YOUR QUESTIONS ANSWERED

							                  YOUR QUESTIONS ANSWERED

What are Guidelines?
Clinical guidelines are ‘systematically developed statements to assist practitioner and
patient decisions about appropriate health care for specific clinical circumstancesi’
They present recommendations for optimal management, informed by published
evidence and broad consensus, and encourage flexible application in individual
patients.

Why do we need guidelines?
To achieve the highest standards of evidence-based practice, to reduce unnecessary
and costly variation in practice both within and between Trusts, and to reduce risk.
This is increasingly important as individual clinicians work shorter hours with patients
being cared for by changing personnel, such as the Hospital at Night team.

What Bedside Guidelines are presently available from the Partnership?
Currently we produce guidelines in General Adult Medicine, General Adult Surgery,
General Paediatrics, Neonatal Care and Nursing and we are currently developing
Obstetrics and Gynaecology for publication in 2008.

Who writes the Guidelines?
Mainly consultant medical staff from the partner Trusts with assistance from other
health, library and publishing specialists

How often are they updated?

Every one to two years

Would we be expected to contribute material to the Guidelines or their
updating if we join?
Not necessarily, but the larger the number of contributors, the lighter is the workload
on each.

Clinical colleagues in my Trust practise in a different way for a particular
problem. Can we adapt the Guidelines?

This is one of the ways the Partnership learns. Much of the day-to-day practice of
medicine is not evidence-based, so a good model of practice is set up by experts in
their work place.

The secretariat likes to know of different practices in the Partner Trusts, then
evidence will be sought. If the literature backs the practice in your Trust, the
Partnership will incorporate it into the master text at the next update.

Where Partners disagree and no consensus can be reached, each Partner pursues
the practice it feels most appropriate until further evidence becomes available.
How much variation is there between Partners?
The larger specialities, Medicine and Surgery, do have local variation, while the
Paediatric and Neonatal have little.

The most a Partner Trust has changed a set of Guidelines (the Medical) to date is
30%. Most change a lot less or none at all.

How much work will my Trust have to do to produce our local version?
The first edition of a set of Guidelines takes most work as you look at local practice.
Once you have your electronic master, the time and effort is reduced. At each
update, you will be sent a spreadsheet of changes, including reasons, which can be
incorporated into your Trust’s master.

Many Trusts involve their Clinical Governance departments, together with a lead
clinician in the specialty (Medicine, Surgery, Paediatrics, Neonatal or Nursing), to
update their Guidelines in liaison with other colleagues in the specialty.

My Trust’s changes need to be written in a consistent style. How can that be
achieved?
The style of each Guideline is similar to allow quick reference. Changes and local
details such as telephone messages are marked to help each Trust edit the master
into their own local version. A style guide is available from the secretariat.

My Trust cannot introduce a change of practice as quickly as others. What do I
do?
Where there is good evidence for a change of practice, but Trusts change practice at
a different pace due to organisational or cost pressures, your local version will reflect
that. This has occurred and was reflected in the preface to that Trust’s Guidelines.

What evidence is used?
Our full-time clinical effectiveness librarian performs the necessary literature and
specialist society searches to provide the evidence base (details on request)

Do you take account of national guidelines from organisations such as NICE?

If guidance is available from reputable sources elsewhere (NICE Guidelines, Royal
College and specialist society guidelines etc), it is consulted. Details are available on
request.

Are the Guidelines not a duplication of those from NICE?
No. Our Guidelines are a fusion of national guidelines and everyday clinical practice
and are in one volume per specialty. They are brief and to the point - a guide to what
to do now.
How reliable are the Guidelines?
The Guidelines are initially written and reviewed by specialists, including a clinical
pharmacologist, in one partner Trust with support from qualified, trained and
experienced pharmacy, library and publication staff.

But this is only the start. Members of the partnership then review the material and
offer challenges, comments and their own contributions. These are always
welcomed as the combined expertise and experience of the contributors make the
Guidelines a robust and reliable bedside tool.

Because they are reviewed and updated so regularly, the Guidelines are kept up to
date and can respond quickly to changes in evidence, practice and even adverse
incident reports. Where evidence is compelling, action is taken between editions.

The current Guidelines are the result of 11 years of energy, commitment, experience,
challenge and review.

Are the Guidelines mandatory?
The Guidelines assist clinicians and help to promote consistency, but they recognise
that patients are individuals, possibly with co-morbidities or allergies that require
alternative management. Clinicians must be free to adapt the Guidelines which are
explicitly advisory, not mandatory. Divergence does not necessarily signify
negligence.

Who are the Guidelines for?
Written by clinicians for clinicians, they are used extensively by junior and senior
doctors and nursing staff in partner Trusts around the country. They cover the
management of conditions that commonly present to every Trust responsible for
delivering acute care.

How effective are the Guidelines?
We cannot reasonably demonstrate any direct benefit to individual patient outcomes
as Guidelines are only one of many influences affecting patient management. An
audit undertaken at University Hospital of North Staffordshire, the home of the
Guidelines, showed an increase in confidence among PRHOs using the Guidelines
over a six month period.

The Guidelines can only be effective if they are used routinely. University Hospital of
North Staffordshire developed a range of methods to encourage use of the
Guidelines (details available on request). A survey in 2003 showed that all PRHOs,
Senior HOs, registrars and senior registrars in the Medical Directorate found the
Guidelines extremely useful, carried the book at all times and referred to them daily.

For a fuller review, see the paper “Bedside Clinical Guidelines: The Missing Link” on
this CD.
What is the history of the Guidelines?
The Guidelines were written initially to support care for adult medical emergency
admissions and allow audit of that care at the University Hospital of North
Staffordshire.
First conceived in 1993, the first edition was issued in February 1996. Updated
editions have been issued annually since.
They have always been advisory, not mandatory, recognising the variability of the
human condition; however, they have become increasingly a core of both care and
debate around that care.
They form the foundation of clinical effectiveness that supports in-patient care.
The Partnership was launched in May 1998. It was conceived on the premises that:
1.   General acute adult medicine is a responsibility common to all Acute Trusts
2.   The Guidelines must be explicitly evidence-based in future
3.   The Guidelines must be reviewed annually
4.   The wider the user base for feedback, the more acceptable is the final result.
The specialties covered have expanded over the years. Until now, Partners have
joined on the recommendation of staff from Trusts already in the Partnership.

How does the Partnership communicate?
The Partners communicate mainly by e-mail. A meeting for representatives from
every Trust and the secretariat is held regularly and an annual meeting to allow in-
depth debate on clinical and managerial matters is planned from spring 2008.

The attendance is variable. Some Trusts are happy to rely on the information
exchange that continues routinely by e-mail.

How much does membership of the Guidelines Partnership cost?
The annual subscription is currently £5,000.

What does my Trust receive for its investment?
All the present Guidelines on CD in a form that can be modified by you to suit your
local circumstances, followed by annual or biennial updates of each set of
Guidelines. A Quark version is provided for typesetting by your local printer.
A PDF version is also provided to enable each Trust to put the Guidelines on their
intranet.

Do the Guidelines provide value for money?

Yes. Guidelines are a vital component of clinical governance. In this age of
evidence-based practice and increasing litigation, perhaps the more relevant
question should be “Can I afford not to make the Bedside Guidelines available to
staff working in my Trust?”

The Guidelines are a unique blend of evidence-based practice combined with clinical
experience. Each Trust’s expertise is shared and best practice built in at each
update.
Does the partnership make a profit?
No. The Partnership is constructed as a non-profit making group. As more Trusts
join the Partnership the increased resources will allow us to add more specialties to
the Bedside Guidelines range and introduce formal audit processes to add further to
their robustness.




i
 Field MJ, Lohr KN, eds. Clinical practice Guidelines: directions for a new program.
Washington, DC: National Academy Press, 1990



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