1. Systematic Review, Synthesis, & Clinical Practice Guidelines

2. Questions to Ask in a Critical Appraisal
Why was the study done?
What is the sample size?
Are measurements reliable and valid?
How were the data analyzed?
Did any untoward event happen during the study?
How do the findings fit with previous research?
What does this mean for practice?

3. Appraising Systematic Reviews
Systematic reviews - compilation of similar studies that address a specific clinical question
Not the same as a literature review or narrative review
Process used to conduct review should be explicit
Detailed description
Databases accessed
Search strategies
Search terms
Clinicians should be able to clearly see which studies were included and which were excluded and how selected studies were assessed

4. Appraising Systematic Reviews (cont’d)
Should inform clinicians about how data were extracted from the individual studies
Should provide an overview of the evaluation of the included studies
Meta-analysis
A statistical approach to synthesizing the results of two or more studies
A relatively new methodology that has become a hallmark of EBP
As with all methodologies, applicability must be considered

5. Question Tell whether the following statement is true or false.
Meta-analysis results in evidence that is applicable to a larger patient population than individual studies.

6. Answer False Rationale:
In meta-analyses, combining the results of several studies produces a larger sample size and thus greater power to accurately determine the magnitude of the effect. This does not, however, increase the size of the relevant patient population.

7. Synthesizing Qualitative Evidence
Meta-studies
Meta-summaries

8. Clinical Practice Guidelines (CPGs)
Systematically developed statements based on the best available evidence
CPGs address regional differences in the diagnosis, treatment, and management of patients
Accessing and synthesizing individual pieces of evidence can be time-consuming and overwhelming
CPGs are a time-effective and accessible source of evidence to guide practice

9. Clinical Practice Guidelines –Examples
Systematic Reviews and Clinical Practice Guidelines from the National Heart, Lung and Blood Institute include:
Joint National Committee guidelines on Hypertension
Expert Panel 3 on Asthma, and
Guidelines on managing overweight, cholesterol, and cardiovascular risk

10. CPGs as Tools
CPGs make finite recommendations for practice while still allowing the flexibility for situation- specific considerations
Evidence-based practice guidelines (EBPGs) can help bridge the gap between published scientific evidence and clinical decision making
However, the rigor of guidelines varies significantly

11. Question Tell whether the following statement is true or false.
EBPGs are a valid guide to practice because they encompass not only research evidence, but also patient preferences and clinical expertise.

12. Answer
False
Rationale: EBPGs are based on the best available evidence, but it is the responsibility of the individual clinician to integrate patient preferences and clinical expertise into consideration when planning care.

13. Accessing Guidelines
Googling “practice guideline” will yield numerous sources, including
National Guideline Clearinghouse
Centre for Health Evidence
Canadian Medical Association
Registered Nurses’ Association of Ontario (RNAO)
The term “practice guideline” can be used as a limit to define a publication type in PubMed
Guidelines International Network (G-I-N) has the world’s largest guideline library

14. National Guideline Clearinghouse (NGC)
Developed in partnership with the American Medical Association and the American Association of Health Plans
Of all the guidelines sources, the NGC contains the most descriptive information about guidelines

15. National Library of Medicine (NLM) Gateway
Allows users to input search term that is then sent out to eight different NLM databases
Health Services/Health Technology Assessment Text (HSTAT)
Takes large guidelines, systematic reviews, and technology assessments and enables their texts to be searchable on the Internet

16. Question
Which of the following online databases is the most likely source of a CPG to guide a nurse’s care?
CINAHL
EBSCO
PubMed
PsycInfo

17. Answer
c. PubMed
Rationale: PubMed can be searched for CPGs by setting publication limits on the query to “practice guideline.” The other databases, while containing a great deal of literature relevant to nursing, don’t have this option to search for CPGs only.

18. Finding the Right Guideline
Locating and reviewing current guidelines on a particular subject is often overwhelming
CPG should specify information such as:
Who developed and funded it
Who was on the panel
How the guideline was developed
What dates the literature review covered

19. Finding the Right Guideline (cont’d)
Need to keep in mind that “one size does not fit all”
Assess their application to the right person at the right time and in the right way
Ask
What are the guideline recommendations?
Are the guideline recommendations valid?
How useful are the recommendations?

20. Reading Guidelines
Recommendations should be as unambiguous as possible
Consider the developers’ values
Should specify the process used to systematically search and review the evidence that underlies the guideline
Evidence should be graded using a recognized format
Recommendations themselves should be graded
Updates are important
Consider whether a particular guideline will help your patients

21. Evaluating Guidelines
Consider
Validity
Reliability and reproducibility
Clinical applicability
Clinical flexibility
Clarity
Documentation
Development by a multidisciplinary process
Plans for review

22. Evaluating Guidelines (cont’d)
Rapid critical appraisal (RCA) checklist – see text
AGREE instrument
NGC summaries

23. Question Tell whether the following statement is true or false.
A valid, reliable, and applicable clinical practice guideline becomes a permanent component of the healthcare literature.

24. Answer
False
Rationale: Because a body of evidence is constantly growing and changing, CPGs cannot be considered static documents. Regular reviews and changes are necessary.

25. Developing Guidelines
There is a need for a CPG that addresses a topic when:
The topic is clinically important
The topic is complex and requires clarity
There is evidence of a gap between actual and optimal care
There are no existing valid or relevant guidelines available
There is evidence available to support guideline development
The topic is central to healthy public policy

26. Developing Guidelines (cont’d)
Processes and panels
Both must be identified
Review questions must be created
Conducting the literature search and review
Drafting recommendations
Peer review and dissemination

27. Implementing CPGs Requires multifaceted and sustained interventions
Practitioners’ commitment and organizational leadership are keys
Use of best practice champions
EBP mentors
Guideline implementation must be sustained over time
Context must be considered

28. Question
Which of the following factors has the greatest bearing on the success or failure of CPG implementation?
The strength of the evidence that underlies the guideline
The validity of the process that was used to develop the guideline
The education level of the nurses who will implement the guideline
The commitment of the caregivers who will put the guideline into practice

29. Answer
d. The commitment of the caregivers who will put the guideline into practice
Rationale: While CPGs must be based on strong evidence and must be developed in a valid manner, these factors do not determine the success of their clinical implementation. Successful implementation is dependent on the commitment of practitioners to the process. Education level is not a key determinant of success.