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

Alexandria University Hospitals
Healthcare 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 CPGs
2009 (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).

G-I-N 2009 Lisbon

G-I-N 2012 Berlin

Evidence-Based
Clinical Practice Guidelines
For Staff of
King Saud Medical City

NICU
PART 1: Introduction
Instructor
Dr. Yasser Sami A. Amer 2013
Pediatrician - HC Informatician
CPGs General Coordinator,
QMD, CPGC, KKUH, KSU

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
Clinical
with clinical expertise and patient
values Expertise
Sackett et al 2000
Research Patient
Evidence 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)…

Clinical Practice Guidelines (CPGs)

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.


CPGs New Definition
CPGs are “Statements that include
Recommendations intended to optimize
patient care that are informed by a
Systematic Review of evidence and an
assessment of the benefits and harms of
alternative care options”.
Committee on Standards for
Developing Trustworthy CPGs (IOM-
AHRQ)

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 Best
Care GAP Practice


• Doctors
• Nurses
• Decision makers
• Patients
• Public


• Specialized societies

• National agencies
NICE
SIGN


CPG Producers:
Specialized Societies: e.g. AAP


CPG Producers:
National Agencies

SIGN
Scottish
Intercollegiate
Guidelines Network
www.sign.ac.uk


CPG Producers:
National Agencies

NICE
National Institute for
Health & Clinical
Excellence
www.nice.org.uk


AHRQ
National Guideline
Clearinghouse
www.guidelines.gov


Guidelines
International
Network
(G-I-N)
www.g-i-n.net

Org. Member since
2009


Shaikh Bahamdan’s Research Chair for Evidence-
Based Health Care & Knowledge Translation
Member of G-I-N since Oct. 2009
Free 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

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


Boston Children's Hospital
http://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://www.chop.edu/

2nd US Nationally Ranked


http://www.cincinnatichildrens.org/service/j/anderson-center/evidence-based-
care/recommendations/default/
James M. Anderson Center for Health Systems Excellence
Evidence-Based Guidelines
3rd US Nationally Ranked


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

9th US Nationally Ranked


Manual of Neonatal Care 7th Ed. (Lippincott Manual
Series) 2012


Neonatal Resuscitation TEXTBOOK
6th Ed. 2012


UK


the child first and always
http://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?

Develop
Adapt
Adopt

Read

CPGs ?

Topic

Team

Content

Search

FOUND NOT FOUND

Appraise Develop

Adopt or Adapt Appraise

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/


Adaptation Phase
We identified 3 main ADAPTE steps:-

Search & Selection of source CPGs
Health Questions (PIPOH)
AGREE II Instrument
Assess 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 Questions

Evidence Pyramid

Grades of Recommendations
MA
Levels of Evidence

I A
RCT

Cohort
II
Case control
B
Case series
III
Case report

IV Expert opinion C


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 Domains
DOMAINS

1 Scope & Purpose
2 Stakeholder Involvement
3 Rigour of Development
4 Clarity & Presentation
5 Applicability
6 Editorial Independence


AGREE Instrument
http://www.agreetrust.org

AGREE Training Manual
http://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.

Implementing Guidelines
• 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


Launching of
KSMC-NICU
Clinical Practice Guidelines
Taskforce/ Committee
TEAM WORK


Dr. Yasser Sami Amer
MSc Pediatrics, MSc HC Informatics
CPGs G. Coordinator,
QMD, CPGC, KKUH/ KAUH

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

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