How to create an evidence-How to create an evidence-based guidelinebased guideline

Eric Finlay January 2008Eric Finlay January 2008

EBM GuidelinesEBM Guidelines

Choosing a topicChoosing a topic

Developing a questionDeveloping a question

Finding the evidenceFinding the evidence

Evaluating the evidenceEvaluating the evidence

Write the guidelineWrite the guideline

Implement the guidelineImplement the guideline

EBM GuidelineEBM Guideline

Why?Why?

Where?Where?

What?What?

How?How?

Why?Why?

What the RCPCH says 1What the RCPCH says 1

Clinical guidelines are increasingly being developed in order to help improve the health outcomes for patients and to help reduce unacceptable variations in clinical practice. However, guidelines can only be effective if they are developed to the highest standards and are based upon the best available evidence. Clinical guidelines must also be seen to be of value to clinicians so that they are implemented in everyday clinical practice.

Choose a topicChoose a topic

Remember creating a guideline is Remember creating a guideline is resource-intensive and time-consumingresource-intensive and time-consuming

Perceived need?Perceived need?

What is to be gained by the guideline?What is to be gained by the guideline?

What is the scope of the guideline?What is the scope of the guideline?

Measure current practiceMeasure current practice

Knowing what is currently happening is Knowing what is currently happening is very usefulvery useful

AuditAudit

Survey MonkeySurvey Monkey

Talk to your stakeholdersTalk to your stakeholders

Where?Where?

Not a problem here-BAPNNot a problem here-BAPN

Organisation analysisOrganisation analysis

‘‘The culture and politics of many organisations The culture and politics of many organisations constrain the degree of transformation and constrain the degree of transformation and change in which they can successfully engage’ change in which they can successfully engage’ Morgan 1989Morgan 1989Organisations are well integrated entities within Organisations are well integrated entities within which everybody works harmoniously together- which everybody works harmoniously together- the reality is very different’ the reality is very different’ J Hayes 2002J Hayes 2002‘‘My Arse’ My Arse’ Ricky Tomlinson 2008Ricky Tomlinson 2008To change an organisation you must first To change an organisation you must first understand it!understand it!

What?What?

What the RCPCH says 2What the RCPCH says 2

Appropriate, efficient and cost effective Appropriate, efficient and cost effective healthcarehealthcare

Important part of clinical governanceImportant part of clinical governance

Rigorously developedRigorously developed

Transparent methodTransparent method

Careful planningCareful planning

Searching the medical databasesSearching the medical databases

Get your question rightGet your question right

Know where to lookKnow where to look

Know your synonymsKnow your synonyms

ChunkingChunking

Save your search stringsSave your search strings

That all important questionThat all important question

What do you want the search to answer?What do you want the search to answer?

PICO(T)PICO(T)

The question then forms the structure of The question then forms the structure of your search.your search.

Finding the evidenceFinding the evidence

Your question should lead youYour question should lead you

Know your databasesKnow your databases

The more databases searched the more The more databases searched the more sensitive the searchsensitive the search

Know your synonymsKnow your synonyms

Increase the number of search terms Increase the number of search terms increase your search sensitivityincrease your search sensitivity

Look at Cochrane search strings for Look at Cochrane search strings for synonymssynonyms

DatabasesDatabases

Medline/PubmedMedline/Pubmed

CinahlCinahl

EmbaseEmbase

AMEDAMED

Biomed CentralBiomed Central

CochraneCochrane

DH-DataDH-Data

BNIBNI

Psyche-infoPsyche-info

LISALISA

EmeraldEmerald

ERICERIC

BEIBEI

HMICHMIC

ChunkingChunking

Join all your (P) synonyms with ORJoin all your (P) synonyms with ORJoin all your (I) synonyms with ORJoin all your (I) synonyms with ORJoin all your (C) synonyms with ORJoin all your (C) synonyms with ORJoin all your (O) synonyms with ORJoin all your (O) synonyms with OR

Now P AND I AND C AND ONow P AND I AND C AND O

That’s chunkingThat’s chunking

Example of synonymsExample of synonyms

(haemodialysis catheter) OR (tesio-cath) (haemodialysis catheter) OR (tesio-cath) OR (central venous dialysis catheter) OR OR (central venous dialysis catheter) OR (vascular access) OR (vascular access) (vascular access) OR (vascular access) OR (central venous catheter) OR (central-OR (central venous catheter) OR (central-venous catheter) OR (francis catheter) OR venous catheter) OR (francis catheter) OR (vascath) OR (permcath) OR (vascath) OR (permcath) OR (haemodialysis venous catheter) OR (haemodialysis venous catheter) OR (central venous line) OR ('central venous (central venous line) OR ('central venous line') OR (dialysis catheter*)line') OR (dialysis catheter*)

Watch outWatch out

Only add in limits at the end if despite chunking Only add in limits at the end if despite chunking you still have hundreds of pagesyou still have hundreds of pages

MESHMESH

CochraneCochrane

Save your searches-my NCBISave your searches-my NCBI

Avoid NOTAvoid NOT

Critical AppraisalCritical Appraisal

CASP toolsCASP tools

Look for flaws- written and omissionsLook for flaws- written and omissions

Can you use it?Can you use it?

Is it applicable and transferable?Is it applicable and transferable?

Write the guidelineWrite the guideline

Be concrete, unambiguous and use Be concrete, unambiguous and use specific terms.specific terms.

Key recommendationsKey recommendations

Audit criteriaAudit criteria

Algorithms/pathwaysAlgorithms/pathways

Short version/comprehensive versionShort version/comprehensive version

Educational packagesEducational packages

How?How?

ImplementationImplementation

The hardest partThe hardest part Find out where the stakeholders standFind out where the stakeholders stand

Actively for, passive, active againstActively for, passive, active against

What are the resistive forcesWhat are the resistive forces

How can these resistive forces be underminedHow can these resistive forces be undermined Strategic planningStrategic planning

Best to erode resistance rather than push Best to erode resistance rather than push harderharder

Organisational AnalysisOrganisational Analysis

SWOTSWOT Strengths, weaknesses, opportunities and threatsStrengths, weaknesses, opportunities and threats

PESTELIPESTELI Political, economic, sociological, technological, Political, economic, sociological, technological,

ecological, legislative and industryecological, legislative and industry

Force-fieldForce-field Driving forces against resistive forcesDriving forces against resistive forces

The Seven S’sThe Seven S’s Strategy, structure, system, staff, style, shared validity Strategy, structure, system, staff, style, shared validity

and skillsand skills

Peer review and UpdatingPeer review and Updating

All guidelines will be reviewed by the All guidelines will be reviewed by the Clinical Standards CommitteeClinical Standards Committee

Must be up-to-date to be usefulMust be up-to-date to be useful

Set and update date based on frequency Set and update date based on frequency of relevant publications in the preceding of relevant publications in the preceding year.year.

In ConclusionIn Conclusion

This is effectively a systematic review This is effectively a systematic review without the statistical analysis.without the statistical analysis.

Choose something that interests you as Choose something that interests you as well as is clinically relevant.well as is clinically relevant.

Choose a small subject, or a small portion Choose a small subject, or a small portion of a larger one.of a larger one.

Set yourself deadlines for each of the Set yourself deadlines for each of the stages.stages.

FinallyFinally

www.bapn.orgwww.bapn.org is your best friend. is your best friend.