Introduction To EM Practice Guidelines Update
EM Practice Guidelines Update was created to meet the need of emergency physicians to stay current with practice guidelines that can assist clinical decision-making in the emergency department. The practice guidelines are drawn from a variety of specialty sources, are analytically reviewed using a systematic approach, and include an editorial commentary, if indicated. We hope this free, online, interactive publication will become a valued resource to our Emergency Medicine Practice subscribers, and will help facilitate best practice in emergency care. As always, we welcome your comments and feedback.
WHAT ARE PRACTICE GUIDELINES?
Practice guidelines are documents developed to assist clinical decision-making. They are intended to assimilate the large volume of knowledge available from both the literature and from expert opinion into strategies helpful in diagnostic, management, and resource utilization decision-making. Practice guidelines have been used as tools in quality assurance programs, in creating health care policy, in directing research agendas, and in medicolegal determinations.
In recent years, there has been a proliferation of practice guidelines (also referred to as "clinical policies" or "practice parameters"). Thousands are in existence, and though many are directly related to emergency practice, these recommendations often fail to reach the primary users. To facilitate practice guideline utilization, a National Guideline Clearinghouse (www.guideline.gov) has been established. Unfortunately, practice guideline posting is often delayed, so there continues to be a need for physicians to have timely access to current practice guidelines, especially those published outside of emergency medicine literature.
The methodologies used to develop practice guidelines are divided into 2 general categories: consensus-driven and evidence-based. A number of practice guidelines have used both methodologies, but evaluating guidelines involves understanding the rationale for why a practice guideline was developed and how the final recommendations were derived. Ideally, a practice guideline is developed to assist readers’ comprehension and application of the literature available on a given subject and to provide sound recommendations based on the best available information.
Consensus practice guidelines: Consensus practice guidelines are formulated by a group of experts who assemble, discuss the issues at hand, and draw their conclusions based on those discussions. This process may or may not involve some degree of literature review. This approach to practice guideline development has been described as "global subjective judgment" and is highly susceptible to bias that enters the decision-making process.
Evidence-based practice guidelines: Evidence-based practice guidelines are the preferred method for guideline development. In this method, appropriate literature is reviewed by a panel experienced in reading the literature, and each piece of evidence is graded according to set criteria. Recommendations are then made based on the strength of available evidence.
Once a practice guideline is developed, its recommendations can be constructed into an implementation tool such as a "clinical pathway" or an "annotated algorithm" which takes into account the resources available; such a tool is incorporated into each issue of Emergency Medicine Practice.
Critically Assessing Practice Guidelines
Because of variations in practice guideline development methodology, it is necessary to critically assess a practice guideline before it is adopted. In order to do this, several questions must be asked:
In conclusion, practice guideline development has been driven by a need to summarize the medical literature in a critical and constructive way. Recommendations made should allow for practice flexibility that is tailored to an individual patient’s situation. Strict "standards of care" are rarely established and the format of grading recommendations based on strength of evidence serves to reinforce the fact that the practice of medicine is an art that must take into consideration a number of variables. From a medicolegal point of view, practice guidelines should be referenced only as a framework, and deviations from recommendations are appropriate when there is documentation of the clinician’s decision-making process, tailored to meet the needs of the patient at hand.
By: Reuben Strayer, MD, Editor-In-Chief, Assistant Professor of Emergency Medicine, Mount Sinai School of Medicine, New York, NY
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