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By
Valerie
J. Nelson The use of clinical guidelines is unfolding faster than you can say, "What is your Internet address?" While the World Wide Web already makes guidelines easily accessible to hospitals and clinicians, the drive to improve patient care and contain costs through standardized processes is fueling the development of more guidelines all the time, experts say. Practice what you preach "People are realizing that when there is good research, we should listen to that and standardize care around that," said Douglas Kamerow, MD, director of the center for practice and technology assessment at the Agency for Health Care Policy and Research (AHCPR) in Rockville, Maryland. Sometimes derided by detractors as "cookbook medicine," clinical guidelines present carefully written expert opinions that are supposed to guide—not set—clinical practice, Kamerow said. "That’s why they call it a guideline," said Yvette De Jesus, MSN, RN, clinical coordinator for pathways and clinical guidelines at the University of Texas M.D. Anderson Cancer Center in Houston. The center’s 16 guidelines, accessible via the Web, contain a disclaimer that points out that the ultimate decision depends on the individual clinical necessity. Do they work? Medical centers that implement guidelines based on proven successful approaches—called "best practices"—are more likely to achieve improved treatment, more efficient and cost-effective care, and increased patient satisfaction, according to a study conducted last fall by researchers at the Mt. Zion Medical Center-University of California, San Francisco. Hospitals that implemented AHCPR guidelines for congestive heart failure enjoyed improvements in patient care, fewer readmissions, and decreased cost and length of stay, researchers found. A University of California, Los Angeles School of Medicine study published in November also supported the effectiveness of guidelines. The study showed that computer-based charting systems are more successful when equipped with medical guidelines and a series of on-screen prompts designed to help clinicians assess conditions. The interactive charting system improved quality and consistency of care. It also lowered costs by eliminating unnecessary tests. A guidelines boom A "dramatic" number of guidelines are being established by a number of different sectors, including physician and nurse associations, Kamerow said. Federal, state, and local governments are crafting practice guidelines. So are managed care organizations, and private companies that set up guidelines when they buy health insurance. From 1992 to 1996, AHCPR produced 19 guidelines, including protocols as specific as how to measure low back pain that are "widely used," he said. Now, the agency is shifting its role from establishing guidelines to helping groups in the private sector develop their own guidelines. This work occurs at regional "evidence-based practice centers." "We had to ask ourselves: What was the best way we could try to change and improve care given the resources we had?" Kamerow said. Since the agency knew that many of its guidelines were being adopted, it felt that a better use of resources would be to produce the "front line" of guidelines, and then work with groups to review the effectiveness of the guidelines in various situations. The AHCPR also is setting up a national clearing house on the Internet that is expected to be up by the end of the year. Calling it a "big order," Kamerow said the goal is to try to link all existing guidelines to help practitioners see what is available and have them create their own. Friendly guidelines The challenge for guideline-makers is how to deliver the information so that healthcare professionals will incorporate it into daily use, said David L. Schriger, MD, MPH, associate professor of emergency medicine at the University of California, Los Angeles School of Medicine and the leader of the computer-based charting study. Writing a computer-based charting program is tricky, he said. The program has to be broad enough to accommodate a vast array of problems and combinations of problems that could be plaguing a patient. Yet the program also has to be narrow enough so that the user doesn’t pull up huge lists of unnecessary considerations. Evidence-based practice guidelines should be user-friendly tools, said Mary E. Kingston, MN, RN, creative solutions director of the Best Practices Network in Aliso Viejo, California, which has launched an Internet site in collaboration with a number of nursing and healthcare organizations, including the American Association of Critical-Care Nurses and the American Nurses Association. While best practices can be clinical guidelines, they can also encompass a broader approach to all levels of care, Kingston said. The Best Practice Network Web site, www.best4health.org, is meant "to stimulate creativity and innovation," she said. Part of its Web site will showcase best practices. For example, one of the best practices described is a course developed in New England to deal with a shortage of critical-care nurses. The more the merrier At M.D. Anderson, one of the goals is to have a guideline for everything. Having them in place helps everyone "sing the same song," De Jesus said. Guidelines help "lay out the map," and make it easier to identify the key point from the patient’s perspective, according to De Jesus. Without realizing it, consumers have been the catalyst behind the development of clinical guidelines, because they are much more interactive with their health care than they were in the past, she said. |
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SITES Mt. Zion Medical Center-University of California |
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M.D. ANDERSON The need for the comprehensive cancer center to stay competitive has always made M.D. Anderson research driven, De Jesus said.The center’s clinical pathways today were its research protocols three or four years ago. |
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