A. Introduction

Defined by the Institute of Medicine (1992) as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances," clinical guidelines are important components in the delivery of evidence based health care practice. By incorporating guidelines into their practice, nurses anticipate minimizing risks to their patients, improving the quality of their care, and increasing cost effectiveness. Although clinical guidelines have been shown to benefit patient care, they remain a challenge to locate.

The effectiveness of clinical guidelines depends on the methodology used in their development as well as the composition of the group involved. The group members should be from multiple disciplines and represent patients as well as health care professionals. By providing such a broad base of expertise and views, the authoring agency adds to the validity and acceptability of the guidelines. All group participants have a chance to discuss and resolve differences in their values and clarify their roles in guideline implementation.

The development is rigorous and carefully controlled. It usually begins with the consideration of whether a problem is an appropriate subject for a guideline. Successful guidelines usually focus on a problem that occurs frequently, receives differing treatments, has a high cost, involves a societal issue or has been a vocalized concern of the patient population. Then the group engages in a thorough and systematic literature review to uncover relevant published and unpublished studies. From the evidence in the research studies, the group drafts a series of recommendations which are submitted to other patient and professional groups for review. After the comments of these groups are incorporated into the recommendations, the guideline development group works on reaching a consensus. Guideline development proceeds from the revised recommendations. The Institute of Medicine state in 1992 that guidelines should be valid, reproducible, reliable, representative, applicable to the patient population, flexible, clear, meticulous, reviewed regularly, and be amenable to clinical audit. In view of the extensive effort involved in guideline development, it is not surprising to find that the primary sources are government agencies and professional medical and nursing associations.

B. Web Sources

Government agencies and professional associations that have developed clinical guidelines may include them on their Web sites. The New York Academy of Medicine maintains a list of agencies and organizations as a part of their Evidence-based Medicine Resource Center. The list also has guidelines categorized by subject.

1. Professional Associations

A selective list of nursing and medical associations' Web pages that include guidelines follows:

American Society of PeriAnesthesia Nurses

Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN)

National Kidney Foundation

Registered Nurses Association of Ontario

2. Government Agencies

Examples of government agency pages with guidelines include the following:

Centers for Disease Control and Prevention (CDC)

National Institute of Health and Clinical Excellence (UK National Health Service)

3. National Guideline Clearinghouse

To support the implementation of guidelines, the American Medical Association, the American Association of Health Plans, and the U.S. Agency for Healthcare Research and Quality collaborated on the development of the National Guideline Clearinghouse. The Clearinghouse is now under the sole auspices of the Agency for Healthcare Research and Quality. The collection of guidelines is comprehensive and international in scope. Submission guidelines stipulate that the authoring groups belong to a medical specialty association or professional society, government agency at the federal, state, or local level, a public or private organization, or a health care organization or plan. In effect, the Clearinghouse is a "one stop shopping" clinical guideline site.

To locate guidelines, you may choose Basic or Detailed Search screens. Basic Search is ready to use in the Search box in the upper left. The Detailed Search screen displays when you click on Search at the top of the sidebar. Both search options allow you to use the Boolean operators, "and" and "or." Search terms may be truncated using an asterisk (*) so you can include variant endings without entering all the terms in the search box. For example,

neuro* = neurologic OR neurological OR neuroendocrine

With more complex searches, you may indicate which part of the search you want to be performed first by surrounding the terms in parentheses. Phrases in your search should be enclosed in double quotation marks. For example, "cerebral vascular accident" When you use Basic Search, the search engine looks for the terms anywhere in the descriptive record for the guideline. When you use Detailed Search, you are asked to enter the search terms in a particular field of the record. The search engine retrieves only those guidelines that have your search terms in that field. To review a list of the fields in the guideline record, go to Detail Search help.

In addition to searching, the NGC search engine allows you to collect appropriate guidelines and then compare them. As you find guidelines, add them to "My Collection." When you are finished reviewing search results, click on "Compare Selected Guidelines." The next screen will display a table with the guidelines fields running down the page and the relevant sections from the guideline record running across.

C. Journal Articles

Guidelines may also be disseminated through publication in a scholarly journal. The journal indexes CINAHL and Medline (Rutgers-restricted Access) as well as PubMed include practice guidelines as a publication type which will make your search highly accurate. "Publication Type" is an option in the Limit function.

1. CINAHL and Medline

When you use CINAHL or Medline, enter your search terms for the problem, diagnosis or test, and scroll down to the Limit section of the search screen. At Publication Type, select "practice guidelines" from the pull-down menu. Although the indexes also include "practice guidelines" as a subject heading, the heading is used for articles discussing the guideline as a format, i.e., its value, use, form and creation. Using the phrase as a subject heading will NOT help you identify appropriate articles containing guidelines.

2. PubMed

PubMed allows you to set limits before you enter your search. Click on Limits and then select "Practive Guidelines" from the Publication Type pull down menu. Any limits you set will apply to all subsequent searches in the session until you go to Limits and make some changes.

PubMed includes an additional feature to aid in locating guidelines. When you open the database, look at the sidebar and select Clinical Queries under PubMed Services. When you scroll down the page, you will see a search box under the heading, Find Systematic Review. PubMed considers guidelines to be a type of systematic review. Enter the disease or problem as well as

AND systematic[sb] AND "practice guideline"[pt].

Results will be limited to practice guidelines only

D. Evaluating Guidelines

Your critical stance in reviewing guidelines should include their level of quality as well as their appropriateness to your patient and the problem. The rigor and strength of the research evidence and the guideline development process may vary. The following sources offer question lists for you to use in your assessment.

AGREE is an "international collaboration of researchers and policy makers who work together to improve the quality and effectiveness of clinical practice guidelines by establishing a shared framework for their development, reporting and assessment." With funding from the European Union and coordination by St. George's Hospital Medical School, the group developed an appraisal instrument to assess existing guidelines and add uniformity to guideline development. Instructions for instrument use are included.

Evidence-based Medicine Working Group. "Users' guides to the medical literature. VIII. How to use clinical practice guidelines. A. Are the recommendations valid?" JAMA 274, 7 (August 16, 1995): 570-4.

Evidence-based Medicine Working Group. "Users' guides to the medical literature. VIII. How to use clinical practice guidelines. B. What are the recommendations and will they help you in caring for your patients?" JAMA 274, 20 (November 22/29, 1995): 1630-2.

How to Use a Clinical Practice Guideline (Evidence-based Medicine Working Group)
A web based synthesis of the above two articles.

What Makes a Good Clinical Guideline? (PDF file)
Includes evaluation checklist with questions arranged in 15 categories. Adapted from St. George's Health Care Evaluation Unit's Appraisal Instrument for Clinical Guidelines, the Leicestershire Evidence Based Guidelines Checklist and the U. S. Agency for Health Care Research and Quality Guidelines.

E. For more information...

Duff, L. A., et al. "Clinical guidelines: an introduction to their development and implementation." Journal of Advanced Nursing 23, 5 (May 1996): 887-895.

How to read a paper.
A series of articles written by Trisha Greenhalgh and published in BMJ: British Medical Journal in 1997. Dr. Greenhalgh discusses qualitative research, statistics, systematic reviews, meta-analyses, and methodological quality.

McSweeney, Maryellen, Spies, Martha, and Cann, Cheryle J. "Finding and evaluating clinical practice guidelines." Nurse Practitioner 26, 9 (September 2001):30-34, 39, 43-44, 46-47.
Includes list of archives with guidelines. Also guideline related content of search engines, citation databases and other web resources. Authors have also included a flowchart to guide decision making during the guideline search process.

Mead, Paula. "Clinical guidelines: promoting clinical effectiveness or a professional minefield?" Journal of Advanced Nursing 31, 1 (January 2000): 110-16.
Concise list of evaluation points with health related examples.

In 2001, the Journal of the American Academy of Nurse Practitioners began a column, "Clinical practice guidelines," edited and often written by Mary Jo Goolsby. The columns review published guidelines for problems commonly seen by advanced practice nurses in a variety of settings. To locate the other columns, go to CINAHL and enter the search statement:

TI "clinical practice guidelines" and SO "journal of the american academy of nurse practitioners"

in Basic Search. The first column introduced clinical practice guidelines and described their use in daily practice. The articles published in 2004 use a case study approach with the same hypothetical patient which provides a very specific view of guideline application.

Goolsby, Mary Jo. "Evaluating and applying clinical practice guidelines." Journal of the American Academy of Nurse Practitioners 13, 1 (January 2001): 3-6.

Goolsby, Mary Jo. "Clinical practice guidelines. Integrating the principles of evidence-based practice: prognosis and the metabolic syndrome." Journal of the American Academy of Nurse Practitioners 16, 5 (May 2004): 178, 180, 182, 184.

Klardie, Kathleen A., Johnson, Judith, McNaughton, Molly Ann, and Meyers, Wendy. "Clinical practice guidelines. Integrating the principles of evidence-based practice into clinical practice." Journal of the American Academy of Nurse Practitioners 16, 3 (March 2004): 98-105.

McNaughton, Molly Ann, Klardie, Kathleen, and Meyers, Wendy. "Clinical practice guidelines. Integrating the principles of evidence-based practice: testing and diagnosis." Journal of the American Academy of Nurse Practitioners 16, 1 (January 2004): 2-7.