Models and frameworks for assessing the implementation of clinical practice guidelines: a systematic review

Clinical practice guidelines: who reads them? who needs them?

BackgroundCommunication and swallowing disorders are a common consequence of stroke. Clinical practice guidelines (CPGs) have been created to assist health professionals to put research evidence into clinical practice and can improve stroke care outcomes. However, CPGs are often not successfully implemented in clinical practice and research is needed to explore the factors that influence speech pathologists’ implementation of stroke CPGs. This study aimed to describe speech pathologists’ experiences and current use of guidelines, and to identify what factors influence speech pathologists’ implementation of stroke CPGs.MethodsSpeech pathologists working in stroke rehabilitation who had used a stroke CPG were invited to complete a 39-item online survey. Content analysis and descriptive and inferential statistics were used to analyse the data.Results320 participants from all states and territories of Australia were surveyed. Almost all speech pathologists had used a stroke CPG and had found the guideline “somewhat useful” or “very useful”. Factors that speech pathologists perceived influenced CPG implementation included the: (a) guideline itself, (b) work environment, (c) aspects related to the speech pathologist themselves, (d) patient characteristics, and (e) types of implementation strategies provided.ConclusionsThere are many different factors that can influence speech pathologists’ implementation of CPGs. The factors that influenced the implementation of CPGs can be understood in terms of knowledge creation and implementation frameworks. Speech pathologists should continue to adapt the stroke CPG to their local work environment and evaluate their use. To enhance guideline implementation, they may benefit from a combination of educational meetings and resources, outreach visits, support from senior colleagues, and audit and feedback strategies.

There is a gap in understanding the barriers and facilitators related to guideline implementation in Saudi Arabia. A descriptive cross sectional study was conducted to identify the factors that may act as barriers or facilitators of clinical practice guidelines used by physicians working in Riyadh, Saudi Arabia. A survey was distributed to 215 physicians working at universities and government hospitals in Riyadh city. The survey was pilot-tested on a small group of physicians to improve the clarity and limit response bias. A total of 157 physicians completed the questionnaire. 88.5% of the physicians indicated that they did implement clinical practice guidelines in their practice while 9.6% declared that they did not implement any guidelines. Clinical practice guideline implementation was not affected by the physician role, years of experience or nationality. There were less female physicians that opted for clinical practice guidelines (P<0.5). Eighty four percent of the physicians chose them because they are evidence-based while only 40.1% incorporated them because it was part of their institutions’ regulation. There was a weak positive relation between the total scores of barriers and facilitators assessment tool and the nationality of the physician. The reasons for choosing specific guidelines were not determined by the physician role, years of experience, nationality or gender. Most agreed that clinical practice guidelines served as a good foundation for self-study and still provide space for them to come to their own conclusions, but at the same time, they would like to know more about them before they decide to apply it. The implementation of guidelines was obstructed by three barriers, which were lack of support by the leadership, lack of awareness and lack of knowledge. On the other hand, the ease of access and autonomy has driven the implementation of clinical practice guidelines. Nonetheless, the barriers and facilitators experienced by the physicians may differ depending on their ethnicity and gender.

Late-onset sepsis (LOS) is a common cause of neonatal morbidity and mortality. Professional organizations recommend avoiding empiric vancomycin use in neonates without risk factors for methicillin-resistant Staphylococcus aureus infection. We aimed to reduce the mean vancomycin antibiotic utilization rate (AUR) by 30% for 12 months in our neonatal intensive care unit (NICU). We included neonates admitted to our level-3 NICU from March 15, 2023, to February 29, 2024, with suspected LOS in the intervention period. A multidisciplinary team used the Model for Improvement. Interventions tested using plan-do-study-act cycles included provider education, clinical practice guideline (CPG) implementation, and prospective audit with feedback (PAF). The outcome measure was the mean vancomycin AUR measured in days of therapy per 1,000 patients days, plotted monthly and analyzed for special cause variation. The process measure was CPG adherence. We tracked balancing measures related to morbidity and mortality. During the intervention period, 50 neonates underwent LOS evaluations. The mean vancomycin AUR decreased by 37.1%, from 27 to 17 days of therapy per 1,000 patient days, and was sustained postintervention. CPG adherence was 96%. Three neonates required changing from oxacillin to vancomycin for coagulase-negative staphylococci bacteremia (n = 2) and urinary tract infection (n = 1). There were no drug-related morbidity or sepsis-related mortality events. This quality improvement project allowed a safe, rapid and sustained reduction of NICU-wide vancomycin use. Provider education, CPG implementation, and PAF were critical to optimizing empiric antibiotic management.

BackgroundThe implementation of clinical practice guidelines in rehabilitation practice is often troublesome and incomplete. An intervention to enhance the implementation of guidelines is the knowledge transfer program built around the activities of a knowledge broker (KB).This study investigates the use of KBs to implement guideline recommendations for intensive therapy and physical activity for patients post-stroke in 22 stroke units in hospitals and rehabilitation centers in The Netherlands.Methods/DesignThis study includes a quantitative evaluation with a non controlled pre-post intervention design and a mixed methods process evaluation. From each stroke unit, enterprising nurses and therapists will be recruited and trained as KB. The KB will work for one year on the implementation of the guideline recommendations in their team. To evaluate the effectiveness of the KB, a questionnaire will be administered to patients, health professionals and KBs at baseline (T0) and after one year (T1). Furthermore, semi structured interviews with 5 KBs will be performed at T1.The primary outcome of this implementation project will be the support health professionals give patients to exercise and be physically active, as reported by patients and health professionals themselves. The support immediately after the intervention is compared with the support at the start of the intervention.Additionally we will explore the influence of socio-demographic characteristics of health professionals and determinants identified in the Theory of Planned Behavior (intention, attitude, subjective norm and perceived behavioral control) on the change of supportive behavior of health professionals. Finally, KBs will complete a questionnaire on their own psychological and social demographic characteristics and on organizational conditions needed for health-care improvement such as time, workforce, sponsoring and support from management.DiscussionWith this study we will gain insight in when and why knowledge brokers seem to be effective. Also we will identify determinants that predict which health professionals are susceptible to change their behavior. This study will provide guidance how to implement guidelines and will help to improve stroke rehabilitation services.

Teaching health sciences students how to evaluate and implement clinical practice guidelines (CPGs) is challenging. Physical therapist education offers experiential learning opportunities to teach students how to evaluate and implement CPGs. Knowledge translation (KT) guides the process of moving research evidence into practice. Experiential learning using KT principles can teach students to assess barriers to evidence use and overcome implementation challenges. The purpose of this retrospective phenomenological qualitative study was to explore the beliefs, perceptions, and experiences of former physical therapist students' who completed a neurologic elective course implementing 2 CPGs. Furthermore, how the course impacted their clinical experiences is also described. Nine third-year physical therapist students. Students who participated in an elective experiential learning course developed using KT principles were recruited. Focus groups were held to determine the students' perceptions and experiences with implementing CPGs in the classroom and during their clinical experiences. Content analysis was used to identify codes and categories, and they were aligned with the Consolidated Framework of Implementation Research. Trustworthiness was established through member checking, peer debriefing, and an external audit. Students reported individual and contextual facilitators during the elective that supported CPG use. Students identified improved knowledge, confidence, and skill to perform the CPGs that facilitated their transfer of knowledge from the classroom to the clinic. During their clinical experiences, students discussed contextual factors, such as culture, environment, and patient population, which served as both facilitators and barriers to CPG use. Experiential learning enhanced knowledge, confidence, and skill with using CPGs and facilitated students' integration of evidence-based practice into their clinical experiences. Where possible, physical therapy curricula should incorporate experiential learning with KT principles to help students identify barriers to CPG use and develop strategies to enhance future evidence-based practice implementation.

Background/Objectives: Clinical Practice Guidelines (CPGs) have been published on a number of topics in spinal cord injury (SCI) medicine. Research in the general medical literature shows that the distribution of CPGs has a minimal effect on physician practice without targeted implementation strategies. The purpose of this study was to determine (a) whether dissemination of an SCI CPG improved the likelihood that patients would receive CPG recommended care and (b) whether adherence to CPG recommendations could be improved through a targeted implementation strategy. Specifically, this study addressed the " Neurogenic Bowel Management in Adults with Spinal Cord Injury" Clinical Practice Guideline published in March 1998 by the Consortium for Spinal Cord MedicineMethods: CPG adherence was determined from medical record review at 6 Veterans Affairs SCI centers for 3 time periods: before guideline publication (T1 ), after guideline publication but before CPG implementation (T2), and after targeted CPG implementation (T3). Specific implementation strategies to enhance guideline adherence were chosen to address the barriers identified by SCI providers in focus groups before the intervention.Results: Overall adherence to recommendations related to neurogenic bowel did not change between T1 and T2 (P = not significant) but increased significantly between T2 and T3 (P < 0.001) for 3 of 6 guideline recommendations. For the other 3 guideline recommendations, adherence rates were noted to be high at T1.Conclusions: While publication of the CPG alone did not alter rates of provider adherence, the use of a targeted implementation plan resulted in increases in adherence rates with some (3 of 6) CPG recommendations for neurogenic bowel management.

8:30 Implementation of clinical practice guidelines in workers compensation board patients with acute mechanical back pain: a prospective randomized trial

AMDA Guidelines Clarify Treatment Goals

The Department of Veterans Affairs (VA) mandated the system-wide implementation of clinical practice guidelines (CPGs) in the mid-1990s, arming all facilities with basic resources to facilitate implementation; despite this resource allocation, significant variability still exists across VA facilities in implementation success. This study compares CPG implementation strategy patterns used by high and low performing primary care clinics in the VA. Descriptive, cross-sectional study of a purposeful sample of six Veterans Affairs Medical Centers (VAMCs) with high and low performance on six CPGs. One hundred and two employees (management, quality improvement, clinic personnel) involved with guideline implementation at each VAMC primary care clinic. MEASURES; Participants reported specific strategies used by their facility to implement guidelines in 1-hour semi-structured interviews. Facilities were classified as high or low performers based on their guideline adherence scores calculated through independently conducted chart reviews. High performing facilities (HPFs) (a) invested significantly in the implementation of the electronic medical record and locally adapting it to provider needs, (b) invested dedicated resources to guideline-related initiatives, and (c) exhibited a clear direction in their strategy choices. Low performing facilities exhibited (a) earlier stages of development for their electronic medical record, (b) reliance on preexisting resources for guideline implementation, with little local adaptation, and (c) no clear direction in their strategy choices. A multifaceted, yet targeted, strategic approach to guideline implementation emphasizing dedicated resources and local adaptation may result in more successful implementation and higher guideline adherence than relying on standardized resources and taxing preexisting channels.

Objectives: To assess the opinions of general dental practitioners regarding the development and importance of clinical practice guidelines and their contribution to the quality of dental care. Methods: A questionnaire...

: This paper discusses issues relating to clinical practice guideline development and implementation, and recommends a step by step plan for guideline use in the Department of Defense. Individual clinical expertise and opinion has historically taken precedence over an evidence based approach, which has resulted in large amounts of practice variation throughout the Military Healthcare System. Clinical practice guidelines attempt to reduce this practice variation and improve patient outcomes by using evidence based medicine and identifying best practices.

We aimed to determine the effect of Clinical Practice Guideline (CPG) implementation on length of hospital stay of children and adolescents with diabetic ketoacidosis (DKA). This was a 6-year (2008-2014) case-control retrospective study conducted at King Khalid University Hospital, Riyadh, that compared patients with DKA managed using CPG with those treated before CPG implementation. There were 63 episodes of DKA in 41 patients managed using CPG compared with 40 episodes in 33 patients treated before implementation of CPG. Baseline characteristics of the 2 groups were similar (age, sex, newly diagnosed patients, recurrent DKA, DKA severity, and mean glycosylated hemoglobin). The mean length of hospital stay (±SD) was 68.6±53.1hours after implementation of CPG compared with 107.4±65.6hours before implementation (P<.001). The reduction in length of hospital stay equals to 1700 bed days saved per year per 1000 patients. Implementation of CPG for DKA decreased the length of hospital stay.

Cancer et récidive thromboembolique veineuse : les clés d’une prise en charge optimale

Evidence-Based Review and Discussion Points.