Keeping up to date with guidelines
Q We recently found that two of our partners are using old versions of the British Thoracic Society guidelines. How can we ensure that we do not miss updates of important national guidelines?
A There is no simple answer to this question. It looks as if things will get better fairly soon. The IT strategy recently announced by the Department of Health sets out plans for a National Electronic Library, accessible via the NHSnet. This will include up-to-date copies of guidelines. Modern electronic technology makes it possible to distribute updates automatically to registered users.
Guidelines should have review dates written into them, and many already do. If the review date has passed, this should trigger a further enquiry to the authors or originating organisation. And, of course, there is a need for good housekeeping – throwing away the old version when a new one comes along.
Other suggestions for keeping up to date include:
- Carry out periodic literature searches on MEDLINE through your PGMC library or the BMA library
- Surf the internet
- Contact the RCGP
- Contact the National Centre for Clinical Audit (NCCA)
How can I keep my team motivated as guidelines change?
Q Recently the practice team carried out an audit over a year to look at diabetes care given to patients. The gold standard blood pressure identified was 140/90mmHg, and patients and medical staff have worked enthusiastically to reduce blood pressure to these figures. However, the latest guidelines suggest an even lower figure of 135/85mmHg. How do you re-focus your team, who have worked extremely well and hard over the preceding year, to achieve a lower figure?
A Controlling the blood pressure of some patients can be a major challenge, and your team should be congratulated on their efforts and success. Many teams have yet to follow your example.
Guidelines should not be regarded as obligatory and not open to challenge. Why not encourage a few members of the team to check the evidence that has prompted the new recommendation?
The team may be able to estimate the likely benefit to the practice population of people with diabetes in terms of numbers needed to treat. The team as a whole can then decide whether they think the new target should be adopted.
The new blood pressure recommendation may initially be seen as demoralising, but you could use it as an opportunity to familiarise the team with the appraisal and interpretation of research evidence.
The team will then progress from merely following guidelines to being inquisitive practitioners of evidence-based practice.
How can I get PCG members to follow guidelines?
Q How do you ensure that a primary care group follows guidelines that are well recognised by an august body?
A I don't think you can ensure that the guidelines are followed – practitioners and patients are free to make their own decisions. However, it is possible to provide the opportunity for members of the PCG to consider the guidelines.
Even before that, the group needs to debate how they will coordinate policy making and their approach to monitoring and improving the quality of care. Thus, a decision to use guidelines will depend on the general development of communication and decision making systems in the group.
If the group agrees to employ guidelines together, the next step would be agreement on how to implement them, and monitor their use.
Computer-based reminder systems could be developed. Reminders in paper records can also be helpful. Various forms of education for different groups of staff could be considered. Educational outreach may be used for those who would otherwise be difficult to engage. It is important to remember that no method is reliable, and monitoring and audit will be essential.
What if people are reluctant to follow guidelines?
Q How do you improve the recalcitrant's performance?
A Most people are not deliberately difficult, but for one reason or another find the required change in performance particularly difficult. The way forward is to identify the reasons in each individual case.
Some practitioners are genuinely overworked and cannot find time to think about how they would change performance. Others may be stressed or depressed, and the last thing they need is yet more pressure. If you want them to change, you have to offer them help with their problems first.
Understanding the motives of the recalcitrant practitioner might point to a solution. However, sometimes there may be nothing you can do, and it can help to recognise this.
You then have to decide whether to take action or wait. Maybe the practitioner is close to retirement, or maybe they will eventually change their opinion in time as they realise how extreme they are compared with their colleagues.
If you cannot afford to wait, you need agreed and explicit procedures to apply. These are likely to have been discussed within the PCG, and may involve cooperation with other agencies such as the local medical committee.
When can the guidelines be overruled?
Q Recently a patient presented with a twisted ankle. As recommended in the guidelines, no X-ray was performed. However, when the patient returned a week later, as the guidelines suggest, an (Ottawa) X-ray was performed and a fracture was found. How do we deal with this in practice, even when the patient is fully informed and agreeable to following the guidelines?
A In this case it would be appropriate to explain to the patient how unusual this sequence of events is, that no lasting harm has been done, and of course express regret.
It would be worth checking the guidelines in case there is some discussion of exceptions to the general advice about not performing an X-ray. Are there particular features of ankle injuries that would justify taking an X-ray? Depending on the 'small print' in the guidelines, you might ask the local library to send you a photocopy of the most relevant references.
The guidelines are not rules that must be obeyed in all circumstances. The clinician can always overrule them if there are good reasons for doing so.
If the guidelines do not discuss when an X-ray might be justified, why not write to the guideline developers and tell them about your case. This could provide them with useful information for the next version.