Transcript Imperial College London

DEVELOPING AND IMPLEMENTING CLINICAL
GUIDELINES
Mauritius 2007
Dr John Riordan
[email protected]
Developing and Implementing Clinical Guidelines
DEFINITION
“Clinical guidelines are systematically
developed statements to assist practitioner and
patient decisions about appropriate health care
for specific clinical circumstances.”
SIGN ( www.sign.ac.uk )
Developing and Implementing Clinical Guidelines
• Evidence of effectiveness is slow to be
implemented leading to unnecessary deaths, illness
and financial waste
• Prevent these by developing and implementing
guidelines
Developing and Implementing Clinical Guidelines
•Variation in practice
•Effective care not delivered
Developing and Implementing Clinical Guidelines
DEVELOPMENT OF GUIDELINES
•Do not reinvent the wheel
•Choose from reputable sources
•Evidence vs consensus
•Adapt to local needs
Developing and Implementing Clinical Guidelines
Development of Guidelines
•Systematic review of evidence
•Critical appraisal
•Multi-professional development group
Developing and Implementing Clinical Guidelines
Sources of Guidelines
•NICE
•SIGN
•Royal Colleges
•Specialist Societies
•National Guideline Clearinghouse (US)
•NHMRC (Australia)
Developing and Implementing Clinical Guidelines
Secondary prevention for coronary heart disease in UK general
practice (Campbell NC et al: BMJ 1998 316 1430-1434)
 Beta blockers post MI : 32%
 ACE inhibitors in heart failure:40%
 Aspirin : 63%
 BP guidelines: 82%
 Lipid guidelines:17%
 Exercise: 49%
 Not smoking : 82%
 Obesity: 36%
 Dietary fat: 48%
Developing and Implementing Clinical Guidelines
Implementation of Guidelines
•Implementation is difficult!
•Evidence base is weak
•Multifaceted approach is essential
Developing and Implementing Clinical Guidelines
Consistently
effective
Variably effective
Little or no effect
Unknown
effectiveness
Educational
outreach visits
Audit and
feedback
Educational
materials alone
Financial
incentives
Decision support
systems and other
reminders
Local opinion
leaders
Didactic
educational
meetings
Administrative
interventions
Interactive
educational
meetings
Local consensus
processes
Multifaceted
interventions
Patient-mediated
interventions
Mass media
interventions
Developing and Implementing Clinical Guidelines
•Leadership
•Implementation team
•Implementation plan
Developing and Implementing Clinical Guidelines
IMPLEMENTATION
People
•Opinion leaders
•Implementation leaders
•Staff training/education
•Involve all staff
Processes
•Information and feedback
•Audit
•IT
•Clinical protocols/care pathways
•Incentives eg QOF
Developing and Implementing Clinical Guidelines
TOP-DOWN IMPLEMENTATION
•National projects
•National Service Frameworks (NSFs)
BOTTOM-UP IMPLEMENTATION
•Clinical audit
•Clinical protocols/ integrated care pathways
Developing and Implementing Clinical Guidelines
deaths
Annual sudden infantnumber
deaths
in Australia 1979 -1997
700
600
500
400
number deaths
300
200
100
0
1975
1980
1985
1990
1995
2000
% bed occupancy total hip replacement
Developing and Implementing Clinical Guidelines
Integrated care pathways/ Clinical Protocols
•Improve quality of care
•Reduce variation
•Improve efficiency
•Improve multi-professional teamwork
•Assist clinical audit
Variation In Asthma Care 1
Central Middlesex Hospital 1998
100%
100%
90%
100%
93%
91%
80%
70%
60%
58%
50%
40%
43%
43%
37%
30%
20%
10%
0%
Inhaled steroids started NEB's stopped >24hrs
day 2
before disc
Chest
Steroids on discharge
Non Chest
Follow up appointment
Variation In Asthma Care 2
Central Middlesex Hospital 1999
100%
100%
90%
80%
100%
100%
100%
100%
100%
90%
81%
70%
60%
50%
40%
30%
20%
10%
0%
Inhaled steroids started
day 2
NEB's stopped >24hrs
before disc
Steroids on discharge
Follow up appointment
Chest
Non Chest
Developing and Implementing Clinical Guidelines
INTEGRATED CARE PATHWAYS
•Locally agreed processes
•Structured record
•Multidisciplinary
•Evidence based
•Planned care
•Key processes and outcomes
•Variance recording and analysis
Podiatry Traffic Light - Overview
Risk
Examination
Referral
Primary Care Action
Grade 0
Low
Risk
- normal sensation
- normal pulses
- no callus or
deformity
- no previous ulcer
- Manage in Primary Care
- No referral necessary to Podiatry
- Provide foot care advice and
education at review (supplement
with leaflet)
- Agree management plan
- Next foot check 6-12 months
Grade1
At risk
- Loss of protective
sensation
or
- Absent pulses
or
- callus / ingrown nail /
deformity
- no previous ulcer
- Refer to community foot clinic
- Consider vascular referral if rest
pain or claudication distance <200m
- Orthotist referral if deformity
- Enhance foot care education
- Agree management plan
- Next foot check 3-6 months
- Optimise glycaemic control
- Assess CVS risk if absent foot
pulses
Grade2
High risk
As Grade 1 plus:
- skin changes
- minor ulceration
- previous ulcer
- previous Charcot joint
Early referral to High Risk foot clinic
- Consider vascular referral if rest
pain or claudication distance <200m
- Orthotist referral if deformity
Grade3
Active
problem
- acute ischaemia / gangrene
- unilateral swelling
- cellulitis / acute infection
- new deformity
acute foot pain
Immediate referral
- specialist diabetic foot service
Jeffrey Kelson Centre, BeCAD
- vascular surgery team for acute
ischaemia
At regular diabetes review check
patient is receiving:
- intensified foot care education
- specialist footwear / insoles
- regular podiatric skin and nail
care
- Aim for tight glycaemic control
- Ensure appropriate
arrangements for patients with
special needs / disability
Podiatry Traffic Light 1
Risk
Examination
Referral
- normal
- Manage in Primary
sensation
Care
Grad
- normal pulses
- No referral
e0
necessary to Podiatry
- no callus or
Low deformity
- no previous
Risk
ulcer
Primary Care
Action
- Provide foot care
advice and education at
review (supplement
with leaflet)
- Agree
management plan
- Next foot check
6-12 months
- Loss of
- Refer to community
- Enhance foot
protective sensation foot clinic
care education
or
- Consider vascular
- Agree
Grad
management plan
- Absent pulses referral if rest pain or
claudication distance
e1
- Next foot check
or
<200m
3-6 months
At
- callus /
- Orthotist referral if
- Optimise
risk ingrown nail /
deformity
glycaemic control
deformity
- Assess CVS risk
- no previous
if absent foot pulses
ulcer
Podiatry Traffic Light 2
Risk
Examination
As Grade 1
plus:
Gra
de2
Hig
h risk
Gra
de3
Acti
ve
problem
- skin
changes
- minor
ulceration
- previous
ulcer
- previous
Charcot joint
- acute
ischaemia /
gangrene
- unilateral
swelling
- cellulitis /
acute infection
- new
deformity
Referral
Early referral to
High Risk foot clinic
- Consider
vascular referral if
rest pain or
claudication distance
<200m
- Orthotist
referral if deformity
Immediate referral
- specialist diabetic
foot service Jeffrey
Kelson Centre,
BeCAD
- vascular surgery
team for acute
ischaemia
Primary Care
Action
At regular diabetes
review check patient is
receiving:
- intensified foot
care education
- specialist
footwear / insoles
- regular podiatric
skin and nail care
- Aim for tight
glycaemic control
- Ensure
appropriate
arrangements for
patients with special
needs / disability
% Bed Occupancy Total Hip Replacement
100
90
LOS Target
80
70
1992 - 14
1993 - 11
60
%
50
40
30
20
10
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
days
% Bed Occupancy Total Hip Replacement
100
90
LOS Target
80
70
1992 1993 1994 1995 -
60
%
14
11
10
10
50
40
30
20
10
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
days
% Bed Occupancy Total Hip Replacement
100
90
LOS Target
80
1992 1993 1994 1995 1996 1997 1999 -
70
60
%
50
14
11
10
10
9
5
4
40
30
20
10
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
days
Developing and Implementing Clinical Guidelines
Some useful websites
National Library for Health (UK): www.library.nhs.uk
National Guideline Clearinghouse (US): www.guideline.gov
National Institute of Clinical Excellence (UK): www.nice.org.uk
National Health and Medical Research Council (Aus): www.nhmrc.gov.au
Scottish Intercollegiate Guideline Network (UK) : www.sign.ac.uk
Developing and Implementing Clinical Guidelines