towards evidence-based clinical practice guidelines implementation at king saud university medical...
TRANSCRIPT
05/03/2023 1
Towards implementation of Evidence-Based Clinical
Practice Guidelines (CPGs)
Dr. Yasser S. AmerMBBCh, MPed, MHI, CPHQ, FISQua
Quality Management DepartmentMedical-City Wide CPGs Steering Committee
Research Chair for Evidence-Based Health Care & Knowledge Translation
05/03/2023 2
Training Plan Program
Training Program Title :
Towards Implementation of Evidence-Based Clinical Practice Guidelines
Training Program Duration : Four (4) hours
Targeted Employees : • Department Quality Team Members• Department CPG Committee Members• Residents/ Interns
Training Programs Goals : To provide participants with an overview on the state-of-the-art knowledge, skills, and tools on using evidence-based clinical practice guidelines in daily practice at King Saud University Medical City
Training Program Objectives: At the end of the training program, participants should be able to:1. Define Evidence-Based Medicine (EBM) and Clinical Practice Guidelines (CPGs).2. Discuss the rationale and aims for using CPG.3. Name the stakeholders involved in CPGs.4. Identify types of CPGs.5. Recognize standards of trustworthy or high quality CPGs6. Describe the difference between the (de novo) development versus adaptation of CPGs.7. Define CPG implementation and recognize different types of CPGs implementation tools.8. Discuss facilitators and barriers to implementation of CPGs.9. Memorize CPGs that are applicable in the concerned department of the target audience.10. Locate and access the CPGs (online and/or offline) that are applicable in the concerned department of the target
audience.11. Identify which sections to read in the CPG full documents.12. Recognize the contact person(s) for CPGs in the concerned department of the target audience.13. Recognize the composition of the CPG program at KSUMC.14. Appraise CPGs using the AGREE II Instrument.15. Understand the CPG-related QI/ accreditation standards.
05/03/2023 3
CPGs: Definitions, concepts and standards
05/03/2023 4
Uncertainty!.....Probability!Sir William Osler (1849 – 1919)
05/03/2023 5
The Epsom Derby, 1821 (oil on canvas) by Theodore Gericault; Louvre, Paris, France – Slide Courtesy of Prof. Abdelhamid Attia
Importance of ResearchPeople observe what they expect to observe, until shown otherwise
05/03/2023 6
Importance of ResearchPeople observe what they expect to observe, until shown otherwise
• http://www.youtube.com/watch?v=IEqccPhsqgA&list=PLSC6ykdWzbjHk4fKrmB94yj11dqfkXF0U
57 years later!Sallie Gardner (horse) at a Gallop
Eadweard Muybridge in 1878 – 3 seconds silent film, USA
05/03/2023 7
Importance of ResearchPeople observe what they expect to observe, until shown otherwise
Sallie Gardner (horse) at a Gallop Eadweard Muybridge in 1878 – 3 seconds silent film, USA
05/03/2023 8
“EBM” - birth of a termUpdate of CMAJ series on how to read a
paper
JAMA User guides 1991authors seek a new term
Clinical epidemiology?
Scientific medicine?
Evidence-based medicine!Research evidence should guide clinical
practice! Wasn’t it always that way?!
Slide courtesy of Dr. Paul Glasziou
Evidence-Based Medicine (EBM) Movement: Not new!• 865–925 Al-Razi (Rhazes)
1st need for experiments, comparisons in clinical studies
• 981–1037 Ibn Sina (Avicenna)test effect of drugs on humans not animals only
• 1987 David M. Eddy, MD, PhD ‘EB’ in EBCPGs, policies in workshops, manual
• 1992 Gordon Guyatt, MD‘EBM’ term in JAMA
• 1996 David Sackett, MD‘EBM’ definition in BMJ
05/03/2023 9
05/03/2023 10
How can we find the research that will improve the care of our patients?
0
500000
1000000
1500000
2000000
2500000
Biomedical MEDLINE Trials Diagnostic?
Med
ical
Art
icle
s pe
r Yea
r
5,000?per day
1,500 per day
95 per day
Med
ical A
rticle
s Per
Year
19 of 20
Slide courtesy of Dr. Paul Glasziou
05/03/2023 11
Two Different Approaches to Evidence-Based Practice
Clinical Practice Guidelines (CPGs)•“Top-down” approach• Tell clinicians how to practice• Favored by health care systems
Evidence-Based Medicine (EBM)•“Bottom-up” approach• Teach clinicians how to find answers• Favored by medical educators
Slide courtesy of Prof. Afaf Ibrahim
05/03/2023 12
The EBM Triad
05/03/2023 13
Knowledge TranslationKnowledge transfer & exchange
Implementation science/ researchResearch utilization
System/ Provider and Quality ImprovementDissemination & diffusion Research useKnowledge transfer & uptake
05/03/2023 14
Definition: (old)
“Systematically developed statements to assist
practitioner and patient decisions about
appropriate health care for specific clinical
circumstances” (IOM 1990)
Clinical Practice Guidelines (CPGs)
05/03/2023 15
“Statements that include Recommendations
intended to optimize patient care that are
informed by a Systematic Review of evidence
and an assessment of the benefits and harms of
alternative care options” (IOM-AHRQ 2011)
05/03/2023 16
Although CPGs have been identified as tools for improvement of patient healthcare outcomes, there is an increasing and often unmanageable volume of published CPGs that creates confusion for healthcare providers due to the variability in the quality of these CPGs (Altokhais 2016, Greenhalgh 2014)
05/03/2023 17
Evidence Pyramid (Study design)
SR
RCT
Cohort
Case control
Case series
Case report
Expert opinion
I
II
III
IV
A
B
C
Leve
ls o
f Evi
denc
eG
rades of Recom
mendations
MA
05/03/2023 18
The proposed new EBM pyramid.
M Hassan Murad et al. Evid Based Med 2016;21:125-127©2016 by BMJ Publishing Group Ltd
New evidence pyramid
05/03/2023 19
It’s peer-reviewed, therefore it must be OK?
Slide courtesy of Dr. Paul Glasziou
05/03/2023 20
methods
Benefits
Risks/ Burden
QoE!
05/03/2023 21
LevelEvidence
(LoE)
GradeRecomm.
(GoR)
Strength
EVIDENCE PYRAMID
05/03/2023 22
05/03/2023 23
Crisis in EBM?
05/03/2023 24
What is ‘real EBM’ and how to achieve it?
05/03/2023 25
What is ‘real EBM’ and how to achieve it? (cont’d)
05/03/2023 26
05/03/2023 27
Relationships between Quality Improvement (QI) and Evidence-Based Medicine (EBM).
Paul Glasziou et al. BMJ Qual Saf 2011;20:i13-i17
Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.
05/03/2023 28
HWCPG-SURG-001
05/03/2023 29
CPG-OBGYN-001
05/03/2023 30
HWCPG-ENT-001 (ABRS) 2013
05/03/2023 31
WhyDo we need
CPGs?
05/03/2023 32
Rationale for CPGs• Worldwide concerns about:-
▫Unexplained variation/ variability in CP!
▫Rising healthcare costs!
▫Exponential growth of health information!
• Aim of CPGs:-To facilitate more consistent, effective and efficient practice and improve health outcomes for patients
05/03/2023 33
CPGs:For whom?
05/03/2023 34
Stakeholders (TEAM)
•Physicians•Nurses•Pharmacists•Technicians•Technologists•Decision makers•Patients•Public
05/03/2023 35
Types of CPGs1. Evidence-Based CPGs (evidence-
based methodology)2. Consensus/ expert-based CPGs
Which type do you think is better?
05/03/2023 36
The EBM Triad
05/03/2023 37
CPGs on the Web
Producers Finders
05/03/2023 38
Guideline Producers• Specialized (professional) societies• Healthcare Organizations• Governmental (National) organizations:
NICE, SIGN, NHMRC, ,etc.• International organizations
05/03/2023 39
Organization Name Country URL Producer
Finder
Guidelines International Network (G-I-N) International http://www.g-i-n.net F
World Health Organization (WHO) International http://www.who.int/topics P
National Institute for Health & Care Excellence (NICE)
UK http://www.nice.org.uk/page.aspx?o=ourguidance P
Scottish Intercollegiate Guidelines Network (SIGN) UK http://www.sign.ac.uk/guidelines/
index.html P
National Guidelines Clearinghouse (NGC), AHRQ USA http://www.guidelines.gov F
EBSCO DynaMed USA dynamed.ebscohost.com/user/login
Institute for Clinical Systems Improvement (ICSI) USA http://www.icsi.org/knowledge/ P F
US National Library of Medicine, National Institutes of Health (PubMed) USA
http://www.ncbi.nlm.nih.gov/pubmed
OR http://www.pubmed.govF
Google Scholar USA https://scholar.google.com/?hl=ar&safe=on
F
05/03/2023 40
CPG Producers: National Agencies
NICENational Institute for Health & Clinical Excellencewww.nice.org.uk
05/03/2023 41
NICE Guidance
132 CPGs
05/03/2023 42
CPG Producers: National Agencies
SIGNScottish Intercollegiate Guidelines Networkwww.sign.ac.uk
14 groups
05/03/2023 43
World Health Organization
• WHO guidelines for safe surgery: safe surgery saves lives (2009)
• Best Practice Guidelines on Emergency Surgical Care in Disaster Situations (2007)
05/03/2023 45
CPGs Finders• National Guidelines Clearinghouse (NGC/
AHRQ)• Guidelines International Network (G-I-N)• EBSCO DynaMed• PubMed/ MedLine• Google Scholar
CPG Finders
AHRQ-NGCNational Guideline
Clearinghouse
www.guidelines.gov
> 408 CPGs
05/03/2023 46
05/03/2023 47
Shaikh Bahamdan’s Research Chair for Evidence-Based Health Care & Knowledge Translation
Member of G-I-N since Oct. 2009Free access to International CPG Library of G-I-N
http://c.ksu.edu.sa/ebhc
05/03/2023 49
05/03/2023 50
05/03/2023 51
CPG FindersPubMed: US National Library of Medicine,
National Institutes of Health (NIH)
05/03/2023 52
05/03/2023 53
Specialized Societies: PEDIA AAP
05/03/2023 54
SURG RCS
05/03/2023 55
SURG ACOS
05/03/2023 56
MED ACP
05/03/2023 57
FM/PC AAFP
05/03/2023 58
OBS-GYNE RCOG
05/03/2023 59
CARDIO ESC
05/03/2023 60
PSYCH The Maudsley Hospital
05/03/2023 61
PSYCH APA
05/03/2023 62
ORTHO AAOS
05/03/2023 64
Radiology ACR
05/03/2023 65
Radiology ACR
05/03/2023 66
What makes a trustworthy CPG?
05/03/2023 67
Standards for high quality CPGsIOM 2011 – G-I-N 2012 – AGREE 2013
05/03/2023 68
Standards for trustworthy CPGsIOM 2011 G-I-N 2012
1- Establishing Transparency 1- Decision making process. 2- Methods
2- Management of COI 3- COI
3- (GDG) composition 4- GDG composition
4- (CPG – SR) intersection 5- Evidence reviews
5- Assign/ link to (LoE) & (GoR) 6- Rating of E & Rs
6- Articulation of (Rs) 7- CPG Rs (formulation/ wording)
7- External Review 8- Peer review & stakeholder consultation
8- Updating 9- Expiration & updating
10- Scope of CPG
11- Financial support/ sponsoring organization
05/03/2023 69
How to assess of the quality of any CPG?
05/03/2023 70
23 Items in 6 Domains USER’S MANUAL page 7
DOMAINS No. of Items
1 Scope & Purpose 3
2 Stakeholder Involvement 3
3 Rigour of Development 8
4 Clarity & Presentation 4
5 Applicability 3
6 Editorial Independence 2
05/03/2023 71
CPG development methodologies
05/03/2023 72
CPGsWhat to do?
05/03/2023 73
Read
AdoptAdapt
Develop
CPGs ?Slide courtesy of Prof. Nabil Dowidar
05/03/2023 74
CPGsDEVELOPMENT
(de novo)vs.
ADAPTATION
05/03/2023 75
Different Options to deal with CPGAdoption
Adaptation
Rejection
05/03/2023 76
05/03/2023 77
Process/ Methods
05/03/2023 78
Adaptation of CPGsIs the systematic approach to the endorsement and/or
modification of a guideline(s) produced in one cultural and organizational setting for application in a different context. Adaptation may be used as an alternative to de novo guideline development, e.g., for customizing (an) existing guideline(s) to suit the local context.
http://www.adapte.org/http://www.g-i-n.net/
05/03/2023 79
05/03/2023 80
Team - TopicTotal Number of Health Topics for CPGs from all departments
53
05/03/2023 81
Selecting a CPG Topic Prevalence of the condition (high volume) Patient safety concern (high risk) Under-, over-, misuse of intervention(s) Burden due to the condition Practice variation Costs of different practice options Likelihood of effectiveness of CPG Potential for improving quality of care and/or
outcomes Existence of relevant good quality CPGs
05/03/2023 82
KSUMC Protocol for New CPG
05/03/2023 83
Health/ Clinical/ Key QuestionsPatient (& disease characteristics)
Intervention(s)
Professionals (Target users)
Outcomes (purpose of the CPGs)
Healthcare settings (& context)
CPG Scope: PIPOH Model
05/03/2023 84
Health Question Tool (modif.)
05/03/2023 85
05/03/2023 86
05/03/2023 87
05/03/2023 88
05/03/2023 89
05/03/2023 90
Inclusion / Exclusion CPGs Selection Criteria (6) 1. Methods of Development: Evidence-Based CPGs:
(Detailed Methodology not Consensus-based CPGs (Expert opinion)
2. Author(s): Organization and Specialized Society not single authors.
3. Country: International not national CPGs.4. Date of Publication: range of year of publications: last 5
years or less (e.g. 2011 – 2016) – except if none!
5. Language: English CPGs only6. Status: only Original source CPG (de novo developed)
rather than adapted CPGs
05/03/2023 91
CPG selection criteria Tool (new)
05/03/2023 92
05/03/2023 93
CPGs on the Web
Producers Finders
05/03/2023 94
05/03/2023 95
How to assess of the quality of any CPG?
05/03/2023 96
The concept of the ‘LIVING’ CPG
05/03/2023 97
End of Finalization Phase1. After end of External review2. CPG Dept. committee submit finalized CPG draft to R & D Unit,
Quality Management Department for review;3. Submit to CPG Steering Committee for review of adaptation
process methodology and final approval;4. Congratulations letter to Chairman of department5. Start dissemination and implementation in relevant
departments;6. Follow up, clinical auditing & measurement in relevant
departments;
05/03/2023 98
:: Evidence to practice/ knowledge to action cycle ::
CPG Implementation (CPGI)
Strategies & Tools
05/03/2023 99
CPGI“The concrete activities and interventions undertaken to turn policies into desired results“Guidelines for clinical practice: from development to use. IOM, 1992
CPGs Practice
05/03/2023 100
CPG “Implementability”
Set of characteristics that PREDICT the relative ease of implementation of CPG recommendations.
Implementability…….BEFORE implementation
05/03/2023 101
How to Measure Implementability?
Ease and accuracy of translation of guideline advice into systems that influence care.
05/03/2023 102
Dissemination & Implementation
Nothing could be more frustrating than producing a CPG that is then ignored by not being disseminated
nor implemented nor updated.
The concept of the ‘LIVING’ CPG
05/03/2023 103
CPGI Tools
05/03/2023 104
Adapt/ design CPGI Tools to be made available at the point of care (* MR/ EMR)
Examples• Clinical Algorithms• Integrated Care/ Clinical Pathways• Protocols• Policies & Procedures• Chart Documentation/ forms (e.g. Physician Order
Sets: paper vs. CPOE system +/- CDSS)• Quick Reference Guides/ Physician Guides &
Pocket Guide/Reference Cards (at-a-glance summary of key recommendations).
• Mobile Apps
05/03/2023 105
• Clinical audit criteria (tool)• Quality/ Performance measures (process, outcome
KPIs)• Quality Tools (e.g. FMEA)• Slide Presentation.• Wall Poster.• Patient Resources/ Information (HE guides).• Foreign language Translation (Non-Arabic, Non-French).• Implementation Tool Kits (collections of tools and/or
strategies).• Staff Training/ Competency Material.
CPGI tools (cont’d)
05/03/2023 106
Mobile Apps for CPGs (mHealth)
05/03/2023 107
MEDICINE/ CARDIOLOGYSpecs detail
Specialty Medicine
Organization American College of Cardiology Foundation
Cost Free
System Android
05/03/2023 108
PEDIATRICSSpecs detail
Specialty Pediatrics
Organization Royal Children’s Hospital, Melbourne
Cost Free
System Android
05/03/2023 109
GeneralSpecs detail
Specialty Medicine
Organization NICE
Cost Free
System Android
05/03/2023 110
GeneralSpecs detail
Specialty General
Organization SIGN
Cost Free
System Android
05/03/2023 111
NURSINGSpecs detail
Specialty Nursing
Organization RNAO
Cost Free
System Android
05/03/2023 112
ORTHOPEDICSSpecs detail
Specialty Medicine
Organization American Academy of Orthopedic Surgeons
Cost Free
System Android
05/03/2023 113
PSYCHIATRYSpecs detail
Specialty Psychiatry
Organization (?)
Cost Paid
System Android
05/03/2023 114
General Specs detail
Specialty General
Organization Guideline Central
Cost Free/ paid
System Android
05/03/2023 115
NICE Guidance‘Tools and resources’
• Baseline assessment
• Clinical audit• E-learning
module• Slide set• Tailored
education support
• Case scenario
• Commissioning guide
• Costing statement
• shared learning
• ‘Do not do’ recommendations
• Research
recommendations
• Guidance into practice
05/03/2023 116
CPG implementation strategies/ interventions
05/03/2023 117
CPG implementation strategies
Dissemination Process (print/ e-/website)Local Clinical Champions.Awareness raising/ training activities.Networking and linking with existing projects
(e.g. CPD/CME activities, Accreditation, etc..).
Patients as champions for change.Regular M & E (The ‘living’ CPG concept!).
05/03/2023 118
Audit: Manual
• Source of data: paper patient files (before May 2015) and eSiHi afterwards
• Data collection tools: audit tools included in CPGs (review)
• Specific clinical audit criteria or KPI formulae • Data collection • Data cleansing • Data analysis • Graphical representation and reporting the results
05/03/2023 119
Audit: Electronic• Continue working on eSiHi quality solutions to
generate reports of CPG-based POWERPLANS or CPOE per diagnosis for CPG (Discern Analytics©, Power-Insight©,..etc.)
• Ensure inclusion of the identified CPG-based KPIs in the built of the new Database of the KPI project
05/03/2023 120
“Multi-faceted” are more effective than single strategies in CPGI!
05/03/2023 121
Facilitators and Barriers in CPGI
05/03/2023 122
Facilitators of CPGIDomain
Positive attitudeLearning through small group interaction
Individual
Leadership supportChampionsTeam work collaboration
Organizational
Scientific specialized association supportInter-organizational collaboration
networks
Environmental
05/03/2023 123
CPG Implementation Failure! BARRIERS!Extrinsic to CPG:provider & care system-related
Intrinsic to CPG: (>Methodology!)ambiguity – inconsistency - incompleteness
05/03/2023 124
FMEA RESULTS – Major Failure Modes
Identified potential failure modes in CPGs implementation with the highest RPN (≥ 80):-1. Auditing of the CPGs (e.g. data management process).2. Adaptation process (e.g. AGREE appraisal, Ext. review).3. Networking with existing projects.4. Awareness/training activities.5. Accessible printed & electronic implementation tools6. Advocates from clinical/ quality champions
05/03/2023 125
RESULTS - Actions taken1. Auditing: Supported by Pedia. CGC, DQT & QMD as a part of
Quality sustainability plan and CPG Program.2. Adaptation: (e.g. AGREE: 4 appraisers, Review: all
Stakeholders)3. Networking: (e.g. Dept. QIP, CPD, Accreditation, Research)4. Awareness/ training activities: Organized regularly.5. Printed & electronic copies*: Available and accessible to HC
providers at points of care. *eSiHi!6. Champions: Consultants/ senior practitioners encouraged to
get involved in CPG adaptation/ implementation.
05/03/2023 126
CPG Implementation cycle
05/03/2023
CPG Implementation cycle
127
Fina
l CPG
App
rove
d +
CPG
I Too
ls +
Pla
n
Form
ulat
e Im
plem
enta
tion
mul
tidis
cipl
inar
y te
am
Base
line
(Pre
-) Au
dit o
f cur
rent
CP
Pilo
t Im
plem
enta
tion
Iden
tify
barr
iers
Prio
ritize
diss
emin
ation
stra
tegi
es
and
star
t
Prio
ritize
1 –
3 k
ey R
s to
impl
emen
t
Prio
ritize
impl
emen
tatio
n st
rate
gies
Post
-impl
emen
tatio
n M
& E
Reg
ular
ch
eckp
oint
s (PI
POH-
KPI)
Regu
lar r
evie
w &
upd
ate
of p
ublis
hed
sour
ce C
PG +
/- e
vide
nce
05/03/2023 128
05/03/2023 129
Effectiveness of CPGs implementation interventions
Slide courtesy of Dr. Ulfat Shaikh
05/03/2023 130
05/03/2023 131
G-I-N Working Groups (IWG, PMWG)
05/03/2023 132
The CPG lifecycle at KSUMC: The CPG Adaptation Program
05/03/2023 133
KSUMC CPG PROGRAMcurrent status 1437-2016
05/03/2023 134
Clinical Practice Guidelines (CPGs) Program of King Saud University Hospitals/ Medical City
KSUHs Taskforce Responsible Staff from:KSUMC-Wide CPG Steering Committee;Departmental CPG Committees (former CPGs
subcommittees);Shaikh Bahamdan Research Chair for Evidence-Based
Health Care and Knowledge Translation;Quality Management Department;Head of Units & Chairpersons/ Directors of DepartmentsTop Management & Leadership of College of Medicine
and University Hospitals (Future KSU Medical City)
Guidelines International Network (G-I-N)www.g-i-n.net
EBHC-KT Chair, King Saud UniversityOrg. Member since 2009
(1st Member from Gulf & 3rd Member from MENA Countries)
Founded in Nov. 2002
05/03/2023 135
05/03/2023 136
HWQPP – Standing orders development, revision & deletion (2014)
05/03/2023 137
21 KSUMC CPGs Subcommittees1. Department of Pediatrics 2. Department of Critical Care 3. Department of Psychiatry 4. Primary Care/ Family Medicine Clinics
(Ambulatory Care Services) 5. Department of Pharmacy 6. Department of Emergency Medicine 7. Department of Medicine8. Department of Orthopedic Surgery 9. Department of Otorhinolaryngology 10. Department of Ophthalmology 11. Department of Cardiac Sciences/ KFCC
(Cardiology – Cardiac Surgery) 12. Department of Surgery 13. Department of Obstetrics & Gynecology 14. Department of Dermatology 15. Department of Anesthesiology 16. Department of Laboratory Medicine &
Pathology 17. Department of Nursing
18. Department of Radiology 19. Health Education Center 20. Department of Rehabilitation Medicine21. Department of Infection Control
New (in progress)1. Department of Occupational Health & Safety2. Department of Clinical Nutrition
05/03/2023 138
0
2
4
6
8
10
12
7
10
6
232321111
01000000000
KSUMC CPGs in al l departments approved by cgc(FEB 2015 - Jumada' I 1436)
# CPGs approved
*Pooling specialties (reviewers)
05/03/2023 139
KSUMC CPGs in Numbers KSUMC-Wide CPG Committee Members: 12 Departments participating in CPG Program: 21 Health topics identified for CPG projects: 53 CPG adaptation projects finalized: 33 CPGs finalized & approved by CPG Committee: 29 CPGs finalized & implemented: 17 CPGs uploaded to QM website & relevant desktop in points of
care: 28 CPGs implemented & audited (data collected): 13 CPGs implemented & audited (data analyzed): 3
05/03/2023 140
How to access our CPGs
05/03/2023 141
05/03/2023 142
05/03/2023 143
05/03/2023 144
Who is the contact person for EBCPGs in each clinical department?
Chairperson & members, CPG Departmental Committee
Lead & members, Department Quality Teams Department Chairman & Units’ Heads Coordinator, CPG Steering Committee: Dr. Yasser Amer Ext. # 91341, Email: [email protected] Medical Secretary, CPG Steering CommitteeMs. Dorothy Villena Ext. # 91281, Email: [email protected]
05/03/2023 145
05/03/2023 146
Approved KSUMC Adapted CPGs (cont’d)
How to read the KSUMC CPGs full documents?
Go to TABLE OF CONTENTS:-• Preface by authors• Acknowledgments• Abbreviations• Overview material• Introduction • Statement of intent
• Scope & Purpose (Health Questions PIPOH)• Recommendations (Key & details)• External review & consensus• Plan for scheduled review & update• List of funding sources• Adaptation process methodology• Implementation considerations & Tools• References
05/03/2023 147
05/03/2023 148
KSUMC CPG Adaptation Program Deliverables
05/03/2023 149
05/03/2023 150
CPGI• Start with prioritized with strong evidence.• Used a planned and structured approach.• Identify key stakeholders.• Understand facilitators and barriers.• Use evidence-based implementation interventions.• Monitor and evaluate effectiveness.• Modify and improve your approaches.• PLAN – DO – STUDY – ACT – ENJOY!
Slide courtesy of Dr. Catherine Marshall
05/03/2023 151
Desktop Icon
05/03/2023 152
With or without Clinical Decision Support (CDS)
05/03/2023 153
05/03/2023 154
CPOE with Order Sets = In eSiHi are called “POWERPLANS”
05/03/2023 155
05/03/2023 156
05/03/2023 157
6 PowerPlans from Pediatrics CPGs
1. PED Diabetic ketoacidosis CPG2. PED Severe sepsis/ septic shock CPG3. PED acute asthma CPG4. PED acute bronchiolitis CPG5. PED Fever of known cause in infants 60 days or less
CPG6. NICU Neonatal Hyperbilirubinemia CPG
05/03/2023 158
05/03/2023 159
5 PowerPlans from Medicine CPGs
1. MED Diabetic Ketoacidosis CPG (adults)2. MED Gout CPG3. MED Hypertensive emergencies/urgencies
CPG 4. MED oncology premedication5. PULM Asthma CPG (adults)
05/03/2023 160
1 from DEM/ ICU CPGsED septic shock (adults)
1 from Cardiology (KFCC) CPGsCARD Heart Failure CPG
05/03/2023 161
1 from Orthopedics CPGs
ORTHO persistent non-specific Low Back Pain
CPG (adults)
05/03/2023 162
2 from ENT CPGs
1. ENT Acute Bacterial Rhinosinusitis CPG (adults)
2. ENT Acute Bacterial Rhinosinusitis CPG (children)
05/03/2023 163
1 from Family Medicine CPGsFAM Dyslipidemia CPG
1 from Psychiatry CPGsPSYCH Bipolar disorder
CPG
05/03/2023 164
Paper Days!If it’s not documented, you didn’t do it!
05/03/2023 165
EMR Days!“eSiHi” days
You documented it . . . . . . . . . Did you (e-) document it properly? Did you do it?
05/03/2023 166
Anesthesiology (+4)
1. Heart Failure (Adult)2. Surgical Antibiotic prophylaxis (Adult)3. Central Vascular Access Device4. Vancomycin dosing and monitoring (Adult)
05/03/2023 167
Critical Care (ICU) (2+6)1. Severe Sepsis and Septic Shock (Adult) 2. Venous Thromboembolism Prophylaxis 3. Diabetic ketoacidosis (Adult)4. Vancomycin dosing and monitoring (Adult)5. Surgical Antibiotic prophylaxis (Adult)6. Heart Failure (Adult)7. Surgical Site Infection Prevention 8. Central Vascular Access Device
05/03/2023 168
Emergency Medicine: Adult/ Pedia ( +18)1. (Acute) Asthma (Adult)
2. Diabetic ketoacidosis (Adult)3. Hypertensive emergencies & urgencies4. Severe Sepsis and Septic Shock (Adult) 5. Gout (acute gouty arthritis)6. Venous Thromboembolism Prophylaxis 7. Vancomycin dosing and monitoring (Adult)8. Surgical Antibiotic prophylaxis (Adult) (NSG
care)9. Heart Failure (Adult)10. Bipolar disorder 11. Persistent non-specific Low back pain (Acute
attack)
1. Acute Asthma exacerbations (Child)
2. Acute viral Bronchiolitis3. Diabetic Ketoacidosis (Child) 4. Fever without a source in
infants 60 days or less5. Neonatal Jaundice6. Severe Sepsis and Septic Shock
(Child)7. Status Epilepticus in (Child)8. Pediatric and neonatal
parenteral nutrition (TPN)
05/03/2023 169
Otorhinolaryngology/ ENT (1 + 2)
1. Acute Bacterial Rhino-sinusitis (Adult/ Child)2. Surgical Antibiotic prophylaxis (Adult)3. Venous Thromboembolism Prophylaxis
05/03/2023 170
Family & Community Medicine (1+3)
1. Dyslipidemia and prevention of atherosclerosis2. Gout (acute gouty arthritis/ hyperuricemia)3. Persistent Non-specific Low Back Pain4. Asthma
05/03/2023 171
Infection Control (+2)
• Surgical Site Infection Prevention • Surgical Antibiotic prophylaxis
05/03/2023 172
King Fahad Cardiac Center (2+ 8)
1. Heart Failure (Adult)2. Cardiac Artery Bypass Graft Surgery3. Hypertensive emergencies & urgencies4. Dyslipidemia 5. Venous Thromboembolism Prophylaxis6. Vancomycin dosing and monitoring (Adult) 7. Surgical Site Infection Prevention 8. Surgical Antibiotic prophylaxis (Adult)9. Pediatric and neonatal parenteral nutrition (TPN)10. Central Vascular Access Device
05/03/2023 173
Laboratory Medicine & Pathology
Review 99.99% CPGs!
05/03/2023 174
Medicine (6 +5)1. Asthma (Adult)2. Diabetic ketoacidosis (Adult)3. Hypertensive emergencies & urgencies4. Gout (acute gouty arthritis/ hyperuricemia)5. Lung Cancer 6. Antiemetics for Chemotherapy-induces nausea & vomiting 7. Venous Thromboembolism Prophylaxis 8. Dyslipidemia 9. Vancomycin dosing and monitoring (Adult)10. Surgical Antibiotic prophylaxis (Adult)11. Heart Failure (Adult)
05/03/2023 175
Nursing (3)• Surgical Site Infection Prevention• Central Vascular Access Device• Extravasation in chemotherapy
05/03/2023 176
Obstetrics & Gynecology (2 +3)
1. Antenatal corticosteroids for fetal maturation2. Number of Embryos to transfer in IVF
Treatment3. Venous Thromboembolism Prophylaxis4. Surgical Site Infection Prevention 5. Surgical Antibiotic prophylaxis (Adult)
05/03/2023 177
Ophthalmology (+2)
• Surgical Antibiotic prophylaxis (Adult)
• Venous Thromboembolism Prophylaxis
05/03/2023 178
Orthopedics (1 +3)1. Persistent Non-specific Low Back Pain2. Venous Thromboembolism Prophylaxis3. Surgical Site Infection Prevention 4. Surgical Antibiotic prophylaxis (Adult)
05/03/2023 179
Pediatrics (7+2)1. Acute Asthma exacerbations (Child) 2. Acute viral Bronchiolitis3. Diabetic Ketoacidosis (Child) 4. Fever without a source in infants 60 days or less5. Neonatal Jaundice6. Severe Sepsis and Septic Shock (Child)7. Status Epilepticus in (Child)8. Pediatric and neonatal parenteral nutrition (TPN)9. Acute bacterial rhinosinusitis (Child)
05/03/2023 180
Pharmacy Services (3)• Vancomycin dosing and monitoring (Adult)• Pediatric and neonatal parenteral nutrition (TPN)• Antiemetics for Chemotherapy-induces nausea &
vomiting
05/03/2023 181
Psychiatry (1+ 1?) 1. Bipolar Disorder2. Venous Thromboembolism Prophylaxis
05/03/2023 182
Physical/Rehabilitation Medicine (+1)
1. Persistent Non-specific Low Back Pain2. (?)
05/03/2023 183
Radiology/ Imaging (+4) 1. (Acute) Asthma (Adult) - ?CXR2. Acute Asthma exacerbations (Child) - ?CXR3. Acute viral Bronchiolitis - ?CXR4. Status Epilepticus in (Child) - ?CT/ MRI Brain5. Acute Bacterial Rhino-sinusitis (Adult/ Child) - ?CT/
MRI PNS
05/03/2023 184
Surgery (1 + 4) 1. Surgical Antibiotic prophylaxis (Adult/
Pedia)2. Venous Thromboembolism Prophylaxis3. Surgical Site Infection Prevention 4. Vancomycin dosing and monitoring (Adult)5. Pediatric and neonatal parenteral nutrition
(TPN)
05/03/2023 185
Examples of KSUMC Clinical Practice Guideline Adaptation
& Implementation Projects
presented and/or published in national/ international conferences
and/or journals
05/03/2023 186
Lists of publications that resulted from the program (list is not exclusive)
1. Schünemann HJ, Al-Ansary LA, Forland F, Kersten S, Komulainen J, Kopp IB, et al. Guidelines International Network: Principles for Disclosure of Interests and Management
of Conflicts in Guidelines. Ann Intern Med. 2015;163:548-553. doi:10.7326/M14-1885
2. Mohamed S. From Concept to Bedside: What Pediatricians Should Know about Synthesis of Clinical Practice Guidelines? Iran J Pediatr 2014; 24(5): 557-64
3. Ciocson MAFR, Hernandez MG, Atallah M, Amer YS. Central Vascular Access Device: An Adapted Evidence-Based Clinical Practice Guideline. JAVA 2014; 19(4): 221-37
4. Al-Ansary LA, Tricco AC, Adi Y, Bawazeer G, Perrier L et al.
A systematic review of recent clinical practice guidelines on the diagnosis, assessment and management of hypertension. PLoS One. 2013;8(1):e53744. doi:
10.1371/journal.pone.0053744.
5. Al-Otair HA, Khurshid, Alzeer AH, Venous thromboembolism in a medical intensive care unit the effect of implementing clinical practice guidelines. Saudi Med J 2012; 33
(1): 55-60.
6. Eldawlatly A, Qureshi S, Schumann R. "ROAD MAP" toward establishing clinical practice guidelines for anesthesia in morbidly obese patients undergoing weight loss
surgery. Saudi J Anaesth 2012;6:319-21
7. Wahabi HA, Alzeidan RA. Reasons behind non-adherence of healthcare practitioners to pediatric asthma guidelines in an emergency department in Saudi Arabia. BMC
Health Serv Res 2012; 12: 226 (doi:10.1186/1472-6963-12-226)
8. Wahabi HA, Al-Ansary LA. Innovative teaching methods for capacity building in knowledge translation. BMC Med Educ 2011 Oct 14;11:85 (doi: 10.1186/1472-6920-11-85)
9. Wahabi HA, Alzeidan RA, Fayed AA, Esmaeil SA, Al Aseri ZA.
Attitude and practice of the health care professionals towards the clinical practice guidelines in King Khalid University Hospital in Saudi Arabia. J Eval Clin Pract. 2011 Aug;
17(4):763-7 (doi: 10.1111/j.1365-2753.2011.01694.x.)
10. Wahabi HA, Al-Ansary LA. Great expectations from the chair of evidence-based health care and knowledge translation. Saudi Med J 2009; 30(8): 989-90.
11. Al-Ansary, L. A. and A. Alkhenizan. Towards evidence-based clinical practice guidelines in Saudi Arabia. Saudi Med J 2004; 25(11): 1555-1558.
05/03/2023 187
Conference papersNational and International Conferences:
1. Al-Ansary L. Oral presentation. KSUMC CPG program at the Second wave of CPGs at the Saudi Evidence-Based Healthcare Center, Ministry of Health (2015).
2. Mohamed S et al. Substantial Reduction in Length of Hospital Stay of Patients with Diabetic Ketoacidosis after Implementation of Clinical Practice Guidelines at a University Hospital in Saudi Arabia at Conference: ENDO 2015: The Endocrine Society's 97th Annual Meeting and Expo, At San Diego, California, USA. March 5-8 2015.
3. Amer YS. Poster. Amer YS, Alswat K, Al-Ansary L, Wahabi HA, Shaikh F. Capacity building for adaptation of clinical practice guidelines at International Forum for Quality and Safety in Healthcare, IHI/ BMJ. London, UK 2015.
4. Amer YS. Oral presentation. Babiker A, Amer YS, Wahabi H, Alswat K. Failure Mode and Effect Analysis (FMEA) For Implementation of Clinical Practice Guidelines at a Tertiary Care Teaching Hospital in Saudi Arabia at 32nd International conference of The International Society for Quality in Health Care (ISQua), Doha, Qatar, 4-7 October 2015.
5. Titi M. Oral presentation. Alhabeeb W, Titi M, Rabea N, Amer YS. Adaptation and Implementation of an Evidence-Based Clinical Practice Guideline for Management of Heart Failure in a University Medical City at the 32nd International conference of The International Society for Quality in Health Care (ISQua), Doha, Qatar, 4-7 October 2015.
6. Ciocson MAFR. Poster. Central Vascular Access Device: An Adapted Evidence-Based Clinical Practice Guideline at International Nursing Conference at KSUHS (2015).
7. Al-Ansary L. Oral Presentation. Al-Ansary L, Amer YS, Fattouh R, Adi Y. Partnering To Transform Clinical Research into Evidence-Based Health Care Guidelines at 10th International conference of Guidelines International Network 2013, San Francisco, USA. (abstract published in BMJ Quality & Safety 2013).
8. Amer YS. Poster. Abahussain E, Fatani S, Tawariji M, Al-Ansary L, Amer YS. Management of Patients With Bipolar Disorder: An Adapted Clinical Practice Guideline from King Saud University, King Khalid University Hospital, Clinical Practice Guidelines Committee, College of Medicine and Department of Psychiatry at 10th International conference of Guidelines International Network, San Francisco, USA (abstract published in BMJ Quality & Safety 2013)
9. Mohamed S. Featured Poster and oral presentation. Development and implementation of Clinical Practice Guidelines in Pediatric Endocrinology: Challenges and opportunities at ENDO 2013 The Endocrine Society's 95th Annual meeting and Expo, San Francisco June 15-18, 2013.
10. Mohamed S. Poster. Mohamed S et al. Development and implementation of clinical practice guidelines in diabetic ketoacidosis: NICE is also nice in the Middle East at 9th Joint Meeting of European Society of Paediatric Endocrinologists 19-22 September 2013.
11. Mohamed S. Oral presentation. Development and implementation of Clinical Practice Guidelines in Pediatrics Department, KSUHS: Challenges and opportunities at First Quality Day Symposium at KSUHS (2013).
12. Hasan G. Oral presentation. Sepsis in PICU: Obstacles for implementation of Sepsis Guidelines at the Saudi Critical Care Society. SCCS, Dammam. (2012). Video: http://rmsolutions.net/sccs/2012/?q=node/29
13. Hasan G. Oral presentation. Implementation of sepsis and septic shock clinical practice guidelines: overcoming the challenge at 2nd Annual International Conference of the Saudi Critical Care Society SCCS 2011, Riyadh (2011).
14. Wahabi HA. Oral presentation. From evidence to practice in countries where health policy is not evidence-based (S7) at 7th International conference of the Guidelines International Network, Chicago, USA, 2010. Link: http://www.g-i-n.net/conference/past-conferences/document-store/g-i-n-conferences/chicago-2010/presentations-chicago-2010/wahabi-s7.pdf
15. Alzeidan R. Oral presentation. Reasons behind non-adherence to pediatric asthma guidelines in emergency department of King Khalid University (S90) at 7th International conference of the Guidelines International Network, Chicago, USA, 2010.
05/03/2023 188
05/03/2023 189
What is your role as a HCP in CPGs? “spread the word”
1) CPG implementers/users:“Your continuous feedback!”
2) CPG developers/adapters.3) Improvement research projects.