The Scottish Intercollegiate Guidelines Network

Pan‐American Clinical Guideline on Rhinosinusitis

Surgical site infection not only brings morbidity and mortality to patients, but it also bring substantial financial burden to the hospital and the healthcare system. To minimize the clinical consequences of surgical site infection, it is crucial that all appropriate measures for reduction of surgical site infection should be implemented. Since patient’s skin is a potential source of pathogens, normal skin flora is a common cause of surgical site infections. Preoperative skin disinfection of the surgical site with an antiseptic agent is an effective method to remove the soil and transient organisms from the skin. Currently, there are different skin antiseptics available and the most commonly used agents are povidone iodine and chlorhexidine gluconate. Although povidone iodine has a long-standing recommendation and it is widely used in various surgical procedures, it has several limitations. On the other hand, there is an increasing interest of the use of chlorhexidine in indwelling catheter placement and care, surgical hand scrubbing, as well as wound dressing.
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\nIn view of this, there is a potential of replacing povidone iodine by chlorhexidine as preoperative skin antiseptic agent. As there is no existing guideline supportingthis innovative movement, this dissertation aimed to review the currently available evidence on preoperative skin preparation and to develop an evidence-based guideline of using chlorhexidine in preoperative skin preparation for reducing surgical site infection in patients undergoing general surgery.
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\nFive randomized controlled studies were identified from MEDLINE, CINAHL and PUBMED and evaluated by a critical appraisal tool, the Scottish Intercollegiate Guidelines Network. All studies reported that preoperative skin preparation with chlorhexidine is more effective than the use of povidone iodine in reducing surgical site infection. An evidence-based guideline is developed according to the guideline development process from the Scottish Intercollegiate Guideline Network. Patient characteristics, local clinical setting, organizational infrastructure and staff competency is congruent with the proposed innovation. The new protocol not only can minimize the risk of postoperative surgical site infection but also save costs. The cost-benefit analysis showed that the new protocol can help to save $675,552 to $1,097,772 (HK dollars) in six-month period after implementation.
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\nTo facilitate a more comprehensive plan in actual implementation of the proposed guideline, stakeholders at administrative, managerial, and operational levels would be invited to take part in the 12-week pilot test. Surgical site infection, staff satisfaction and compliance, as well as cost and benefit ratio of the guideline would be measured in the evaluation plan. The refined guidelines would then be implemented for one year. The effectiveness of the guideline would be determined by reduction in postoperative surgical site infection, increase in staff knowledge and satisfaction, and the overall expenditure.

The SCAN breast cancer workgroup aimed to develop Singapore Cancer Network (SCAN) clinical practice guidelines regarding the optimal time-point for initiation of bisphosphonates when using adjuvant aromatase inhibitors (AIs) and provide a consensus for their role in modifying clinical breast cancer outcomes. The workgroup utilised a modified ADAPTE process to calibrate high quality international evidence-based clinical practice guidelines to our local setting. Six international guidelines were evaluated-those developed by the National Cancer Comprehensive Network (2015), the European Society of Medical Oncology (2014), the National Institute for Clinical Evidence (2012), the Scottish Intercollegiate Guidelines Network (2013), the British Columbia Cancer Agency (2013) and the treatment algorithm based on the National Osteoporosis Foundation guidelines (2006). Recommendations on the use of bisphosphonates in postmenopausal women initiating adjuvant AIs in breast cancer to preserve bone health and the use of adjuvant bisphosphonates to improve breast cancer outcomes were developed. These adapted guidelines form the SCAN Guidelines on the use of adjuvant bisphosphonates to influence breast cancer outcomes and maintenance of bone health when on AIs.

Low back pain (LBP) is a common complaint and health problem in Hong Kong, particularly among middle-aged individuals. LBP is the main cause of chronic disability which significantly affects the daily life activities of patients. Pain might result in repeated hospital admissions and subsequently increase the burden on health care providers in Hong Kong. LBP has an enormous effect on quality of life and therefore deserves research attention.
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\nGrowing evidence shows that yoga may help reduce the level of chronic LBP in adult patients. However, no systematic review has been conducted to support the translation of this theory into practice. Therefore, this thesis aims to evaluate the current evidence on the efficacy of yoga in reducing chronic LBP among adult patients to achieve the following objectives: formulate an evidence-based protocol on yoga practice, assess the implementation potential of the formulated protocol, and develop implementation strategies and evaluation plan for the use of this protocol in a local public hospital in Hong Kong.
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\nFive databases were used for the systemic review of relevant studies. These databases were those of Cochrane Library, CINAHL Plus, PudMed, British Nursing Index and Medline (Ovid). A total of eight papers (randomized controlled trials) fulfilled the inclusion criteria of this study. The Scottish Intercollegiate Guidelines Network (SIGN) was used to extract the data and evaluate the paper quality. The findings of the selected papers indicated that yoga practice has a significant effect on reducing pain among adult patients with chronic LBP.
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\nThe innovation is proposed to be conducted in an adult orthopedic and traumatoloy (O&T) ward. Evidence-based yoga guideline is developed to guide nurses in the effective implementation of the protocol. The SIGN grading system is chosen to grade the recommendations in the guideline. Adult patients with persistent LBP longer than three months are the target population. All study participants practice specific yoga postures under the supervision of yoga instructors and trained nurses in the outpatient clinic. These patients continue home practice for 30 minutes daily or at least twice a week. Based on the findings of the reviewed literatures and the adaptation of these findings into the proposed innovation, the feasibility of implementing evidence-based yoga guideline in the local clinical setting in Hong Kong is demonstrated.
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\nAn effective communication plan is developed to gain support from stakeholders and efficiently implement the innovation. A two-month pilot study is designed to test the feasibility of the guideline. Pain level, which is the primary outcome of the study, is measured by using Pain Numerical Pain Scale (NRS). Evaluation will be completed after the pilot test and at the end of the whole programme and refinement of the protocol will be accomplished according if necessary. Protocol effectiveness will be determined by a decrease in back pain level after practicing yoga. Other outcomes include the knowledge and satisfactory level of the staff with regards to the protocol, as well as and the costs and benefits of program implementation.

POS1448 EVIDENCE BASED PRACTICE: WHAT IS THE EVIDENCE THAT BRITISH SOCIETY FOR RHEUMATOLOGY GUIDELINES ARE EVIDENCE BASED?

Clinical practice guidelines are increasingly being recognised as integral to the clinical effectiveness agenda. According to the recent Scottish White Paper, Scotland "leads the way in clinical effectiveness". The Scottish Intercollegiate Guidelines Network (SIGN), established in 1993, has produced over 20 clinical practice guidelines, and plans to produce at least as many more, while reviewing existing guidelines at a minimum of every two years. This represents a substantial investment of NHS resources. This paper investigates whether this investment is being recouped in Scottish NHS acute trusts via the implementation of SIGN guidelines, and whether their implementation is being audited properly. It is argued that without clinical audit, guideline implementation is unlikely to succeed. This has important ramifications for the implementation of clinical governance.

Expression of Human Kallikrein Protein and mRNA in Maxillofacial Cysts and Tumors

Long COVID guidelines need to reflect lived experience

David C Gillespie, Sara Joice, Maggie Lawrence, Janice Whittick Background: Stroke is a leading cause of death and disability. A high proportion of those who survive participate in programmes of rehabilitation. Clinical practice guidelines have come to play an increasingly important role in stroke rehabilitation, providing accessible summaries of the evidence for the management of specific consequences of the condition. Among the most common - and disabling - consequences of stroke are disorders of mood and emotional behaviour. Content: This article reports the development of clinical practice recommendations for post-stroke emotional disturbance for the Scottish Intercollegiate Guidelines Network (SIGN). SIGN 118 Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications and Discharge Planning was published in June 2010. Suggestions are made for ways in which the SIGN 118 recommendations for disorders of mood and emotional behaviour can be implemented in routine clinical practice. Limitations of the guidelines are also discussed. Conclusions: Although gaps in the evidence base exist, SIGN guideline 118 has an important role to play in closing the gap between what stroke multi-disciplinary teams do to promote good psychological outcomes, and which aspects of practice are supported by a robust evidence base.

Background: Autism spectrum disorder (ASD) is a multifaceted neurodevelopmental disorder requiring multimodal intervention and an army of multidisciplinary teams for a proper rehabilitation plan. Accordingly, multiple practice guidelines have been published for different disciplines. However, systematic evidence to detect and intervene must be updated regularly. Our main objective is to compare and summarize the recommendations made in the clinical practice guidelines (CPGs) for ASD in children released from November 2015 to March 2022. Methods: CPGs were subjected to a systematic review. We developed the inclusion and exclusion criteria and health-related questions, then searched and screened for CPGs utilizing bibliographic and CPG databases. Each of the CPGs used in the study were critically evaluated using the Appraisal of Guidelines for REsearch and Evaluation II (AGREE II) instrument. In a realistic comparison table, we summarized the recommendations. Results: Four eligible CPGs were appraised: Australian Autism CRC (ACRC); Ministry of Health New Zealand (NZ); National Institute for Health and Care Excellence (NICE); and Scottish Intercollegiate Guidelines Network, Healthcare Improvement Scotland (SIGN-HIS). The overall assessments of all four CPGs scored greater than 80%; these findings were consistent with the high scores in the six domains of AGREE II, including: (1) scope and purpose, (2) stakeholder involvement, (3) rigor of development, (4) clarity of presentation, (5) applicability, and (6) editorial independence domains. Domain (3) scored 84%, 93%, 86%, and 85%; domain (5) 92%, 89%, 54%, and 85%; and domain (6) 92%, 96%, 88%, and 92% for ACRC, NICE, NZ, and SIGN-HIS, respectively. Overall, there were no serious conflicts between the clinical recommendations of the four CPGs, but some were more comprehensive and elaborative than others. Conclusions: All four assessed evidence-based CPGs demonstrated high methodological quality and relevance for use in practice.

Guiding Principles for the Care of Older Adults with Multimorbidity: An Approach for Clinicians

Promoting a culture of evidence-based practice within a health care facility is a priority for health care leaders and nursing professionals; however, tangible methods to promote translation of evidence to bedside practice are lacking. The purpose of this quality improvement project was to design and implement a nursing education intervention demonstrating to the bedside nurse how current evidence-based guidelines are used when creating standardized stroke order sets at a primary stroke center, thereby increasing confidence in the use of standardized order sets at the point of care and supporting evidence-based culture within the health care facility. This educational intervention took place at a 286-bed community hospital certified by the Joint Commission as a primary stroke center. Bedside registered nurse (RN) staff from 4 units received a poster presentation linking the American Heart Association's and American Stroke Association's current evidence-based clinical practice guidelines to standardized stroke order sets and bedside nursing care. The 90-second oral poster presentation was delivered by a graduate nursing student during preshift huddle. The poster and supplemental materials remained in the unit break room for 1 week for RN viewing. After the pilot unit, a pdf of the poster was also delivered via an e-mail attachment to all RNs on the participating unit. A preintervention online survey measured nurses' self-perceived likelihood of performing an ordered intervention based on whether they were confident the order was evidence based. The preintervention survey also measured nurses' self-reported confidence in their ability to explain how the standardized order sets are derived from current evidence. The postintervention online survey again measured nurses' self-reported confidence level. However, the postintervention survey was modified midway through data collection, allowing for the final 20 survey respondents to retrospectively rate their confidence before and after the educational intervention. This modification ensured that the responses for each individual participant in this group were matched. Registered nurses reported a significant increase in perceived confidence in ability to explain how standardized stroke order sets reflect current evidence after the intervention (n = 20, P < .001). This sample was matched for each individual respondent. No significant change was shown in unmatched group mean self-reported confidence ratings overall after the intervention or separately by unit for the progressive care unit, critical care unit, or intensive care unit (n = 89 preintervention, n = 43 postintervention). However, the emergency department demonstrated a significant increase in group mean perceived confidence scores (n = 20 preintervention, n = 11 postintervention, P = .020). Registered nurses reported a significantly higher self-perceived likelihood of performing an ordered nursing intervention when they were confident that the order was evidence based compared with if they were unsure the order was evidence based (n = 88, P < .001). This nurse education strategy increased RNs' confidence in ability to explain the path from evidence to bedside nursing care by demonstrating how evidence-based clinical practice guidelines provide current evidence used to create standardized order sets. Although further evaluation of the intervention's effectiveness is needed, this educational intervention has the potential for generalization to different types of standardized order sets to increase nurse confidence in utilization of evidence-based practice.

This article presents a comprehensive review of clinical practice guidelines (CPGs) for the evaluation and/or diagnosis of attention deficit/hyperactivity disorder (ADHD) in children and adolescents. A systematic review was undertaken to summarise the recommendations reported in CPGs. MEDLINE® (National Library of Medicine, Bethesda, Maryland, USA), Cumulative Index to Nursing and Allied Health Literature® (EBSCO Information Services, Ipswich, Massachusetts, USA) and other databases were searched to retrieve CPGs. A total of five guidelines were included for analysis. The selected CPGs were appraised independently by five reviewers using the AGREE II instrument. The highest total score was achieved by the National Institute for Health and Care Excellence guidelines (91.4%) followed by the CPGs from the Scottish Intercollegiate Guidelines Network, Canadian Attention Deficit Hyperactivity Disorder Resource Alliance, British Association of Psychopharmacology and the American Academy of Paediatrics. By appraising current ADHD guidelines, clinicians cannot only identify CPGs related to ADHD but can also determine which guidelines should be considered of high quality and trustworthy to follow during clinical practice. The researchers recommend using the AGREE II instrument for CPG appraisal in healthcare professional education and training. Improvements in the applicability of guidelines are warranted in the future to enhance its clinical use and relevance.

IntroductionThe development of evidence-based clinical practice guidelines (CPGs) in traditional medicine (TM) is an ongoing challenge as it is unique area. This study describes a unified platform with Preferred Reporting Items for the Development of Evidence-based CPGs in TM (PRIDE-CPG-TM), which has been successfully used by the evidence-based CPGs committee for TM. MethodsInitially we searched the literature and CPG handbooks, collected items from methodology references and drew on experiences gained from Korean medical physicians and methodology experts. A group of experts subsequently edited drafts of the items, identified one or more examples of good reporting for each item, and developed text that explained the rationale and discussed relevant evidence. Face to face meetings were held with experts to finalize the items with the most extensive elaboration. ResultsThe PRIDE-CPG-TM, in the form of a checklist and description of items with TM approach and TM examples, were designed to improve the reporting of CPG in TM and thereby facilitate their interpretation and replication. The PRIDE-CPG-TM included 5 domains and 40 items. The items pertain to the development methodology (22 items), Overview of diseases and symptoms (6 items), Recommendations (4 items), Implementation and dissemination (5 items) and others (3 items). ConclusionsThe completeness of CPG descriptions in TM is very poor. Therefore, a complete description of the recommendations for TM in CPGs is necessary for physicians to implement the recommendations in clinical practice areas. The PRIDE-CPG-TM will provide useful guidance for TM developers in the development of evidence-based CPGs.

Background&#13;\nPressure ulcer prevention has been an important and a common health care problem in every health care setting. Pressure ulcers are the clinical situation that can be avoided. To prevent pressure ulcer, the main strategy is to reduce either the pressure contact time, or magnitude of pressure, between a patient and his or her support surface. Pressure-relieving support surfaces are shown to be effective in preventing the development of pressure ulcer with strong evidence support.&#13;\n&#13;\nIn Hong Kong, the low compliance of the ward staff to apply pressure-relieving support surfaces for at risk patients is compared with other countries. Therefore, a feasible evidence-based guideline of using pressure-relieving support surfaces to prevent pressure ulcers stands out from the multi-interventions pressure ulcer prevention guideline to maximize its effectiveness in this clinical issue.&#13;\n&#13;\nPurpose&#13;\nReviewing the needs in modifying the current clinical practice and guidelines in local setting, the aim of the dissertation is to develop evidence-based guidelines for prevention of pressure ulcers using pressure‐relieving support surface for bedbound elderly. The findings are used to develop recommendations for nursing guideline to prevent pressure ulcers through the utilization of pressure‐relieving support surface in Hong Kong public hospital setting.&#13;\n&#13;\nMethods&#13;\nFour electronic databases published from 1937 to 2012 were searched. All the studies extracted were randomised controlled trials while focusing on using pressure-relieving support surfaces to prevent pressure ulcers of adult patients. The quality of each study was assessed by a methodology checklist, the Scottish Intercollegiate Guideline Network in order to justify the level of evidence of the studies’ internal validity.&#13;\n&#13;\nConclusion&#13;\nFrom the evidence, the clearest conclusion that can be drawn is that a range of pressure‐relieving mattresses and overlays in the prevention of pressure ulcers can outperform the standard hospital mattress. It can be applied to any health care settings. The reviewed studies have shown that pressure‐relieving mattresses are effective on at risk patients, especially they are in advanced age with low mobility. Therefore, this evidence-based guidelines will serve in the medical rehabilitation wards to reduce the number of elderly from developing pressure ulcer after using the pressure‐relieving supporting surfaces.