evidence-based clinical practice guidelines for the staff of nicu of king saud medical city (moh),...
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Alexandria University HospitalsHealthcare Quality Directorate
Center for Evidence-Based Clinical Practice Guidelines(AUH – HCQD, CEBCPGs)
(Founded Nov. 2008)
Member of Guidelines International Network (G-I-N)(Since May 2009)
Founding Members 2008
• Prof. Dr. Mahmoud Elzalabany
• Prof. Dr. Tarek Omar
• Prof. Dr. Nabil Dowidar
• Prof. Dr. Afaf Ibrahim
• Dr. Yasser S. Amer
• Dr. Hossam Ashour
• Eng. Ahmed Mourady
*12 M.Sc. Theses plus 1 Ph.D. thesis to produce 13 Adapted EBCPGs
4 Finalized Adapted CPGs by CEBCPGs, HCQD-AUHs through MSc
Theses (till 3/2012) in PEDIATRICS DEPT.:1- Treatment of Acute Childhood Asthma in ER - AUCH: Dr. Yasser Sami Amer
(Finalized, Approved , Disseminated & Implemented).
2- Treatment of Positioning & Attachment Breast Feeding Problems in BFCC - AUCH:
Dr. Georgina Ramsis (Finalized & Approved).
3- Triage and Acuity Scale in A & E Dept., AMUH: Dr. Mary Christeen Nabiel Sharobeem
(Finalized, Approved & Disseminated ) – the only thesis outside the Pediatrics Dept.
4- Treatment of HIE in Neonates in NICU: Dr. Walid Gamal AbdelKhaliq
(Finalized & Approved).
5- Treatment of ADHD in children in AUCH: Dr. Mariana Iskander Amin
9 Adapted CPGs in progress by Pediatrics Dept. & CEBCPGs, HCQD-AUHs
through MSc/PhD Theses (till 8/2012):
1. Diagnosis of acute attack of seizures in AUCH: Dr. Soheir Farouk AbdelSalam (Set
Up Phase).
2. Treatment of acute attack of seizures in AUCH : Dr. Islam Yousry A.Moneium (Set Up
Phase).
3. Management of Epilepsy in children in AUCH: Dr. Shimaa Anwar (Set Up Phase)
4. Treatment of Childhood Autism in AUCH: Dr. Farioz Ibrahim (Set Up Phase).
5. Management of Acute Bacterial Meningitis in AUCH: Dr Mariam Adly (Set Up Phase).
6. Treatment of Chronic Asthma in AUCH: Dr. Reem Galal Ghazal (Set Up Phase).
7. Treatment of Community Acquired Pneumonia in AUCH: Dr. Zobaida Eltazmany (Set
Up Phase).
8. Treatment of Allergic Rhinitis in AUCH: Dr. Shahinaz (Set Up Phase).
Evidence-Based
Clinical Practice Guidelines For Staff of
King Saud Medical City
2013
PART 1: IntroductionInstructor
Dr. Yasser Sami A. AmerPediatrician - HC InformaticianCPGs General Coordinator,QMD, CPGC, KKUH, KSU
NICU
Two Different Approaches to Evidence-Based
Practice (EBP)
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
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EBM definition
The integration of best research evidence
with clinical expertise and patient
valuesSackett et al 2000
Clinical
Expertise
Research
Evidence
Patient
Preferences
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What is “EBM” NOT?• What we have always done !;
(not old hat or just the same old medical practice; as evidenced in wide practice variation)
• “Cookbook Medicine”!EBM specifically advocates for individualized application of evidence to patient care, not forcing patient care to conform to generalized evidence
• Only a cost-cutting trick !;it is intended to guide practitioners to provide the best, not necessarily the cheapest, care.
• Only RCTs !;(Also with best relevant evidence applicable to the situation in question)
– EBM is tracking down the best external evidence from scientific research to answer our clinical question(s)…
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Definition: (old)“Systematically developed statements to assist
practitioner and patient decisions about
appropriate health care for specific clinical
circumstances” (Institute of Medicine 1990).
Increasing international interest in the
development and implementation of CPGs.
Clinical Practice Guidelines (CPGs)
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CPGs New DefinitionCPGs are “Statements that includeRecommendations intended to optimizepatient care that are informed by aSystematic Review of evidence and anassessment of the benefits and harms ofalternative care options”.
Committee on Standards for Developing Trustworthy CPGs (IOM-AHRQ)
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Rationale for CPGs
• Worldwide concerns about: ▫ Unexplained variations in clinical practice
▫ Rising Healthcare costs
▫ Exponential growth of information
• Aim of Clinical Practice Guidelines:▫ To facilitate more consistent, effective and
efficient practice and improve health outcomes for patients
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• Doctors
• Nurses
• Decision makers
• Patients
• Public
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• Specialized societies
• National agencies
NICE
SIGN
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SIGNScottish
Intercollegiate Guidelines Network
www.sign.ac.uk
CPG Producers:
National Agencies
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CPG Producers:
National Agencies
NICENational Institute for
Health & Clinical Excellence
www.nice.org.uk
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AHRQ
National Guideline Clearinghouse
www.guidelines.gov
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Guidelines International
Network (G-I-N)
www.g-i-n.net
Org. Member since 2009
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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
PubMed
US National Library of Medicine
National Institutes of Health (NIH)
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Worldwide Best Children’s Hospitals 2012-13
These hospitals excel in caring for sick kids IN
USA UK Arab World – Arab Gulf –Middle East - EMRO
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Boston Children's Hospitalhttp://www.childrenshospital.org/
1st US Nationally Ranked
• #2 in Pediatrics: Cancer
• #1 in Pediatrics: Cardiology & Heart Surgery
• #2 in Pediatrics: Diabetes & Endocrinology
• #2 in Pediatrics: Gastroenterology
• #3 in Pediatrics: Neonatology
• #1 in Pediatrics: Nephrology
• #1 in Pediatrics: Neurology & Neurosurgery
• #3 in Pediatrics: Orthopedics
• #4 in Pediatrics: Pulmonology
• #2 in Pediatrics: Urology
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http://www.chop.edu/
2nd US Nationally Ranked
• #1 in Pediatrics: Cancer
• #2 in Pediatrics: Cardiology & Heart Surgery
• #1 in Pediatrics: Diabetes & Endocrinology
• #1 in Pediatrics: Gastroenterology
• #4 in Pediatrics: Neonatology
• #2 in Pediatrics: Nephrology
• #2 in Pediatrics: Neurology & Neurosurgery
• #1 in Pediatrics: Orthopedics
• #1 in Pediatrics: Pulmonology
• #1 in Pediatrics: Urology
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http://www.cincinnatichildrens.org/service/j/anderson-center/evidence-based-care/recommendations/default/
James M. Anderson Center for Health Systems ExcellenceEvidence-Based Guidelines
3rd US Nationally Ranked
• #3 in Pediatrics: Cancer
• #8 in Pediatrics: Cardiology & Heart Surgery
• #5 in Pediatrics: Diabetes & Endocrinology
• #3 in Pediatrics: Gastroenterology
• #1 in Pediatrics: Neonatology
• #3 in Pediatrics: Nephrology
• #4 in Pediatrics: Neurology & Neurosurgery
• #4 in Pediatrics: Orthopedics
• #2 in Pediatrics: Pulmonology
• #4 in Pediatrics: Urology
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http://www.hopkinschildrens.org/tpl_nav1up_nav2up.aspx?id=1090
9th US Nationally Ranked
• #15 in Pediatrics: Cancer
• #16 in Pediatrics: Cardiology & Heart Surgery
• #8 in Pediatrics: Diabetes & Endocrinology
• #24 in Pediatrics: Gastroenterology
• #10 in Pediatrics: Neonatology
• #16 in Pediatrics: Nephrology
• #5 in Pediatrics: Neurology & Neurosurgery
• #19 in Pediatrics: Orthopedics
• #11 in Pediatrics: Pulmonology
• #20 in Pediatrics: Urology
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Manual of Neonatal Care 7th Ed. (Lippincott Manual
Series) 2012
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the child first and alwayshttp://www.gosh.nhs.uk/health-professionals/clinical-guidelines/
• Health Professionals > Clinical Guidelines
SEARCH by:• Search bar
• Alphabetical A-Z
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Topic
Team
Content
Search
FOUND NOT FOUND
Appraise Develop
AppraiseAdopt or Adapt
Implement
Evaluate impact
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Adaptation of Clinical Practice Guidelines
The ADAPTE collaboration is an
international collaboration of CPG researchers, developers and
implementers. Their main aim is to develop and validate a
generic adaptation process that will foster valid and high-quality
adapted guidelines as well as the user’s sense of ownership of
the adapted guideline.
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Guideline Adaptation
• Is 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/
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We identified 3 main ADAPTE steps:-
Adaptation Phase
Search & Selection of source CPGs
Health Questions (PIPOH)
AGREE II InstrumentAssess source CPGs quality
External Review
(Departmental Consensus)
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Alexandria CEBCPGs Adapted ADAPTE Methods
for CPGs adaptation
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CPG Scope: PIPOH Model
Patient (& disease characteristics)
Intervention(s)
Professionals (Target users)
Outcomes (purpose of the CPGs)
Healthcare settings (& context)
= Health/ Clinical/ Key Questions19th March 2013 EBCPGs: Dr. Yasser Sami Amer 60
Evidence Pyramid
MA
RCT
Cohort
Case control
Case series
Case report
Expert opinion
I
II
III
IV
A
B
C
Leve
ls o
f E
vid
en
ce
Gra
des o
f Reco
mm
en
datio
ns
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Assess guideline
quality
ADAPTE TOOL 9 AGREE II Instrument
23 items in 6 domains
7 point response scale
Domain scores
Recommendations
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AGREE DomainsDOMAINS
1 Scope & Purpose
2 Stakeholder Involvement
3 Rigour of Development
4 Clarity & Presentation
5 Applicability
6 Editorial Independence
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AGREE Instrumenthttp://www.agreetrust.org
AGREE Training Manualhttp://fhswedge.csu.mcmaster.ca/pebc/
agreetrust
CPGs: Two separate documents
FIRST (Clinicians’ Version)• Accessible from ALL points-of-
care for the NICU & hospital staff:
• Details of evidence-based recommendations for management (with only references to the other document)
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SECOND:(Methodologist’s Version) ;
• Accessible from Libraries of e.g. NICU, KSMC, TQMD, Authorship group,…etc. (Reference for Replication & Documentation)
• Detailed description of the CPG Adaptation process with ALL relevant data.
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Dissemination & Implementation
Nothing could be more
frustrating than producing
a CPG that is then ignored
by not being disseminated
nor implemented
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Dissemination of CPGs• Full CPGs documents published on
websites
• Implementation tools will also be published:
examples for choice:-
▫ Quick Reference Guide (Summary Key Rs)
▫ Clinical Algorithms (decision tree)
▫ Clinical pathways (Integrated care pathways)
▫ Patient Information (Education Guide) Arabic
▫ Gantt chart for dissemination & Implementation
▫ Audit and Research Rs.
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• If CPGs are to have a positive impact on patient care outcomes they must be implemented and incorporated into everyday clinical practice
• The identification of any barriers to implementation, and strategies for overcoming them, will form an essential part of discussions at CPGs Subcommittee/ Adaptation Group meetings
Implementing Guidelines
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Launching of
KSMC-NICU
Clinical Practice Guidelines
Taskforce/ Committee
TEAM WORK
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