A critical evaluation of clinical practice guidelines in neonatal medicine: does their use improve quality and lower costs?

Quality assessment of clinical practice guidelines for neonatal sepsis using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument: A systematic review of neonatal guidelines

Background and objective

Neonatal sepsis (NS) continues to be a critical healthcare priority for the coming decades worldwide. The aim of this study was to critically appraise the quality of recent clinical practice guidelines (CPGs) for neonatal sepsis and to summarize and compare their recommendations.

Methods

This study involves a systematic review of CPGs. We identified clinical questions and eligibility criteria and searched and screened for CPGs using bibliographic and CPG databases and professional societies. Each included CPG was assessed by four independent appraisers using the Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) instrument. We summarized the recommendations in a comparison practical table. The systematic review was drafted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Its protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42021258732).

Results

Our search retrieved 4,432 citations; of which five CPGs were eligible and appraised: American Academy of Pediatrics (AAP 2018) (35 and 34 weeks); Canadian Pediatric Society (CPS 2017); National Institute for Health and Care Excellence (NICE 2021); and Queensland Maternity and Neonatal Services (QH 2020). Among these, the overall assessment of two evidence-based CPGs scored > 70% (NICE and QH), which was consistent with their higher scores in the six domains of the AGREE II instrument. In domain 3 (rigor of development), NICE and QH scored 99 and 60%, respectively. In domain 5 (applicability), they scored 96 and 74%, respectively, and in domain 6 (editorial independence), they scored 90 and 71%, respectively.

Conclusion

The methodological quality of the NICE CPG was superior followed by the QH CPG with relevant recommendations for use in practice.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021258732, PROSPERO (CRD42021258732).

Development of a small baby unit to improve outcomes for the extremely premature infant

Survival and outcomes for extremely premature (EP) infants have improved and even infants born at 23 and 24 weeks that were previously considered non-viable are now routinely surviving. This review describes our particular institution's basis for and process of creating and sustaining a small baby program for a quaternary, referral-based neonatal intensive care unit. Through multi-disciplinary collaboration, small baby guidelines were developed that established uniform care and optimized evidence-based practice for the care of this unique patient population. A focus on parent-centered care while removing noxious stimuli for the patient has improved neurodevelopmental outcomes. Data collection, quality improvement, and ongoing research are incorporated in the small baby program to establish and sustain best practices and outcomes for the EP patient. Through the establishment of a small baby unit, we have improved survival, decreased short-term morbidities, and improved neurodevelopmental outcomes for the EP infant in our region.

Eliminating Undesirable Variation in Neonatal Practice: Balancing Standardization and Customization

Consistency of care and elimination of unnecessary and harmful variation are underemphasized aspects of health care quality. This article describes the prevalence and patterns of practice variation in health care and neonatology; discusses the potential role of standardization as a solution to eliminating wasteful and harmful practice variation, particularly when it is founded on principles of evidence-based medicine; and proposes ways to balance standardization and customization of practice to ultimately improve the quality of neonatal care.

Patient assessment within the context of healthcare delivery packages: A comparative analysis

BACKGROUND

Due to an increased focus on productivity and cost-effectiveness, many countries across the world have implemented a variety of tools for standardizing diagnostics and treatment. In Denmark, healthcare delivery packages are increasingly used for assessment of patients. A package is a tool for creating coordination, continuity and efficient pathways; each step is pre-booked, and the package has a well-defined content within a predefined category of diseases. The aim of this study was to investigate how assessment processes took place within the context of healthcare delivery packages.

METHODS

The study used a constructivist Grounded Theory approach. Ethnographic fieldwork was carried out in three specialized units: a mental health unit and two multiple sclerosis clinics in Southern Denmark, which all used assessment packages. Several types of data were sampled through theoretical sampling. Participant observation was conducted for a total of 126h. Formal and informal interviews were conducted with 12 healthcare professionals and 13 patients. Furthermore, audio recordings were made of 9 final consultations between physicians and patients; 193min of recorded consultations all in all. Lastly, the medical records of 13 patients and written information about packages were collected. The comparative, abductive analysis focused on the process of assessment and the work made by all the actors involved. In this paper, we emphasized the work of healthcare professionals.

RESULTS

We constructed five interrelated categories: 1. "Standardized assessing", 2. "Flexibility", which has two sub-categories, 2.1. "Diagnostic options" and 2.2. "Time and organization", and, finally, 3. "Resisting the frames". The process of assessment required all participants to perform the predefined work in the specified way at the specified time. Multidisciplinary teamwork was essential for the success of the process. The local organization of the packages influenced the assessment process, most notably the pre-defined scope of relevant diseases targeted by the package. The inflexible frames of the assessment package could cause resistance among clinicians. Moreover, expert knowledge was an important factor for the efficiency of the process. Some types of organizational work processes resulted in many patients being assessed, but without being diagnosed with at package-relevant disease.

CONCLUSION

Limiting the grounds for using specialist knowledge in structured health care delivery may affect specialists' sense of professional autonomy and can result in professionals employing strategies to resist the frames of the packages. Finally, when organizing healthcare delivery packages, it seems important to consider how to make the optimal use of specialist knowledge.

Integrated care pathways: a tool to improve infant monitoring in a neonatal unit

An integrated care pathway (ICP) is a structured chart that prompts for key observations and interventions in patients to be recorded at set times by medical and nursing staff. ICPs were introduced into the neonatal department of the Queen Elizabeth Central Hospital in Blantyre, Malawi. The number of observations of babies recorded in the year before and 2 years after the introduction of ICPs were compared. When ICPs were in use, 9-96% of the 18 possible daily observations were recorded as having been carried out, compared with 0-33% before their introduction. In the 2nd of the 3 years, there was a fall-off in some observations made, probably because of staff shortages. The ICPs proved effective and easy to use. When adapted to local needs they play an important role in delivering neonatal care.

[Development of an internet-based clinical pathway exemplified by the fibromyalgia syndrome]

Clinical pathways (CP) are considered to be a tool of clinical process management describing the optimal route for diagnostic and therapeutic medical treatment of a specified patient. Apart from economic aspects CPs can make a contribution to optimization of health quality management as well as to improvement of medical staff and both patient satisfaction and patient safety whereas the feasibility and acceptance of evidence-based medicine guidelines are often found to be low. In order to stimulate critical discussion by offering the opportunity to easily gain first practical experience, a free web-based clinical pathway system for diagnosis and treatment for patients with fibromyalgia syndrome (FMS) will be presented.

Nosocomial infection reduction in VLBW infants with a statewide quality-improvement model

OBJECTIVE

To evaluate the effectiveness of the California Perinatal Quality Care Collaborative quality-improvement model using a toolkit supplemented by workshops and Web casts in decreasing nosocomial infections in very low birth weight infants.

DESIGN

This was a retrospective cohort study of continuous California Perinatal Quality Care Collaborative members' data during the years 2002-2006. The primary dependent variable was nosocomial infection, defined as a late bacterial or coagulase-negative staphylococcal infection diagnosed after the age of 3 days by positive blood/cerebro-spinal fluid culture(s) and clinical criteria. The primary independent variable of interest was voluntary attendance at the toolkit's introductory event, a direct indicator that at least 1 member of an NICU team had been personally exposed to the toolkit's features rather than being only notified of its availability. The intervention's effects were assessed using a multivariable logistic regression model that risk adjusted for selected demographic and clinical factors.

RESULTS

During the study period, 7733 eligible very low birth weight infants were born in 27 quality-improvement participant hospitals and 4512 very low birth weight infants were born in 27 non-quality-improvement participant hospitals. For the entire cohort, the rate of nosocomial infection decreased from 16.9% in 2002 to 14.5% in 2006. For infants admitted to NICUs participating in at least 1 quality-improvement event, there was an associated decreased risk of nosocomial infection (odds ratio: 0.81 [95% confidence interval: 0.68-0.96]) compared with those admitted to nonparticipating hospitals.

CONCLUSIONS

The structured intervention approach to quality improvement in the NICU setting, using a toolkit along with attendance at a workshop and/or Web cast, is an effective means by which to improve care outcomes.

Using a clinical pathway to support normal birth: impact on practitioner roles and working practices

BACKGROUND

Widespread concerns are being voiced in the Western world about rising rates of childbirth intervention. In Wales, United Kingdom, a Clinical Pathway for Normal Labour (Normal Labour Pathway) was devised to support normal childbirth and reduce unnecessary interventions. This study investigated the implementation of the pathway, from the perspective of midwives, doctors, and midwifery managers.

METHODS

An ethnographic approach was used to observe use of the Normal Labour Pathway in real life settings and evaluate its implementation. Data were collected by means of semiparticipant observation, focus groups, and interviews. Participants (n = 56) included senior practitioners involved in creating the pathway (n = 4), midwives (n = 41), managers (n = 5), and doctors (n = 6). Data were analyzed thematically.

RESULTS

Key themes related to the effect of the Normal Labour Pathway on Welsh maternity care, and midwives' and doctors' experiences. Midwives' views focused on the pathway as a decision-making protocol and record of care. Recently qualified midwives were more likely to view the pathway positively than those with more experience. Doctors were critical of the pathway, experiencing it as exclusionary. Midwives and doctors considered that the Normal Labour Pathway had increased interprofessional tensions. There was no evidence that it had increased the normal birth rate.

CONCLUSIONS

The Normal Labour Pathway is a complex intervention with complex outcomes. It has had intended and unintended consequences, for maternity care in general and for the roles and relationships of maternity care practitioners. The study raises questions about the appropriateness of clinical pathways and other standardized decision-making tools for the complexity of childbirth.

Decreasing central line associated bloodstream infection in neonatal intensive care

Central Line Associated Bloodstream Infections (CLABSIs) have come to be recognized as preventable adverse events that result from lapses in technique at multiple levels of care. CLABSIs are associated with increased mortality and adverse outcomes that may have lifelong consequences. This review provides a summary of evidence-based strategies to reduce CLABSI in the newborn intensive care unit that have been described in the literature over the past decades. Implementation of these strategies in "bundles" is also discussed, citing examples of successful quality improvement collaboratives. The methods of implementation require an understanding of the scientific data and technical developments, as well as knowledge of how to influence change within the unique and complicated milieu of the newborn intensive care unit.

Does implementation of a paediatric asthma clinical practice guideline worksheet change clinical practice?

Background

Despite the development of evidence-based practice guidelines in many countries for asthma treatment in children, there is limited evidence that using such guidelines improves patient care.

Aims

Our aim was to evaluate whether the implementation of an evidence-based asthma clinical practice guideline (CPG) worksheet changes clinical practice.

Methods

The study was a before and after study of the implementation of a paediatric asthma CPG in a tertiary paediatric emergency department (ED). All children aged 2–16 years who had a diagnosis of asthma were included. Clinical data were obtained by retrospective chart review for time periods before (May to September 2003) and after (May to September 2005) the introduction of the CPG worksheet. Primary outcomes were: use of spacers for salbutamol instead of nebulisers, use of ipratropium and use of corticosteroids. Secondary outcomes were use of an ED action plan, ordering chest X-rays (CXR) and admission rate.

Results

Before implementation, 240 children presented with asthma and after implementation, 286 children presented. The two groups had similar ages, asthma severity, admission respiratory rate (RR) and oxygen saturation. Following implementation there was an increase in spacer use from 17 to 26% [+9%; 95% confidence interval (CI): 2–16%; p = 0.015] and a reduction in ipratropium use from 58 to 44% (−13%; 95% CI: −22 to −5%; p = 0.0029). The proportion of patients treated with corticosteroids did not change. The number of patients with an ED action plan increased. The number of CXR ordered decreased and the hospital admission rate decreased.

Conclusions

The study demonstrates that implementation of an asthma CPG worksheet in a tertiary paediatric ED resulted in modest changes in clinical practice, mainly by increasing clinician adherence to the guidelines.

Re-mapping client journeys and professional identities: a review of the literature on clinical pathways

OBJECTIVES

To explore the growing use of clinical pathways by nurses and midwives, their impact on client care, and the potential consequences of widespread pathway utilisation for the professional identity and knowledge base of nursing and midwifery.

METHODS

A keyword search was performed within CINAHL and PubMed for the period 1995-2006 to identify relevant material, and article bibliographies were examined to identify relevance references. Thirty-nine publications were selected for inclusion in the analysis on the basis that they offered the most original account of the development of pathways or their effectiveness, or because they provided useful theoretical concepts. A thematic analysis of the selected articles was undertaken.

RESULTS

The review identified four main themes: the multiple aims of clinical pathways; the process of initial development; pathway implementation in practice, and the impacts of pathways on client care, professional identities, and the nature of written documentation. Clinical pathways have multiple aims, including standardising practice, levering external evidence into local health care work, and improving interprofessional co-ordination. The review found limited evidence of pathways' impact on client care, but the existing research suggests that they may be most suitable for predictable, routinised surgical procedures. Key concepts, such as variance and audit were found to be poorly defined. Clinical pathways appear to achieve many of their effects at the development stage and the reshaping of professional interactions.

CONCLUSIONS

Given their widespread adoption and valorisation as tools of evidence-based practice, the dearth of evidence for clinical pathways should raise concerns. Clinical pathways may have significant impacts on nursing and midwifery as professions, both through redrawing professional identities and boundaries, and transforming the ways in which nurses and midwives document care. The impact of standardised pathways on professional ideologies which emphasise individualised care, and clinical autonomy will require long-term programmes of research.

Clinical practice guidelines: a critical review

PURPOSE

Clinical practice guidelines (CPGs) have been developed for many years with the aim of improving the quality of care. A review of the use of CPGs and assessments of CPG compliance among practitioners so far would aid the understanding of factors influencing CPG compliance. This study seeks to provide this.

DESIGN/METHODOLOGY/APPROACH

A general review and discussion of CPGs in areas of their attributes, benefits and pitfalls were carried out. Articles concerning the assessment of CPG compliance were also reviewed to understand the kind of data collected for such assessments (qualitative vs quantitative), the methods used to collect data (objective versus subjective), and the assessment measures employed (process versus outcome).

FINDINGS

A total of 57 CPG compliance assessment studies were reviewed. Almost two-thirds employed objective methods. Of the subjective assessments, 47 per cent analysed solely quantitative data, 32 per cent analysed solely qualitative information and 21 per cent analysed both. More than four-fifths of all studies used process measures to determine CPG compliance and only 5 per cent used solely outcome measures.

PRACTICAL IMPLICATIONS

Depending on the methods used, assessments can help identify various factors influencing CPG compliance. Such factors may be related to the physician, guidelines, health system or patient. A good understanding of these factors and their role in influencing compliance behaviour will help health regulators and administrators plan better and more effective strategies to improve doctors' CPG compliance.

ORIGINALITY/VALUE

This review looks at the various aspects of CPGs to understand how these influence practitioners' compliance.

A descriptive study of medical malpractice cases in Turkey

BACKGROUND

Medical malpractice claims in Turkey have increased. We evaluated the problem by describing medical malpractice cases assessed by the Higher Health Council between 1993 and 1998. Our recommendations should help to improve care and decrease medical malpractice claims.

METHODS

We reviewed 997 medical malpractice cases reported to the Higher Health Council between 1993 and 1998 and examined the decisions made by the Higher Health Council. We collected data on demographic characteristics, such as the type of the institution where the defendants worked, type of medical malpractice, and medical outcome.

RESULTS

There were 997 medical malpractice cases reported to the Higher Health Council in the six years between 1993 and 1998. The Higher Health Council decided that 47.7% of the physicians were liable. Malpractice cases were mostly seen in state hospitals (42.4%). Fifty-nine percent of the cases resulted in death. Among actions that led to malpractice lawsuits against all health care workers, including physicians, the most common were negligence, inappropriate treatment, and diagnostic failure.

CONCLUSION

We think it is necessary to revise the health system and working conditions in hospitals and to develop clinical practice guidelines. We are of the opinion that an emphasis on the use of diagnosis and therapy protocols, standards, post-graduation education, clear and informed patient consent, and improved communication with patients will drastically decrease medical malpractice claims.

Managing information

Information management is an essential component in risk management and clinical governance. In neonatology, the areas related to information management are: (1) clinical records; (2) clinical information databases; (3) evidence-based practice; and (4) audit and outcome measures. Record keeping is an integral part of clinical practice and medical records should be an accurate account of clinical details. Clinical information is used for many purposes other than patient-care documentation. Evidence-based medicine is the use of current best evidence to make decisions about the care of individual patients. Benchmarking using illness severity adjustment is a crucial tool for studying variations in outcomes. Neonatal intensive care is well suited to such benchmarking but further development of standardised audit tools - both for interventions and for outcome measures - are required.

Lessons from the past

This article considers errors of care in neonatology. In the 19th century errors that resulted in high infant mortality were shaped by the social environment, and in this setting the development of the incubator failed. In the early 20th century, with the emergence of the modern hospital as a technological, science-driven system, physicians had more control of patients' environments, and thus medical errors could occur from systematic care and affected larger numbers. Later in the 20th century, the development of randomized controlled trials and systematic reviews began to improve care and to decrease the risks associated with new treatment methods. Large variations in practice still exist between physicians as individuals and institutions. Considering these variations as risks has led to the use of institutional databases, benchmarking and clinical care guidelines. The efficacy and safety of these methods is unproven. Risks will never disappear from medicine. The question of what risks are 'acceptable' is, in general, unanswerable.

Early NICU discharge of very low birth weight infants: a critical review and analysis

Early neonatal intensive care unit (NICU) discharge has been advocated for selected preterm infants to reduce both the adverse environment of prolonged hospital stay and to encourage earlier parental involvement by empowering parents to contribute to the ongoing care of their infant, and thereby reducing costs of care. Randomized trials and descriptive experiences of early discharge programs are critically reviewed over the last 30 years, and the key elements necessary for successful early discharge are reviewed and defined. Early discharge is clearly achievable for a large number of infants. Variations in neonatal care practices are reviewed since these variations have been documented to influence NICU stay. Management of apnea of prematurity and feeding practices is documented to significantly influence NICU length of stay, as is timing of discharge based on institutional factors. Developmentally centered care, use of nutritional supplements pre- and postdischarge, hearing screening programs, evaluation for retinopathy of prematurity, evaluation for apnea and bradycardia events, and cardiopulmonary stability while in a car seat all influence timing of discharge. Programs of early hospital discharge with home nursing and neonatologist support have been successful in lowering the length of NICU stay. However, trends in length of stay in NICUs indicate that for infants >750 g at birth over the last decade there have been insignificant reductions in length of hospital stay. Thus, because of the increase in the percentage of low birth weight infants in the US, there remain opportunities to improve on variations in care that will be translated to fewer NICU days in hospitals for selected infants. Several professional guidelines are summarized, and standards of care as related to discharge of premature infants are reviewed.

Clinicians' attitudes to clinical practice guidelines: a systematic review

OBJECTIVE

To systematically review surveys of clinicians' attitudes to clinical practice guidelines.

DATA SOURCES

MEDLINE, HealthStar, Embase and CINAHL were searched electronically for English-only surveys published from 1990 to 2000.

STUDY SELECTION

We included surveys with responses to one or more of seven propositions (see below). Studies were excluded if they had fewer than 100 respondents or if the response rate was less than 60%.

RESULTS

Thirty studies included responses to one or more of the seven items, giving a total of 11 611 responses. The response rate for the included studies was 72% (95% confidence interval [CI], 69%-75%). Clinicians agreed that guidelines were helpful sources of advice (weighted mean, 75%; 66%-83%), good educational tools (71%; 63%-79%) and intended to improve quality (70%; 60%-80%). However, clinicians also considered guidelines impractical and too rigid to apply to individual patients (30%; 23%-36%), that they reduced physician autonomy and oversimplified medicine (34%; 22%-47%), would increase litigation (41%; 32%-49%) and were intended to cut healthcare costs (52.8%; 39%-66%).

CONCLUSIONS

Surveys of healthcare providers consistently report high satisfaction with clinical practice guidelines and a belief that they will improve quality, but there are concerns about the practicality of guidelines, their role in cost-cutting and their potential for increasing litigation.