EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES for the Staff of NICU of King Saud Medical City (MOH), Riyadh, KSA 2013

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An Overview on Evidence-Based Clinical Guidelines for the Staff of the NICU of King Saud Medical City Presented in Wednesday March 20th, 2013 in Riyadh, KSA by Dr. Yasser Sami Amer

Participants: Dr Nabil AlOthaidan, Dr Haider Sumaily, Dr Tarek Abo ElMaaty, Dr Mohamed Jaaffar, Dr Samer Askoul, Dr Kussai Awad, Dr Angelito Narito, Dr Faiza Gaber, Dr Eiman Darwish, Dr Sharifa Alassiri. Michael Randy, Shanon and Dr Yazid, Dr Omnia, Dr Alaa and Dr Titiana and the respectable staff of the NICU in KSMC.
Special Thanks to Miss Nawf El-Noumsy for organization

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EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES for the Staff of NICU of King Saud Medical City (MOH), Riyadh, KSA 2013

  1. 1. 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 1
  2. 2. 20061999 2004
  3. 3. Alexandria University Hospitals Healthcare Quality DirectorateCenter for Evidence-Based Clinical Practice Guidelines (AUH – HCQD, CEBCPGs) (Founded Nov. 2008) Member of Guidelines International Network (G-I-N) (Since May 2009)
  4. 4. Founding Members 2008• Prof. Dr. Mahmoud Elzalabany• Prof. Dr. Tarek Omar• Prof. Dr. Nabil Dowidar• Prof. Dr. Afaf Ibrahim• Dr. Yasser S. Amer• Dr. Hossam Ashour• Eng. Ahmed Mourady
  5. 5. G-I-N Annual Report 2009 EGYPT (EG)
  6. 6. First Workshop in Egypt: Adaptation of CPGs 2009 (AFM-GIN-ADAPTE)
  7. 7. *12 M.Sc. Theses plus 1 Ph.D. thesis to produce 13 Adapted EBCPGs4 Finalized Adapted CPGs by CEBCPGs, HCQD-AUHs through MScTheses (till 3/2012) in PEDIATRICS DEPT.:1- Treatment of Acute Childhood Asthma in ER - AUCH: Dr. Yasser Sami Amer(Finalized, Approved , Disseminated & Implemented).2- Treatment of Positioning & Attachment Breast Feeding Problems in BFCC - AUCH:Dr. Georgina Ramsis (Finalized & Approved).3- Triage and Acuity Scale in A & E Dept., AMUH: Dr. Mary Christeen Nabiel Sharobeem(Finalized, Approved & Disseminated ) – the only thesis outside the Pediatrics Dept.4- Treatment of HIE in Neonates in NICU: Dr. Walid Gamal AbdelKhaliq(Finalized & Approved).5- Treatment of ADHD in children in AUCH: Dr. Mariana Iskander Amin9 Adapted CPGs in progress by Pediatrics Dept. & CEBCPGs, HCQD-AUHsthrough MSc/PhD Theses (till 8/2012):1. Diagnosis of acute attack of seizures in AUCH: Dr. Soheir Farouk AbdelSalam (Set Up Phase).2. Treatment of acute attack of seizures in AUCH : Dr. Islam Yousry A.Moneium (Set Up Phase).3. Management of Epilepsy in children in AUCH: Dr. Shimaa Anwar (Set Up Phase)4. Treatment of Childhood Autism in AUCH: Dr. Farioz Ibrahim (Set Up Phase).5. Management of Acute Bacterial Meningitis in AUCH: Dr Mariam Adly (Set Up Phase).6. Treatment of Chronic Asthma in AUCH: Dr. Reem Galal Ghazal (Set Up Phase).7. Treatment of Community Acquired Pneumonia in AUCH: Dr. Zobaida Eltazmany (Set Up Phase).8. Treatment of Allergic Rhinitis in AUCH: Dr. Shahinaz (Set Up Phase).
  8. 8. 5 Finalized Adapted CPGs
  9. 9. G-I-N 2009 Lisbon G-I-N 2012 Berlin
  10. 10. Evidence-Based Clinical Practice Guidelines For Staff of King Saud Medical City NICU PART 1: Introduction InstructorDr. Yasser Sami A. Amer 2013Pediatrician - HC InformaticianCPGs General Coordinator,QMD, CPGC, KKUH, KSU
  11. 11. Concepts & Definitions19th March 2013 EBCPGs: Dr. Yasser Sami Amer 15
  12. 12. Two Different Approaches to Evidence-Based Practice (EBP) 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 educators19th March 2013 EBCPGs: Dr. Yasser Sami Amer 16
  13. 13. EBM definitionThe integration of best research evidence Clinical with clinical expertise and patient values Expertise Sackett et al 2000 Research Patient Evidence Preferences19th March 2013 EBCPGs: Dr. Yasser Sami Amer 17
  14. 14. What is “EBM” NOT?• What we have always done !; (not old hat or just the same old medical practice; as evidenced in wide practice variation)• “Cookbook Medicine”! EBM specifically advocates for individualized application of evidence to patient care, not forcing patient care to conform to generalized evidence• Only a cost-cutting trick !; it is intended to guide practitioners to provide the best, not necessarily the cheapest, care.• Only RCTs !; (Also with best relevant evidence applicable to the situation in question) – EBM is tracking down the best external evidence from scientific research to answer our clinical question(s)… 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 18
  15. 15. Clinical Practice Guidelines (CPGs)Definition: (old) “Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” (Institute of Medicine 1990). Increasing international interest in the development and implementation of CPGs.19th March 2013 EBCPGs: Dr. Yasser Sami Amer 19
  16. 16. CPGs New DefinitionCPGs are “Statements that includeRecommendations intended to optimizepatient care that are informed by aSystematic Review of evidence and anassessment of the benefits and harms ofalternative care options”. Committee on Standards for Developing Trustworthy CPGs (IOM- AHRQ) 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 20
  17. 17. Why do we need guidelines?
  18. 18. Rationale for CPGs • Worldwide concerns about: ▫ Unexplained variations in clinical practice ▫ Rising Healthcare costs ▫ Exponential growth of information • Aim of Clinical Practice Guidelines: ▫ To facilitate more consistent, effective and efficient practice and improve health outcomes for patients19th March 2013 EBCPGs: Dr. Yasser Sami Amer 22
  19. 19. Clinical Best Care GAP Practice19th March 2013 EBCPGs: Dr. Yasser Sami Amer 23
  20. 20. Who needs guidelines?
  21. 21. • Doctors • Nurses • Decision makers • Patients • Public19th March 2013 EBCPGs: Dr. Yasser Sami Amer 25
  22. 22. 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 27
  23. 23. • Specialized societies• National agencies NICE SIGN 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 28
  24. 24. CPG Producers: Specialized Societies: e.g. AAP19th March 2013 EBCPGs: Dr. Yasser Sami Amer 29
  25. 25. CPG Producers: National Agencies SIGN Scottish Intercollegiate Guidelines Network www.sign.ac.uk19th March 2013 EBCPGs: Dr. Yasser Sami Amer 30
  26. 26. CPG Producers: National Agencies NICENational Institute for Health & Clinical Excellence www.nice.org.uk 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 31
  27. 27. AHRQNational Guideline Clearinghouse www.guidelines.gov 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 32
  28. 28. Guidelines International Network (G-I-N) www.g-i-n.netOrg. Member since 2009 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 33
  29. 29. 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
  30. 30. 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 35
  31. 31. 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 36
  32. 32. 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 37
  33. 33. 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 38
  34. 34. PubMedUS National Library of MedicineNational Institutes of Health (NIH) 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 39
  35. 35. Some CPGs are only retrievable by “Googling” them!19th March 2013 EBCPGs: Dr. Yasser Sami Amer 40
  36. 36. Worldwide Best Children’s Hospitals 2012-13 These hospitals excel in caring for sick kids IN Arab World – Arab Gulf – USA UK Middle East - EMRO19th March 2013 EBCPGs: Dr. Yasser Sami Amer 41
  37. 37. 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 42
  38. 38. Boston Childrens Hospital http://www.childrenshospital.org/ 1st US Nationally Ranked• #2 in Pediatrics: Cancer• #1 in Pediatrics: Cardiology & Heart Surgery• #2 in Pediatrics: Diabetes & Endocrinology• #2 in Pediatrics: Gastroenterology• #3 in Pediatrics: Neonatology• #1 in Pediatrics: Nephrology• #1 in Pediatrics: Neurology & Neurosurgery• #3 in Pediatrics: Orthopedics• #4 in Pediatrics: Pulmonology• #2 in Pediatrics: Urology19th March 2013 EBCPGs: Dr. Yasser Sami Amer 43
  39. 39. http://www.chop.edu/ 2nd US Nationally Ranked• #1 in Pediatrics: Cancer• #2 in Pediatrics: Cardiology & Heart Surgery• #1 in Pediatrics: Diabetes & Endocrinology• #1 in Pediatrics: Gastroenterology• #4 in Pediatrics: Neonatology• #2 in Pediatrics: Nephrology• #2 in Pediatrics: Neurology & Neurosurgery• #1 in Pediatrics: Orthopedics• #1 in Pediatrics: Pulmonology• #1 in Pediatrics: Urology19th March 2013 EBCPGs: Dr. Yasser Sami Amer 44
  40. 40. http://www.cincinnatichildrens.org/service/j/anderson-center/evidence-based- care/recommendations/default/ James M. Anderson Center for Health Systems Excellence Evidence-Based Guidelines 3rd US Nationally Ranked• #3 in Pediatrics: Cancer• #8 in Pediatrics: Cardiology & Heart Surgery• #5 in Pediatrics: Diabetes & Endocrinology• #3 in Pediatrics: Gastroenterology• #1 in Pediatrics: Neonatology• #3 in Pediatrics: Nephrology• #4 in Pediatrics: Neurology & Neurosurgery• #4 in Pediatrics: Orthopedics• #2 in Pediatrics: Pulmonology• #4 in Pediatrics: Urology19th March 2013 EBCPGs: Dr. Yasser Sami Amer 45
  41. 41. http://www.hopkinschildrens.org/tpl_nav1up_nav2up.aspx?id=1090 9th US Nationally Ranked• #15 in Pediatrics: Cancer• #16 in Pediatrics: Cardiology & Heart Surgery• #8 in Pediatrics: Diabetes & Endocrinology• #24 in Pediatrics: Gastroenterology• #10 in Pediatrics: Neonatology• #16 in Pediatrics: Nephrology• #5 in Pediatrics: Neurology & Neurosurgery• #19 in Pediatrics: Orthopedics• #11 in Pediatrics: Pulmonology• #20 in Pediatrics: Urology19th March 2013 EBCPGs: Dr. Yasser Sami Amer 46
  42. 42. Manual of Neonatal Care 7th Ed. (Lippincott Manual Series) 201219th March 2013 EBCPGs: Dr. Yasser Sami Amer 47
  43. 43. Neonatal Resuscitation TEXTBOOK 6th Ed. 201219th March 2013 EBCPGs: Dr. Yasser Sami Amer 48
  44. 44. UK19th March 2013 EBCPGs: Dr. Yasser Sami Amer 49
  45. 45. the child first and always http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/• Health Professionals > Clinical Guidelines SEARCH by: • Search bar • Alphabetical A-Z19th March 2013 EBCPGs: Dr. Yasser Sami Amer 50
  46. 46. How do we react to guidelines?
  47. 47. Develop Adapt Adopt Read CPGs ?19th March 2013 EBCPGs: Dr. Yasser Sami Amer 52
  48. 48. Topic Team Content Search FOUND NOT FOUND Appraise Develop Adopt or Adapt Appraise Implement Evaluate impact19th March 2013 EBCPGs: Dr. Yasser Sami Amer 53
  49. 49. 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 54
  50. 50. Adaptation of Clinical Practice Guidelines The ADAPTE collaboration is an international collaboration of CPG researchers, developers and implementers. Their main aim is to develop and validate a generic adaptation process that will foster valid and high-quality adapted guidelines as well as the user’s sense of ownership of the adapted guideline.19th March 2013 EBCPGs: Dr. Yasser Sami Amer 55
  51. 51. Guideline Adaptation• 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/ 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 56
  52. 52. ©Copyright ADAPTE 200719th March 2013 EBCPGs: Dr. Yasser Sami Amer 57
  53. 53. Adaptation Phase We identified 3 main ADAPTE steps:- Search & Selection of source CPGs Health Questions (PIPOH) AGREE II Instrument Assess source CPGs quality External Review (Departmental Consensus)19th March 2013 EBCPGs: Dr. Yasser Sami Amer 58
  54. 54. Alexandria CEBCPGs Adapted ADAPTE Methods for CPGs adaptation19th March 2013 EBCPGs: Dr. Yasser Sami Amer 59
  55. 55. CPG Scope: PIPOH ModelPatient (& disease characteristics)Intervention(s)Professionals (Target users)Outcomes (purpose of the CPGs)Healthcare settings (& context) = Health/ Clinical/ Key Questions19th March 2013 EBCPGs: Dr. Yasser Sami Amer 60
  56. 56. 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 61
  57. 57. Evidence Pyramid Grades of Recommendations MA Levels of Evidence I A RCT Cohort II Case control B Case series III Case report IV Expert opinion C19th March 2013 EBCPGs: Dr. Yasser Sami Amer 62
  58. 58. How to assess of the quality of any CPG ?19th March 2013 EBCPGs: Dr. Yasser Sami Amer 63
  59. 59. Assess guideline quality ADAPTE TOOL 9 AGREE II Instrument 23 items in 6 domains 7 point response scale Domain scores Recommendations19th March 2013 EBCPGs: Dr. Yasser Sami Amer 64
  60. 60. AGREE Domains DOMAINS 1 Scope & Purpose 2 Stakeholder Involvement 3 Rigour of Development 4 Clarity & Presentation 5 Applicability 6 Editorial Independence19th March 2013 EBCPGs: Dr. Yasser Sami Amer 65
  61. 61. AGREE Instrument http://www.agreetrust.org AGREE Training Manualhttp://fhswedge.csu.mcmaster.ca/pebc/ agreetrust 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 66
  62. 62. CPGs: Two separate documentsFIRST (Clinicians’ Version)• Accessible from ALL points-of- care for the NICU & hospital staff:• Details of evidence-based recommendations for management (with only references to the other document) 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 67
  63. 63. SECOND: (Methodologist’s Version) ;• Accessible from Libraries of e.g. NICU, KSMC, TQMD, Authorship group,…etc. (Reference for Replication & Documentation)• Detailed description of the CPG Adaptation process with ALL relevant data. 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 68
  64. 64. Dissemination & Implementation Nothing could be more frustrating than producing a CPG that is then ignored by not being disseminated nor implemented19th March 2013 EBCPGs: Dr. Yasser Sami Amer 69
  65. 65. Dissemination of CPGs• Full CPGs documents published on websites• Implementation tools will also be published: examples for choice:- ▫ Quick Reference Guide (Summary Key Rs) ▫ Clinical Algorithms (decision tree) ▫ Clinical pathways (Integrated care pathways) ▫ Patient Information (Education Guide) Arabic ▫ Gantt chart for dissemination & Implementation ▫ Audit and Research Rs.19th March 2013 EBCPGs: Dr. Yasser Sami Amer 70
  66. 66. Implementing Guidelines• If CPGs are to have a positive impact on patient care outcomes they must be implemented and incorporated into everyday clinical practice• The identification of any barriers to implementation, and strategies for overcoming them, will form an essential part of discussions at CPGs Subcommittee/ Adaptation Group meetings19th March 2013 EBCPGs: Dr. Yasser Sami Amer 71
  67. 67. Launching of KSMC-NICU Clinical Practice Guidelines Taskforce/ Committee TEAM WORK19th March 2013 EBCPGs: Dr. Yasser Sami Amer 72
  68. 68. Dr. Yasser Sami Amer MSc Pediatrics, MSc HC Informatics CPGs G. Coordinator, QMD, CPGC, KKUH/ KAUH19th March 2013 EBCPGs: Dr. Yasser Sami Amer 73

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