RECENT ADVANCESHow to implement change in clinical practice
Section snippets
INTRODUCTION
There are many potential barriers to promoting change within an organisation.1., 2. Developing and using guidelines and care pathways are ways to promote evidence-based, safe, cost-effective clinical care and change clinical practice.3., 4., 5.
Improving knowledge does not necessarily alter behaviour. Whether we are discussing patients with diabetes, educating families and children with asthma or developing a teaching programme for junior doctors, the alteration of behaviour to improve outcome
INTERNAL FACTORS
It is worthwhile considering the internal factors and barriers associated with a guideline in two sections: the pre-development stage, examining the need for the change in practice, and then the development stage, in which a valid guideline is developed from national recommendations or new research evidence and refined for local use.
EXTERNAL FACTORS
Once the guideline or care pathway has been developed and accepted by the key local players, a clear strategy of implementation is required. It would seem appropriate to develop the implementation strategy in two sections: first, a period of time before the launch of the guideline or pathway in order to prepare for the change in practice;13 second, the launch of the guidelines and the change in practice, considering the strategies to sustain, and ensuring that the change in practice continues
CONCLUSION
Change in clinical practice requires time, resources and planning. Guidelines or care pathways will aid the change in clinical practice but clear, well-defined strategies are required when considering development, dissemination, implementation and evaluation. There may be many reasons why any attempt to change practice will fail (Table 1) and if these issues are addressed prior to the process, it is likely that the change will be successful. It is no longer acceptable for a guideline simply to
PRACTICE POINTS
Factors to consider in the development and implementation of a guideline or clinical care pathway:
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Internal factors – developing a valid guideline or care pathway
- (1)
Pre-development
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Is there a gap between research and practice?
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What is the prevalence of the disease in the local community?
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- (2)
Development of the guideline
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Is there a national evidence-based guideline already available for local adaptation?
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Has there been wide, local, multi-disciplinary consultation before the pathway or guideline is
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- (1)
RESEARCH DIRECTIONS
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As guidelines and clinical pathways proliferate, further research needs to be focused on the impact that these guidelines have on patients and service costs.
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Surprisingly little is known about the effectiveness and cost-effectiveness of interventions that aim to change practice or the delivery of health care.23
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Studies examining patient outcome and satisfaction with changes in practice, along with cost to the health service and families, need to augment studies addressing the safety and efficacy
References (37)
- et al.
Survey of asthma practice among emergency physicians
Chest
(1996) - et al.
Costs and effectiveness of spacer versus nebulizer in young children with moderate to severe asthma
J. Pediatr.
(2000) - et al.
Barriers and bridges to evidence based clinical practice
BMJ
(1998) - et al.
Making better use of research findings
BMJ
(1998) - et al.
Clinical practice guidelines: the potential benefits, limitations and harms of recommending how to care for patients
BMJ
(1999) - et al.
Effectiveness of a clinical pathway for inpatient asthma management
Pediatrics
(2000) - et al.
Effectiveness of a croup clinical pathway in the management of children with croup presenting to an emergency department
J. Paed. Child Health
(2002) - Global Initiative for Asthma. GINA Guidelines, 2002. Global Strategy for Asthma Management and Prevention. Bethesda,...
- National Asthma Campaign Australia. Asthma Management Handbook 2002....
- British Thoracic Society/Scottish Intercollegiate Guidelines Network. British Guideline on the management of asthma....
Self reported practices for children with asthma: are national guidelines followed?
Pediatrics
Asthma in children: gaps between current management and best practice
J. Paediatr. Child Health
Reasons for pediatrician non-adherence to asthma guidelines
Arch. Pediatr. Adolesc. Med.
Successful implementation of spacer treatment guideline for acute asthma
Arch. Dis. Child
Evaluating the effectiveness of evidence-based guidelines for the use of spacer devices in children with acute asthma
Med. J. Austr.
Metered dose inhaler accessory devices in acute asthma: a literature review
Arch. Dis. Adolesc. Med.
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2016, Journal of Pediatric SurgeryCitation Excerpt :The difference in the rates of compliance among these types of procedures could be potentially attributed to surgeons choosing to continue antimicrobial prophylaxis until the removal of urinary catheters (although it is not recommended by relevant guidelines) [5], to the high risk of SSIs associated with the contaminated procedures, or to the small sample size in those subgroups. International PAP guidelines exist but local adaptation and refinement of those guidelines are required [17,18]. This study revealed that an appropriate educational and multidisciplinary intervention, which highlighted and informed the pediatric surgeons about the needed changes in clinical practice was an effective strategy.
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