- Email: [email protected]
The differences between clinical practice guidelines, recommended practices
SEPTEMBER 1993, VOL 58, NO 3
AORN JOURNAL
Clinical Issues The differences between clinical practice guidelines, recommended practices
Q
uestion: I have heard and read about federal clinical practice guidelines. What are they?
A
nswer: The Agency for Health Care Policy and Research (AHCPR), part of the US Public Health Service, publishes clinical practice guidelines to “improve the quality, appropriateness, and effectiveness of health care and improve access to health services.”’ Clinical practice guidelines serve as recommendations to help health care providers reduce ineffective or inappropriate services and make better decisions regarding patient care. The guidelines describe appropriate and inappropriate care for specific clinical conditions and present evidence that supports care as appropriate or inappropriate. The guidelines are developed in a formal, systematic way and are developed for conditions that are common or expensive to treat or whose treatment varies significantly in practice. The guidelines, developed by multidisciplinary panels, are supported extensively by clinical research. Currently, the following clinical practice guidelines are available: “Cataracts in adults: Man age m e n t of function a1 impairment , “Acute pain management: Operative or medical procedures and trauma,” “Prevention of pressure ulcers,” “Urinary incontinence in adults,” “Depression in primary care,” “Sickel cell disease: Screening, diagnosis, and counseling in newborns and infants,” and “Benign prostatic hypertrophy.” Future guidelines will include treatment of pressure ulcers, management of cancer-related pain, mammography, low-back ”
disorders, and treatment of HIV-positive patients. Clinical practice guidelines offer guidelines, similar to algorithms, to help patients and health care providers make informed decisions regarding treatment. For instance, the cataract guideline provides information on referral pathways, treatment settings and providers of care, diagnoses, preoperative testing, alternative treatments, postoperative care, rehabilitation, and specific procedures. The information provided about cataract treatment includes nonsurgical and surgical management, surgical indications, contraindications to surgery, preoperative evaluation, types of anesthesia, surgical techniques, and complications.2 Clinical practice guidelines are published in three formats. Each complete guideline includes pertinent research references and a detailed description of how the guideline and rationales were developed. The quick-reference form is an easy-to-read, succinct guide to be used by clinicians. The third form is a patient guide, written in easy-to-understand language that helps patients make informed decisions related to their care. Copies of all clinical practice guidelines are available, at no charge, from the AHCPR by calling (800) 358-9295 or writing to AHCPR Publications Clearinghouse PO Box 8547 Silver Springs, MD 20907.
Q
uestion: How should we implement clinical practice guidelines in our practice setting? 587
AORN JOURNAL
SEPTEMBER 1993, VOL 58, NO 3
nswer: Yes. Most guidelines have been pubished by medical organizations and may be called practice parameters, recommended practices, or guidelines. According to the American Medical Association, practice parameters are strategies for patient management developed to assist physicians in clinical decision making. Practice parameters include standards, guidelines, and other. patient manugemerit To date, few practice guidelines have been developed by nursing organizations; however, the American Nurses Association (ANA) is working with specialty organizations such as AORN to develop clinical practice guidelines.
patient safety issues such as positioning the surgical patient or using pneumatic tourniquets or clinical practices (eg, scrubbing, gowning, gloving, IV conscious sedation, disinfection). Overall, the difference between a clinical practice guideline and an AORN recommended practice is the focus. Clinical practice guidelines focus on patient-specific diagnoses or clinical conditions, while recommended practices describe the multiple clinical activities related to patient care in the perioperative setting. Clinical practice guidelines must be credible and easily disclosed; valid, reliable, and reproducible; clinically adaptable, flexible, and clear; reviewed on a schedule; applicable to health system management; and research relevant. The AORN recommended practices are credible because they are grounded in research, developed by clinicians with diverse experience and backgrounds, and compatible with the real world. To a degree, easy disclosure is achieved through the use of interpretive statements. Validity of the recommended practices is established through research. They are reliable, reproducible, and adaptable to multiple clinical sites and differences in practice settings. Exceptions are not specifically stated in the recommended practices, and patient preference is not a consideration in determining their flexibility. The recommended practices also are clear about perioperative practice, are reviewed regularly, and may be used to link quality assurance and health systems management. CAROL DUNGAN APPLEGEET, RN, MSN, CNOR, CNAA, FAAN DIRECTOR. CENTER FOR NURSING PRACTICE
Q
uestions: What is the difference between an AORN recommended practice and a clinical practice guideline?
Notes 1. Agency for Health Care Policy and Research, A H C P R Fact S h e e t , (Washington, DC: US
A
Management of Cataracts in Adults: Quick Reference Guide f o r Clinicians (Washington, DC: US Government Printing Office, 1993). 3 . American Medical Association Office of Quality Assurance, QA Practice Parameters Update (Chicago: American Medical Association, August 1990) 1. 4.Ibid.
A
nswer: It is important to review the guidelines. When you request copies, make sure that you request all three guidelines (ie, complete, quick-reference, patient guidelines). After reviewing them, select the guidelines that are most appropriate for your clinical setting. The guidelines related to postoperative acute pain, prevention of pressure ulcers, benign prostatic hypertrophy, and cataracts are especially pertinent to perioperative patients. After you have selected the most pertinent guidelines, it will be important to enlist the support of the nursing, surgical, and anesthesia staff members to implement the guidelines. An unlimited number of patient guidelines are available for distribution to patients. In addition, the publications may be duplicated as necessary.
Q
uestion: Do other organizations publish guidelines?
A
nswer: AORN’s recommended practices are suggested optimal performance criteria related to clinical practices in the perioperative setting. Recommended practices generally help the nurse provide a safe patient environment and often are focused on procedure^.^ For example, recommended practices deal with 588
Government Printing Office, 1992) 1. 2. Agency for Health Care Policy and Research,
AORN JOURNAL
Clinical Issues The differences between clinical practice guidelines, recommended practices
Q
uestion: I have heard and read about federal clinical practice guidelines. What are they?
A
nswer: The Agency for Health Care Policy and Research (AHCPR), part of the US Public Health Service, publishes clinical practice guidelines to “improve the quality, appropriateness, and effectiveness of health care and improve access to health services.”’ Clinical practice guidelines serve as recommendations to help health care providers reduce ineffective or inappropriate services and make better decisions regarding patient care. The guidelines describe appropriate and inappropriate care for specific clinical conditions and present evidence that supports care as appropriate or inappropriate. The guidelines are developed in a formal, systematic way and are developed for conditions that are common or expensive to treat or whose treatment varies significantly in practice. The guidelines, developed by multidisciplinary panels, are supported extensively by clinical research. Currently, the following clinical practice guidelines are available: “Cataracts in adults: Man age m e n t of function a1 impairment , “Acute pain management: Operative or medical procedures and trauma,” “Prevention of pressure ulcers,” “Urinary incontinence in adults,” “Depression in primary care,” “Sickel cell disease: Screening, diagnosis, and counseling in newborns and infants,” and “Benign prostatic hypertrophy.” Future guidelines will include treatment of pressure ulcers, management of cancer-related pain, mammography, low-back ”
disorders, and treatment of HIV-positive patients. Clinical practice guidelines offer guidelines, similar to algorithms, to help patients and health care providers make informed decisions regarding treatment. For instance, the cataract guideline provides information on referral pathways, treatment settings and providers of care, diagnoses, preoperative testing, alternative treatments, postoperative care, rehabilitation, and specific procedures. The information provided about cataract treatment includes nonsurgical and surgical management, surgical indications, contraindications to surgery, preoperative evaluation, types of anesthesia, surgical techniques, and complications.2 Clinical practice guidelines are published in three formats. Each complete guideline includes pertinent research references and a detailed description of how the guideline and rationales were developed. The quick-reference form is an easy-to-read, succinct guide to be used by clinicians. The third form is a patient guide, written in easy-to-understand language that helps patients make informed decisions related to their care. Copies of all clinical practice guidelines are available, at no charge, from the AHCPR by calling (800) 358-9295 or writing to AHCPR Publications Clearinghouse PO Box 8547 Silver Springs, MD 20907.
Q
uestion: How should we implement clinical practice guidelines in our practice setting? 587
AORN JOURNAL
SEPTEMBER 1993, VOL 58, NO 3
nswer: Yes. Most guidelines have been pubished by medical organizations and may be called practice parameters, recommended practices, or guidelines. According to the American Medical Association, practice parameters are strategies for patient management developed to assist physicians in clinical decision making. Practice parameters include standards, guidelines, and other. patient manugemerit To date, few practice guidelines have been developed by nursing organizations; however, the American Nurses Association (ANA) is working with specialty organizations such as AORN to develop clinical practice guidelines.
patient safety issues such as positioning the surgical patient or using pneumatic tourniquets or clinical practices (eg, scrubbing, gowning, gloving, IV conscious sedation, disinfection). Overall, the difference between a clinical practice guideline and an AORN recommended practice is the focus. Clinical practice guidelines focus on patient-specific diagnoses or clinical conditions, while recommended practices describe the multiple clinical activities related to patient care in the perioperative setting. Clinical practice guidelines must be credible and easily disclosed; valid, reliable, and reproducible; clinically adaptable, flexible, and clear; reviewed on a schedule; applicable to health system management; and research relevant. The AORN recommended practices are credible because they are grounded in research, developed by clinicians with diverse experience and backgrounds, and compatible with the real world. To a degree, easy disclosure is achieved through the use of interpretive statements. Validity of the recommended practices is established through research. They are reliable, reproducible, and adaptable to multiple clinical sites and differences in practice settings. Exceptions are not specifically stated in the recommended practices, and patient preference is not a consideration in determining their flexibility. The recommended practices also are clear about perioperative practice, are reviewed regularly, and may be used to link quality assurance and health systems management. CAROL DUNGAN APPLEGEET, RN, MSN, CNOR, CNAA, FAAN DIRECTOR. CENTER FOR NURSING PRACTICE
Q
uestions: What is the difference between an AORN recommended practice and a clinical practice guideline?
Notes 1. Agency for Health Care Policy and Research, A H C P R Fact S h e e t , (Washington, DC: US
A
Management of Cataracts in Adults: Quick Reference Guide f o r Clinicians (Washington, DC: US Government Printing Office, 1993). 3 . American Medical Association Office of Quality Assurance, QA Practice Parameters Update (Chicago: American Medical Association, August 1990) 1. 4.Ibid.
A
nswer: It is important to review the guidelines. When you request copies, make sure that you request all three guidelines (ie, complete, quick-reference, patient guidelines). After reviewing them, select the guidelines that are most appropriate for your clinical setting. The guidelines related to postoperative acute pain, prevention of pressure ulcers, benign prostatic hypertrophy, and cataracts are especially pertinent to perioperative patients. After you have selected the most pertinent guidelines, it will be important to enlist the support of the nursing, surgical, and anesthesia staff members to implement the guidelines. An unlimited number of patient guidelines are available for distribution to patients. In addition, the publications may be duplicated as necessary.
Q
uestion: Do other organizations publish guidelines?
A
nswer: AORN’s recommended practices are suggested optimal performance criteria related to clinical practices in the perioperative setting. Recommended practices generally help the nurse provide a safe patient environment and often are focused on procedure^.^ For example, recommended practices deal with 588
Government Printing Office, 1992) 1. 2. Agency for Health Care Policy and Research,