Tag Archives: best practice

How To Craft A Practice Guideline

All US trauma centers verified by the American College of Surgeons are required to have clinical practice guidelines (CPG). Trauma centers around the world generally have them, but may not be required to by their designating authority. But don’t confuse a policy about clinical management, say for head injury, with a real CPG. Policies are generally broad statements about how you (are supposed to) do things, whereas a CPG is a specific set of rules you use when managing a specific patient problem.

  1. Look around; don’t reinvent the wheel! This is the first mistake nearly every center makes. It seems like most want to spend hours and hours combing through the literature, trying to synthesize it and come up with a CPG from scratch. Guess what? Hundreds of other centers have already done this! And many have posted theirs online for all to see and learn from. Take advantage of their generosity. Look at several. Find the one that comes closest to meeting your needs. Then “borrow” it.
  2. Review the newest literature. Any existing CPG should have been created using the most up to date literature at the time. But that could have been several years ago. Look for anything new (and significant) that may require a few tweaks to the existing CPG.
  3. Create your draft, customizing it to your hospital. Doing things exactly the same as another center doesn’t always make sense, and it may not be possible. Tweak the protocols to match your resources and local standards of care. But don’t stray too far off of what the literature tells you is right.
  4. Make sure it is actionable. It should not be a literature summary, or a bunch of wishy-washy statements saying you could do this or consider doing that. Your CPG should spell out exactly what to do and when. (see examples below)
  5. Get buy-in from all services involved. Don’t try to implement your CPG by fiat. Use your draft as a launching pad. Let everyone who will be involved with it have their say, and be prepared to make some minor modifications to get buy-in from as many people as possible.
  6. Educate everybody! Start a campaign to explain the rationale and details of your CPG to everyone: physicians, nurses, techs, etc. Give educational presentations. You don’t want the eventual implementation to surprise anyone. Your colleagues don’t like surprises and will be less likely to follow along.
  7. Roll it out. Create processes and a timeline to roll it out. Give everyone several months to get used to it.
  8. Now monitor it! It makes no sense to implement something that no one follows. Create a monitoring system using your PI program. Include it in your reports or dashboards so providers can see how they are doing. And if you really want participation, let providers see how they are doing compared to their colleagues. Everyone wants to be the top dog.

Some sample CPGs:

Double CT Scanning in Trauma

Typical order: “chest CT with and without contrast”

A review of Medicare claims from 2008 showed that 5.4% of patients received double CT scans of the chest. Although the median was about 2% across 3,094 hospitals, 618 hospitals performed double scans on more than 10% of their patients. And 94 did it on more that half! One of the outliers was a small hospital in Michigan that double scanned 89% of Medicare patients! As expected, there was wide variation from hospital to hospital, and from region to region around the US. 

Time for some editorial comment.

This practice is very outdated and shows a lack of understanding of the information provided by CT. Furthermore, it demonstrates a lack of concern for radiation exposure by both the ordering physician and the radiologist, who should know better. 

Some officials at hospitals that had high scan rates related that radiologists ordered or okayed the extra scan because they believed that “more information was better.” There are two problems with this thinking.

  1. Information for information’s sake is worthless. It is only important if it changes decision making and ultimately makes a difference in outcome. 
  2. As with every test we do, there may be false positives. But we don’t know they are false, so we investigate with other tests, most of which have known complications. 

The solution is to do only what is clinically necessary and safe. The tests ordered should be based on the best evidence available, which demands familiarity with current literature.

In trauma, there are a few instances where repeat scanning of an area is required. Examples include solid organ lesions which may represent an injury or a hemangioma, and CT cystogram to exclude bladder trauma. In both cases, only a selected area needs to be re-scanned, not the entire torso.

Bottom line: Physicians and hospitals need to take the lead and rapidly adopt or develop guidelines which are literature-based. State or national benchmarking is essential so that we do not continue to jeopardize our patient’s safety and drive up health care costs.

Tomorrow I’ll share the blunt trauma imaging protocol we use which has decreased trauma CT use significantly at Regions Hospital.

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