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Clinical guidelines: How can we improve adherence and implementation?

Baron, David M.; Metnitz, Philipp G.H.; Rhodes, Andrew; Kozek-Langenecker, Sibylle A.

European Journal of Anaesthesiology: June 2017 - Volume 34 - Issue 6 - p 329–331
doi: 10.1097/EJA.0000000000000603

From the Department of Anesthesia, General Intensive Care, and Pain Management, Medical University of Vienna, Vienna (DMB); Department of General Anaesthesiology, Emergency and Intensive Care Medicine, Medical University of Graz, Graz, Austria (PGHM); Department of Intensive Care Medicine, St George's Healthcare NHS Trust, and St George's Hospital, St George's University of London, London, United Kingdom (AR); and Department of Anesthesia and Intensive Care, Evangelical Hospital Vienna, Vienna, Austria (SAKL)

Correspondence to Sibylle A. Kozek-Langenecker, Department of Anesthesia and Intensive Care, Evangelical Hospital Vienna, Hans-Sachs-Gasse 10-12, 1180 Vienna, Austria E-mail:

“By three methods we may learn wisdom: First, by reflection, which is noblest; Second, by imitation, which is easiest; and third by experience, which is the bitterest.”

Confucius (551 BC to 479 BC)

Increasing amounts of data are published in medical journals every year, making it challenging for physicians to stay up to date with every aspect of their profession. Thus, in our constantly changing medical world, reviews, meta-analyses and guidelines are necessary to assist physicians in their decision-making processes by condensing, summarising and interpreting the evidence. In recent years, the European journal of Anaesthesiology has published guidelines on preoperative fasting,1 management of severe perioperative bleeding2 and cardiovascular assessment and management in noncardiac surgery.3 In this editorial, we describe why the translation of recommendations from clinical practice guidelines into changes in clinical practice is difficult and can be protracted.

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Development of clinical guidelines: a solid foundation

According to Merriam-Webster's dictionary, guidelines are ‘instructions that show how something should be done’.4 A robust clinical guideline should present scientific evidence relevant to the individual patient encounter, preferably well digested and ready to be applied by clinicians. Recommendations should be formed out of published data with the aim of increasing safety, reducing risk and ultimately improving clinical outcomes. The development of clinical guidelines is a complex process with many pitfalls. Jackson and Feder5 published an editorial dealing with the essential components of a useful clinical guideline. Even though almost two decades have passed since publication, key points remain valid. The main arguments showcased in guidelines should be comprehensible and transparent. In addition, when evidence-based guidance is presented, the benefits, risks and costs of alternative decisions should be identified. Furthermore, when evidence is lacking or extrapolated from other patient populations, these limitations should be explicitly acknowledged. Finally, evidence required to make decisions should be condensed into a simple, accessible format, ideally simplified by adding a short summary or diagram.

In an effort to increase the quality of clinical guidelines, the Institute of Medicine has published a methodology on how to develop guidelines.6 According to the authors, trustworthy guidelines should be based on a systematic review of the existing evidence and be developed by a knowledgeable, multidisciplinary panel of experts. Important subgroups of patients should be considered, and detailed relationships between alternative care options and outcomes should be provided. Guidelines should further be based on an explicit and transparent process that minimises distortions, biases and conflicts of interest. Peer review has to be a fundamental part of guideline development to increase trust and credibility. The European Society of Anaesthesiology (ESA) usually publishes its guidelines online prior to publication, accessible for all ESA members. This open peer review is likely to improve quality of guidelines and to increase subsequent adherence to guidelines. Finally, guidelines should provide ratings of both the quality of evidence and the strength of the recommendations, and be revised when important new evidence warrants modifications of recommendations. Not adhering to these standards can impede successful implementation. These issues, among others, have been addressed in a recent editorial describing the strategy for development of clinical practice guidelines to be followed by the ESA.7

Taken together, low quality of studies included in guidelines and a bias of members of the guidelines committee can lead to lack of trust from physicians. Similarly, inadequate transparency with respect to quality of evidence can hinder the implementation of guidelines. Grading systems are used to overcome these shortcomings. One of these grading systems is the approach developed by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group. This approach assesses methodological flaws, consistency and generalisability of data, and the efficacy of treatment. Guidelines designed using the GRADE approach communicate both the strength of recommendations and the quality of evidence.

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Dissemination of clinical guidelines: the advertising campaign

Another major obstacle for successful implementation is inadequate dissemination.8 The development of a sound guideline requires a huge coordinated effort from many parties, consuming both resources and energy. Physicians are unable to adhere to a guideline they do not know about. Just like a good product, clinical guidelines have to be advertised (online, at scientific meetings, during grand rounds etc.) and presented as product samples (i.e. summaries, handouts, flyers etc.). This process has to be quick, well prepared and start immediately following publication – ideally even before publication. Otherwise, by the time people know about the existence of a guideline, read its contents in detail and implement the contents into their clinical practice, the guidelines may be outdated.

We live in a constantly evolving medical world. The pace of employing new technologies and scientific achievements has increased over the last decades. This progress might be favourable for patients, but puts guidelines at risk of quickly becoming outdated. Thus, complete or partial updates of guidelines have to be performed on a regular basis. The decisions about timing of updates and selection of content to update are usually made by the task force designing the initial guidelines. In addition, clinicians can actively assist with the update of clinical guidelines just like end users can be integrated into the process of peer review.

The dissemination strategy is as important and time consuming as developing the guideline itself. Many resources are needed, mostly the time of people who are able to facilitate implementation. These people have to present the guidelines to the target audience and convey benefits of using the guidelines. Defining the target audience is not always straightforward. As anaesthesiologists, we know that solid food should be prohibited for 6 h and that adults and children should be encouraged to drink clear fluids up to 2 h before elective surgery.1 In daily routine, however, most of us probably have attended to patients who have fasted for 12 h or more. On the other hand, most of us have seen patients who have eaten a small snack a couple hours before elective surgery because nobody told them not to. These examples illustrate the fact that guidelines published in journals of our specialty are not necessarily read by other disciplines. Even though we know what is recommended does not mean others do. Thus, we have to constantly educate people who are responsible for putting guidelines into practice.

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Implementation of clinical guidelines: an endless task?

Guidelines are used to establish a standard and summarise state-of-the-art clinical routine. Both the European and American Society of Anaesthesiology have published guidelines to facilitate implementation of perioperative patient blood management into daily clinical routine.2,9 In 2015, we performed a survey among members of the ESA to evaluate the dissemination and implementation of the ESA guidelines for the management of severe perioperative bleeding.10 More than 75% of physicians stated that they were aware of these ESA guidelines, indicating good dissemination. Despite this high level of awareness, results obtained through the survey indicate that several recommendations found in the guidelines are not being implemented in daily practice. We found potential for improvement in the preoperative assessment of bleeding risk and anaemia, in intraoperative transfusion practices and in specific pharmacologic treatment of significant bleeding. So what can be done to improve adherence to clinical guidelines?

Gagliardi et al.11 published strategies to support implementation of clinical guidelines by identifying potential barriers to implementation and to address these barriers either in the guidelines or in adjunctive publications. Reasons for resistance from clinicians might be manifold: some might say that there are just too many guidelines; for others, guidelines are not specific enough. Patients cannot be standardised: guidelines might be too simplified for complex processes, not taking into account all comorbidities of a patient. Some physicians have been treating patients in a certain way throughout their whole career and have never had any problems, so why change now? These issues are difficult to address and require a very dedicated and convincing effort. Educational resources adapted towards each target group of healthcare individuals should be developed, using multiple formats and channels for guideline dissemination. Even though a recent publication did not find a benefit in the use of social media to disseminate or implement guidelines, a proper use of these new platforms could provide benefits in the future.12 Some educational resources should also be designed to target patients themselves. Involving patients in treatment decisions can promote guideline use. In addition, resources necessary for implementation should be identified, ensuring their availability before publication. Finally, the implementation process should be monitored by audits, surveys or by assessing outcome data to quantify the impact of guidelines. Quality improvement practices can effectively be applied for guideline implementation, especially at a local level. One of the most commonly applied methods of quality improvement is plan-do-study-act, as outlined in a publication from the Royal College of Anaesthetists.13 The key to quality improvement is a precise definition of the status quo. This is achieved by collecting data, which can then be used to identify problems and deficits. Once problems are defined, solutions can be created. After a period of implementation, the cycle starts anew and is repeatedly performed until the desired results are achieved.

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Benefits of using guidelines

Following guidelines has several benefits.14 Patient care can be optimised and streamlined by adhering to guidelines, potentially reducing the use of personnel and financial resources. Ineffective or even dangerous interventions are less likely to be performed when negative implications are stated in guidelines. Increased compliance with guidelines has even been associated with reduced mortality.15 Even though clinical guidelines are not legally binding, it may be helpful in defending against allegations of substandard practice to be able to show that current guidelines have been appropriately followed. This in turn might reduce the likelihood of being convicted in legal disputes.

In summary, our understanding about patient care changes and evolves continuously. In today's medical world, guidelines are a valuable tool to condense current evidence. Standards summarised in guidelines offer the potential to positively affect outcome and patient safety. Several factors can improve implementation of clinical guidelines: the development process should be robust and based on high-quality evidence. Multidisciplinary groups should be formed for guideline development. Elaborate academic marketing strategies and extensive educational initiatives should attract the attention of guideline users. Guidelines should be tailored to specific target audiences to disseminate the content appropriately. Patients likely to be encountered in clinical reality – with their comorbidities – should be captured by the guidelines. Furthermore, clinicians should be able to understand the reasoning behind clinical recommendations. From a societal perspective, guideline-harmonised processes have the potential to not only increase healthcare savings, but even more so to improve patient outcome.

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Acknowledgements related to this article

Assistance with the Editorial: none.

Financial support and sponsorship: none.

Conflicts of interest: none.

Comment from the Editor: this Editorial was checked by the editors but was not sent for external peer review.

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