The most paramount potential benefit of the implementation and use of clinical practice guidelines is the improvement of health outcomes. Guidelines that promote interventions of proven clinical benefit and discourage ineffective ones have the ‘potential to reduce morbidity and mortality while improving the quality of life’ (Woolf, Grol, Hutchinson, Eccles, and Grimshaw 1999, p.527). Although it has been shown in rigorous evaluations that clinical practice guidelines can improve the quality of care, whether they achieve this in daily practice is less clear (Field and Lohr 1992, p. 7), This is partly because patients, doctors, payers, and managers define quality differently and because current evidence about the effectiveness of guidelines is incomplete.
In circumstances such as pre-hospital care and emergency medicine the use of guidelines may benefit potential health outcomes, based on their ability to simplify clinical decisions in situations often wrought with urgency and confusion. For example, NSW Ambulance Service has utilised the benefits of clinical practice guidelines based on the concept that ‘the vast majority have omitted background materials, thereby highlighting the steps required to deliver the appropriate pre-hospital care (Adelstein and O’Connell 2001, p.1).
For example, if a clinician wanted to rapidly treat bradycardia as a Paramedic in NSW Ambulance Service he or she may attempt to process the first step in the EBP, by converting the information needs into answerable questions. In this case, how do you treat a patient with bradycardia who is poorly perfused? Through the research and evidence accumulated by those on the clinical practice guidelines committee the second step in the process, tracking down the best evidence with which to answer the questions may be achieved; in particular the bradycardia guideline written, based on current research and clinical practice evidence. The third step in the process, critically appraise the evidence for usefulness, would be rapidly achieved by answering the question, will these clinical guidelines successfully treat this patient? The Fourth step in the process, apply the results to the clinical practice, would then be put into place by the administration of atropine, followed by adrenaline the patient’s heart rate (HR) did not increase or perfusion did not improve with atropine (Adelstein and O’Connell 2001, Protocol 10). Lastly, the fifth step in EBP, evaluate the performance, would be applied by clinically examining the patient afterwards and determining whether the patient responded to the treatment adequately. In this case: did the patient’s HR increase and perfusion improve? In this circumstance the Paramedic may be capable of delivering EBP without reducing physical time of urgent treatment, so long as those involved in writing the guidelines have done so through the use of EBP.
Guidelines can improve the consistency of care. Studies around the world show that the ‘frequency with which procedures are performed varies dramatically among doctors, specialties, and geographical regions’ (Chassin, Brook, Park, Keesey , Fink, Kosecoff 1986, p. 314). It has been seen that many patients with identical clinical problems receive different and conflicting care depending on their pre-hospital clinician, ambulance service, hospital, or physical location. Guidelines may offer a solution, by making it more likely that patients will be cared for in the same manner regardless of where or by whom they are treated. In NSW Ambulance Service all clinicians practice the same clinical procedures based on the evidence applied in the clinical practice guidelines. For example the treatment for vomiting and nausea in NSW Ambulance Service includes the administration of metoclopramide and then treating associated symptoms if present, such as dehydration or hypovolemia (Adelstein and O’Connell 2001, Protocol 62). This will ensure consistency of treatment, providing equal quality of health care and EBP throughout NSW; however, the obvious downside is if this treatment is incorrect, in which case it will only ensure the equally incorrect health care throughout NSW.
In this case, there is some evidence to suggest that although metroclopramide is successful in treating nausea, there is no evidence that this the case when the nausea is related to motion sickness. According to Golembiewski, Chernin and Chopra ‘there is no evidence to suggest that metoclopramide actually works in patients with motion related nausea’ (2005, p.5).
Clinical guidelines can improve the quality of clinical decisions. By offering explicit recommendations for clinicians who are uncertain about how to proceed. Clinical practice guidelines are able to provide the rapid means of providing conscientious, explicit and judicious use of current best evidence without the time normally required to gather such evidence. Guidelines may overturn the beliefs of doctors accustomed to outdated practices, improve the consistency of care, and provide authoritative recommendations that reassure practitioners about the appropriateness of their treatment policies. Guidelines based on a critical appraisal of scientific evidence (evidence based guidelines) clarify which interventions are of proved benefit and document the quality of the supporting data. They alert clinicians to interventions unsupported by good science, reinforce the importance and methods of critical appraisal, and call attention to ineffective, dangerous, and wasteful practices.
Clinical guidelines can support quality improvement activities. The first step in designing quality assessment tools, such as standing orders, reminder systems, critical care pathways, algorithms and audits, is to reach an agreement on how patients should be treated, often by developing a guideline (Agency for Health Care Policy and Research 1995, p. 95). Guidelines are a common point of reference for prospective and retrospective audits of clinicians’ or hospitals’ practices: the tests, treatments, and treatment goals recommended in guidelines provide ready process measures (review criteria) for rating compliance with best care practices (Agency for Health Care Policy and Research 1995, p. 95)
Medical researchers benefit from the spotlight that evidence-based guidelines shine on gaps in the evidence. The methods of guideline development that emphasise systematic reviews focus attention on key research questions that must be answered to establish the effectiveness of an intervention (Chassin et al 1986, p. 314) and highlight gaps in the known literature. Critical appraisal of the evidence identifies design flaws in existing studies. Recognising the presence and absence of evidence can redirect the work of investigators and encourage funding agencies to support studies that fulfil this effectiveness based agenda (Hoolf et al 1999, p.4).
Healthcare systems that provide services, and government bodies and private insurers that pay for them, have found that ‘clinical guidelines may be effective in improving efficiency (often by standardising care) and optimising value for money’ (Shapiro, Lasker, Bindman and Lee 1993, p. 219). Implementation of certain guidelines reduces outlays for hospitalisation, prescription drugs, surgery, and other procedures. Publicising adherence to guidelines may also improve public image, sending messages of commitment to excellence and quality. Such messages can promote good will, political support, and (in some healthcare systems) revenue. Many believe that the economic motive behind clinical guidelines is the principal reason for their popularity (Grimshaw and Hutchinson 1995, p.2).