Developing or Updating a Guideline

The thought of updating or developing a new guideline fills most of us with dread. This information is designed to make the process as quick and easy as possible.

Useful Definitions

Evidence Based Guideline “Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” The key word here is systematic, these guidelines take 1-2 years to develop and involve a huge amount of time trawling the literature and appraising the evidence. Many guidelines state they are evidence based but in practice they are a combination of evidence and best practice or sometimes just the latter.

Best Practice Guidelines In paediatrics, there are many areas where no evidence exists. As clinicians, we still need guidance in order to manage children appropriately. Best practice guidelines are statements which describe how best to investigate or manage a child in a particular situation. They are based on advice from experts or non-experts, sometimes a group of people and other times a single person. Sometimes they are combined with evidence. The important distinction is that the guideline developer has not tried to search the literature for all possible evidence in this area indeed in most cases they may not have searched the literature at all.

So what do you need to do ?

Developing a new guideline

1. Search the guideline sites listed below to see if a national guideline already exists. If it does then don’t re-invent the wheel !

• ww.pier.org.uk Paediatric guideline site based in Sheffield which has hundreds of guidelines password protected but as a clinician you just need to email them to get a password.
• http://www.guideline.gov/ This is the site of the National Guideline Clearing House, this is a US based site funded by the department of health. It has structured abstracts and summaries about guidelines and their development. Links to full-text guidelines, where available and palm-based downloads.
• http://www.nelh.nhs.uk/ National electronic library for health, this site contains a guideline finder.
• http://www.rcpch.ac.uk/ Royal College of Paediatrics and Child Health This site contains appraisals of guidelines the Quality of Practice Committee has reviewed but not the actual guideline. The appraisal document should have a link to the website where the full guideline can be found.

Also check the relevant websites for the specialty relevant to the guideline you are updating and speak to the lead consultant who may be aware of a guideline.

2. If you find a guideline the next thing to do is try and decide whether its an evidence based guideline or a best practice guideline. Either way the guideline can be used but its important to make the distinction between the 2 so clinicians using the guideline know which it is. If you need help with this please discuss with the lead clinician.

3. Most guidelines need altering to take into account local practice and services. For example, imagine you find a guideline for management of head injury which includes MRI head for all patients who meet certain criteria. If you work at a DGH which has a CT scanner but no MRI the guideline will not work. It would have to be altered to take into account the local situation. Most guidelines need some local tailoring.

4. If you are unable to find a guideline the process takes a bit longer. Discuss with the lead clinician. Try and decide what the important points are which need to be covered. Try and present the information in a flow diagram which clincians often find easier to follow. As described above you do not need to undertake a systematic literature search, however it’s a good idea to look at the Cochrane Collaboration to see whether there are any systematic reviews on the subject as these provide high quality evidence. This can be accessed via the National Electronic Library for Health (website above). If you are unfamiliar with searching this database all hospital libraries will provide teaching sessions.

Updating an existing guideline

1. Its still good practice to go through steps 1-4 above. If you find a good evidence based guideline you may want to use this in preference to the guideline already in use.

2. If you do not finding anything superior to the guideline already in use then its just a case of making sure its still user friendly and covers the important points. Discuss with colleagues who have used the guideline, check if there are any gaps where guidance is needed but not provided or advice which is confusing. Is the guideline easy to read and use ?

3. At the end of this process you may have a completely new guideline with different recommendations, the same guideline but presented in a different format or the same guideline with no changes at all. Any of these outcomes are acceptable.

N.B. If your guideline involves recommendations for any radiology investigations please discuss with Dr K Halliday.

Please also note that many medical guidelines may overlap with nursing guidelines. Please check and liase with a senior nurse if this is the case. This will ensure the same advice is being given at all times.

Ratification of guideline

Once the new or updated guideline has been reviewed by the lead clinician and accepted, it should be presented at the monthly guideline meeting (hosted by the appropriate speciality). Any problems / clarifications with the guideline can be discussed and ironed out then. Any changes required will be made before the next monthly meeting and at that point the guideline will enter the Nottingham Paediatric guidelines folder (with a 3 year expiry date).