What are clinical guidelines?

An internationally accepted definition of clinical guidelines is that they are systematically developed statements to assist health professional and client decisions about appropriate health care for specific circumstances.¹

A well-developed guideline contains rigorously compiled information and recommended actions to guide practice that are based on a comprehensive review of the available research evidence about a particular topic area, often combined with client input and expert opinion. Guidelines are designed to help health professionals decide how to prevent, diagnose and/or treat the client’s presenting symptoms. For example, occupational therapists, physiotherapists, speech pathologists or other health professionals who work with people who are recovering from a stroke may find the National Stroke Foundation’s ‘Clinical Guidelines for Stroke Rehabilitation and Recovery’ useful for informing practice (available from http://www.nhmrc.gov.au/publications/synopses/cp105syn.htm).

Why use guidelines?

As we saw in Chapter 2, health professionals are continually exposed to an overwhelming amount of health research and there are thousands of new studies published each year. Keeping abreast of this enormous volume of information is not possible for busy health professionals and the development of healthcare guidelines is one way in which information overload is being addressed. Guidelines are a useful tool for evidence-based practice as they help us to translate evidence into practice recommendations, which can then be applied to clinical situations.

Guidelines aim to help health professionals and clients make better decisions about health care. They aim to reduce variations in practice across health professionals for the same condition and improve client outcomes. Guidelines achieve these aims by clarifying and providing recommendations about those parts of healthcare practice that can be examined through established scientific methods.² The development of guidelines—the act of amassing and scrutinising the relevant research about a specific topic and making research accessible to health professionals and clients—is part of evidence-based practice at the organisational level. The subsequent translation of guidelines in the clinical setting is more about evidence-based individual decision making, as well as the implementation of evidence into practice.

Clinical guidelines are increasingly being used by health professionals. It is anticipated that their use will continue to become more common. The direct applicability to contemporary clinical practice is what makes a clinical guideline useful. As with other types of evidence, care needs to be taken to ensure that guidelines are of high quality and that they are implemented effectively. This process includes adapting them for a local setting and tailoring evidence-based implementation strategies to local settings. Guidelines will not address all the uncertainties of current clinical practice and should be seen as only one strategy that can help improve the quality of client care.³

Guidelines: the pros and cons

Guidelines have a number of benefits. By drawing together all of the evidence that is known about a particular clinical topic and making sense of it, a guideline can save health professionals a lot of time. Clinical guidelines typically provide an overview of the management of a condition or the use of an intervention. They usually have a broader scope than systematic reviews, which tend to focus on a single clinical question. A guideline may also provide a more coherent synthesis of research about how to manage a condition. Compared to systematic reviews, which usually draw conclusions from only the best available research evidence, the conclusions (recommendations) of guidelines are typically the result of a synthesis of the best available research evidence, expert opinion (such as clinicians and researchers) and client input. Guideline development is not easy and involves large amounts of time, money, expertise and effort. As the development process can be lengthy, there is a possibility that the evidence used in a guideline may not be the most current evidence by the time the guideline is finally published.

When considering using a guideline, the key word to remember is ‘guide’. Rigorously developed guidelines are the result of a comprehensive examination of the literature by a panel of experts. This panel has drawn research findings together into a useful, practical resource that can assist in the prevention, diagnosis and treatment of health conditions. However, guideline recommendations are not fixed protocols that must be followed. As with evidence-based practice in general, responsible and informed clinical judgement about the management of clients remains important. You need to work together with your client to develop an individual intervention plan that is tailored to their specific needs and circumstances, and that is achievable, affordable and realistic.⁴

One of the potentially limiting factors about guidelines is that they generally tend to deal with a specific situation in isolation. However, in practice, clients often present with a range of comorbid conditions. Even when a client presents without comorbidities, translating a guideline in practice still needs to take into account factors such as:

• client preferences and desired outcomes

• the likelihood of adherence

• client’s readiness to change behaviours

• the risk to the client if the guidelines are not followed

• the availability and affordability of any services, medications or other interventions that are recommended in the guidelines.

Client factors will be discussed in more detail later in this chapter when we discuss using a clinical guideline in practice.

How guidelines fit with other evidence-based practice products

As well as clinical guidelines, there are other evidence-based practice products or aids that can help health professionals and clients to make decisions about care. Examples of these products include:

• Decision support tools for health care (sometimes these are available for both clients and health professionals). More detail about decision aids is provided in Chapter 14.

• Practice software and personal digital assistants (PDAs) which incorporate, or have links to, evidence-based guidelines

• Educational modules and information packs which are sent out to health professionals by federal and state health departments

Guidelines can complement these other products, when the information contained in them is aligned and consistent. Some of these products may contain guidelines and sometimes the products may share the same evidence base as the relevant guidelines. However, there is not always consistency across products. Situations can arise where there are discrepancies in the recommendations made in various products. When discrepancies occur, you need to decide which resource to use. Later in this chapter, we discuss how to evaluate the quality of guidelines so that you can choose the one with the highest quality that will be of the most use to your particular clinical situation.

Where and how to find guidelines

It is probably clear to you by now that there are thousands of clinical guidelines across the health professions. The obvious question is: Where and how should you look for guidelines relevant to your client/clinical situation? In general, there are three main electronic sources that can be used to locate clinical guidelines:

• large bibliographic databases (such as PubMed, Embase, CINAHL)

• guideline-specific databases (such as the National Guidelines Clearinghouse, The National Library of Guidelines)

• specific organisations (such as the Heart Foundation, Diabetes Australia).

Bibliographic databases

Although the large bibliographic databases do contain some clinical guidelines, the problem is that only a small proportion of guidelines are published in journals. As a result, only a small proportion is indexed in the traditional databases. In addition, none of these bibliographic databases appraise the quality of guidelines, and it may be difficult to access more than just the abstract from their sites. However, if you decide to search the large bibliographic databases to locate guidelines, here are a few tips:

• PubMed: When searching for clinical guidelines in PubMed, you can select the limit ‘practice guideline’ under publication type.

• MEDLINE: Methodological search strategies for retrieving guidelines in MEDLINE (via Ovid) have been created ⁵ and are summarised in Table 13.1, showing strategies that are aimed at locating all articles classified as a guideline and strategies that are aimed at locating methodologically sound guidelines. In the study that developed these search filters, all articles retrieved that met the definition of a clinical practice guideline were evaluated for methodological quality according to the following criteria if they were concerned with the development of a guideline: 1) the article contained an explicit statement that described the process of developing the guideline, including methods of evidence assembly, method of review of studies and at least one of a) the organisations and the individuals involved, b) the methods of formulating guidelines and c) the methods of reaching agreement or consensus and 2) evidence was cited in support of at least one of the recommendations contained in the guideline. If the article related to the application (as opposed to development) of a clinical guideline, the following criterion was used to evaluate the article’s scientific merit: at least one of the exact guidelines was provided in a table, figure or text of the article. Combine the methodological search strategies in Table 13.1 with your content terms (such as the keywords from your clinical question) when searching for clinical guidelines in MEDLINE.

• Embase: Embase has a thesaurus term ‘practice guideline’ which you can use as part of your search strategy; however, be aware that the term refers to more than just clinical practice guidelines.

• CINAHL: You can select the limit ‘practice guideline’ under publication type when searching in CINAHL.

TABLE 13.1 Search strategies (hedges) for locating practice guidelines in MEDLINE (via OVID) ⁵

Hedge	All classified guidelines	Methodologically sound guidelines
Best sensitivity	exp health services administration OR tu.xs. OR management.tw.	guideline:.tw. OR exp data collection OR recommend:.tw. guidelines.tw. OR practice guidelines.sh. OR recommend:.tw.
Best specificity	guideline:.tw.	guideline adherence.sh. OR physician’s practice patterns.sh. practice guidelines.tw. OR practice guidelines.sh.
Best optimisation of sensitivity and specificity	guide:.tw. OR recommend:.tw. OR exp risk	exp “quality assurance (health care)” OR recommend:.tw. OR guideline adherence.sh.

Colon = truncation; tw = textword; exp = explosion; tu = therapeutic use; sh = subject heading; xs = exploded subheading; + = explode

Chapter 3 provides further details about these databases, as well as advice about how to use search strategies such as those shown in Table 13.1 when looking for evidence to answer a clinical question.