1. DEVELOPING AND IMPLEMENTING CLINICAL GUIDELINES Mauritius 2007 Dr John Riordan john.riordan@nhs.net

2. Developing and Implementing Clinical Guidelines DEFINITION “ Clinical guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” SIGN ( www.sign.ac.uk )www.sign.ac.uk

3. Developing and Implementing Clinical Guidelines Evidence of effectiveness is slow to be implemented leading to unnecessary deaths, illness and financial waste Prevent these by developing and implementing guidelines

4. Developing and Implementing Clinical Guidelines Variation in practice Effective care not delivered

5. Developing and Implementing Clinical Guidelines DEVELOPMENT OF GUIDELINES Do not reinvent the wheel Choose from reputable sources Evidence vs consensus Adapt to local needs

6. Developing and Implementing Clinical Guidelines Development of Guidelines Systematic review of evidence Critical appraisal Multi-professional development group

7. Developing and Implementing Clinical Guidelines Sources of Guidelines NICE SIGN Royal Colleges Specialist Societies National Guideline Clearinghouse (US) NHMRC (Australia)

8. Developing and Implementing Clinical Guidelines Secondary prevention for coronary heart disease in UK general practice (Campbell NC et al: BMJ 1998 316 1430-1434)  Beta blockers post MI : 32%  ACE inhibitors in heart failure:40%  Aspirin : 63%  BP guidelines: 82%  Lipid guidelines:17%  Exercise: 49%  Not smoking : 82%  Obesity: 36%  Dietary fat: 48%

9. Developing and Implementing Clinical Guidelines Implementation of Guidelines Implementation is difficult! Evidence base is weak Multifaceted approach is essential

10. Developing and Implementing Clinical Guidelines Consistently effective Variably effectiveLittle or no effectUnknown effectiveness Educational outreach visits Audit and feedback Educational materials alone Financial incentives Decision support systems and other reminders Local opinion leaders Didactic educational meetings Administrative interventions Interactive educational meetings Local consensus processes Multifaceted interventions Patient-mediated interventions Mass media interventions

11. Developing and Implementing Clinical Guidelines Leadership Implementation team Implementation plan

12. Developing and Implementing Clinical Guidelines IMPLEMENTATION People Opinion leaders Implementation leaders Staff training/education Involve all staff Processes Information and feedback Audit IT Clinical protocols/care pathways Incentives eg QOF

13. Developing and Implementing Clinical Guidelines TOP-DOWN IMPLEMENTATION National projects National Service Frameworks (NSFs) BOTTOM-UP IMPLEMENTATION Clinical audit Clinical protocols/ integrated care pathways

14. Developing and Implementing Clinical Guidelines Annual sudden infant deaths in Australia 1979 -1997

15. % bed occupancy total hip replacement

16. Developing and Implementing Clinical Guidelines Integrated care pathways/ Clinical Protocols Improve quality of care Reduce variation Improve efficiency Improve multi-professional teamwork Assist clinical audit

17. Variation In Asthma Care 1 Central Middlesex Hospital 1998

18. Variation In Asthma Care 2 Central Middlesex Hospital 1999

19. Developing and Implementing Clinical Guidelines INTEGRATED CARE PATHWAYS Locally agreed processes Structured record Multidisciplinary Evidence based Planned care Key processes and outcomes Variance recording and analysis

21. Podiatry Traffic Light - Overview RiskExaminationReferralPrimary Care Action Grade 0 Low Risk - normal sensation - normal pulses - no callus or deformity - no previous ulcer - Manage in Primary Care - No referral necessary to Podiatry - Provide foot care advice and education at review (supplement with leaflet) - Agree management plan - Next foot check 6-12 months Grade1 At risk - Loss of protective sensation or - Absent pulses or - callus / ingrown nail / deformity - no previous ulcer - Refer to community foot clinic - Consider vascular referral if rest pain or claudication distance <200m - Orthotist referral if deformity - Enhance foot care education - Agree management plan - Next foot check 3 ‑ 6 months - Optimise glycaemic control - Assess CVS risk if absent foot pulses Grade2 High risk As Grade 1 plus: - skin changes - minor ulceration - previous ulcer - previous Charcot joint Early referral to High Risk foot clinic - Consider vascular referral if rest pain or claudication distance <200m - Orthotist referral if deformity At regular diabetes review check patient is receiving: - intensified foot care education - specialist footwear / insoles - regular podiatric skin and nail care - Aim for tight glycaemic control - Ensure appropriate arrangements for patients with special needs / disability Grade3 Active problem - acute ischaemia / gangrene - unilateral swelling - cellulitis / acute infection - new deformity acute foot pain Immediate referral - specialist diabetic foot service Jeffrey Kelson Centre, BeCAD - vascular surgery team for acute ischaemia

22. Podiatry Traffic Light 1 RiskExaminationReferral Primary Care Action Grad e 0 Low Risk - normal sensation - normal pulses - no callus or deformity - no previous ulcer - Manage in Primary Care - No referral necessary to Podiatry - Provide foot care advice and education at review (supplement with leaflet) - Agree management plan - Next foot check 6-12 months Grad e1 At risk - Loss of protective sensation or - Absent pulses or - callus / ingrown nail / deformity - no previous ulcer - Refer to community foot clinic - Consider vascular referral if rest pain or claudication distance <200m - Orthotist referral if deformity - Enhance foot care education - Agree management plan - Next foot check 3 ‑ 6 months - Optimise glycaemic control - Assess CVS risk if absent foot pulses

23. Podiatry Traffic Light 2 RiskExaminationReferral Primary Care Action Gra de2 Hig h risk As Grade 1 plus: - skin changes - minor ulceration - previous ulcer - previous Charcot joint Early referral to High Risk foot clinic - Consider vascular referral if rest pain or claudication distance <200m - Orthotist referral if deformity At regular diabetes review check patient is receiving: - intensified foot care education - specialist footwear / insoles - regular podiatric skin and nail care - Aim for tight glycaemic control - Ensure appropriate arrangements for patients with special needs / disability Gra de3 Acti ve problem - acute ischaemia / gangrene - unilateral swelling - cellulitis / acute infection - new deformity acute foot pain Immediate referral - specialist diabetic foot service Jeffrey Kelson Centre, BeCAD - vascular surgery team for acute ischaemia

24. % Bed Occupancy Total Hip Replacement

27. Developing and Implementing Clinical Guidelines Some useful websites National Library for Health (UK): www.library.nhs.ukwww.library.nhs.uk National Guideline Clearinghouse (US): www.guideline.govwww.guideline.gov National Institute of Clinical Excellence (UK): www.nice.org.ukwww.nice.org.uk National Health and Medical Research Council (Aus): www.nhmrc.gov.auwww.nhmrc.gov.au Scottish Intercollegiate Guideline Network (UK) : www.sign.ac.ukwww.sign.ac.uk

28. Developing and Implementing Clinical Guidelines