Pediatric Informatics: Computer Applications in Child Health (Health ...

9 Pediatric Care, Safety, and Standardization 121
the balance between anticipated benefits and harms when the recommendation
is carried out, and 3. designation of recommendation strength.” 10 Assignation
of recommendation strength is based on 1. level of aggregate evidence quality,
ranging from A to D, where A is the strongest evidence e.g. well designed trials,
and on 2. benefit-harm assessment (preponderance of benefit/harm or a balance
between them). An additional category exists for recommendations which may
not be supported by evidence, but for which the benefits or harms are clearly
evident. As stated by the AAP: “Guidelines are never intended to overrule
professional judgment; rather they should be viewed as a relative constraint on
individual clinician discretion in a particular clinical circumstance…. Clinicians
should always act and make decisions on behalf of their patients’ best interests
and needs regardless of guideline recommendations. Guidelines represent the
best judgment of a team of experienced clinicians and methodologies addressing
the scientific evidence for a particular topic.”
One has then to ask the obvious question, what evidence supports CPGs? Stated
otherwise, do CPGs improve patient safety? Maybe! In a classic article, Grimshaw
and Russell evaluated the impact, and determinants of the impact of 59 CPGs. 11
Twenty-four guidelines addressed specific clinical conditions, 27 dealt with preventive
care and 8 focused on prescribing or support services. Fifty-five (93%)
demonstrated significant improvement in processes of care, and of those that measured
outcomes, 82% (9/11) demonstrated significant improvement in outcomes.
The authors concluded that although specific CPGs can improve clinical practice,
dissemination, and implementation strategies are critical success factors in determining
whether the guidelines will be effective. Guidelines were more likely to be
effective if they were developed internally, included a specific education intervention
as part of dissemination, and included a patient-specific reminder at the time
of consultation.
As an example of a dissemination strategy, “safety e-mail alerts” have been
used successfully at the Rush University Medical Center to notify housestaff
that new CPGs are available. The notification originates from the Chief of Staff,
underscoring the leadership’s commitment to the guideline. Personal accountability
is incorporated into the process by requiring the residents to respond through the
e-mail that the CPGs have been read; if no response is received after a period of
time, the chief resident follows up. 12 By incorporating decision alerts into the electronic
order entry, use of the CPGs has then been facilitated.
Example of a Clinical Practice Guideline (CPG)
Issue
Perioperative antibiotic prophylaxis should be administered within 60 min prior to
the incision.
It is often administered too late, which increases the risk of surgical site infection.