The EDUCATE Study: A Continuing Education Exemplar for Clinical Practice Guideline Implementation

AMDA Guidelines Clarify Treatment Goals

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.

IntroductionBronchiolitis is a leading cause of hospital admissions and death in young children. Clinical practice guidelines (CPG) to diagnose and manage bronchiolitis have helped healthcare providers to avoid unnecessary investigations and interventions and to provide evidence-based treatment. Aim of this study is to determine the effect of implementing CPG for the diagnosis and management of bronchiolitis in a tertiary hospital in Jordan.MethodsThe study compared children (age <24 months) diagnosed with bronchiolitis and who required admission to King Abdullah University Hospital in Irbid during the winter of 2017 (after CPG implementation) and age-matched children admitted in the winter of 2016. The proportion of patients receiving diagnostic tests and treatments in the two groups were compared.ResultsEighty-eight and 91 patients were diagnosed with bronchiolitis before and after CPG implementation, respectively. Respiratory syncytial virus rapid antigen detection testing decreased after CPG implementation [n=64 (72.7%) vs n=46 (50.5%), p=0.002]. However, there was no significant change in terms of other diagnostic tests. The use of nebulized salbutamol [n=44 (50%) vs n=29 (31.9%), p=0.01], hypertonic saline [n=39 (44.3%) vs n=8 (8.8%), p<0.001], and inappropriate antibiotics [n=31 (35.2%) vs n=15 (16.5%), p=0.004] decreased after CPG implementation. There was no difference in mean LOS (standard deviation; SD) between the pre- and post-CPG groups [3.5(2) vs 4 (3.4) days, p=0.19]. The mean cost of stay (SD) was 449.4 (329.1) US dollars for pre-CPG compared to 507.3 (286.1) US dollars for the post-CPG group (p=0.24).ConclusionWe observed that the implementation of CPG for bronchiolitis diagnosis and management helped change physicians’ behavior toward evidence-based practices. However, adherence to guidelines must be emphasized to improve practices in developing countries, focusing on the rational use of diagnostic testing, and avoiding use of unnecessary medications when managing children with a diagnosis of bronchiolitis.

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.

: 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.

BackgroundThe implementation of clinical practice guidelines (CPGs) is a cyclical process in which the evaluation stage can facilitate continuous improvement. Implementation science has utilized theoretical approaches, such as models and frameworks, to understand and address this process. This article aims to provide a comprehensive overview of the models and frameworks used to assess the implementation of CPGs.MethodsA systematic review was conducted following the Cochrane methodology, with adaptations to the "selection process" due to the unique nature of this review. The findings were reported following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines. Electronic databases were searched from their inception until May 15, 2023. A predetermined strategy and manual searches were conducted to identify relevant documents from health institutions worldwide. Eligible studies presented models and frameworks for assessing the implementation of CPGs. Information on the characteristics of the documents, the context in which the models were used (specific objectives, level of use, type of health service, target group), and the characteristics of each model or framework (name, domain evaluated, and model limitations) were extracted. The domains of the models were analyzed according to the key constructs: strategies, context, outcomes, fidelity, adaptation, sustainability, process, and intervention. A subgroup analysis was performed grouping models and frameworks according to their levels of use (clinical, organizational, and policy) and type of health service (community, ambulatorial, hospital, institutional). The JBI’s critical appraisal tools were utilized by two independent researchers to assess the trustworthiness, relevance, and results of the included studies.ResultsDatabase searches yielded 14,395 studies, of which 80 full texts were reviewed. Eight studies were included in the data analysis and four methodological guidelines were additionally included from the manual search. The risk of bias in the studies was considered non-critical for the results of this systematic review. A total of ten models/frameworks for assessing the implementation of CPGs were found. The level of use was mainly policy, the most common type of health service was institutional, and the major target group was professionals directly involved in clinical practice. The evaluated domains differed between the models and there were also differences in their conceptualization. All the models addressed the domain "Context", especially at the micro level (8/12), followed by the multilevel (7/12). The domains "Outcome" (9/12), "Intervention" (8/12), "Strategies" (7/12), and "Process" (5/12) were frequently addressed, while "Sustainability" was found only in one study, and "Fidelity/Adaptation" was not observed.ConclusionsThe use of models and frameworks for assessing the implementation of CPGs is still incipient. This systematic review may help stakeholders choose or adapt the most appropriate model or framework to assess CPGs implementation based on their specific health context.Trial registrationPROSPERO (International Prospective Register of Systematic Reviews) registration number: CRD42022335884. Registered on June 7, 2022.

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.

In 2020, our group published physical therapy clinical practice guidelines (CPG) for people with Huntington's disease (HD). The guideline recommendations were categorized according to six primary movement impairment classifications. To facilitate implementation of this CPG, we have developed guideline-based algorithms for physical therapy assessments and interventions and recommendations for therapists to overcome barriers to CPG implementation for people with HD. We conducted a literature review of papers that evaluated physical therapy interventions in individuals with HD (n = 26) to identify assessments for each of the primary movement impairment classifications, and then searched for papers (n = 28) that reported their clinometric/psychometric properties in HD. Assessments were evaluated using modified Movement Disorder Society Committee on Rating Scales criteria and other relevant criteria. We identified a "core set" of physical therapy assessments for persons with HD, including the Six Minute Walk Test, Timed Up and Go Test, Berg Balance Scale, and the Medical Outcomes Study Short Form 36 (SF-36). We then developed guideline-based decision trees to assist in decision making and implementation of the CPG into practice for persons with HD across the continuum of care. Finally, we developed strategies for overcoming barriers to implementation, such as seeking specialized training in HD, engaging caretakers or family members to help the person with HD to exercise, and establishing clinical pathways that support early physical therapy referrals. Knowledge translation documents such as this are essential to promoting implementation of the physical therapy CPGs into clinical practice.

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.

To measure the effect of implementing quality improvement (QI) methodology on the rate of chest radiograph (CXR) ordering for pediatric patients with acute asthma exacerbations.A total of 6680 pediatric patients age ≥2 years seen in the emergency department (ED) of a tertiary care children’s hospital for acute asthma were included in the study.Children ≥2 years old were retrospectively identified by chart review from May 2013 to April 2017. Included subjects had a primary International Classification of Diseases, Ninth Revision or 10th Revision billing code for asthma. An asthma clinical practice guideline (CPG) for CXR ordering in the ED was implemented in May 2014. Thus, the data from May 2013 to April 2014 were included as a 1-year baseline before intervention. Additional QI methods included removal of CXR as a default component of the electronic medical record asthma order set (July 2015), public reminder placement (January 2016), and targeted resident education (February 2016). The primary measure was CXRs ordered as a percentage of total acute asthma encounters, with a preintervention goal of <20%.A total of 1539 CXRs were ordered during 6680 patient encounters. Hospital-wide implementation of an asthma CPG was associated with a decrease in CXR use in acute asthma visits, from 29.3% to 23.0%. Implementation of targeted QI measures was associated with a further reduction in CXR use to 16.0%, which was sustained for 14 months (from February 2016 to April 2017). CXR use decreased from 21.3% to 12.5% in the subset of patients discharged from the hospital from the ED and from 53.5% to 31.1% among patients ultimately admitted to the hospital.Investigators in this study describe sustained reduction in CXR ordering in pediatric patients with acute asthma exacerbations after implementation of a CPG, later followed by QI interventions targeted at the electronic medical record system and at provider education.Old habits die hard. Previous studies have established that routine use of CXR in the evaluation of children with acute asthma exacerbations, the most frequent cause of childhood hospitalization in the United States, is of low diagnostic yield and is associated with significant risk, including unnecessary antibiotic administration. Despite evidence demonstrating low utility of CXR in this setting, implementation of “best” practice into clinical routine is challenging and can take years before change occurs. This study demonstrates how QI methodology can help break old habits, improve clinical care through patient-centered outcome measures, and most importantly, assist clinicians working in busy medical settings. It is impossible for any of us to stay current with the rapidly evolving world of medical knowledge. That is why dedicated use of QI methodology and commitment to changing culture can be so valuable.

BackgroundAs a source of readily available evidence, rigorously synthesized and interpreted by expert clinicians and methodologists, clinical guidelines are part of an evidence-based practice toolkit, which, transformed into practice recommendations, have the potential to improve both the process of care and patient outcomes. In Brazil, the process of development and updating of the clinical guidelines for the Brazilian Unified Health System (Sistema Único de Saúde, SUS) is already well systematized by the Ministry of Health. However, the implementation process of those guidelines has not yet been discussed and well structured. Therefore, the first step of this project and the primary objective of this study was to summarize the evidence on the effectiveness of strategies used to promote clinical practice guideline implementation and dissemination.MethodsThis overview used systematic review methodology to locate and evaluate published systematic reviews regarding strategies for clinical practice guideline implementation and adhered to the PRISMA guidelines for systematic review (PRISMA).ResultsThis overview identified 36 systematic reviews regarding 30 strategies targeting healthcare organizations, healthcare providers and patients to promote guideline implementation. The most reported interventions were educational materials, educational meetings, reminders, academic detailing and audit and feedback. Care pathways—single intervention, educational meeting—single intervention, organizational culture, and audit and feedback—both strategies implemented in combination with others—were strategies categorized as generally effective from the systematic reviews. In the meta-analyses, when used alone, organizational culture, educational intervention and reminders proved to be effective in promoting physicians' adherence to the guidelines. When used in conjunction with other strategies, organizational culture also proved to be effective. For patient-related outcomes, education intervention showed effective results for disease target results at a short and long term.ConclusionThis overview provides a broad summary of the best evidence on guideline implementation. Even if the included literature highlights the various limitations related to the lack of standardization, the methodological quality of the studies, and especially the lack of conclusion about the superiority of one strategy over another, the summary of the results provided by this study provides information on strategies that have been most widely studied in the last few years and their effectiveness in the context in which they were applied. Therefore, this panorama can support strategy decision-making adequate for SUS and other health systems, seeking to positively impact on the appropriate use of guidelines, healthcare outcomes and the sustainability of the SUS.

BackgroundThere is a significant treatment gap in provision of effective treatment for people with mental disorders globally. In some Low and Middle Income Countries (LMICs) this gap is 90% or more in terms of untreated cases. Clinical practice guidelines (CPGs) are one tool to improve health care provision. The aim of this review is to examine studies of the effectiveness of evidence-based CPG implementation across physical and mental health care, to inform mental healthcare provision in low and middle income countries (LMICs), and to identify transferable lessons from other non-communicable diseases to mental health.MethodsA systematic literature review employing narrative synthesis and utilising the tools developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group was conducted. Experimental studies of CPG implementation relating to non-communicable diseases, including mental disorders, in LMICs were retrieved and synthesised.ResultsFew (six) studies were identified. Four cluster randomised controlled trials (RCTs) related to the introduction of CPGs for non-communicable diseases in physical health; one cluster-RCT included CPGs for both a non-communicable disease in physical health and mental health, and one uncontrolled before and after study described the introduction of a CPG for mental health. All of the included studies adopted multi-faceted CPG implementation strategies and used education as part of this strategy. Components of the multi-faceted strategies were sometimes poorly described. Results of the studies included generally show statistically significant improvement on some, but not all, outcomes.ConclusionEvidence for the effectiveness of interventions to improve uptake of, and compliance with, evidence-based CPGs in LMICs for mental disorders and for other non-communicable diseases is at present limited. The sparse literature does, however, suggest that multifaceted CPG implementation strategies that involve an educational component may be an effective way of improving guideline adherence and therefore of improving clinical outcomes. Further work is needed to examine cost-effectiveness of CPG implementation strategies in LMICs and to draw conclusions on the transferability of implementation experience in physical health care to mental health practice settings. Strategies to ensure that CPGs are developed with clear guidance for implementation, and with explicit, methods to evaluate them should be a priority for mental health researchers and for international agencies.