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4. Developing clinical practice guidelines and protocols

By discussing cases and how they are managed with other staff within your practice, it may become apparent that having some structured guidance based on the existing evidence may be beneficial. If the evidence doesn’t exist, making sure that the practice is approaching these type of cases in a broadly similar way will be important. One way of doing this is by creating clinical practice guidelines and protocols.

Through the development of unambiguous and concise clinical guidelines and protocols, practitioners can be motivated to trial new ways of approaching a case. Both protocols and guidelines support clinician decision-making and are evidence based.

Despite the terms frequently being used interchangeably, protocols and guidelines are not the same thing. As the names imply, protocols are much more rigid rules compared to more flexible guidelines. However, both should be clear and concise and include sufficient information so that they can be understood without reference to other supporting materials.

Guidelines

Clinical guidelines are intended to provide information to assist decision making in the management of a case based on an appraisal of the current best evidence. (Hewitt-Taylor, 2004)

Clinical guideline recommendations should be unambiguous, consistent and define target patient populations and expected clinical outcomes. Successful guidelines are simple documents that guide veterinarians through a process (be that diagnostic, treatment or any other process), without describing how each procedure is delivered to a patient. Guidelines can assist communication of evidence within a practice or community of veterinarians.

See RCVS Knowledge resources which include tools to assist in creating guidelines, links to published guidelines and CPD .

Protocols

Protocols are rigid statements or rules which must be adhered to. A protocol sets out a precise sequence of activities in the management of a specific clinical condition (Hewitt-Taylor, 2004). In areas such as biosecurity, surgical checklists, radiation safety and operating procedures for equipment, protocols are more appropriate than guidelines.

You might have an area of practice in which you feel improvements could be made. Consider the following example:

Your practice has recently invested in laparoscopic equipment. You are the only vet currently experienced and confident in performing laparoscopic ovariectomy in dogs. You wonder whether a change in practice from open ovariectomy would be beneficial for the practice’s patients. You find a relevant BestBET supporting this theory with the following clinical bottom line:

In small dogs (<10kg), use of a laparoscopic ovariectomy technique may lead to greater activity levels in the 48 hour post-operative period than if ovariectomy is performed using a conventional midline open technique. (Read the full BestBET )

You also find a knowledge summary comparing ovariectomy (OVE) with ovariohysterectomy (OVH), which concludes:

whilst the evidence does suggest OVE may be associated with some modest improvement in surgical time and incision length, due to the small sample sizes and varying techniques used, further studies are required before definitive conclusions can be made. (Read the full Knowledge Summary )

The practice team agrees with your recommendation and decides to adopt laparoscopic surgery more widely. To support the effective implementation of this change, you produce a clinical protocol outlining the important steps in setting up the equipment and performing the laparoscopic technique and set up training for the rest of the team, including surgical training for operating vets and nurses and informing support staff who may be involved in communicating with owners.

Whether you choose to develop a protocol or a guideline, there are a number of steps involved:

Identify the specific clinical scenario for which you wish to address.
Select the team of practice staff interested in the specific topic to support the evidence gathering for the guidelines or protocol.
Search for existing research-based guidelines (don’t reinvent the wheel). If nothing appropriate exists, then search the evidence on the specific clinical scenario. You will need to Ask a clinical question and Acquire and Appraise that evidence.
Produce your practice guidelines or protocol based on your evidence. They should be short, straightforward, logical, and focus on the needs of the client/patient; have realistic times and outcome goals; and highlight roles and responsibilities, with measurable outcomes that can be assessed).
Pilot the guidelines or protocol within a defined time/space and modify the protocol as needed from the pilot.
Implement the guidelines or protocol, including any training needed.
Monitor the compliance and effectiveness of the guidelines or protocol.
Conduct an annual or biannual review of the compliance and effectiveness of the guidelines or protocol.

Figure 4: Process for developing guidelines or protocol

The use of clinical practice guidelines and protocols provides practitioners with a reflective tool. Periodically and systematically assessing the effectiveness is important to ensure that they have had the desired effect on patient outcomes and as part of practice quality improvement, or clinical governance. Techniques for doing this assessment can be found in the next stage of the EBVM cycle under Assess.