KNH Clinical Practice Guidelines

Adaptation Methodology
Jhessie L. Abella, RN, RM, MAN, CPSO, SMRIN
Learning and Development, Acting Manager
KNH CPG Executive Secretary
Clinical Practice Guidelines

• Clinical guidelines are consensus statements developed to assist in

clinical management decisions.
• Are sponsored or supported by professional associations or
societies, public or private organizations, government agencies,
etc., and include evidence if modified to meet the population
served
• CPG’s are developed on the focus of quality, based on scientific
evidence and the assessment of likely benefits and harms of a
particular treatment
WHAT IS THE
IMPORTANCE
OF CPGs?
CPG’s guide practitioners with:

 Questions to ask and physical signs to check

 Lab and other studies to request
 Assessments of the condition
 Treatments to prescribe
 Improve healthcare decision making
HOW CAN WE
INTEGRATE
GUIDELINES IN
OUR HOSPITAL
 Types of implementation tools used to integrate
guidelines into daily practice and into the patient
care system are:
 Clinical pathways/critical pathway/care maps
 Clinical protocols
 Standardized order sets
 Process flow charts
 These tools often include automatic triggers for care
according to the guidelines
DO WE HAVE
EXISTING CPGs
in the Hospital?
What do we OFTEN
used a guide to clinical
management in KNH?
 UpToDate, “is designed to get physicians the
concise, practical answers they need when they
need them most—at the point of care.”
Often referred to as an evidence-based resource.
It is peer reviewed but not all recommendations
are graded.
• UpToDate follows a hierarchy of evidence consistent with most evidence-
based resources.
• Grades have two components, a number (1 or 2) reflecting the strength of
the recommendation and a letter (A, B, or C) reflecting the quality of the
evidence supporting that recommendation.
• A Grade 2 recommendation is a weaker recommendation, where the risks
and benefits are more closely balanced or are more uncertain. The
majority of recommendations will be grade 2 recommendations. UpToDate
uses a wording that reflects the strength of the recommendation: Strong
(Grade 1) recommendations are "recommended" and weak (Grade 2)
recommendations are "suggested."
CLINICAL
PRACTICE
GUIDELINES LEVEL
OF
HOW DID WE
PRIORITIZE OUR
CLINICAL PRACTICE
GUIDELINES?
Criteria for Choosing CPG at KNH (OLD)

 The prevalence of the condition and/or burden associated with the condition
 Existence of underuse, overuse or misuse of interventions
 The likelihood that the guideline will be effective in influencing practice
 The existence of relevant good quality evidence-based guidelines
 CRITERIA

High Risk Impact of Disease/Condition 5 3 4 2

Disease/Condition Has High Individual Cost 5 3 4 3

Priority Health Areas According to RCA

Recommendation 5 4 3 4

Priority Health Areas According to M & M

Recommendation 5 5 5 4

Availability of Effective Methods Shown By

Methodologically Adequate Studies

SUM 20 15 16 13
Criteria for Choosing CPG at KNH (NEW)

Acute
Acute
CRITERIA Sepsis Pneumonia Coronary
Appendicitis
Syndrome
High Risk Impact of Disease/Condition 3 4 4 4

Disease/Condition Has High Individual Cost 3 4 4 4

Priority Health Areas According to RCA

Recommendation 3 4 4 4

Priority Health Areas According to M & M

Recommendation 1 4 4 4

Availability of Effective Methods Shown By

Methodologically Adequate Studies. 2 4 4 4

Availability of High Volume of Evidence Regarding

The CPG Topic 3 4 4 4
SUM 3 4 4 4
 Availability of Effective Availability Of High
Disease/Conditi Priority Health Areas Priority Health Areas
Disease/Condition Has Methods Shown By Volume of Evidence
CPG TOPICS on Has High
High Individual Cost
According to RCA According to M & M
Methodologically Regarding The CPG
RATING
Individual Cost Recommendation Recommendation
Adequate S tudies. Topic
EMERGENCY ROOM
1 Ches t Pain 4 2 4 4 3 4 3.5
2 Arthymia 4 2 4 4 3 4 3.5
3 Pneumonia 4 4 2 4 3 4 3.5
4 Multi trauma 4 4 4 3 4 2 3.5
SURGERY DEPARTMENT
1 Acute Appe ndicitis 3 3 3 1 2 3 2.5
2 DVT 3 3 3 1 2 3 2.5
3 Ble e ding as a complication afte r ade no tons ile ctomy 4 2 2 3 4 4 3.2
4 Intravitre al Inje ction of AVGEF 4 4 3 3 4 4 3.7
5 Rupture Globe 4 4 3 3 4 4 3.7
6 Dis tal Radius Fracture 1 4 1 4 4 4 4
7 Loin Pain 3 3 3 4 4 4 3.5
8 Acute Scrotum 4 3 4 4 4 2 3.5
INTERNAL MEDICINE
1 Manage me nt of Pne umonia                3 4 3 3 4 4 3.5
2 Acute Che s t Syndrome in Patie nt with Sickle Cell Dise as e 4 3 3 3 4 4 3.5
3 Manage me nt of Acute Che s t Syndrome 4 4 3 3 4 4 3.7
INTENS IVE CARE DEPARTMENT
1 Se ps is 4 4 4 4 4 4 4
2 Pne umonia 4 4 4 4 4 4 4
3 Stroke 4 4 4 4 4 4 4
4 Acute Coronary Syndrome 4 4 4 4 4 4 4
PEDIATRICS AND NICU
1 Re s piratory dis tre s s 4 3 3 3 4 3 3.3
2 Pre te rm infant 4 3 3 3 4 2 3.2
3 Shock 4 3 2 4 4 4 3.5
4 Se ps is 4 3 2 4 4 3 3.3
5 Status As thmaticus 4 3 2 4 4 3 3.3
6 Status Epile pticus 4 4 2 4 4 2 3.3
OBS TETRICS AND GYNECOLOGY
1 Se ve re Pre -Eclamps ia 4 4 4 4 4 4 4
2 Pos tpartum Hae morrhage 4 4 4 4 4 4 4
3 Cord Prolaps e 4 4 4 4 4 4 4
DEVELOPED
OR ADAPTED?
Guideline Adaptation (ADAPTE Approach)

• 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 contents
ADAPTE postulates that….

• Existing high quality CPGs as a resources may be an

alternative to de novo development to reduce
duplication of effort, enhance efficiency, and promote
local uptake of quality CPG recommendations.
ADAPTE Guideline Adaption

 Is an international collaboration of researchers, guideline

developers, and guideline implementers who aim to
promote the development and use of CPGs through the
adaptation of existing guidelines.
 Our institutional CPG policy is solely based on this toolkit
developed by ADAPTE collaboration.
ADAPTE - a systematic approach to
guideline adaptation

Why develop a systematic approach ?

 Help ensure the quality and validity of the adapted guideline
 Enhance relevance of adapted guideline to the context of use
 Encourage confidence in and acceptance of the guidelines by
targeted users
CPG PRODUCERS

1. Governmental (National) Organizations: NICE, SIGN,

NHMRC,
2. International Organization; WHO
3. Healthcare Organization e.g. Mayo Clinic, Cleveland
Clinic, Cincinnati Children’s Hospital, NHS
4. Specialized Societies e.g European Society of
Cardiology, American Academy of Pediatrics etc.
 SOURCES OF HIGH QUALITY CPGs

1. National Institute for health and Clinical Excellence (NICE; in the

UK),
2. Scottish Intercollegiate Guidelines Network (SIGN, in Scotland),
3. Agency for Healthcare research and Quality (AHRQ, in the USA)
4. National Guidelines Clearing House (NGC, in the USA)
5. Guidelines Advisory Committee (GAC, in Canada)
6. Australian National Health and Medical Research Council
(NHMRC, Australia)
7. New Zealand Guidelines Group
ADAPTE PROCESS
 ADAPTE process
 Target audience
 Guideline developers, health care professionals and decision makers
 Groups from local to international level
 Manual takes into account level of experience with guideline development and available
resources

 Applications
 Groups interested in selecting 1 cpg and adapting it to the local context
 Groups wishing to identify all high quality guidelines and customize one that meets their needs
 Manual designed to be flexible

 Scope
 CPGs of any disease area
 Screening, diagnosis, treatment, supportive care, health promotion

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 Adaptation Phase
Scope and Purpose Module

PIPOH
Patient population and disease
characteristics
Intervention (s) of interest
Professionals targeted by the guideline
Outcomes and endpoints to be taken into
consideration
Healthcare setting and context
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THE SET UP PHASE
ADAPTATION PHASE
ADAPTATION PHASE
Appraisal of Guidelines Research &
Evaluation (AGREE 2 INTRUMENT)
 Was developed to address the issue of variability in guideline
quality. To that end, the AGREE (Appraisal of Guidelines for
Research & Evaluation) instrument is a tool that assesses the
methodological rigour and transparency in which a guideline is
developed.
 Domain 1. Scope and Purpose
 Domain 2. Stakeholder Involvement
 Domain 3. Rigour of Development
 Domain 4. Clarity of Presentation
 Domain 5. Applicability
 Domain 6. Editorial Independence
ASSESSMENT PHASE
ADAPATATION PHASE
ADAPATATION PHASE
FINALIZATION PHASE