Portal de Periódicos da CAPES

Important Information About Clinical Practice Guidelines: Key Tools for Improving Quality of Care and Patient Outcomes

2015; Wiley; Volume: 12; Issue: 1 Linguagem: Inglês

10.1111/wvn.12079

1741-6787

Bernadette Mazurek Melnyk,

Health Sciences Research and Education

Worldviews on Evidence-Based NursingVolume 12, Issue 1 p. 1-2 EditorialFree Access Important Information About Clinical Practice Guidelines: Key Tools for Improving Quality of Care and Patient Outcomes Bernadette Mazurek Melnyk, Bernadette Mazurek Melnyk EditorSearch for more papers by this author Bernadette Mazurek Melnyk, Bernadette Mazurek Melnyk EditorSearch for more papers by this author First published: 12 January 2015 https://doi.org/10.1111/wvn.12079Citations: 10AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from well-designed studies and evidence-based theories with a clinician's expertise and a patient's preferences and values in making the best clinical decisions (Melnyk & Fineout-Overholt, 2014). Clinical practice guidelines, which should be routinely incorporated into EBP, are statements with recommendations for clinical practice that are rigorously developed based on systematic reviews of evidence and an evaluation of their benefits and harms (Melnyk et al., 2012). Guidelines are important tools in EBP that can reduce healthcare variation and improve patient outcomes. However, guidelines produced from multiple sources often conflict with one another, which can be confusing for clinicians. Further, many clinicians unknowingly follow recommendations and guidelines that have not undergone rigorous development. For example, Belamarich, Gandica, Stein, and Racine (2006) conducted a study in which findings revealed that none of the 162 verbal health advice directives from 57 policy statements by the American Academy of Pediatrics on which pediatricians should provide council to their patients and parents included the evidence upon which the advice should be based. In another review of 53 guidelines by the American College of Cardiology and the American Heart Association, it was found that the recommendations were largely based on lower level evidence such as nonrandomized trials, case studies, and expert opinions (Tricoci, Allen, Kramer, Califf, & Smith, 2009). Since many clinicians turn to their professional organizations to provide guidelines that can be incorporated into care, it is critical for them to understand not only how guidelines should be formulated, but also how to critically appraise them and where the best "gold standard" guidelines can be accessed. The Institute of Medicine (IOM) in the United States has described eight attributes of good guideline development (IOM, 2011). These attributes include: (a) validity, (b) reliability and reproducibility, (c) clinical applicability, (d) clinical flexibility, (e) clarity, (f) documentation, (g) development by a multidisciplinary process, and (h) plans for review. Two groups that undergo rigorous processes to develop evidence-based recommendations and guidelines are the United States Preventive Services Task Force (USPSTF) and the Registered Nurses Association of Ontario, Canada (RNAO). The USPSTF is comprised of a group of 16 scientists and experts in primary care who produce evidence-based recommendations for clinical preventive services, such as screening tests (e.g., mammography; lipid screening), behavioral counseling services, and preventive medications. More than 100 recommendations are published in an annual updated guide for clinicians entitled Guide to Clinical Preventive Services, which can be accessed at http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/index.html. The USPSTF receives support for its work from the Agency for Healthcare Research and Quality's (AHRQ) funded EBP centers, which conduct systematic reviews of evidence for the task force. The reviews that are conducted by the EBP centers are guided by a set of key questions and an analytic framework that includes the benefits and harms of the recommendations for each topic selected by the task force (Melnyk et al., 2012). Each systematic review conducted by an EBP center is brought to the task force for review and critical appraisal. Before an evidence-based recommendation is released in final form by the USPSTF, feedback from national experts and the public is sought. Recommendations from the USPSTF receive a recommendation of either: A (the USPSTF recommends the service; there is high certainty that the net benefit is substantial); B (the USPSTF recommends the service; there is high certainty that the net benefit is moderate); C (the USPSTF recommends against routinely providing the service; there is at least moderate certainty that the net benefit is small); D (the USPSTF recommends against the service; there is moderate to high certainty that the service has no net benefit or that the harms outweigh the benefits); or I (the USPSTF concludes the current evidence is insufficient to assess the balance of benefits and harms of the service; see http://www.ahrq.gov/CLINIC/upstix.htm). The RNAO also has rigorously produced and disseminated over 50 best practice guidelines that focus on clinical topics (e.g., assessment and management of pain, assessment and management of stage I to IV pressure ulcers, breastfeeding best practices) and healthy work environments (e.g., preventing and mitigating nurse fatigue; preventing and managing violence in the workplace). These guidelines are available and freely downloadable on its website at http://www.rnao.org, and are widely used throughout Canada as well as internationally. There also is a toolkit and educator's resource available to assist with guideline implementation. Another excellent source for clinical practice guidelines (CPGs) is the National Guideline Clearinghouse (NGC), which is an initiative of AHRQ. The NCG, originally developed as a partnership between the American Medical Association and the American Association of Health Plans, is a comprehensive database of over 10,000 clinical guidelines from developers throughout the world (see http://guideline.gov). To be considered for inclusion in the NGC, guideline developers must conduct a systematic literature search and review of existing evidence published in peer-reviewed journals. All guidelines housed at the NGC must be developed, reviewed, or revised in the last 5 years. Expert commentaries that provide insights on current issues of importance to CPGs also are available. In addition, a nice feature of the NGC allows clinicians to register to receive weekly e-mails that outline changes in the practice guidelines housed on this site. Once a CPG is accessed, critical appraisal of the guideline should be performed. Strength of clinical practice guidelines is based on their validity and reliability of the recommendations (Grinspun, Melnyk, & Fineout-Overholt, 2014). Some key rapid critical appraisal questions to ask when reviewing a CPG include: Who were the guideline developers? Did the team have a valid development strategy? Was an explicit, sensible and impartial process used to identify, select, and combine evidence? Did the developers carry out a comprehensive, reproducible literature review within the past 12 months of its publication or revision? Were all important options and outcomes considered? Is each recommendation in the guideline tagged by the level or strength of evidence upon which it is based and linked with the scientific evidence? Has the guideline been subjected to peer review and testing? Are the recommendations clinically relevant? Will the recommendations help me in caring for my patients (Melnyk & Fineout-Overholt, 2014)? It must be remembered that access to and dissemination of CPGs alone often does not result in their wide-scale uptake in real world practice settings. Implementing CPGs in healthcare systems often requires a multipronged approach that includes targeted intervention strategies with both clinicians and the healthcare system (Grinspun, Melnyk, & Fineout-Overholt, 2014). The culture and environment of the system in which the CPGs are to be implemented must be carefully assessed in order to identify strengths and barriers to adoption of the new guideline, followed by the development of a strategic plan to overcome barriers in widespread implementation. Top leadership and middle management support, provision of EBP mentors, grassroots efforts by clinicians, along with tools and resources that support implementation are all necessary for successful wide-scale adoption and sustainability (Melnyk, 2007, 2014). References Belamarich, P. F., Gandica, R., Stein, R. E., & Racine, A. D. (2006). Drowning in a sea of advice: Pediatricians and American Academy of Pediatrics policy statements. Pediatrics, 118(4), e964– 78. Retrieved from www.pediatrics.org/cgi/content/full/118/4/e964 Grinspun, D., Melnyk, B. M., & Fineout-Overholt, E. (2014). Advancing optimal care with rigorously developed clinical practice guidelines and evidence-based recommendations. In B. M. Melnyk & E. Fineout-Overholt (Eds.), Evidence-based practice in nursing & healthcare. A guide to best practice ( 3rd ed., pp. 182– 201). Philadelphia, PA: Wolters Kluwer. Institute of Medicine. (2011). Clinical practice guidelines we can trust. Washington, DC: National Academies Press. Melnyk, B. M. (2007). The evidence-based practice mentor: A promising strategy for implementing and sustaining EBP in healthcare systems. Worldviews on Evidence-Based Nursing, 4(3), 123– 125. Melnyk, B. M. (2014). Building cultures and environments that facilitate clinician behavior change to evidence-based practice: What works? Worldviews on Evidence-Based Nursing, 11(2), 79– 80. Melnyk, B. M., & Fineout-Overholt, E. (2014). Evidence-based practice in nursing & healthcare. A guide to best practice ( 3rd ed.). Philadelphia, PA: Wolters Kluwer. Melnyk, B. M., Grossman, D. C., Chou, R., Mabry-Hernandez, I., Nicholson, W., Dewitt, T. G., Cantu, A. G., Flores, G., U.S. Preventive Services Task Force. (2012). USPSTF perspective on evidence-based preventive recommendations for children. Pediatrics, 130(2), e399– e407. doi: 10.1542/peds.2011-2087 Tricoci, P., Allen, J. M., Kramer, J. M., Califf, R. M., & Smith, S. C. (2009). Scientific evidence underlying the ACC/AHA Clinical Practice Guidelines. JAMA, 30(8), 831– 841. Citing Literature Volume12, Issue1February 2015Pages 1-2 ReferencesRelatedInformation