PAEDIATRIC EMERGENCY MEDICINE

Paediatric emergency guidelines: Could onesize fit all?Sarah Dalton1 and Franz E Babl2–4

1Emergency Departments, Sydney Children’s Hospital, Sydney, New South Wales, and 2MurdochChildren’s Research Institute, 3Royal Children’s Hospital, Parkville, and 4University of Melbourne,Melbourne, Victoria, Australia For the Paediatric Research in Emergency Departments InternationalCollaborative (PREDICT)

Abstract

Objectives: The development of clinical practice guidelines (CPG) is a core task in EDs and CPGs arewidely used. The process of CPGs development in Australian and New Zealand ED isunknown. We aim to describe this process in paediatric EDs and examine the feasibility ofdeveloping collaborative guidelines.

Methods: A piloted questionnaire regarding CPG development, dissemination, implementation andevaluation was circulated to all 13 Paediatric Research in Emergency Departments Inter-national Collaborative (PREDICT) sites. Specific questions regarding feasibility of com-bined guidelines were included.

Results: All PREDICT EDs participated in the survey. All used CPGs in EDs and 12/13 hadED-specific guidelines. EDs had an average of 77 guidelines with approximately 5 newguidelines generated annually. Staff at most sites (10/13) also accessed guidelines fromexternal sources. Most hospitals (10/13) had a guideline committee, generally comprising ofsenior ED and general paediatric staff. Guidelines were usually written by committeemembers and 10/13 hospitals adopted modified external guidelines. An average committeemet six times a year for 90 min and involved seven clinicians. Most sites did not have aproject manager or dedicated secretarial support. Few hospitals included literature refer-ences (3/13) or levels of evidence (1/13) in their guidelines. Most did not consider imple-mentation, evaluation or teaching packages. Most sites (10/13) supported the developmentof collaborative guidelines.

Conclusions: Paediatric EDs expend significant resources to develop CPGs. Collaborative guidelineswould likely decrease duplication of effort and increase the number of available, currentand evidence-based CPGs.

Key words: clinical practice guideline, child, Paediatric Research in Emergency Departments InternationalCollaborative, PREDICT.

Correspondence: Dr Sarah Dalton, Paediatric Emergency Physician, Emergency Department, Sydney Children’s Hospital, High StRandwick, NSW 2031, Australia. Email: sarah.dalton@sesiahs.health.nsw.gov.au

Sarah Dalton, BMed and MApp Mgt(Hlth), Paediatric Emergency Physician; Franz E Babl, MD, MPH, FRACP, FAAP, Paediatric EmergencyPhysician, Clinical Associate Professor.

doi: 10.1111/j.1742-6723.2008.01148.x Emergency Medicine Australasia (2009) 21, 67–70

© 2009 The AuthorsJournal compilation © 2009 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Introduction

Clinical practice guidelines (CPGs) are produced bymany institutions, including national and internationalbodies, and are variable in terms of accessibility, qualityand evidence base.1 Guideline development and imple-mentation have become a core component of the workof ED staff throughout Australasia and CPGs arewidely used.

Disease-specific CPGs were investigated within thePaediatric Research in Emergency Departments Inter-national Collaborative (PREDICT).2 PREDICT includesall tertiary children’s hospitals in Australia and NewZealand as well as large combined adult and paediatricdepartments. Although all EDs within this networkproduce individual CPGs, their content is largelyduplicative.3–5 At the severe end of the spectrum ofillness, however, there can be high variability in CPGcontent. An example of this is the management of severeasthma, where a recent study demonstrated highlyvariable CPG recommendations and practice patternsfor i.v. bronchodilator use across Australasia.3

The central role CPGs play in providing ED care andthe resources needed to produce high-quality guidelinesprompt the consideration of a collaborative, evidence-based approach to paediatric emergency care inAustralasia.

The process of ED development and implementationof CPGs has not been previously studied. We set out todescribe this process in 13 Australian and New Zealandpaediatric EDs and examine the feasibility of develop-ing collaborative guidelines.

Methods

A survey of the CPG development process was under-taken at all PREDICT sites in 2007. PREDICT is anewly formed research network of 13 paediatric EDs inAustralia and New Zealand with a combined annualcensus of 360 000 patients.2 A questionnaire was devel-oped based on National Health and Medical ResearchCouncil (NHMRC) recommendations,6 regarding guide-line development, dissemination, implementation andevaluation. The NHMRC is Australia’s peak govern-ment body for supporting health and medical research.The questionnaire was piloted at two sites and reviewedby site representatives from all PREDICT sites. It wasthen emailed to the clinician in each ED most involvedwith the guideline creation process. Unclear responses

were followed up by direct email contact. Surveyquestions related to guidelines concerning the clinicalmanagement of patients during the acute phase in theED. Specific questions regarding feasibility of combinedguidelines were included. Completed surveys wereassigned a study number, and results were entered asde-identified data into an Excel spreadsheet. Data wereanalysed descriptively.

Results

Representatives at all 13 PREDICT sites completed andreturned the questionnaire (response rate 13/13). Allhospitals surveyed used CPGs in EDs and 12/13 hadguidelines specifically designed for use in ED. Eachdepartment had an average of 77 current guidelines(range 5 to 220, median 70) with approximately 5 newguidelines generated annually.

Who develops guidelines?

Of the 13 departments surveyed, 10 had a guidelinecommittee that comprised primarily of ED consultants(13/13), paediatricians (9/13) and nurses (9/13). Guide-lines were written by ED consultants in most cases(12/13) with subspecialist review (8/13). Three of thir-teen sites had a CPG project manager and there were noinstances of dedicated secretarial support.

What guidelines are developed?

Most departments developed CPG for frequent present-ing conditions (13/13) or infrequent serious conditions(10/13). In many cases, the generation of a guideline wasin response to identified problems or incidents (10/13).

How are guidelines developed?

The average department held guideline committeemeetings six times a year for 60 min with approxi-mately seven clinicians in attendance. Guidelines werefrequently accessed from external sources before localadaptation (10/13). Literature references were not oftenincluded (3/13) and only one site included levels ofevidence in CPGs.

What is the target audience?

Most EDs produce guidelines that are designed for usein their own hospitals only (9/13). In some cases, CPGs

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68 © 2009 The AuthorsJournal compilation © 2009 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

are disseminated to other hospitals within the AreaHealth Service (4/13) or statewide (5/13). All guidelinesare written for use by medical staff, with a lessernumber targeting nurse practitioners (8/13) and nurses(10/13). Guidelines are disseminated via the intranet(12/13) and Internet (4/13), and are externally availablein many cases (10/13). Most sites indicated that theyalso access external guidelines for use in their ED (10/13), with 9/13 indicating regular use of guidelines fromthe Royal Children’s Hospital in Melbourne, Victoria,Australia.

Implementation and evaluation

Following the development of CPGs, only 6/13 of hos-pitals surveyed had formal teaching packages associ-ated with CPGs. Less than one-third of sites consideredimplementation (4/13), evaluation (4/13) or eliciting andincorporating user feedback (3/13) as part of the CPGdevelopment process.

Overall, 10 of 13 respondents supported the proposalof collaborative PREDICT guidelines, 2 were undecidedand 1 was not in favour. Collaborative guidelines wereseen as improving efficiency, accuracy and consistencyof CPGs, but potential problems, such as difficultyachieving consensus and maintaining local relevance,were identified.

Discussion

This is the first study to investigate the ED guidelinedevelopment process in Australasia. The EDs sur-veyed are committed to the use of CPGs and investconsiderable time and effort in their development.Most departments have multidisciplinary guidelinecommittees who meet regularly, in most cases involv-ing a large number of senior staff. Overall, PREDICTgroup hospitals represent a relatively homogenoushospital type. It likely does not reflect the process ofguideline development for the majority of Australasianhospitals.

A minority of guidelines were accompanied byformal evidence review, and few included planning fordissemination, implementation, teaching packages,feedback or evaluation. Although it is noted that thisis a common scenario, the NHMRC strongly empha-sizes the importance of these elements in guidelinesuccess.6 Guidelines require regular review and modi-fication, with short-term and long-term frameworks forevaluation. Without these crucial elements in place,

CPGs might not actually be used in clinical decision-making and ultimately fail to translate into improvedpatient outcomes.6 An essential component of improv-ing guideline uptake and ensuring better outcomes iseffective education, feedback and evaluation. A col-laborative approach towards guideline developmentmight facilitate this process by sharing the load ofdeveloping the necessary teaching packages and feed-back and evaluation tools, and by individual sitesfocusing on specific CPGs.

The present study demonstrates that most hospitalswould support the introduction of collaborative guide-lines. Although currently most EDs focus on writingguidelines for their own hospitals alone, they regularlyaccess existing guidelines from other sources. Thebasic epidemiology of presentations to the EDs withinthe PREDICT network is also very similar and col-laborative guidelines could be written for a predictablerange of topics. Most hospitals have guidelinesthat are Web-based and staff are familiar with access-ing documents in this way. The development ofWeb-based PREDICT guidelines is a potential solutionto the problem of limited resources. Our study didnot address the feasibility or effectiveness of a collabo-rative approach. As EDs currently have limitedexperience with developing and implementingmulticentre CPG, this process should be studiedwith evaluation of changes in clinical practiceand health outcomes in both tertiary and non-tertiaryfacilities.

The development of collaborative guidelines hassupport from most respondents, but would need toovercome several potential barriers. The most frequentconcern voiced in the study was maintaining local rel-evance. CPGs will require local adaptation to ensureintegration with local clinical organizations and inpa-tient teams. New South Wales Health has addressed thisissue by creating statewide guidelines for 10 frequentpaediatric presentations that are designed to be locallyadapted.7 There is potential for PREDICT to devisesimilar ‘template guidelines’ that are then modified tosuit individual environments.

There are strong advantages to a collaborativeapproach, such as the ability to attract additionalresources, including project managers and researchassistants, to appraise evidence and perform adminis-trative tasks. Even without additional resources, simplyreducing duplication of effort likely improves efficiency.Although it might not be possible to achieve consensusin all aspects of management, a considered, evidence-based review still provides the opportunity for more

Paediatric emergency guidelines

69© 2009 The AuthorsJournal compilation © 2009 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

concordance in management than currently existsthroughout PREDICT sites.3–5

Conclusions

The development of ED clinical guidelines requires sig-nificant resources. Paediatric EDs are producing smallnumbers of duplicative CPGs with variable evidencebase. Many departments already access and modifyguidelines from external sources, a process that could beformalized through the development of evidence-basedand updated collaborative guidelines.

Acknowledgements

We acknowledge the contributions of the site repre-sentatives of all PREDICT sites. Gold Coast Hospital,QL, Royal Children’s Hospital, Brisbane QL, MaterChildren’s Hospital, Brisbane, QL, John Hunter Hospital,Newcastle, NSW, Children’s Hospital Westmead,Sydney, NSW, Monash Medical Centre, Clayton, Vic.,Sunshine Hospital, Vic., Princess Margaret Hospital,Perth, WA, Women’s and Children’s Hospital, Adelaide,SA, Starship Children’s Hospital, Auckland, NZ, Kidz-first at Middlemore, Auckland, NZ.

Competing interests

None declared.

Accepted 23 October 2008

References

1. Grol R, Buchan H. Clinical guidelines: what can we do to increasetheir use? Med. J. Aust. 2006; 185: 301–203.

2. Babl FE, Borland M, Ngo P et al. The Paediatric Research inEmergency Departments International Collaborative (PREDICT):first steps towards the development of an Australian and NewZealand research network. Emerg. Med. 2006; 18: 143–7.

3. Babl FE, Sherrif N, Borland M et al. Paediatric acute asthmamanagement in Australia and New Zealand: practice patterns inthe context of clinical practice guidelines. Arch. Dis. Child. 2008;93: 307–12.

4. Borland ML, Babl FE, Sheriff N, Esson AD. Croup managementin Australia and New Zealand: a PREDICT study of physicianpractice and clinical practice guidelines. Pediatr. Emerg. Care2008; 24: 452–6.

5. Schutz J, Babl FE, Sheriff N, Borland M; the Paediatric Researchin Emergency Departments International Collaborative(PREDICT). Emergency department management of gastro-enteritis in Australia and New Zealand. J. Paediatr. Child Health2008. DOI 10.1111/j.1440-1754.2008.01335.x (Early onlinepublication).

6. National Health and Medical Research Council. A Guide to theDevelopment, Implementation and Evaluation of Clinical PracticeGuidelines. Canberra: National Health and Medical ResearchCouncil, 1999. [Cited 24 Jul 2008.] Available from URL: http://www.nhmrc.gov.au/publications/synopses/_files/cp30.pdf

7. New South Wales Health. Clinical Practice Guideline for Paediat-ric Care. [Cited 24 Jul 2008.] Available from URL: http://www.health.nsw.gov.au/public-health/clinical_policy/guidelines/index.html

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70 © 2009 The AuthorsJournal compilation © 2009 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine