Dr Robert (Bob) Godfrey - Mike South

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RC Godfrey OrationProf Mike South

Dr Robert (Bob) GodfreyMedical Director at PMH 1953- 79. Retired 1987.

One of the first true paediatricians in Western Australia.

Created a staff of children’s specialists at PMH.

Had an intense commitment to high standards of care

Believed that the consultants should be directly involved in the management of seriously ill children



Established a tradition of involving the families of children in the management of their health problems.

PMH was one of the first hospitals in the country to abolish restricted visiting hours.

Access to health care for the poor and disadvantaged and took a close interest in Aboriginal health.

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Raised the standard of paediatrics at PMH to equal the best in Australia



Insisted that the only operas worth listening to were those written by Mozart.

Tall, broad-shouldered, fair-haired and good-looking; he stood very straight and was a magnet to the opposite sex.

Made a Member of the Order of Australia in 1983.

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www.mikesouth.org.au


Clinical Practice GuidelinesRecipe Books for Doctors?

and other dilemmasDr Mike South, Royal Children's Hospital, Melbourne

Part 1 - RCH CPGsHow we got to where we are today

Part 2 - Unanticipated dilemmas and issues

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Clinical Practice Guidelines

Assumptions Clinical Practice Guidelines - a means to deliver evidence-based and/or consensus best-practice recommendations to clinicians.

Clinical Practice Guidelines can aid the clinicians in providing optimal care to patients.

FactClinical Practice Guideline development is very hard work.


Why do we need them? Existing alternatives

• Textbooks• Local Handbooks• National Practice

Guidelines • Journal Articles • Systematic Reviews

• May be out of date

• Long winded – not great for point of care use.

• Single author

• Narrow topic

• No Local Context

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Guidelines are a constructive response to the reality that practicing physicians require assistance to assimilate and apply the exponentially expanding, and often contradictory, body of medical knowledge.

Articles indexed in Medline

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1957 1967 1977 1987 1997 2007

Allan Sniderman, Curt Furberg


What could be useful to the ED resident / registrar?

• 10pm Friday Night• 25 patients in cubicles.

35 more in waiting room

Mild Asthma Septic young infant

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Early RCH Guideline Experience – How we got started on all this.

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Third generation cephalosporins - ED


Antibiotic Guideline Card

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CONDITIONS ON CARD

MeningitisHib prophylaxisN.meningitidis prophylaxisHSV encephalitisPeriorbital cellulitis Orbital cellulitisEndocarditis prophylaxAcute peritonitisAscending cholangitisGiardiasisUrinary tract infection

TonsillitisEpiglottitisOtitis mediaPertussis prophylaxisPneumonia SepticaemiaImpetigoCellulitisBites (animal / human)Compound fracturesOsteomyelitisSeptic arthritisAdenitisHead liceScabies


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6 months before cards issued 6 months after cards issuedstaff not informed of study

“you might find this useful”

Evaluation


Changes following Antibiotic Guideline CardsChoice of antibiotic

P<0.001

19%

78%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Pre-card Post-card

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Changes following Antibiotic Guideline CardsDose

48%

30%

81%

51%

0%10%20%30%40%50%60%70%80%

Pneumonia Orbital/peri-orbital c

p=0.001

p=0.11


Changes

more appropriate choice and doseless broad spectrum

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Use of 3rd Generation Cephalosporins

Trend sustained, good compliance on repeated audit

Cost Effective


Total Antibiotic Budget

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WM RCH B RCH M SCH

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Antibiotic Costs - per Admission

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WM RCH B SCH RCH M


Antibiotic resistance

No VREMinimal hospital-acquired MRSAMinimal Multiresistant Gram negatives

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ResuscitationImmunisation SchedulePain managementTPN

Other Card-Based Guidelines


Why do the cards work?

Same information as in existing policies etcReadily availableConcise

Readily available guidelines can influence clinician behaviour.

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Limitations of this method


RCH CPG Development

Development Group Emergency Department and General MedicineSub-specialists coopted as neededMedical & NursingSeniors and trainees

Fortnightly meetings since 1996

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RCH CPG Development

Need for individual guidelines identified from:Common paediatric presentations Important paediatric conditions Conditions flagged by problems with individual cases Other - see later


RCH CPG Development

Initial Draft

RevisionConsult with 2nd group

member

Consult with other

appropriate groups

CPG meeting

CPG sign off

Formatted

Review process

Published

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RCH CPG Development

~ 250 guidelines.

Mix of problem-based (eg febrile infant)diagnosis-based (eg pneumonia)procedures (eg nitrous oxide)


Paper Guidelines

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Web publishing

July 1999 - IntranetAugust 2001 - Internet

IllustrationsInterlinkingActive algorithms Other resources (internal & external)Easy to update


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> 250,000 Plans


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Integration with other systems


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Research Recruitment Tool


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RCH CPG DevelopmentUpdating

“Expiry” dates – Automatic – 15 & 18 months

Journal watchElectronic TOCUpdate within 2 weeksEmail

abstractsnotification


Delivery

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Quality Care & Risk Reduction

Readily available, up to date, good quality evidence (or consensus) based advice -should be good for quality of care.

Patient Safety Committee Clinician Alert

Medication Safety

Committee

CPG Development

Group


Usage

• ~ 75,000 visitors/month• ~ 450,000 guidelines viewed each month

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Visitors to CPG Site


Usage

Number 1 award winner Australia Health and Medical – Hospitals.

For last 5 years.

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Unintentional visitors?


Part 1 - Conclusions

CPG development is time consuming.

The web provides a good delivery medium.

Popular and well used

? Impact on patient care

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Part 2 - Dilemmas

1. Do they work?

2. Internet publishing & legal issues

3. Should everyone comply with the guidelines?

4. Why don’t we develop an Australian set of CPGs?

5. Why don’t you give references & grade the evidence?

6. Don’t they encourage a “recipe book” approach?


Do they work?

EvaluationUsers

– Usage - monitoring & survey– Value – survey– Site Feedback

Patient Outcomes– Condition audit– Difficulty with pre & post

• Guideline process incremental• Other confounding activities

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Internet publishing & legal issues

July 1999 - IntranetAugust 2001 - Internet

? Legal advice



Parents have access to the guidelines – can be interesting!

Does it change our legal risk if we don’t follow our own guidelines?

Are we liable if staff elsewhere follow our advice (good or bad) and there is a poor outcome?

Liability for RCH and the CPG group?

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Current Vic Coroners case – croup death.Defence: “Treatment was according to RCH CPGs”

Current RCH negligence case – meningitisClaim: “Did not follow RCH CPGs”

Several interstate negligence casesRequests to give written/verbal evidence.

Requests to provide RCH CPGs that were current at time of incident.


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Should everyone comply with the guidelines?

We like it when RCH staff follow our guidelines.They mostly do.

(Daily experience / Audits)

?RCH policy that clinical staff must follow the CPGsCPGs are evidence / consensus based Therefore best practice if everyone uses them



?RCH policy that clinical staff must follow the CPGsThe quality of the evidence is very variable

There isn’t universal consensus

Patients are different. Families are different.

There is often more than one “correct” way

Some degree of practice variation is healthy

Innovation and development

What if we have got it wrong?

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?RCH policy that clinical staff must follow the CPGs

Trainee staff should follow the CPGs or discuss with a consultant if they want to do differently.

Senior staff are not limited by the CPGs but should be prepared to explain why they have chosen a different way.

Helps us understand their thinkingMay lead to a CPG review/update


Why don’t we develop an Australian set of CPGs?

More efficientMore consistent care

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Expensive & Intensive in Clinician Resources

Limited Impact

Costs ~ $50,000 to > $500,000 (£1million +)

Very disappointing uptake



Advantages of Local CPG

Local Context

Clinician involvement & discussion

“buy in”

Local control of content and format

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My view

Distil into localGuidelines

ClinicianExperience


Why don’t you grade the evidence, give references & treatment options?

Limited resourcesPoint of care guidelines

UsabilityNot what users generally want (survey)

Treatment options?Better done elsewhere

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Don’t they encourage a “recipe book” approach?

My biggest concern.

We don’t want trainees who blindly follow instructions.

We want those who:

can think and understand the biological basis for what they are doing and the scientific evidence to support it.

question why and look for better ways.


Don’t they encourage a “recipe book” approach?

Articles indexed in Medline

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1957 1967 1977 1987 1997 2007

One of our biggest challenges

The way we educate or staff.Emphasis on mechanisms and evidence. CRP

example

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Conclusion

Clinical Practice Guidelines have a role in health care delivery.

They introduce a range of challenges and dilemmas.


Conclusion

Web Site Feedback - submitted on 26 September, 2007 (Paed consultant)“I was doing a locum in a country town last weekend. A child came into the ED in diabetic coma and extremely unwell. I haven’t managed DKA for years but your guideline was a great help. Thanks.“

CPGs are a lot of work

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Conclusion

Web Site Feedback - submitted on 13 March, 2009“I’m med student doing my paeds term at PMH (Perth).I think these guidelines are a fantastic resource. They are verypractical.Thanks for making them available“



Thank You

Documents

Dr Robert (Bob) Godfrey - Mike South