Protocol / Guideline Development; Problem Management

Guideline Definition

Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific circumstances; evidence based, authority of issuing organisation

implement solution / guideline: Set date; co-ordinate day to day; use visual aids / reminders; publiciseAudit effectiveness: Measure progress (toward/away from goal), guideline compliance, use performance measures, errors and adverse events, utilisation, chart review Take corrective action, deliver feed backCQI / PDSARegular review: determine date for review; regular audit, education, guideline promotion; revision as required

Planning

Identify need / define problem: Gather and analyse facts of current situationAssemble stakeholders and formalise proceedings: gather representatives from relevant groups (nursing, support staff)Research / investigate: benchmarks / standards; EBM; other hospital guidelines Develop alternative courses of action, equipment / education / staff required Identify negative consequences of each course of action Apply for fundingDecide a course of action, strategies (priorities, sequence, timing of major steps) Determine when and how auditing will occurIdentify and analyse job tasks necessary to complete projectRecruitment: Qualifications for new positions; Relationships, responsibilities, authority of new positions; train personnelDetermine allocation of resources (eg. Budget, facilities)Ensure compatibility with other hospital protocolsDevelop draft guideline and circulate for comment; revise as required

Content of a Protocol

Purpose and scopeContent of protocolIndications for use of protocolEnd-point desiredInclusion / exclusion criteria (absolute and relative) criteriaSite of implementation (pre-hospital, triage)Patient explanation and consentPreparation (staff, equipment, patient, location)Duration of treatment / procedure, doseContra-indicationsSide effectsComplications and management thereofRequirements to retain treatment phaseMonitoring during maintenance phaseRequirement to exit protocolPost-treatment monitoring / aftercareDispositionDocumentation (take home, for audit)Controversies

Implement-ation

ProsTranslates current evidence into useable practice guideline; synthesizes large amount of information; improves standard of care; promotes consistency of care; identifies interventions of proven efficacy; discourages use of ineffective interventions; sets standard of practice; can empower patients to make informed choices; supports quality improvement; identifies areas requiring further research

Cons

Variable quality; process issues; may be little governance, independent review; evidence base may be incomplete (eg. Patients with co-morbidities may have been excluded from trial guideline is based on); may not consider cost effectiveness, medico-legal, patient preference; may conflict with other guidelines; may not cover many medical situations; may be used unfairly to define standard of care; may not be universal acceptance; conflict of interest by authors; needs regular update; utilisation requires knowledge of guidelines which is often poor; become invalid after 3-5yrs