Free Essay On Critical Appraisal Of An Ebp Guideline
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Evidence-based guidelines (EBGs) are indispensable in the improvement of clinical systems, processes, and outcomes. The guideline lists recommendations that health care professionals can follow to achieve the stated outcomes. Guidelines are the product of scholarly work and developed using different methods, some more rigorous than others. For this reason, a legitimate concern of users was the variation in the quality of guidelines. To resolve this issue, EBGs are subjected to an appraisal using appropriate tools to ensure quality and for quality to become a basis in choosing to implement the guideline. The AGREE tool is an appropriate instrument for the appraisal process. The tool will be applied to a chronic pain management guideline and the results will inform the decision to adopt it as well as the identification of process and outcome measures and steps for implementation.
Pain is a common complaint and is associated with acute or impending tissue injury as well as chronic illness. Pain is a sensory experience that is subjective in nature. It is the individual feeling the pain who can best describe its location, severity, quality, precipitating factors, and duration. Therefore, the most accurate pain assessment would be the patient’s self-report. Oftentimes, however, pain as a fifth vital sign is ignored especially in outpatient settings where pain tends to be of a chronic nature. That chronic pain is a normal experience in aging or an unavoidable part of life and that the lack of verbalization of pain means the absence of pain are common patient and clinician misconceptions. Coupled with the staff’s lack of knowledge of chronic pain assessment as a basic intervention, misconceptions fuel suboptimal pain relief. The guideline on chronic pain management developed by Hooten et al. (2013) is suitable in improving the quality of care by providing a sound basis for policies on chronic pain assessment and management in the outpatient setting.
Guideline Appraisal Using the AGREE Tool
The scope, purpose, and target population of the guideline was clearly defined with a specific section allotted for this topic. The authors specified what and who the guideline covers and what and who it does not cover. For instance, it covers pain management in adults aged 18 years or over with chronic pain but not those with cancer pain and drug addiction issues. It also does not cover opioid use in a comprehensive manner. Five aims or objectives were also listed to further elucidate the purpose. Additionally, a definition of terms differentiating between acute and chronic pain helped clarify the scope. However, there was no specific health question discussed.
In regards to stakeholder improvement, the guideline developers consisted of US-based professionals representing anesthesiology, physical medicine and rehabilitation, occupational medicine, neurology, internal medicine, pharmacy, and psychology. The affiliation and location of the developers were specified. The participation of a psychologist is warranted considering that the selected approach to chronic pain management is the biopsychosocial model and team-based care. However, there is no representation of geriatric medicine and family medicine given that the targets of the guideline include older adults and the family is part of the patient’s social environment. There is also no representation of primary care physicians given that they are the intended users of the guideline. There is evidence of the involvement of stakeholders as the guideline includes a description of focus groups conducted among patients receiving care for chronic pain. The authors expressly stated that the discussions were used in guideline development.
In terms of rigor, the intended users of the guideline were stated as health care professionals in primary care settings. Specified as well are the ways the users can utilize the guideline, i.e. as aid in the diagnosis and management of different types of pain. The authors described, in brief, the process of searching the literature and reviewing and revising the guidelines. Stated were the types of studies employed and the databases and search terms used. Because the guideline undergoes periodic revision, only new studies published after the most recent revision were considered. However, a full description of the search strategy including the complete exclusion and inclusion criteria was not provided. The GRADE methodology was used to appraise and grade the quality of the evidence, but the guideline did not present the strengths of and limitations of the body of evidence.
While the consensus method was stated as the method for formulating the recommendations, there was no description of the process. There was sufficient discussion of the health benefits, side effects, and risks of different modes of chronic pain management. For instance, the comparability of the risks and benefits between different types of pharmacologic and non-pharmacologic pain interventions and levels of interventions was presented. The recommendations also include patient education on the risks of treating and not treating chronic pain. Risks and how these can be managed are mentioned within the recommendations themselves and not just in the evidence description.
There is evidence of linkage between the recommendations and the evidence. References and the quality of evidence of the reference were cited within the recommendations and the evidence description. Many of the references had links that can bring the user to the relevant section of the appendix or reference annotation. When there is a lack of recommendations, the guideline developers worked through consensus to generate appropriate recommendations albeit, again, there was no description of the process. There was no mention of seeking external review. The developers stated that they will periodically review and update the guideline content and presentation annually. The general procedure was discussed. A note at the end of the document made known that users can post their feedback to the guideline via the organization’s website.
In regards to the clarity of presentation, the recommendations are specific and unambiguous. The intent is indicated by the heading that the recommendation falls under, e.g. assessment, thereby grouping the recommendations appropriately. Given that the target population was already identified at the outset, the recommendations pertain to this population except when otherwise indicated. For example, recommendations that apply to both children and adults are noted as such. The different levels of chronic pain management and types of interventions, namely pharmacologic and non-pharmacologic, showed the range of treatments available and allowed informed choices. Recommendations are easily located as they are in larger fonts and bulleted. Moreover, an algorithm was developed to reflect the recommendations.
The guideline considered the aspect of applicability by providing information on the barriers and facilitators of assessment and treatment. The appendices also include tools and resources that will assist the user in guideline implementation. Criteria were established to direct the selection of tools and resources. A missing section of the guideline relates to the costs of implementation. If available, the information would assist the user in planning the practice change by securing the necessary budget. In addition, the developers also included a section on outcomes and measures to facilitate the use of the guideline in quality improvement.
The final domain of the AGREE tool is editorial independence. The developers practiced transparency by giving information on the funding sources for guideline development with a statement that the recommendations were the outcome of independent evaluations of available evidence. Each of the author also disclosed potential conflicts of interest including financial or non-financial conflicts and research grants.
Process Measures and Outcome Measures
Process measures pertain to the steps or procedures that can predict the achievement of outcomes following practice change (Ransom et al., 2008). On the other hand, outcome measures pertain to the indicators of the overall result of the change. In the implementation of the guideline on the assessment and management of chronic pain, process measures include the following: compliance with assessment protocols; performing a comprehensive assessment when there is a new complaint of pain; consistent use of valid and reliable tools in the assessment of pain; collaboration with the patient in regard to the choice of pain relief method; discussion of pharmacological and non-pharmacologic interventions; exhausting Level I interventions before proceeding to higher levels that are more reliant on specialist care and medications; reassessing pain following interventions. The outcome measures include pain levels, quality of life, patient satisfaction with care, functional status, and disability.
The process outcomes positively impact the clinical problem of suboptimal pain assessment and relief in patients in the clinic setting. By integrating these outcomes into the workflow and measuring them, the advanced practice nurse can determine the degree of staff compliance with the evidence-based guidelines. The information will help in determining what additional actions are needed to promote adherence towards a higher likelihood of improving pain outcomes in patients with chronic pain. Meanwhile, monitoring the outcome measures ensures that practice change is goal-directed which means efforts lead to tangible improvements. Awareness of performance in this manner helps drive continuous quality improvement.
Applying the Guideline
The quality of the guideline appraised above is sufficient to warrant adoption in the clinic. The guideline scored high in the domains of scope and purpose, stakeholder applicability, clarity of presentation, editorial independence. It is “average” in terms of rigor because of missing information about the procedures of developing the recommendations. A guideline cannot be implemented successfully just by instituting related policies. Misconceptions and knowledge gaps among the staff need to be addressed through education, and skills training may be necessary to facilitate the translation of knowledge into practice. Staff awareness of the importance of pain assessment improves buy-in. Lastly, a budget must be secured for staff education and skills training.
Steps in Implementing the EBG
Performance must be monitored for adherence as well and reinforced through recognizing the staff with the best level of adherence. Steps must be made to further integrate the guideline into practice. Pain assessment tools can be made easily available to the staff via clinical decision support integrating the tools into the patient’s electronic chart. The protocol can also be reproduced in large print and posted to remind the staff of the practice change. The amount of time allotted for each patient during consultation can be lengthened to cover pain assessment. Performance observations with immediate feedback can be done by the APN to assist the staff in adopting the new practice.
Pain must be adequately assessed and treated in the primary care setting to improve the health and quality of life of patients with chronic pain. A suitable guideline has been selected and was found to be of acceptable quality following an appraisal using the AGREE tool. Process and outcome measures were considered in order to guarantee that the practice change will truly impact pain assessment and relief among patients. Implementing the EBG will require new policies and the provision of staff education and training with its related budget. Subsequently, reinforcement is necessary to sustain the change and can be in the form of recognizing the staff, integrating the protocol and tools into the electronic health records, and performance observations.
Hooten, W.M., Timming, R., Belgrade, M., Gaul, J., Goertz, M., Haake, B., Walker, N. (2013). Assessment and management of chronic pain. Retrieved from https://www.icsi.org/_asset/bw798b/ChronicPain.pdf
Ransom, E.R., Joshi, M.S., Nash, D.B., & Ransom, S.B. (2008). The healthcare quality handbook (2nd ed.). Chicago, IL: Health Administration Press.
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