3043 Chapter008

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 8
Advancing Optimal Care With
Clinical Practice Guidelines

Clinical Practice Guidelines (CPGs)
• Systematically developed statements based on the best
available evidence
• CPGs address regional differences in the diagnosis,
treatment, and management of patients
• Accessing and synthesizing individual pieces of evidence
can be time-consuming and overwhelming
− CPGs are a time-effective and accessible source of
evidence to guide practice

CPGs as Tools
• CPGs make finite recommendations for practice while still
allowing the flexibility for situation-specific considerations
• Evidence-based practice guidelines (EBPGs) can help
bridge the gap between published scientific evidence and
clinical decision making
• However, the rigor of guidelines varies significantly

Question
• Tell whether the following statement is true or false.
• EBPGs are a valid guide to practice because they
encompass not only research evidence, but also patient
preferences and clinical expertise.

Answer
• False
• Rationale: EBPGs are based on the best available
evidence, but it is the responsibility of the individual
clinician to integrate patient preferences and clinical
expertise into consideration when planning care.

Accessing Guidelines
• Googling “practice guideline” will yield numerous sources,
including
− National Guideline Clearinghouse
− Centre for Health Evidence
− Canadian Medical Association
− Registered Nurses’ Association of Ontario (RNAO)
• The term “practice guideline” can be used as a limit to
define a publication type in PubMed
• Guidelines International Network (G-I-N) has the world’s
largest guideline library

National Guideline Clearinghouse (NGC)
• Developed in partnership with the American Medical
Association and the American Association of Health Plans
• Of all the guidelines sources, the NGC contains the most
descriptive information about guidelines

National Library of Medicine (NLM)
Gateway
• Allows users to put in a search term that is then sent out
to eight different NLM databases
• Health Services/Health Technology Assessment Text
(HSTAT)
− Takes large guidelines, systematic reviews, and
technology assessments and enables their texts to be
searchable on the Internet

Question
• Which of the following online databases is the most likely
source of a CPG to guide a nurse’s care?
a. CINAHL
b. EBSCO
c. PubMed
d. PsycInfo

Answer
• c. PubMed
• Rationale: PubMed can be searched for CPGs by setting
publication limits on the query to “practice guideline.”

Finding the Right Guideline
• Locating and reviewing current guidelines on a particular
subject is often overwhelming
• CPG should specify information such as:
− Who developed and funded it
− Who was on the panel
− How the guideline was developed
− What dates the literature review covered

Finding the Right Guideline (cont’d)
• Need to keep in mind that “one size does not fit all”
• Assess their application to the right person at the right
time and in the right way
• Ask
− What are the guideline recommendations?
− Are the guideline recommendations valid?
− How useful are the recommendations?

Reading Guidelines
• Recommendations should be as unambiguous as possible
• Consider the developers’ values
• Should specify the process used to systematically search
and review the evidence that underlies the guideline
− Evidence should be graded using a recognized format
• Recommendations themselves should be graded
• Updates are important
• Consider whether a particular guideline will help your
patients

Evaluating Guidelines
• Consider
− Validity
− Reliability and reproducibility
− Clinical applicability
− Clinical flexibility
− Clarity
− Documentation
− Development by a multidisciplinary process
− Plans for review

Evaluating Guidelines (cont’d)
• Rapid critical appraisal (RCA) checklist – see Box 8.4
• AGREE instrument
• NGC summaries

Question
• Tell whether the following statement is true or false.
• A valid, reliable, and applicable clinical practice guideline
becomes a permanent component of the healthcare
literature.

Answer
• False
• Rationale: Because a body of evidence is constantly
growing and changing, CPGs cannot be considered static
documents. Regular reviews and changes are necessary.

Developing Guidelines
• There is a need for a CPG that addresses a topic when:
− The topic is clinically important
− The topic is complex and requires clarity
− There is evidence of a gap between actual and
optimal care
− There are no existing valid or relevant guidelines
available
− There is evidence available to support guideline
development
− The topic is central to healthy public policy

Developing Guidelines (cont’d)
• Processes and panels
− Both must be identified
• Review questions must be created
• Conducting the literature search and review
• Drafting recommendations
• Peer review and dissemination

Implementing CPGs
• Requires multifaceted and sustained interventions
• Practitioners’ commitment and organizational leadership
are keys
• Use of best practice champions
• EBP mentors
• Guideline implementation must be sustained over time
• Context must be considered

Question
• Which of the following factors has the greatest bearing
on the success or failure of CPG implementation?
a. The strength of the evidence that underlies the guideline
b. The validity of the process that was used to develop the
guideline
c. The education level of the nurses who will implement the
guideline
d. The commitment of the caregivers who will put the
guideline into practice

Answer
• d. The commitment of the caregivers who will put the
guideline into practice
• Rationale: While CPGs must be based on strong evidence
and must be developed in a valid manner, these factors
do not determine the success of their clinical
implementation. Successful implementation is dependent
on the commitment of practitioners to the process.
Education level is not a key determinant of success.

3043 Chapter008

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