Stroke: Clinical Guidelines

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Introduction

The movement towards evidence-based healthcare has been gaining ground quickly over the past few years, motivated by clinicians, politicians and management concerned about quality, consistency and costs. CPGs, based on standardised best practice, have been shown to be capable of supporting improvements in quality and consistency in healthcare. Many have been developed, though the process is time- and resource-consuming. Many have been disseminated, though largely in the relatively difficult to use format of narrative text. As yet they have not had a major impact on medical practice, but their importance is growing.

According to Woolf et al (2012) Clinical Guidelines have become one of the foundation of efforts to improve healthcare and health care management. Methods of guideline development have progressed both in terms of methods and necessary procedures and the context for guideline development has changed with the emergence of guideline clearinghouses and large scale guideline production organisations e.g National Institute for Health and Clinical Excellence. The standard definition for Clinical Practice Guidelines was defined by Field and Lohr (1990) as "systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific circumstances". 

Clinical guidelines provide recommendations on how healthcare professionals should care for people with specific conditions. They can cover any aspect of a condition and may include recommendations about providing information and advice, prevention, diagnosis, treatment and longer-term management. Guidelines are designed to support the decision-making processes in patient care . The content of a guideline is based on a systematic review of clinical evidence - the main source for evidence-based care. 

" The aim of clinical guidelines is to improve quality of care by translating new research findings into practice. There is evidence that the following characteristics contribute to their use: inclusion of specific recommendations, sufficient supporting evidence, a clear structure and an attractive lay out. In the process of formulating recommendations, implicit norms of the target users should be taken into account. Guidelines should be developed within a structured and coordinated programme by a credible central organisation. To promote their implementation, guidelines could be used as a template for local protocols, clinical pathways and interprofessional agreements. "

Purpose

Clinical guidelines aim to help health professionals and patients make the best decisions about treatment or care for a particular condition or situation. The guidelines are typically written in statement form by a reputable organization. The authors of guidelines review the research literature and take advice from experts to gather the current evidence on which to base the recomendations in a guideline. Doctors, nurses and other health care professionals are encouraged to follow clinical guidelines where appropriate. 

• To describe appropriate care based on the best available scientific evidence and broad consensus;
• To reduce inappropriate variation in practice;
• To provide a more rational basis for referral;
• To provide a focus for continuing professional education;
• To promote efficient use of resources;
• To act as focus for quality control, including audit;
• To highlight shortcomings of existing literature and suggest appropriate future research. 
  

Guideline Organisations

• National Institute for Health and Clinical Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Guidelines and Audit Implementation Network (GAIN)
• USA National Guideline Clearing House
• New Zealand Guidelines Group
• Guidelines International Network
  

Limitations & Controversy

Note : not every patient or situation fits neatly into a guideline. A guideline may not cover every eventuality and each patient's circumstance needs to be taken into consideration when a treatment is decided upon. Some doctors are critical of guidelines that may be too restrictive in their recommendations. Some guidelines are controversial.

" The problems of getting people to act on evidence based guidelines are widely recognised.1 An overview of 41 systematic reviews found that the most promising approach was to use a variety of interventions including audit and feedback, reminders, and educational outreach.1 The effective interventions often involved complicated procedures and were always an addition to the provision of guidelines. None of the studies used the simplest intervention—that is, changing the wording of the guidelines. We examine the importance of precise behavioural recommendations and suggest how some current guidelines could be improved. ... "

For a fuller discussion on the pros and cons of guidelines, see the folowing series of articles written in the British Medical Journal. 

• Potential Benefits, Limitations, and Harms of Clinical Guidelines[6]
• Developing Guidelines[7]
• Legal and Political Considerations of Clinical Practice Guidelines[8]
• Using Clinical Guidelines[9]
• Guidelines for Clinical Guidelines: A Simple, Pragmatic Strategy for Guideline Development[10]

Stroke Clinical Guidelines

Acute

Sub Acute

Secondary Prevention

Rehabilitation

Long Term

Recent Related Research (from Pubmed)

References

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