Guidelines in professions allied to medicine

 

Abstract

Background

Clinical practice guidelines aim to reduce inappropriate variations in practice and to promote the delivery of evidence-based health care.

Objectives

To identify and assess the effects of studies of the introduction of clinical practice guidelines in nursing (including health visiting), midwifery and other professions allied to medicine.

Search methods

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE (1975 to 1996), EMBASE, Cinahl and Sigle to 1996, the NHS Economic Evaluations Database (1994 to 1996), DHSS-Data (1983 to 1996), the Database of Abstracts of Reviews of Effectiveness (1994 to 1996) and reference lists of articles. We also hand searched the journal Quality in Health Care, made personal contact with content experts and contacted libraries identified by an expert panel.

Selection criteria

Randomised trials, controlled before-and-after studies and interrupted time series analyses of the introduction of interventions comparing 1. Clinical guidelines plus dissemination and/or implementation strategies versus no guidelines; 2. Guidelines plus dissemination and/or implementation strategies versus guidelines plus alternative dissemination and/or implementation strategies; and 3. (post hoc) Guidelines used by professions allied to medicine versus standard physician care. The participants were nurses, midwives and other professions allied to medicine.

Data collection and analysis

Two reviewers independently extracted data and assessed study quality.

Main results

Eighteen studies were included involving more than 467 health care professionals. The reporting of study methods was inadequate for all studies. In all but one study, nurses were the targeted professional group; one study was aimed solely at dieticians. The various behaviours targeted included the management of hypertension, low back pain and hyperlipidaemia. Nine studies were identified for comparison 1. Three out of five studies observed improvements in at least some processes of care and six out of eight studies observed improvements in outcomes of care. Only one study included a formal economic evaluation, with equivocal findings. Three studies were identified for comparison 2 but it was difficult to draw firm conclusions because of poor methods. Six studies were identified for comparison 3 (post hoc). These studies generally supported the hypothesis that there was no difference between care given by nurses using clinical guidelines and standard physician care.

Authors' conclusions

There is some evidence that guideline-driven care is effective in changing the process and outcome of care provided by professions allied to medicine. However, caution is needed in generalising findings to other professions and settings.

 

Plain language summary

Professions allied to medicine, such as nurses, midwives and dietiticians, can effectively incorporate clinical guidelines to improve patient care

The issuing of clinical guidelines to nurses, midwives, dieticians and other health-care professionals allied to medicine may reduce variations in practice and improve patient care. This review found that, despite limited research, there is some evidence that guidelines can improve care and that professional roles can be substituted effectively, for instance a nurse can perform the function of a physician in certain circumstances. Such interventions offer the possibility of reduced costs but further research is needed in all areas of this topic.

 

摘要

背景

醫學相關的專業指引

臨床工作指引的主要目的是減少臨床處置中不當的變化，並增進提供以實證為基礎的健康照護。

目標

確定並評估將臨床指引引進護理(包含健康訪視)、助產術及其他醫學相關專業領域研究的效果。

搜尋策略

我們檢索Cochrane Effective Practice and Organisation of Care Group專業的登記資料庫，MEDLINE (1975至1996年)，EMBASE， Cinahl and Sigle至1996年，the NHS Economic Evaluations Database (1994至1996年)，DHSSData (1983至1996年)，the Database of Abstracts of Reviews of Effectiveness (1994至1996年)及文章的參考文獻。我們也人工檢索the journal Quality in Health Care，個人聯繫原文的專家並聯繫專家小組確定的圖書館。

選擇標準

採用介入措施的隨機試驗，前後對照試驗及間斷時間序列分析。比較1.臨床指引加上傳播及/或執行策略對照於無指引；2.指引加上傳播及/或執行策略對照於指引加上其他的傳播且/或執行策略；及3.(事後)醫學相關專業指引對照標準的醫師照護。研究對象為護士，助產士及醫學相關的其他專家。

資料收集與分析

兩名回顧作者分別摘錄資料並評估研究品質。

主要結論

納入18篇研究共包含超過467名健康照護專家。所有研究的研究方法皆不適當。除了一篇研究，所有研究的目標專業群體皆為護士；一篇研究僅針對營養師。各種行為包括高血壓，下背痛及高血脂的管理。確認有9篇研究進行比較1。五分之三的研究觀察到至少有些照護過程有改善，且八分之六的研究觀察到照護結果有改善。只有一篇研究包括經濟學的評估，但結果模稜兩可。確認有三篇研究進行比較2，但由於研究方法品質不佳，因此難以呈現確切的結論。確認有六篇研究進行比較3(事後)。這些研究通常支持護士採用臨床指引與標準醫師照護兩者間沒有差異的假設。

作者結論

有一些證據指出，以指引為導向的照護可以有效改變醫學相關專家提供的照護過程與結果。然而，需要謹慎推論結果到其他的專家及機構。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

醫學相關的專家，如護士，助產士及營養師，可以有效整合臨床指引以改善病患照護。發行臨床指引給護士，助產士，營養師及其他健康照護的醫學相關的專家，也許可以減少做法的不同並改善病患照護。儘管這篇回顧發現數量有限的研究，但有些證據顯示指引可以改善照護，且專家的角色可以被有效地替換，如在特定的情況下護士可以執行醫師的功能。這種介入措施提供了減少成本的可能性，但需要在所有的領域進一步研究這個問題。