Spinal Cord Injury Clinical Guidelines

Original Editor - Naomi O'Reilly

Top Contributors - Naomi O'Reilly  

Introduction

The momentum for evidence-based healthcare has been gaining ground rapidly, motivated by clinicians, and management concerned about quality, consistency and costs of healthcare intervention. The use of Clinical Guidelines, based on standardised best practice, have been shown to be capable of supporting improvements in quality and consistency in healthcare and is considered one of the main ways that evidence-based medicine can be implemented. Clinical Practice Guidelines was defined by Field and Lohr (1990) as "systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific circumstances".[1][2]

According to Woolf et al (2012) Clinical Guidelines have become one of the foundation of efforts to improve healthcare and health care management. Methods of guideline development have progressed both in terms of process and necessary procedures and the context for guideline development has changed with the emergence of Guideline Clearinghouses and large scale guideline production organisations e.g National Institute for Health and Clinical Excellence [3].

Purpose

Clinical guidelines provide recommendations on how healthcare professionals should care for people with specific conditions. They can cover any aspect of a condition and may include recommendations about providing information and advice, prevention, diagnosis, treatment and longer-term management and are designed to support the decision-making processes in patient care. The content of a guideline is based on a systematic review of research literature and clinical evidence - the main source for evidence-based care.[4]

"The aim of clinical guidelines is to improve quality of care by translating new research findings into practice. There is evidence that the following characteristics contribute to their use: inclusion of specific recommendations, sufficient supporting evidence, a clear structure and an attractive lay out. In the process of formulating recommendations, implicit norms of the target users should be taken into account. Guidelines should be developed within a structured and coordinated programme by a credible central organisation. To promote their implementation, guidelines could be used as a template for local protocols, clinical pathways and interprofessional agreements". [5]

  • To describe appropriate care based on the best available scientific evidence and broad consensus;
  • To reduce inappropriate variation in practice;
  • To provide a more rational basis for referral;
  • To provide a focus for continuing professional education;
  • To promote efficient use of resources;
  • To act as focus for quality control, including audit;
  • To highlight shortcomings of existing literature and suggest appropriate future research. [4]

Limitations and Controversy

Clinical Guidelines can have their limitations and there is controversy surrounding some recommendations within some guidelines e.g. controversy around use of Steroids in Acute Spinal Cord Injury. Not every patient or situation fits neatly into a guideline. Guidelines to not always cover every eventuality and each patient's circumstance needs to be taken into consideration when a treatment is decided upon. Recommendations should be viewed as statements that inform the clinician, the patient and any other user, and not as rigid rules.

" The problems of getting people to act on evidence based guidelines are widely recognised. An overview of 41 systematic reviews found that the most promising approach was to use a variety of interventions including audit and feedback, reminders, and educational outreach. The effective interventions often involved complicated procedures and were always an addition to the provision of guidelines. None of the studies used the simplest intervention-that is, changing the wording of the guidelines. We examine the importance of precise behavioural recommendations and suggest how some current guidelines could be improved. ... "[6][7]

For a fuller discussion on the pros and cons of Clinical Guidelines, see the original series of articles written in the British Medical Journal followed by an updated and extended series with further recent considerations in the development of Clinical Guidelines. 

Development and Use of Clinical Guidelines Series 1:

  1. Potential Benefits, Limitations, and Harms of Clinical Guidelines [8]
  2. Developing Guidelines [9][9][9]
  3. Legal and Political Considerations of Clinical Practice Guidelines[10] [10][10][10]
  4. Using Clinical Guidelines[11] [11][11]

Developing Clinical Practice Guidelines Series 2 - Updated and Extended:

  1. Target Audiences, Identifying Topics for Guidelines, Guideline Group Composition and Functioning and Conflicts of Interest [12]
  2. Types of Evidence and Outcomes; Values and Economics, Synthesis, Grading, and Presentation and Deriving Recommendations [13]
  3. Reviewing, Reporting, and Publishing Guidelines; Updating Guidelines; and the Emerging Issues of Enhancing Guideline Implementability and Accounting for Comorbid Conditions in Guideline Development [14]

Spinal Cord Injury Clinical Guidelines

Many of the Clinical Guidelines related to spinal cord injuries treatments are focused on avoidance of secondary injury from compressive lesions and hemodynamic instability.

Pre Hospital

Dr. William Whetstone, UCSF professor of emergency medicine, and Dr. Lisa Pascual, UCSF professor of rehabilitation, go over how and why spinal cord injuries are managed even before the patient reaches the hospital.

Acute

Rehabilitation

Long Term

References

  1. Field MJ, Lohr KN (Eds). Clinical Practice Guidelines: Directions for a New Program, Institute of Medicine, Washington, DC: National Academy Press, 1990.
  2. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999 Feb 20;318(7182):527-30.
  3. Woolf S, Schünemann HJ, Eccles MP, Grimshaw JM, Shekelle P. Developing clinical practice guidelines: types of evidence and outcomes; values and economics, synthesis, grading, and presentation and deriving recommendations. Implementation Science. 2012 Jul 4;7(1):61.
  4. 4.0 4.1 Open Clinical. Clinical Practice Guidelines. http://www.openclinical.org/guidelines#refs (accessed 2 May 2017).
  5. Wollersheim H, Burgers J, Grol R. Clinical guidelines to improve patient care. Neth J Med. 2005 Jun;63(6):188-92.
  6. Michie S, Johnston M. Changing clinical behaviour by making guidelines specific. BMJ. 2004 Feb 7;328(7435):343-5.
  7. Jackson R, Feder G. Guidelines for Clinical Guidelines: A Simple, Pragmatic Strategy for Guideline Development. British Medical Journal. 1998 Aug 15;317(7156):427-9.
  8. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Potential benefits, limitations, and harms of clinical guidelines. British Medical Journal. 1999 Feb 20;318(7182):527.
  9. Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Developing Guidelines. Bmj. 1999 Feb 27;318(7183):593-6.
  10. Hurwitz B. Legal and Political Considerations of Clinical Practice Guidelines. BMJ: British Medical Journal. 1999 Mar 6;318(7184):661.
  11. Feder G, Eccles M, Grol R, Griffiths C, Grimshaw J. Using Clinical Guidelines. British Medical Journal. 1999 Mar 13;318(7185):728.
  12. Eccles MP, Grimshaw JM, Shekelle P, Schünemann HJ, Woolf S. Developing Clinical Practice Guidelines: Target Audiences, Identifying Topics for Guidelines, Guideline Group Composition and Functioning and Conflicts of Interest. Implementation Science. 2012 Dec;7(1):60.
  13. Woolf S, Schünemann HJ, Eccles MP, Grimshaw JM, Shekelle P. Developing Clinical Practice Guidelines: Types of Evidence and Outcomes; Values and Economics, Synthesis, Grading, and Presentation and Deriving Recommendations. Implementation Science. 2012 Dec;7(1):61.
  14. Shekelle P, Woolf S, Grimshaw JM, Schünemann HJ, Eccles MP. Developing Clinical Practice Guidelines: Reviewing, Reporting, and Publishing Guidelines; Updating Guidelines; and the Emerging Issues of Enhancing Guideline Implementability and Accounting for Comorbid Conditions in Guideline Development. Implementation Science. 2012 Dec;7(1):62.
  15. University of California Television (UCTV). Spinal Cord Injury Management in the First 4 Hours. Available from: https://youtu.be/fONX3arUFN4[last accessed 30/10/18]