Clinical Practice Guidelines: Good for Everyone
There is lots of talk these days about best practices. In medicine these refer to procedures, guidelines or protocols that yield the best outcomes at the best cost. For example it is generally accepted that chest pain patients presenting to the emergency department should have cardiac enzymes done, be given an EKG, and an aspirin.
Another generally accepted guideline is that specimens for blood cultures should be drawn peripherally and the site should be cleaned with chlorhexidine. In a particular situation it's possible to do more than best practices dictate, but the effort might not be worth it. Do the additional actions improve patient outcome? Is the cost justified in the majority of cases?
One principle of best practices is to follow clinical practice guidelines where they exist. In 1990 the Institute of Medicine (IOM) defined clinical practice guidelines as "systematically developed statements to assist practitioners' and patients' decisions about appropriate health care for specific clinical circumstances."
The problem is that many practice guidelines in use:
- are developed without laboratory input, even if they include the use of laboratory data;
- are not updated based on the latest evidence; or
- are not mandated; only suggested.
Since 2006 the CDC has been working on a project called the Laboratory Medicine Best Practices Initiative. Their process is very structured and systematic-extensive literature review, weighting the evidence based on the design of the study making a certain claim, and review of all evidence by an expert panel. For example, in looking at blood culture contamination, the LMBP project started with 1677 references and eliminated all but 30. Those 30 will then be reviewed in depth by an expert panel.
Topics being considered under the CDC LMBP study to date include
1. The effective interventions/practices for reducing patient specimen and/or test result identification errors
- a. bar-coding systems,
- b. point of care bar-coding systems
2. What practices are effective for timely and accurate communication of laboratory critical test results to responsible/licensed caregivers?
- a. Automated notification
- b. Call center
3. What practices are effective for reducing blood culture contamination?
- a. Dedicated phlebotomy
- b. Peripheral venipuncture
- c. Commercial prep kits
I like the fact that the group has started with addressing common concerns that will have significant effect on patient outcomes while helping to reduce costs. They are also willing to look at data from PI projects in individual laboratories, by the way.
Since the method is much more rigorous than those developed by other disciplines, it is hoped that they will be adopted when pubished. After all everyone would benefit. This truly sounds like a win-win for patients and laboratorians.