Using clinical guidelines critically to define and measure best practice

Busy clinicians don’t have time to search for and appraise research articles; however many do use clinical guidelines to inform their practice. At the same time, we know that clinical guidelines do not always synthesise the highest quality research evidence into applicable clinical practice recommendations. Clinical guidelines are being produced by many governments, professional and national groups without full transparency about the quality of included research and the strength of recommendation. Therefore, it is often difficult for clinicians to tell if specific recommendations are applicable, transferable and important for their own patients.

However, a group of researchers at Monash University in Melbourne have demonstrated a pragmatic plan for using clinical guidelines, within knowledge translation research, to set standards for best practice. They describe 6 steps, which I have also seen applied in a different context;

  1. identify all relevant guidelines for the clinical area of interest; identify those of highest quality using the AGREE instrument; extract all clinical recommendations
  2. identify key clinical management areas and identify specific recommendations that have a strong recommendation using the GRADE methodology
  3. update the underlying evidence if required; you may need to do a systematic search
  4. discuss and evaluate the current evidence (including clinical guideline recommendations) with recognised experts to agree on evidence statements
  5. discuss the relevance of this evidence with local stakeholders to determine what recommendations are applicable, transferable and important to the local patient population; in my experience this is a crucial stage which requires facilitated face-to-face meetings with all relevant clinical specialists, and a transparent process of consensus development
  6. redefine local best practice recommendations that are realistic and achievable within existing structures and staff; when all key staff are engaged in the previous stage, they are more committed and engaged in defining practices that they understand, agree with and can adhere to

In my experience, the local best practice recommendations were defined and written into the electronic medical record. This made compliance more straightforward and enabled monitoring of adherence and variance – it was important to recognise that these recommendations were not minimum standards and that there would always be some patients that required less or more intervention to meet their unique set of clinical needs. I would also recommend, as did the authors in this study, that pilot work is required to determine if the measures identified in the best practice recommendations are appropriate for the local setting in terms of their sensitivity to change, feasibility, validity and reliability.

In summary, this could be a pragmatic way for clinicians to update their clinical practice to be truly evidence-based, with some academic facilitation and expertise. I look forward to others’ experiences of using clinical guidelines to inform their clinical practice.

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I conduct and supervise research that promotes the translation of quality research evidence for use in clinical practice.

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Posted in best practice, clinical guidelines, knowledge translation

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