Clinical practice guidelines (CPGs) for trauma have officially been around since the late 1990s. The Eastern Association for the Surgery of Trauma (EAST) was a pioneer in developing and disseminating these best practices to its members. Many other organizations followed suit, and now most trauma centers have either adopted, copied or developed their own CPGs.
The American College of Surgeons has moved from recommending guidelines in the Green Book to requiring them in the Orange Book. Having a set of guidelines is now a must for passing a verification visit. However, every program that has ever tried to develop a CPG runs into predictable barriers to successful implementation.
What are these barriers? What can be done to avoid or counteract them? Here are 13 tips for achieving a smoother implementation of your clinical practice guidelines:
1. Don’t copy CPGs from major trauma organizations
What? Then why do organizations like EAST even bother to create CPGs if you shouldn’t copy them? The answer is that they are not meant to be complete management guidelines for a single clinical condition. These professionally produced CPGs are basically a list of answers to specific clinical questions. They are academic, and not action-oriented (see tip #5 below). Unfortunately, when asked about their CPGs, many trauma program leaders say they use the EAST guidelines. This really means they haven’t put the time into creating their own. They don’t actually have any guidelines, as the EAST CPGs were not designed for comprehensive care.
2. Don’t build trauma clinical guidelines from scratch either…
So many trauma program leaders feel they have to review the literature themselves, convene a committee, and spend months coming up with their very own CPG. It’s okay to borrow guidelines from other trauma centers. Using well developed guidelines as your starting point will save a lot of time! Many Level I and II centers post their practice guidelines on their public websites, so there is a virtual library of CPGs available out there.
3. …however, you absolutely must review and revise borrowed guidelines
Every trauma center is different, with varying resources, personnel and skillsets. What works in LA County will probably not work for you! For example, your center may not have thromboelastography (TEG) available to incorporate in a massive transfusion protocol. Or you may not have point-of-care INR testing to add to a warfarin reversal CPG. Tweak the existing (borrowed) guidelines to fit the capabilities of your center.
4. Make CPGs as evidence-based as possible
Clinicians, and especially those who are skeptical of CPGs in the first place, will resist ones that run counter to current literature. Those skeptics will try to pick apart every one of your guidelines, attempting to find weak or unsupported components to justify their resistance. That being said, the literature will only help you so much. It may provide answers to the big questions. But not always. And don’t expect a lot of help with the small stuff. Even common clinical issues like chest tube management get virtually no guidance from the literature. Much of what we do is really an art, so portions of every guideline will have to be crafted by consensus to some degree. (That’s why tip #7 below is so important.)
5. Make your guidelines “action-oriented” and concise
All too often, a program’s CPGs read like a chapter in a textbook. Pages of text. Hedge words like “consider” or “could.” In a real clinical situation, no one has time to read through all that prose. And the reader wants specific guidance on exactly what to do now, not what to consider. Ideally, your CPGs should look like a flow diagram. If this, then that. Decision points should be easy to identify and follow. And fewer words are definitely better. Limit your CPG to a single page if possible. It should not be completely filled with boxes, triangles and words. It must be very clean and easy to follow. Spend considerable time designing it so the most common flow of care is the most direct and easy to read on the page. Include important information, notes and tips around the edges near the margins. (For examples of clear versus confusing CPGs, see Sample Pediatric Solid Organ Guideline: The Good Vs. The Bad.)
6. Create a final “sample” guideline
This is critically important. Creating a guideline via committee is nearly impossible. You must craft a nearly finished CPG to use as a starting point for discussions. This allows your committee (see tip #7) to discuss and make minor tweaks. They will not need to interpret the literature and build the whole thing from scratch. The final approved version should look suspiciously like your “sample,” with a few changes here and there that they recommend.
7. Get buy-in from every department touched by the CPG
This is crucial. Look at your guideline. Is laboratory involved? Imaging? Nursing (monitoring, vital signs)? Absolutely every department that looks like they may be remotely involved should be at the table. Take an inventory of every department in the hospital that might have an interest in the guideline. Invite them to a meeting to review and discuss the proposed CPG. This is where your “sample” guideline becomes critically important as the foundation for the final result. It is also a good opportunity to get other eyes looking at the CPG. They may see or think of things that you did not. This step will serve to strengthen your guideline and customize it for your hospital.
8. Make sure there is an “escape valve” for unusual clinical situations
It really is impossible to turn clinical care into a cookbook. There are too many variables, making it impossible to include every possibility into a single guideline. As the guideline creator, you must find that line between too much detail and too little guidance. Craft your guideline to cover 90% of the usual clinical situations encountered. Recognize that some situations may arise in which the guideline will not apply. Create an expectation that if one of these does occur, the CPG does not need to be followed. But equally important, the full rationale for deviation must be documented in some way. This may be a direct communication to the trauma performance improvement program or, preferably, documentation in the medical record.
9. Educate, educate, educate
Don’t just email your CPG to everyone and implement it the next day. Roll out your new guideline slowly and methodically. Send out the final copy to providers who are most involved or impacted and ask for comments. Consider any last-minute tweaks. Set a specific start date, taking into account the time it will take to bring everyone up to speed. Then organize a series of educational sessions to make sure everyone involved knows about the new guideline. Send out regular announcements to all involved, with copies of the CPG attached.
10. Post your CPGs in logical, easy to find locations
One of the biggest problems with new guidelines is that clinicians never seem to have them at hand when (and where) they need them. This practically guarantees that they will not be followed. Make sure multiple paper copies are placed in all appropriate clinical areas. Most trauma programs have a website or intranet to house this type of content. But make sure it is easy to navigate to, not ten clicks deep in some obscure hospital site. If your program has many CPGs, consider a web application for smart phones. Everyone carries one these days.
11. Develop a system for monitoring compliance
How will you know if your guideline is not being followed? Somebody needs to watch! That someone depends on the size of your program and specific personnel available. If you are a small center, this task may fall to the trauma program manager. If you have a PI coordinator, nurse clinicians or advanced practice providers, they may be perfect for this. Records of all patients who did or should have had the guideline applied need to reviewed each day. Any variances must be identified, and any documented explanations should be reviewed. The trauma medical director must make the final decision as to the appropriateness of care delivered. In addition, basic information on the number of patients involved and the number of variances should be recorded for later performance improvement analysis.
12. Maintain a tight feedback loop when a variance occurs
We cannot learn from our errors if there are no consequences. If a provider does not follow the guideline and nothing happens, he or she probably won’t follow it the next time either. The trauma medical director must be notified of every noncompliance incident. The TMD, in turn, must communicate promptly and directly with the provider, ideally within 24 hours of the occurrence.
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Either email or direct face-to-face communication can be used. However, it must be done in a way that is non-judgmental and polite yet firm. Remind the clinician that a new CPG has been implemented. Note that it did not appear that it was followed. Provide a copy of the guideline for their “reference” and remind the provider where it can be found. And give the provider an opportunity to explain why he or she didn’t follow it and ask questions about it.
13. And what about “that one doc” who refuses to go along because he or she is already doing it the “right” way?
Some providers don’t believe in a “cookbook” approach to medicine. Others sincerely (and wrongly) believe that their way is the right way, despite what others are doing or what the literature says. There are several ways to deal with them. First, make sure that you followed all the points above while designing and implementing your guideline. This serves to make it as sound as possible from the very start. If you know or suspect who some of these individuals might be in advance, involve them heavily in the entire process. Once you have designed your “sample” guideline (tip #6), run it by them for comment. Make them part of the group (tip #7) that helps customize the guideline for the hospital. Give them feedback (tip #12) every time they don’t follow the CPG so they get tired of hearing about it. And finally, consider circulating a clinician scorecard that shows compliance rates for everyone involved. Even if names are omitted, everyone will be asking who that outlier is. Trauma professionals are a competitive bunch, and none want to be at the bottom of the list!
Michael McGonigal, MD is the director of trauma services at Regions Hospital in St. Paul, Minn. He is also the author of The Trauma Professional’s Blog, which provides injury care education to thousands of trauma providers worldwide.