental Committee
Members, CPG Departmental Committee
Department Quality Team (former Accreditation teams)
Department Chairman & Units’ Heads
General Coordinator, CPG Steering Committee
Medical Secretary, CPG Steering Committee
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107. 9/9/2015 107

108. Pediatrics (7)
Pediatrics
(PED)
Pulmonology
1. Management of Acute Asthma exacerbations (DEM) (2nd Edition)
2. Management of Acute viral Bronchiolitis (DEM) (2nd Edition)
Endocrinology 3. Management of Diabetic Ketoacidosis in children (DEM) (2nd Edition)
Infectious Diseases
4. Management of Fever without a source in infants 60 days or less (DEM)
(1st Edition)
Neonatology 5. Management of Neonatal Hyperbilirubunemia (Jaundice) (1st Edition)
PICU
6. Management of Severe Sepsis and Septic Shock in infants and children
(DEM) (1st Edition)
Neurology 7. Management of Status Epilepticus in infants and children (1st Edition)
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109. Critical Care (ICU) (2)
Critical
Care (ICU)
MICU
1. Management of Severe Sepsis and Septic Shock
(Adult) (DEM) (1st Edition)
2. Venous Thromboembolism Prophylaxis (1st Edition)
9/9/2015 109

110. Medicine (6)
Medicine
(MED)
Pulmonology 1. Management of Asthma in Adults (DEM) (1st Edition)
Endocrinology
2. Management of Diabetic Ketoacidosis in Adults more than 12
years of age (DEM) (1st Edition)
Rheumatology 3. Management of Gout (acute/chronic) (DEM) (1st Edition)
Clinical Teaching
Unit
4. Management of Hypertensive Emergencies/Urgencies (DEM) (1st
Edition)
Hematology-
Oncology
5. Management of Lung Cancer (1st Edition)
6. Antiemetics for Chemotherapy induced Nausea & Vomiting (1st
Edition)
9/9/2015 110

111. Family Medicine(1)
Family
Medicine
(FM/PCC)
(General)
Management of Dyslipidemia and
prevention of atherosclerosis
(1st Edition)
9/9/2015 111

112. Cardiac Sciences & KFCC (2)
Cardiac
Sciences
(KFCC)
KFCC
1. Management of Heart Failure (1st Edition)
1. Cardiac Artery Bypass Graft Surgery (1st Edition)
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113. Psychiatry (1)
Psychiatry
(PSYCH) (General)
Management of Bipolar Disorder
(1st Edition)
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114. Orthopedics (1)
Orthopedic
Surgery
(ORTHO)
Spine
surgery
Management of Persistent Non-specific
Low Back Pain (PCC, DEM) (1st Edition)
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115. Obstetrics & Gynecology (2)
Obstetrics
&
Gynecolog
y (OBGYN)
Maternal-Fetal
Medicine
1. Antenatal corticosteroids for fetal
maturation (PCC) (1st Edition)
IVF &
Reproductive
Techno.
2. Number of Embryos to transfer in IVF
Treatment (1st Edition)
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116. Otorhinolaryngology (ENT) (1)
ENT (General)
Management of Acute
Bacterial Rhino-sinusitis (PCC)
(1st Edition)
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117. Surgery (1)
Surgery
(SURG) (General)
Antimicrobial prophylaxis in surgery
(1st Edition)
9/9/2015 117

118. Pharmacy Services (2)
Pharmacy
(PHARM)
Clinical
Pharmacy/
Drug
Information
Center
1. Vancomycin Adult Dosing and
Monitoring (1st Edition)
2. Pediatric & Neonatal Total Parenteral
Nutrition (1st Edition)
9/9/2015 118

119. Nursing (2)
Nursing
(NSG)
(General)
1.Surgical Site Infection Prevention (1st
Edition)
2. Central Vascular Access Device
(CVAD) (1st Edition)
9/9/2015 119

120. How to read the KSUMC CPGs full documents?
Table of contents
• Preface by authors
• Acknowledgments
• Abbreviations
• Overview material
• Introduction
• Statement of intent
• Scope & Purpose (PIPOH)
• Recommendations (Key & details)
• External review & consensus
• Plan for scheduled review & update
• List of funding sources
• Adaptation process methodology
• Implementation considerations & Tools
• References
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121. Role of physicians in CPGs
• CPG implementers/users: “Your
continuous feedback!”
• CPG developers/adapters.
• Improvement research projects.
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122. 9/9/2015 122
Thank you!
Email: yamer@ksu.edu.sa; dvillena@ksu.edu.sa
Ext. #: 91341, 91281