Page 64 - ACCCN's Critical Care Nursing

Quality and Safety 41

TABLE 3.4 Steps in developing clinical practice guidelines 9

Step Description
Find the evidence After deciding on what is considered evidence, databases such as CINAHL and Medline must be searched to
find relevant studies and expert opinions.
Evaluate the evidence Relevant studies and expert opinion papers must be critically appraised for their strengths and weaknesses.
This may or may not incorporate a systematic review.
Synthesise the evidence General summary statements about the state of knowledge on a particular topic are developed.
Design the guidelines Written summaries, algorithms and/or summary sheets will be developed that include statements about
appropriate healthcare practices and their rationale.
Appraise the guidelines Validity, reliability, clinical applicability, flexibility and clarity are some criteria that can be used to assess the
guidelines.
Disseminate and implement Specific strategies such as seminars and patient chart reminders must be developed to increase awareness,
the guidelines acceptance and implementation of the guidelines.
Review and reassess the Clinical audits and research may be used to regularly evaluate the impact the guidelines have had on
guidelines patient care and outcomes.

assessing the patient, whereas at the unit level, it may Developing, Implementing and Evaluating
involve either a practice audit or research. Practice audits Clinical Practice Guidelines
often involve reviewing patient charts to determine both
the extent to which the new practice has been imple- A number of steps are undertaken when developing clini-
mented and its outcome on the patient. Research may cal practice guidelines. Table 3.4 provides an overview of
seek to understand similar things, but generally takes a these steps, which has been adapted from Miller and
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more formal approach, addressing issues such as appro- Kearney’s work.
priate study designs, ethics approvals, etc. While research, systematic review and expert opinion
form the foundation for CPGs, the quality of evidence
CLINICAL PRACTICE GUIDELINES must be assessed and overall summaries of the knowl-
The development and use of clinical practice guidelines edge to date are essential. These summaries are then used
(CPGs) is one strategy to implement EBN. CPGs are state- to develop the guidelines, which generally include a
ments about appropriate health care for specific clinical series of statements about the care to be provided and a
circumstances that assist practitioners in their day-to-day rationale for this care.
practice. They are systematically developed to assist Once the guidelines are developed, a group of experts and
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clinicians, consumers and policy makers in healthcare users should assess the guidelines for accuracy, clinical
decisions and provide critical summaries of available evi- utility and comprehension. Recently, international experts
dence on a particular topic. Other terms that are often developed a 23-item appraisal instrument, termed the
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used synonymously with CPGs include protocols and Appraisal of Guidelines for Research and Evaluation
algorithms. (AGREE), that assesses five domains: (1) scope and
purpose of the CPG (3 items); (2) stakeholder involve-
There are a number of benefits of using CPGs. They are
seen to be central to quality patient care because, in ment in CPG development (4 items); (3) rigour of devel-
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essence, they standardise care. They can guide decisions opment (7 items); (4) clarity and presentation (4 items);
and can be used to both justify and legitimise activities and (4) applicability (5 items). Instruments such as
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and practices. However, limitations have also been iden- AGREE can be used to assess the quality of CPG.
tified. Poorly developed guidelines may not improve care Based on the assessment of the CPG, revisions may be
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and may actually result in substandard care . In the criti- required. Next, strategies for disseminating and imple-
cal care area, the Intensive Care Coordination and Moni- menting the guidelines should be developed. Impor-
toring Unit of New South Wales Department of Health tantly, simply publishing and circulating CPGs will have
has led the development of CPGs associated with six a limited impact on clinical practice, so specific activities
common nursing interventions: (1) Eye care; (2) Oral must be undertaken to promote CPG adherence. The fol-
care; (3) Suctioning a tracheal tube; (4) Endotracheal lowing seven strategies have been shown to be moder-
tube stabilisation; (5) Central line care; and (6) Arterial ately effective in promoting guideline adherence: (1)
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line care. Clinical audits are often used to establish the interactive small group sessions; (2) educational outreach
need to develop new protocols at the local unit level. visits; (3) reminders; (4) computerised decision support;
Clinical audits generally involve chart reviews, but may (5) introduction of computers in practice; (6) mass media
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also use direct observation or surveys of practice. Clinical campaigns; and (7) combined interventions. Finally, a
audits often establish variation in practice without ade- process for regularly evaluating and updating the guide-
quate justification. lines must be developed, which may involve quality