Development of clinical practice guidelines for the nursing care of people undergoing percutaneous coronary interventions: An Australian & New Zealand collaboration

Summary

Aim

This paper describes the development of nursing practice guidelines for percutaneous coronary intervention (PCI).

Background

Clinical practice guidelines (CPGs) supporting PCI nursing care are limited.

Method

The National Health and Medical Research Council's (NH&MRC) health and medical practice development guidelines were used for the guideline development process. A panel of experts (clinicians and consumers) attended a consensus conference to review existing evidence. Subsequently, nurses’ opinions were identified via an online survey. This was followed by a modified Delphi method was used to refine a draft set of guidelines over two rounds.

Results

The consensus conference was attended by 41 participants (39 cardiovascular nurses and 2 consumer representatives). Eight additional members joined the panel for the modified Delphi rounds with 27 participants completing the online survey. The final guideline document consisted of 75 recommendations. Endorsement was then sought from key peak cardiovascular bodies in Australia and New Zealand.

Discussion/conclusion

Inconclusive evidence precludes definitive recommendations. Therefore, consultation and consensus are important in developing guidelines to achieve standardised nursing care and monitoring of outcomes.

Implications for practice

Nurses play a crucial role in PCI care, yet currently there are limited guidelines to inform practice. This paper describes the method developing clinical practice guideline and deriving consensus.

Introduction

Increasingly, percutaneous coronary interventions (PCIs) are used to manage coronary artery occlusions.¹ Although there is high level evidence for the medical approach to care, there is less evidence to support recommendations related to areas of management such as patient positioning, time to ambulation and sheath removal that are commonly the domain of nursing practice. This paper will document the process of developing clinical practice guidelines. A recent review of the literature found that² nursing care of people undergoing PCIs requires improvement in key areas of practice. Areas identified for improvement monitoring strategies for complications and providing information and educational preparation for discharge.

Guidelines have been published as early as the mid-1970s.³ The emphasis has been on promoting quality and consistency of care leading to increasing use of guideline recommendations. As a consequence, the number of clinical practice guidelines has risen over the past two decades. Field and Lohr⁴ describes clinical practice guidelines (CPGs) as “… systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” Using guidelines helps overcome the limitations of individual institutions producing their own practice guidelines and assists in setting benchmarks and monitoring clinical outcomes.⁵

The strength of a clinical practice guideline is dependent on the rigour of the methods used in development.⁶ One approach used by the AGREE collaborative is to view a “good” clinical practice guideline as “…one that eventually leads to improved patient outcome.”⁷ Developing best-practice guidelines is pivotal to achieving this goal. Systematic and rigorous methods are needed to ensure reliability and validity.5, 8

The efficacy and reliability of clinical practice guideline have been contested.7, 9, 10 In particular, the absence of evidence upon which to base practice¹¹ and subsequent reliance on consensus level recommendations has been criticised.9, 10 Clinical expert consensus is often employed to bridge gaps in the evidence.⁹ Prospective, structured and systematic approaches are the most reliable.11, 12 Techniques such as Nominal Group Technique (NGT)¹¹ and Delphi methods are often used to achieve consensus.¹³ The former relies on group contact, i.e. conference or workshop setting, while the latter uses anonymous methods of collecting information including mail-out questionnaires.

There are strengths and weaknesses inherent in this approach. Consensus recommendations are inferior to having high quality evidence for practice.¹² Engaging clinicians from a variety of settings, using a facilitated method to debate contentious areas of practice, can lead to consensus that would not be attainable and defensible using ad hoc methods. The strength of evidence for such recommendations must be treated cautiously.⁹ However, this approach assists in achieving a broad level of engagement and agreement using prospective methods.11, 12

Barriers to effective implementation are complex. They include clinician adoption10, 14 and adherence to guidelines recommendations. In addition, substantial resources are often needed to ensure their implementation into practice and evaluation of their outcomes.¹⁵ For example, the American Heart Association's ‘Get With the Guidelines’ program has demonstrated improved outcomes for cardiac patients regarding treatment and secondary prevention uptake through promoting awareness of guidelines, networking, monitoring of outcomes and recognition of successful implementation.16, 17

Cardiovascular clinicians have been early adopters of CPGs. The American Heart Association published their first set of guidelines in 1993.¹⁸ Since then, many professional societies have followed in publishing guidelines to support cardiovascular practice.19, 20, 21 Although multiple guidelines exist for PCI care, these do not address nursing care in sufficient detail.² For example there is limited guidance for monitoring post-PCI arterial sheath removal, pain management, positioning and discharge planning.