February 1998

Translating Good Advice Into Better Practice (editorial)
Lee TH, Cooper HL; JAMA 1997;278:2108-2109
No abstract available

Implementation of the Ottawa Knee Rule for the Use of Radiography in Acute Knee Injuries
Stiell IG, Wells GA,Hoag RH, Sivilotti MLA, Cacciotti TF, Verbeck PR, Greenway KT, McDowell I, Owinn AA, Greenberg GH, Nichol G, Michael JA; et al JAMA 1997;278:2075-2079
[ see abstract below ]

Drs. Lee and Cooper comment on an article in the December 17, 1997 issue of JAMA -- Implementation of the Ottawa Knee Rule for the Use of Radiography in Acute Knee Injuries (Ian G. Stiell et al. JAMA 1997;278:2075-2079). While you might not think that this article would apply to the field of anesthesiology, you would be mistaken. It is not the subject matter, but the process of implementation of practice guidelines that drew comment. Why did I like this article? Well, because it validates what we've done at Duke University's Department of Anesthesiology and published in the May 1997 issue of Anesthesiology about pharmaceutical practice guidelines.

The authors of the editorial note the fact that many practice guidelines have been published and languish for lack of widespread implementation, or that the caregivers backslide into old practice patterns once the guidelines have been implemented. Lee and Cooper comment sagely on why this happens.

First, MD's are taught to trust their own judgment. Guidelines rob them of that special feeling of exercising their hard earned ability to make those judgments. Also, if the guidelines are successful, MD's are afraid of being rendered unnecessary. If guidelines are so good at telling MD's what to do, why couldn't they tell a non-MD provider what to do? After all, it is the accumulated wisdom of medical school and residency, the ability to make hard decisions, and to link complex symptoms into a diagnosis that marks most physicians as well-trained.

Second, most guidelines arrive without the input of the people expected to implement the rule. Many are aimed at saving money, and hence are viewed with great suspicion that they might somehow compromise care. There is rarely follow-up information to prove that patient care is the same or better with the use of a practice guideline. Lectures alone don't work. The knee study that prompted this editorial was about developing a rule deciding when to get an x-ray in the ER. One thousand patients were studied to prospectively prove the rule worked.

The principles espoused by the editorial mimic what we in the field of anesthesiology practice guidelines have long taught. Namely, common sense.

1. Careful development and prospective validation to make sure that the decision rules really do what they're supposed to do (like limit unnecessary care without missing necessary care).

2. Small group discussions of those who will be affected by the rule or guideline to get grassroots input.

3. Repeated exposure and availability of the rules when and where MD's need it (i.e. point of service reminders).

4. Agreeing that use of the rule does not make it binding in all cases. Clinical flexibility is allowed.

5. Provide information sheets for the patients who do not get the test the the guideline is designed to avoid. (In this case of the Ottawa Knee Rule article, that was important as the patients were in the ER and did not get an x-ray. Via the information sheet, the patients were made to feel as if their care were being carefully considered.)

6. Frequent contact with those developing the guideline to give feedback about any difficulty in using the guideline.

These principles keep reappearing in many shapes and forms. If we want to successfully implement strategies to impact practice for the better, I hope we're all listening.

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ABSTRACT