EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES for the Staff of NICU of King Saud Medical City (MOH), Riyadh, KSA 2013

19th March 2013 EBCPGs: Dr. Yasser Sami Amer 1

1999

2004

2006

Alexandria University HospitalsHealthcare Quality Directorate

Center for Evidence-Based Clinical Practice Guidelines(AUH – HCQD, CEBCPGs)

(Founded Nov. 2008)

Member of Guidelines International Network (G-I-N)(Since May 2009)

Founding Members 2008

• Prof. Dr. Mahmoud Elzalabany

• Prof. Dr. Tarek Omar

• Prof. Dr. Nabil Dowidar

• Prof. Dr. Afaf Ibrahim

• Dr. Yasser S. Amer

• Dr. Hossam Ashour

• Eng. Ahmed Mourady

G-I-N Annual Report 2009

EGYPT (EG)

First Workshop in Egypt: Adaptation of CPGs2009 (AFM-GIN-ADAPTE)

*12 M.Sc. Theses plus 1 Ph.D. thesis to produce 13 Adapted EBCPGs

4 Finalized Adapted CPGs by CEBCPGs, HCQD-AUHs through MSc

Theses (till 3/2012) in PEDIATRICS DEPT.:1- Treatment of Acute Childhood Asthma in ER - AUCH: Dr. Yasser Sami Amer

(Finalized, Approved , Disseminated & Implemented).

2- Treatment of Positioning & Attachment Breast Feeding Problems in BFCC - AUCH:

Dr. Georgina Ramsis (Finalized & Approved).

3- Triage and Acuity Scale in A & E Dept., AMUH: Dr. Mary Christeen Nabiel Sharobeem

(Finalized, Approved & Disseminated ) – the only thesis outside the Pediatrics Dept.

4- Treatment of HIE in Neonates in NICU: Dr. Walid Gamal AbdelKhaliq

(Finalized & Approved).

5- Treatment of ADHD in children in AUCH: Dr. Mariana Iskander Amin

9 Adapted CPGs in progress by Pediatrics Dept. & CEBCPGs, HCQD-AUHs

through MSc/PhD Theses (till 8/2012):

1. Diagnosis of acute attack of seizures in AUCH: Dr. Soheir Farouk AbdelSalam (Set

Up Phase).

2. Treatment of acute attack of seizures in AUCH : Dr. Islam Yousry A.Moneium (Set Up

Phase).

3. Management of Epilepsy in children in AUCH: Dr. Shimaa Anwar (Set Up Phase)

4. Treatment of Childhood Autism in AUCH: Dr. Farioz Ibrahim (Set Up Phase).

5. Management of Acute Bacterial Meningitis in AUCH: Dr Mariam Adly (Set Up Phase).

6. Treatment of Chronic Asthma in AUCH: Dr. Reem Galal Ghazal (Set Up Phase).

7. Treatment of Community Acquired Pneumonia in AUCH: Dr. Zobaida Eltazmany (Set

Up Phase).

8. Treatment of Allergic Rhinitis in AUCH: Dr. Shahinaz (Set Up Phase).

5 Finalized Adapted CPGs

G-I-N 2009 Lisbon

G-I-N 2012 Berlin

Evidence-Based

Clinical Practice Guidelines For Staff of

King Saud Medical City

2013

PART 1: IntroductionInstructor

Dr. Yasser Sami A. AmerPediatrician - HC InformaticianCPGs General Coordinator,QMD, CPGC, KKUH, KSU

NICU

Concepts & Definitions


Two Different Approaches to Evidence-Based

Practice (EBP)

Clinical Practice Guidelines (CPGs)

•“Top-down” approach

• Tell clinicians how to practice

• Favored by health care systems

Evidence-Based Medicine (EBM)

•“Bottom-up” approach

• Teach clinicians how to find answers

• Favored by medical educators


EBM definition

The integration of best research evidence

with clinical expertise and patient

valuesSackett et al 2000

Clinical

Expertise

Research

Evidence

Patient

Preferences


What is “EBM” NOT?• What we have always done !;

(not old hat or just the same old medical practice; as evidenced in wide practice variation)

• “Cookbook Medicine”!EBM specifically advocates for individualized application of evidence to patient care, not forcing patient care to conform to generalized evidence

• Only a cost-cutting trick !;it is intended to guide practitioners to provide the best, not necessarily the cheapest, care.

• Only RCTs !;(Also with best relevant evidence applicable to the situation in question)

– EBM is tracking down the best external evidence from scientific research to answer our clinical question(s)…


Definition: (old)“Systematically developed statements to assist

practitioner and patient decisions about

appropriate health care for specific clinical

circumstances” (Institute of Medicine 1990).

Increasing international interest in the

development and implementation of CPGs.

Clinical Practice Guidelines (CPGs)


CPGs New DefinitionCPGs are “Statements that includeRecommendations intended to optimizepatient care that are informed by aSystematic Review of evidence and anassessment of the benefits and harms ofalternative care options”.

Committee on Standards for Developing Trustworthy CPGs (IOM-AHRQ)


Why do we need guidelines?

Rationale for CPGs

• Worldwide concerns about: ▫ Unexplained variations in clinical practice

▫ Rising Healthcare costs

▫ Exponential growth of information

• Aim of Clinical Practice Guidelines:▫ To facilitate more consistent, effective and

efficient practice and improve health outcomes for patients


Clinical Care GAP

Best

Practice


Who needs guidelines?

• Doctors

• Nurses

• Decision makers

• Patients

• Public



• Specialized societies

• National agencies

NICE

SIGN


CPG Producers:

Specialized Societies: e.g. AAP


SIGNScottish

Intercollegiate Guidelines Network

www.sign.ac.uk

CPG Producers:

National Agencies


http://www.sign.ac.uk/

CPG Producers:

National Agencies

NICENational Institute for

Health & Clinical Excellence

www.nice.org.uk


http://www.nice.org.uk/

AHRQ

National Guideline Clearinghouse

www.guidelines.gov


http://www.guidelines.gov/

Guidelines International

Network (G-I-N)

www.g-i-n.net

Org. Member since 2009


http://www.g-i-n.net/





Shaikh Bahamdan’s Research Chair for Evidence-Based Health Care & Knowledge Translation

Member of G-I-N since Oct. 2009Free access to International CPG Library of G-I-N





PubMed

US National Library of Medicine

National Institutes of Health (NIH)


Some CPGs are only retrievable by “Googling” them!


Worldwide Best Children’s Hospitals 2012-13

These hospitals excel in caring for sick kids IN

USA UK Arab World – Arab Gulf –Middle East - EMRO



Boston Children's Hospitalhttp://www.childrenshospital.org/

1st US Nationally Ranked

• #2 in Pediatrics: Cancer

• #1 in Pediatrics: Cardiology & Heart Surgery

• #2 in Pediatrics: Diabetes & Endocrinology

• #2 in Pediatrics: Gastroenterology

• #3 in Pediatrics: Neonatology

• #1 in Pediatrics: Nephrology

• #1 in Pediatrics: Neurology & Neurosurgery

• #3 in Pediatrics: Orthopedics

• #4 in Pediatrics: Pulmonology

• #2 in Pediatrics: Urology


http://health.usnews.com/best-hospitals/area/ma/children's-hospital-boston-6140270/pediatric-rankings/cancer

http://health.usnews.com/best-hospitals/area/ma/children's-hospital-boston-6140270/pediatric-rankings/cardiology-and-heart-surgery

http://health.usnews.com/best-hospitals/area/ma/children's-hospital-boston-6140270/pediatric-rankings/diabetes-and-endocrinology

http://health.usnews.com/best-hospitals/area/ma/children's-hospital-boston-6140270/pediatric-rankings/gastroenterology

http://health.usnews.com/best-hospitals/area/ma/children's-hospital-boston-6140270/pediatric-rankings/neonatal-care

http://health.usnews.com/best-hospitals/area/ma/children's-hospital-boston-6140270/pediatric-rankings/nephrology

http://health.usnews.com/best-hospitals/area/ma/children's-hospital-boston-6140270/pediatric-rankings/neurology-and-neurosurgery

http://health.usnews.com/best-hospitals/area/ma/children's-hospital-boston-6140270/pediatric-rankings/orthopedics

http://health.usnews.com/best-hospitals/area/ma/children's-hospital-boston-6140270/pediatric-rankings/pulmonology



http://health.usnews.com/best-hospitals/area/ma/children's-hospital-boston-6140270/pediatric-rankings/urology

http://www.chop.edu/

2nd US Nationally Ranked
















http://health.usnews.com/best-hospitals/area/ma/children's-hospital-boston-6140270/pediatric-rankings/neonatal-care








http://www.cincinnatichildrens.org/service/j/anderson-center/evidence-based-care/recommendations/default/

James M. Anderson Center for Health Systems ExcellenceEvidence-Based Guidelines

3rd US Nationally Ranked































http://www.hopkinschildrens.org/tpl_nav1up_nav2up.aspx?id=1090

9th US Nationally Ranked












http://health.usnews.com/best-hospitals/area/md/johns-hopkins-hospital-PA6320180/pediatric-rankings/cancer

http://health.usnews.com/best-hospitals/area/md/johns-hopkins-hospital-PA6320180/pediatric-rankings/cardiology-and-heart-surgery

http://health.usnews.com/best-hospitals/area/md/johns-hopkins-hospital-PA6320180/pediatric-rankings/diabetes-and-endocrinology

http://health.usnews.com/best-hospitals/area/md/johns-hopkins-hospital-PA6320180/pediatric-rankings/gastroenterology

http://health.usnews.com/best-hospitals/area/md/johns-hopkins-hospital-PA6320180/pediatric-rankings/neonatal-care

http://health.usnews.com/best-hospitals/area/md/johns-hopkins-hospital-PA6320180/pediatric-rankings/nephrology

http://health.usnews.com/best-hospitals/area/md/johns-hopkins-hospital-PA6320180/pediatric-rankings/neurology-and-neurosurgery

http://health.usnews.com/best-hospitals/area/md/johns-hopkins-hospital-PA6320180/pediatric-rankings/orthopedics

http://health.usnews.com/best-hospitals/area/md/johns-hopkins-hospital-PA6320180/pediatric-rankings/pulmonology



http://health.usnews.com/best-hospitals/area/md/johns-hopkins-hospital-PA6320180/pediatric-rankings/urology

Manual of Neonatal Care 7th Ed. (Lippincott Manual

Series) 2012


Neonatal Resuscitation TEXTBOOK

6th Ed. 2012


UK


the child first and alwayshttp://www.gosh.nhs.uk/health-professionals/clinical-guidelines/

• Health Professionals > Clinical Guidelines

SEARCH by:• Search bar

• Alphabetical A-Z


How do we react to

guidelines?

Read

Adopt

AdaptDevelop

CPGs ?


Topic

Team

Content

Search

FOUND NOT FOUND

Appraise Develop

AppraiseAdopt or Adapt

Implement

Evaluate impact



Adaptation of Clinical Practice Guidelines

The ADAPTE collaboration is an

international collaboration of CPG researchers, developers and

implementers. Their main aim is to develop and validate a

generic adaptation process that will foster valid and high-quality

adapted guidelines as well as the user’s sense of ownership of

the adapted guideline.


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 context.

• http://www.adapte.org/


©Copyright ADAPTE 2007


We identified 3 main ADAPTE steps:-

Adaptation Phase

Search & Selection of source CPGs

Health Questions (PIPOH)

AGREE II InstrumentAssess source CPGs quality

External Review

(Departmental Consensus)


Alexandria CEBCPGs Adapted ADAPTE Methods

for CPGs adaptation


CPG Scope: PIPOH Model

Patient (& disease characteristics)

Intervention(s)

Professionals (Target users)

Outcomes (purpose of the CPGs)

Healthcare settings (& context)

= Health/ Clinical/ Key Questions19th March 2013 EBCPGs: Dr. Yasser Sami Amer 60


Evidence Pyramid

MA

RCT

Cohort

Case control

Case series

Case report

Expert opinion

I

II

III

IV

A

B

C

Leve

ls o

f E

vid

en

ce

Gra

des o

f Reco

mm

en

datio

ns


How to assess of the quality of any CPG ?


Assess guideline

quality

ADAPTE TOOL 9 AGREE II Instrument

23 items in 6 domains

7 point response scale

Domain scores

Recommendations


AGREE DomainsDOMAINS

1 Scope & Purpose

2 Stakeholder Involvement

3 Rigour of Development

4 Clarity & Presentation

5 Applicability

6 Editorial Independence



AGREE Instrumenthttp://www.agreetrust.org

AGREE Training Manualhttp://fhswedge.csu.mcmaster.ca/pebc/

agreetrust

CPGs: Two separate documents

FIRST (Clinicians’ Version)• Accessible from ALL points-of-

care for the NICU & hospital staff:

• Details of evidence-based recommendations for management (with only references to the other document)


SECOND:(Methodologist’s Version) ;

• Accessible from Libraries of e.g. NICU, KSMC, TQMD, Authorship group,…etc. (Reference for Replication & Documentation)

• Detailed description of the CPG Adaptation process with ALL relevant data.


Dissemination & Implementation

Nothing could be more

frustrating than producing

a CPG that is then ignored

by not being disseminated

nor implemented


Dissemination of CPGs• Full CPGs documents published on

websites

• Implementation tools will also be published:

examples for choice:-

▫ Quick Reference Guide (Summary Key Rs)

▫ Clinical Algorithms (decision tree)

▫ Clinical pathways (Integrated care pathways)

▫ Patient Information (Education Guide) Arabic

▫ Gantt chart for dissemination & Implementation

▫ Audit and Research Rs.


• If CPGs are to have a positive impact on patient care outcomes they must be implemented and incorporated into everyday clinical practice

• The identification of any barriers to implementation, and strategies for overcoming them, will form an essential part of discussions at CPGs Subcommittee/ Adaptation Group meetings

Implementing Guidelines


Launching of

KSMC-NICU

Clinical Practice Guidelines

Taskforce/ Committee

TEAM WORK


Dr. Yasser Sami AmerMSc Pediatrics, MSc HC Informatics

CPGs G. Coordinator,

QMD, CPGC, KKUH/ KAUH19th March 2013 EBCPGs: Dr. Yasser Sami Amer 73

Health & Medicine

EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES for the Staff of NICU of King Saud Medical City (MOH), Riyadh, KSA 2013