Template for developing hospital clinical guidelines

Purposes of template

A guideline is a statement of “best practice” for the management of common clinical problems. It may be based on local practice policies, consensus of an authoritative group of authors, or evidence from controlled clinical trials in increasing order of rigour.

The purpose of this template is to provide a generalised structure to assist in the design of a common class of hospitial guidelines that are intended to be computerised using Arezzo^â technology. Often the guideline will initially be prepared as a free text, though carefully structured, document by the original authors, and then provided to the PROforma authors to develop the knowledge base. The specific goals of this template are to ensure that:

1. the guideline aims, target population and outcome measures are clear
2. the guideline is systematically structured and documented
3. safety and audit requirements are fully addressed

and to assist in:

1. translation of the text guideline to a PROforma knowledge base
2. reviewing and revising the informal and PROforma guidelines
3. indexing and maintaining the PROforma guideline library

Proposed template for common hospital guidelines

Preamble to guideline

Clinical objectives. Statement of the clinical, resource management or other aims of the guideline.

Target population. Characteristics of the target population (age, sex, new patients etc) who are likely to be eligible for use of the guideline.

Outcome measures. The clinical, cost or other parameters against which the success of the guideline is to be judged and which need to be recorded during execution of the procedure.      

Context of use. Who will use the guideline (e.g. GP, nurse, practice manager, receptionist, pharmacist).

Procedures for use. A description of the conditions under which the guideline will be used (e.g. during the patient encounter; before/after the patient sees the doctor; in the patient’s home etc.)

Associated documents. Any information available on computer or in paper documents which were used in the preparation of the guideline and are available for consultation by the user of the guideline.

Status of guideline. One of: practice policy; consensus; evidence-based, and any further comments or significant qualifying remarks. (NB each component of the guideline may depend on opinion, consensus or evidence.)

Version: A clear identifier for the guideline, its date (creation, last revision) and version number.

Review date: Should be reconsidered on a specific date or following a specific anticipated event.

Authors: Names and contact details of the guideline authors.

Definition of guideline services

Indications. Statement of situations in which the guideline would be considered for use (e.g. diagnosis, emergency).

Patient eligibility decision. Statement of the conditions (e.g. age, sex) which, if true, would make use of the guideline inappropriate.

Workup plan   

History

            Urgent investigations

            Non-urgent investigations

Management decision.

Management plan.

            General management.

            Specific management.

Followup plan.

Rescue           

Associated policies 

Safety policy (free text, pro tem)

This section sets out any important conditions which may impact on safety (e.g. any important “alerts” that the GP should be reminded to check during the work-up, contraindications to management actions, and so on).

Audit policy (free text, pro tem)

This section identifies those clinical data, decisions, reasons etc. which must be recorded on a secure database separate from the patient record, which are relevant to self- or external-audit of the practices of the clinician (e.g. presenting complaint; diagnosis; referral), and other parameters which may be relevant to monitoring the use and value of the guideline (e.g. outcome data; time taken; resource impact).

Coding policy (free text, pro tem) 

It is not clear that a decision about clinical coding should necessarily be included in the guideline, but it would be helpful if the authors were to consider this, in case there are any implications or constraints on the choice which are implied by the design of the guideline.

Preparation for computerisation of the guideline

Task tables

Once the basic task structure has been settled we need to move into a more systematic and rigorous preparation of a knowledge base, which we wish to be as clear and complete as possible. A potentially useful way of beginning this is to prepare a set of “task tables”, which are intended to facilitate cross checking of the consistent use of terms within and between guidelines (e.g. blood_pressure, bp); ensuring that the guideline reuses existing guideline components where possible (e.g. prescribing); reviewing the completeness of the medical content of each task definition.

Assuming that the text guideline is prepared by a clinician or a clinical researcher the preparation of the task tables will probably be carried out jointly by the original author and  the individuals responsible for preparing the PROforma version. (Indeed we hope that the OpenClinical authoring tool will soon be able to automate much of this activity.)

A provisional structure for the task tables is shown below: