Speaker/Oral presentation at the first international EBM and CPGs Conference at PSMMC Riyadh 4-6 February 2020

1. Dr. Yasser S. Amer
MBBCh, MSc, CPHQ, FISQua, IPFPH
Pediatrician, CPG Methodologist
EBCPGs Unit, Quality Management, KKUH
Pediatrics Department, King Saud University Medical City
Research Chair for EBHC-KT, KSU
Adapting and Implementing
Evidence-Based Clinical Practice Guidelines:
A model for the Eastern Mediterranean

2. •865–925 Al-Razi (Rhazes)
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
Evidence-Based Medicine (EBM) Movement:
Not New! (CC)
2

4. Executive Summary
•This KSUMC ‘Modified ADAPTE’ model for EB-CPG
adaptation represents a quick, practical, economical method with
a sense of ownership by the staff. Using this version can be
replicated in other countries to assess its validity.
•Implementation of EB-CPGs at KSUMC has resulted in positive
outcomes that promote patient safety.

5. •The aim of our CPG Program at KSUMC is to
support the provision of consistent, effective,
efficient, high quality, and safe EBHC that
improves health outcomes for our patients.
Patient Safety Objectives
our PEOPLE

6. EBCPG Unit, Quality Management
Department, KSUMC
KSUMC-Wide CPG Steering Committee;
Departmental CPG Committees, KSUMC
Research Chair for Evidence-Based Health
Care and Knowledge Translation, KSU
KSUMC CPG Adaptation Program
(Since 2009)

7. • Baseline survey to study the attitudes and practice of
physicians and other HC providers towards CPGs.
• Variable healthcare providers, variable CPGs, and
variation in practice.
• High priority topics identified through adverse events,
risk assessments, morbidity and mortality reports, and
other QI and safety initiatives and tracers.
• Quality and safety requirements of National and
International Accreditation bodies.
Background- Situational Analysis: The Need

8. The team bases its services on research,
evidence-based guidelines, and best practice
information (**) ……..
Clinical practice guidelines, pathways, and
protocols are developed or adopted to guide
priority care services (CBAHI) …
CPG-related Accreditation Standards

9. “Systematic approach to endorsement and/or
modification of a CPG(s) produced in one
cultural and organizational setting for
application in a different context.
A valid alternative to de-novo CPG development to
customize existing CPG to the needs of local users.”
The ADAPTE Collaboration (2006-2010)
What is CPG adaptation?

10. The ADAPTE Collaboration
www.adapte.org
2009

12. Timeline of CPG adaptation frameworks
(Darzi 2017, Abdul-Khalek 2017, Wang 2018)
1. ADAPTE v2 2009
2. Alberta Ambassador program 2011
3. CAN-IMPLEMENT 2013
4. MAGIC 2014
5. Adapted ADAPTE 2015
6. RAP-ADAPTE 2016
7. GRADE-ADOLOPMENT 2017
8. KSU Modified ADAPTE 2019

13. Formal vs. Informal CPG adaptation frameworks
(Wang 2018)
Informal adaptation
•CPG adaptation is
performed without
using an established
framework.
Formal adaptation
•CPG adaptation is
performed using a
GAG and an
established
framework.

14. Approach: Methodology (KSU Modified ADAPTE)
14
Addition of 2 new & 4 modified tools
Two instead of 5 options

15. Standards for high quality CPGs
IOM 2011 – G-I-N 2012 – AGREE 2013

16. Approach: Trustworthy CPGs?

17. 23 Items in 6 Domains
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

18. This guidance can be applied to SRs of guidelines
developed for use outside clinical medicine
(CPGs), such as those used in the fields of public
health and social care (PHGs).

19. ‘We recommend that CPG developers use either
AGREE plus items unique to RIGHT or RIGHT
plus items unique to AGREE to ensure their CPG
reporting is complete.’ (Yao et al 2019)

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

21. 1) Synthesis of EB-CPGs in KSUMC.
2) Implementation and Evaluation of
EB-CPGs in KSUMC
Approach: Two CPG-related Policies & Procedures

22. Approach: Accessible full CPG documents

23. Approach: Automation of CPGs (EMR/CPOE)
CPOE with Order Sets and CDS

24. Impact – General KSUMC
• 22 clinical departments participated via CPG-DC membership or
review of the clinical content of adapted CPGs.
• Capacity building for 1042 HC providers on EBP/ CPG Skills.
• Finalized/ approved 38 Adapted CPGs with another 12 in progress.
• Commonest CPGI tools: CPOE-order sets, algorithms,
pathways, key recommendations, policies and
procedures, audit criteria, KPIs, medication tables, and
patient information.
• Networking: National (MOH, SPA, SPNS, SES, GLAE,
SADHDS, SSNT, SRS, NCEBHP, SCDC) and International
(WHO-EMRO: Kuwait, Tunisia, Bahrain, & Afghanistan).

25. Phases of a CPG Lifecycle
Babiker et al 2018
A ‘Living’ CPG =
Review & Update plus Audit & Feedback

26. CPGI Strategies/ Interventions

27. CPGI Strategies/ Interventions
1. Leadership engagement and commitment.
2. Local Clinical and Quality Champions.
3. Dissemination to clinicians and patients.
4. Regular Education and Training.
5. Regular Audit and Feedback.
6. Networking and linking with existing
projects.
7. ‘Patients as Champions for change’

28. Positive patient outcomes:
Specific Exemplars

29. Impact – Specific Exemplars:
VTE Prophylaxis CPG
2019

30. Pediatric DKA CPG
107.4 Hrs.
68.6 Hrs.

31. Pediatric Sepsis CPG
Pre- and post-Sepsis CPG implementation mortality rate.

32. Establishing and sustaining the Research Chair in
addition to the CPG Unit, QMD to retain and recruit a
sustainable core team at KSUMC.
Including a new Job title; ‘CPG Methodologist’.
Networking with existing projects (Quality/Safety,
Accreditation, training and education, etc..)
Sharing & exchange experience with the national and
international research and CPG community (e.g.
conference paper, publications)
Sustainability

33. Event Photography

34. Impact - General
Guidelines International
Network (G-I-N)
www.g-i-n.net
EBHC-KT Research Chair,
King Saud University
Org. Member since 2009
(1st Member from GCC)

35. Impact - General

36. TEAM: Together Everyone Achieves More!

37. Identify, adapt or adopt & use only high-
quality EB-CPGs using formal methods.
Audit & communicate your CPGs’ Impact.
Keep your CPGs ‘Alive’! Stay Alert!

38. References
1. Amer YS, Wahabi HA, Abou Elkheir MM, et al. Adapting evidence‐based clinical practice guidelines at university teaching hospitals: A model for the Eastern Mediterranean
Region. J Eval Clin Pract. 2018;1–11. https://doi.org/10.1111/jep.12927 [Epub ahead of print]
2. Hasan GM, Al-Eyadhy AA, Temsah MA, et al. Feasibility and efficacy of sepsis management guidelines in a pediatric intensive care unit in Saudi Arabia: a quality
improvement initiative, International Journal for Quality in Health Care https://doi.org/10.1093/intqhc/mzy077 [Epub ahead of print]
3. Babiker A, Amer YS, Osman ME, et al. Failure Mode and Effect Analysis (FMEA) may enhance implementation of clinical practice guidelines: An experience from the
Middle East. J Eval Clin Pract. 2018;24:206–211. https://doi.org/10.1111/jep.12873
4. Amer YS, Al Nemri A, Osman ME, Saeed E, Assiri AM, Mohamed S. Perception, attitude, and satisfaction of paediatric physicians and nurses towards clinical practice
guidelines at a university teaching hospital. J Eval Clin Pract. 2018;1–7. https://doi.org/10.1111/jep.12923
5. Anwer MA, Al-Fahed OB, Arif SI, Amer YS, Titi MA, Al-Rukban MO. Quality assessment of recent evidence-based clinical practice guidelines for management of type 2
diabetes mellitus in adults using the AGREE II instrument. J Eval Clin Pract. 2017;1–7.
6. Bashiri FA, Hamad MH, Amer YS et al. Management of convulsive status epilepticus in children: an adapted clinical practice guideline for pediatrician in Saudi Arabia’
Neurosciences (Riyadh). 2017 Apr;22(2):146-155. doi: 10.17712/nsj.2017.2.20170093.
7. Altokhais TI, Al-Obaid OA, Kattan AE, Amer YS, CPG Collaborative Groups. Assessment of implementability of an adapted clinical practice guideline for surgical
antimicrobial prophylaxis at a tertiary care university hospital. J Eval Clin Pract. 2017;23:156–164.
8. Al Nemri A, Amer YS, Gasim H, et al. Substantial reduction in hospital stay of children and adolescents with diabetic ketoacidosis after implementation of Clinical Practice
Guidelines in a university hospital in Saudi Arabia. J Eval Clin Pract. 2017;23:173–177.
9. 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
10. 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.
11. 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.
12. 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).
13. 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.).

39. Email: yamer@ksu.edu.sa;
yassersamiamer@gmail.com
Mobile #: +966-508577246;
Office #: +966-11- 46-91341