Evidence-Based Practice Basics: What are Clinical Practice Guidelines?

Clinicians want to make practice decisions based on the best evidence (this is an assumption, of course – but one I’d hope you’d agree with!). Summary evidence includes the regularly updated evidence-based (EB) textbooks and high-quality clinical practice guidelines (CPGs). This post will focus on explaining what a clinical practice guideline is, why it’s a foundation of evidence-based practice, and the benefits of using clinical practice guidelines for busy clinicians.

What is a Clinical Practice Guideline?
Clinical Practice Guidelines (CPGs) are defined as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” (DiCenso, Ciliska, Dobbins, & Guyatt, 2005, p. 155). The Institute of Medicine (IOM) defines CPGs as “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” (2011, p. 1). CPGs may be referred to as Best Practice Guidelines in some countries.

Clinical practice guidelines condense a large amount of evidence into a practical source for busy clinicians. Evidence-based CPGs are summaries and syntheses of best evidence, ideally, from rigorous systematic reviews, which are then delineated as recommendations for practice – a big help for practicing healthcare providers.

The recommendations contained in CPGs usually incorporate multiple sources of evidence, including systematic reviews, professional standards, quality assurance data, expert consensus, and various types of research studies. Thus, CPGs are usually broader in scope than systematic reviews or the other evidence sources used.

A common misconception is that all published CPGs are trustworthy – but that is not true! So be sure to critique any evidence you are interested in implementing. I’ll talk about how to critically appraise a CPG in a future post.

A CPG that is evidence-based and rigorously produced is “gold” to a busy nurse or APN because the evidence is pre-appraised and deemed valid, so the clinician can use the recommendations right away!

Clinical Practice Guidelines and the Hierarchy of Evidence
When trying to get an answer to our “burning” clinical questions – we need to turn to the literature. Since there are so many published research studies, how do you choose the best ones to review to answer your questions?

As with all evidence sources, you want to use the highest level of evidence available to you. You will want the answers to your clinical questions because you will want to deliver the highest quality care to your patients. To do that you need to use the most effective interventions.

Haynes (2007) originally proposed a hierarchical model of evidence sources that depicted a ranking of sources from the most rigorous methods and most helpful (i.e., valid preappraised evidence) to the least helpful (i.e., you have to appraise the evidence by yourself). The purpose of the “6S” version of this model (DiCenso, Bayley, & Haynes, 2009) is to help you see where you should be focusing your search efforts.

6S Pyramid for Finding the Best Evidence
6S Pyramid for Finding the Best Evidence

Systems is the highest quality of evidence level, according to the 6S hierarchy of evidence pyramid, but these are institution-based, evidence-based clinical information systems that link to patient records and not very common yet across the nation. So if your institution does not have a clinical decision support system in place, the next highest level to guide your search efforts to answer your clinical questions is in the Summaries level.

Summary evidence includes the regularly updated evidence-based textbooks and high-quality clinical practice guidelines.
Where Do You Find Clinical Practice Guidelines?
You can find CPGs through a search engine (e.g., Google, Yahoo), through professional organization websites (e.g., Society for Critical Care Medicine, American Heart Association, Registered Nurses Association of Ontario [RNAO]), through bibliographic databases (e.g., OVID, Medline), and through government-sponsored sites, such as The National Guideline Clearinghouse (sponsored by the Agency for Healthcare Research and Quality [AHRQ]). The Scottish Intercollegiate Guidelines Network (SIGN), National Institute for Clinical Excellence, McGill University Health Center, Guidelines International Network, and the Joanna Briggs Institute are excellent resources for CPGs or Best Practice Guidelines.

A heads up about The National Guidelines Clearinghouse (NGC). The NGC is a storage house, a repository for CPGs. According to the site’s Home page, the NGC is described as “a public resource for summaries of evidence-based clinical practice guidelines.” It provides guideline summaries, guideline syntheses, and expert commentaries.

The guidelines found at this site are produced and submitted by a variety of organizations – so you still need to appraise them! The NGC does not critically appraise the guidelines found on its site. Guidelines represented on the NGC website are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria. The criteria for inclusion in the NGC insist that the authors provide evidence that the CPG is based on a systematic review and that rigorous standards have been followed in the development of the CPG.

I wrote about a variety of online clinical practice guideline resources in 2017. You can get more information about some of the sources I named above, as well as additional sources, by reading that post.

Why is Summary Level Evidence Beneficial to Evidence-Based Practice Clinicians?
Summary level resources have many benefits for busy clinicians who want to practice according to the evidence.

Lots of Information Summarized = Easier Decisions, Improved Healthcare, and Efficient use of Resources (Thompson, 2011): Summarizing many research studies and other evidence is helpful to the nurse or advanced practice nurse (APN) because most of the hard work is done for you!
The EB textbook or CPG authors should have systematically searched for all valid and reliable evidence on the clinical topic, evaluated the evidence for scientific merit, and collated the evidence into recommendations for clinical practice. This preappraised evidence source means you don’t have to go through this process!
Healthcare quality is improved by using best evidence for practice and recognizing how scarce resources are used.
Highest Accessible Evidence Level: Since a System level of evidence is not found in most institutions, Summary evidence is the most practical level that can be accessed by practicing healthcare providers.
Standards are high, so Validity is high: If Summary evidence follows a known and rigorous process of development and updating, the clinician using these evidence sources can have confidence in the information they find and quickly translate the evidence into concrete information for practice. Of course, evidence sources have to be vetted by the clinician first. More on how to do that later.
Preappraised Evidence Saves Time!: Once you are assured that the authors of an EB textbook or CPG were rigorous in their methods to produce these resources, you can take the information presented and quickly use that evidence in practice. You will be confident that the Summary evidence will be based on sources that have been evaluated and validated by the authors before being incorporated into the EB text or a CPG. For busy clinicians that means that the evidence is already appraised for you (AKA preappraised or pre-appraised evidence).
How to Cite this Blogpost in APA*: Thompson, C. J. (2018, February 6). Evidence-based practice basics: What are clinical practice guidelines? [Web Log Post]. Retrieved from https://nursingeducationexpert.com/clinical-practice-guidelines *Citation should have hanging indent
References
DiCenso, A., Bayley, L., & Haynes, R. B. (2009). Accessing pre-appraised evidence: Fine-tuning the 5S model into a 6S model. Evidence-Based Nursing, 12(4), 99-101.

DiCenso, A., Ciliska, D., Dobbins, M., & Guyatt, G. (2005). Moving from evidence to action using clinical practice guidelines. In A. DiCenso, G. Guyatt, and D. Ciliska (Eds.). Evidence-based nursing: A guide to clinical practice (pp. 155-171).St. Louis: Elsevier Mosby.

Haynes, B. (2007). Of studies, syntheses, synopses, summaries, and systems: The ‘5S’ evolution of information services for evidence-based healthcare decisions. Evidence-Based Nursing, 10(1), 6-7.

Institute of Medicine. (2011). Graham, R., Mancher, M., Wolman, D. M., Greenfield, S., & Steinberg, E. (Eds.). Clinical practice guidelines we can trust. Washington, D.C.): National Academies Press. Retrieved from http://nationalacademies.org/hmd/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx

Thompson, C. J. (2011). Designing studies for EBP. In J. Houser & K. Oman (Eds.), Evidence based practice: An implementation guide for healthcare organizations (pp. 151-173). Sudbury, MA: Jones and Bartlett.