Several years ago, a study* was done in US showed a huge variation in those who survived a heart attack.

Researchers wanted to know why? So they looked at the various institutions whether they were community hospitals or university hospitals, in the city or the countryside, if their equipment was modern, if they had a cardiac catheterization lab, the time it took for them to receive therapy, the training of their doctors and staff, the availability of the right medications So you would think the best trained doctors with the best equipped hospitals would have the best outcomes, right? * Association Between Hospital Process Performance and Outcomes Among Patients With Acute Coronary Syndromes JAMA, April 26, 2006Vol 295, No. 16

But it was university hospitals which scored the best and who gives care at university hospitals. Junior doctors! Yes, smart and intelligent maybe even handsome, but not experienced. So why do you think university hospitals performed better than the most modern, well-equipped, highly experienced community hospitals? (ask)

We doctors like to think were smart. We like to think we know it all (or enough) to give excellent care and make better care decisions than a nurse or a respiratory therapist Institute of Medicine in US found that medical error is the top six leading causes of death not to mention morbidity, wasted resources, lost wages and lost trust in the doctor and the medical system. TO ERR IS HUMAN: BUILDING A SAFER HEALTH SYSTEM US Institute of Medicine November 1999

Further studies have shown that we, smart as we are, are consistently outthought, out-performed by a simple piece of paper! Clinical Practice Guidelines in Practice and Education, JGIM Volume 12, April (s2) 1997.

Smart doctors dont depend on their recall of information. Smart doctors use practice guidelines!

Sounds convincing, huh?

And here are some examples MoH & WHO

So a lot of work goes into making these but for a practice guideline to be effective, they need to be followed. How many have used practice guidelines say once a week? Those who didnt raise their hands why not?

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Why dont we use them? (ask)

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Cambodian MoH 1999! What I want to do now is go through an example of a practice guideline for community acquired pneumonia to give you and idea of what this looks like. Cincinnati Children's Hospital Medical Center - Evidence-Based Care Guideline for Children with Community Acquired Pneumonia (CAP)

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Can refer to these websites for other guidelines

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This isnt complete the guideline is 16 pages long I just gave you a couple points so you can see whats involved. SEE HANDOUT Definitions not everything can fit into a clinical guideline format. For example, very complex diagnoses or unclear diagnoses. It depends on too many variables to fit a guideline. So we limit what were talking about. Target Population Inclusions And there will be exclusions, too. So septic A brief introduction to the overall guideline. Introduction Next Etiology And again these things are different in different locations. The causative organism, its resistance patterns Assessment and Diagnosis And then into the medications.

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See handout After collecting all this information these research studies they then made an algorithm to help a busy clinician to use these guidelines. So we can see: inclusions and exclusions; how to evaluate the patient both by physical exam; 2nd slide - and laboratory/CXR; medications

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Theres whole books of algorithms like this. Berman, Pediatric Decision Making (4th ed). Mosby-Year Book, Inc. 2003.

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So an algorithm is one adaptation to make clinical guidelines more available to a doctor or nurse. The other thing you can do is develop order sheets from the guidelines. So just as an example You can see I included our definitions an admission for CAP (no other diagnosis), to the IPD (not ICU), in stable condition And the doctor can just check off what they like How you adapt the guidelines is up to you but making it simple and useable is the main purpose.

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