Three-year follow-up after introduction of Canadian best practice guidelines for asthma and foot care in diabetes suggests that monitoring of nursing-care indicators using an electronic documentation system promotes sustained implementation
- Correspondence to John Xavier Rolley
St Vincents/ACU Centre for Nursing Research, Australian Catholic University, Locked Bag 4115, Fitzroy MDC, VIC 3065, Australia;
Implications for practice
■ Use of reminders in chart-based documentation aids adherence to guidelines.
■ Use of electronic health records technologies enables guideline implementation and evaluation.
■ Sustainable guidelines' implementation requires individual and system changes.
Implications for research
■ Development and evaluation of strategies to support evidence-informed practice are required.
Higuchi and colleagues set out the results from a 3-year follow-up study of a set of clinical practice guidelines implemented within two community diabetes education and care sites in Canada. The specific aim was to determine the sustainability of the guidelines' implementation over time. The guidelines under investigation related to two chronic conditions: asthma and diabetes. More specifically, the diabetes guideline looked at reducing risks for foot complications. The specific questions addressed were as follows: 3 years following guideline implementation, what clinical nursing care was being provided according to the guidelines recommendations? and what contextual changes occurred in the clinical settings during the 3 years after guideline implementation?
A 3-year longitudinal follow-up design was chosen to investigate sustainability of two guidelines in the Diabetes Education and Care program. The sample size was calculated based on a 20% detectable difference and an 80% power (α=0.05). A total of 62 patient charts was eligible for inclusion in the asthma guidelines cohort and 65 patient charts included in the diabetes guidelines. Clinical chart audits were undertaken for each cohort. Data were extracted using nursing care indicators appropriate for each guideline. Onsite training was provided for auditors to reduce bias. Other data monitoring methods were also employed to aid data integrity. Additional data collected included field notes, document reviews and interviews. None of these was reported in the article. Fisher-exact tests were used to determine significance. The α level was set at 0.05.
The study found that, following 3 years of guideline implementation, significant improvements were made on 9 out of 12 indicators for diabetes-related foot care. Of the 12 asthma indicators, 3 remained high while 4 had significantly declined, indicating an encouraging impact on patient outcomes arising from implementing the guidelines. A multicentre trial with a larger sample size may have given a greater indication of the generalisability of these findings.
Whether nursing should engage in clinical practice guidelines development remains controversial.1 Regardless, there is increasing pressure for nursing to engage in the process of generating, evaluating and translating evidence to change and support practice.2 When guidelines are developed, evaluation of their efficacy for improved patient outcomes becomes a vital step.
Higuchi and colleagues undertook such a study to evaluate two sets of guidelines in a community setting. The rigour of methods of evaluation is important to note. Equally important was the emphasis the authors placed on the changing context of the setting for the study, in particular, the addition of electronic documentation systems.
There was insufficient detail regarding the statistical methods employed to determine difference over time. In particular, the small sample size of each cohort (asthma and diabetes foot care) and the potentially skewed nature of the findings would lend itself to statistical approaches not described, that is, median and IQR.2
Clinical practice guidelines are resource intensive in their development and implementation.2 As such, individual institutions are not often resourced to undertake projects on the scale required.3 Likewise, evaluation of clinical practice guidelines would be best conducted over multiple settings to determine how institutions uniquely adapt these evidence-based documents into their own settings. Higuchi and colleagues arguably found the need to evaluate one setting, that is, the diabetes education and care service. However, the use of multiple implementation settings would have added weight to the guidelines' transferability.
It is important to note that little in the way of nursing clinical practice guidelines evaluation is seen in the literature.4 As clinical practice guidelines gain greater traction in healthcare practice, shifts will be required in healthcare systems and professions. These include greater ownership of the evidence required for practice outcomes, a longitudinal approach to guideline development whereby the documents are ‘living’ works with commitment to their regular update and greater emphasis on clinical practice outcomes stakeholder collaboration.
Higuchi and colleagues present an approach required to progress the competent translation of evidence into practice through clinical practice guidelines' development and implementation. However, more work is required to improve how guidelines are implemented and evaluated. The use of electronic medical records using standardised data definitions will aid this endeavour substantially along with greater professional collaboration internationally.