Healthcare practice guidelines are systematically developed statements based on the best available evidence designed to assist practitioners to make decisions on the most appropriate care practice to use in special circumstances. The guidelines are intended to offer concise instructions and recommendations on how to provide healthcare services. The guidelines encourage interventions of proven benefit and discourage the use of ineffective or potentially harmful interventions to lessen disparities and consequently empower patients. Production and implementation of guidelines across healthcare facilities are on the rise. The rise is informed by the fact that guidelines play a critical role in developing disease performance measures and defining high-value care. This paper seeks to provide an example of a health care practice guideline for a clinic I have worked for.
Question 1: Introduce an overview of a healthcare system practice guideline, preferably where you work or have worked.
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The healthcare practice guideline concerned "screening for diminished visual acuity." The clinical orientation for this guideline is that it is a clinical condition and aims at screening and prevention (Medicine & Committee on Clinical Practice Guidelines, 1992). The complexity of the issue can be rated as being medium. The intended users for these guidelines are the practitioners as well as the patients. The guideline is recommended to all children- to undergo vision screening once before entering school, those around the age of 3 and 4. The clinicians are supposed to be alert for signs of ocular misalignment when screening children and in elderly persons. The guideline advices that routine vision testing is not recommended. Moreover, the guideline does not recommend screening among adults and adolescents.
The clinical practice guideline outlines the clinical standard for identifying the presence of impaired visual acuity by evaluation of visual acuity by the use of a Snellen eye chart. It notes that promising techniques that can be used include grating acuity cards, preferential looking, and refractive screening. The guideline also indicates the strengths and weaknesses of these techniques. Moreover, the guidelines offer some screening questions that may be asked to elicit self-perceived problems with vision.
Question 2: Discuss how different professionals in the healthcare system (nurses, pharmacists, technicians, etc.) are held to this guideline.
Clinical practice guidelines are mainly developed for use by practitioners. The practitioners were mainly accountable to the clinical practice guideline. Moreover, they ensured that children and the elderly got priority for visual acuity screening. Their decision to use the guideline is informed by the fact that it minimizes the risk of harm. The guideline also enhanced them to enhance their knowledge base through experience by updating it to the latest evidence. Ophthalmologists are held accountable by the guideline in that they must make a decision on the best technique to use. For example, the guideline notes that refractive screening does not directly offer a diagnosis for amblyopia or strabismus. The ophthalmologist also needs to be careful to avoid a patients conduct that can mistakenly make them pass or fail a visual acuity test. The technicians are also involved in upholding the guidelines in that photo-screening devices, auto-refraction instruments, and instrument-based devices ought to meet the standards. Based on the recommendations by the guideline, it is clear that not screening for visual acuity is not for everyone. Thus, doctors must, therefore, consciously decide who outside the recommended age brackets ought to undergo the screening. Moreover, since repeated testing is not recommended, also practitioners involved must make sure they strictly follow the guideline and capitalize on the opportunity given to the patient. Pharmacists who are tasked with administering drugs are also liable to the guideline.
Question 3: Identify the research/reference used by the system to adopt the guideline.
The guideline was produced from the realization that the prevalence of visual acuity was on the rise. As of 2011, roughly 12.2 percent of Americans aged between 65 to 74 and 15.2 percent of those aged 75 years and above reported experiencing vision loss (Centers for Disease Control and Prevention (CDC) and National Center for Health Statistics (NCHS), 2011). Moreover, it is reported that 2 to 5 percent of American children suffer from amblyopia (lazy eye) and strabismus. Amblyopia mainly develops between infancy and ages 5 to 7 (CDC & NCHS, 2011). Sanke (1988), who examined the effects of amblyopia noted that since normal vision from birth was necessary for eye development, failure to treat the condition could result in irreversible visual defects. Other effects he identified included the likelihood of developing cosmetic defects, educational and occupational limitations, and permanent amblyopia, among others. Rosner and Rosner (1987) compared the visual characteristics in children with and without learning difficulties. In their study, they noted that myopia, which is a refractive error of the eye was common among school-age going children. The authors also associated the condition with diminished academic performance. Diminished visual acuity among the older population was associated with injuries from falls, both major and minor accidents, lower productivity, and loss of independence (Stults, 1984).
Enough literature suggests that early detection and treatment of vision disorders among children adults increases the chances of normal eye development and vision recovery. Feldman et al. (1980) measured the efficacy of screening among kindergarten children. Their study examined 763 screened 743 non-screened children for a period of 6 to 12 months. The study found that the group that had been tested had fewer vision problems than the non-screened group, which shows that screening improves the results. The finding by Feldman et al. (1980) is complemented by a study by Ehrlich, Reinecke, and Simons (1983) which found that early detection of myopia in children increased their chances of developing a near-normal vision and improved excellent motor skills. In adults, early detection of visual disorders play a critical role in preventing injuries and facilitates them to carry out their day to day activities.
Screening tests are recommended when diagnosing the possibility of visual disorders. Studies by Jenkins et al. (1985) identified Snellen eye chart, alternate stimulation, grating acuity cards, among other as some of the techniques that could be used for vision screening. Some of the factors that ophthalmologists can consider when choosing the type screening technique include the cost, age of the patient, and probability of detecting the visual disorder. Practitioners can also consider utilizing a combination of more than one visual test.
From the evidence provided by the research, the guideline for screening for diminishing visual acuity is informed by the increasing prevalence of ocular disorders, and the detrimental effects it has on both the children and the elderly. Moreover, early detection has been associated with positive outcomes. It thus stands out to reason that the clinical practice guideline is necessary.
Question 4: Define the evidence used to define the guideline.
This particular guideline is adopted from the US Preventive Services Task Force (USPSTF) (Medicine & Committee on Clinical Practice Guidelines, 1992). In defining the clinical practice guideline, a systematic review of the evidence is necessary. The quality of evidence is reflective of the certainty and confidence in the expected outcomes. From the evidence and references mentioned, it is clear that screening is associated with positive results and a reduction in the diminishing visual acuity. Guidelines with poor analysis of benefits and harms will likely have weak recommendations. With poor balance in the advantage and disadvantages, it is less likely that the guideline developers will offer to recommend interventions since the evidence used is also relatively weak.
In defining the evidence for this clinical practice guideline, the outcomes of the screening are measurable and achievable. Moreover, the large pool of practitioners involved is crucial at reviewing the quality performance measures associated with the guideline.
The quality of the evidence used for this particular clinical guideline can be rated as direct, consistent, and free of bias. The directness arises since the evidence informs specifically on the screening for visual acuity either on children and the elderly. The empirical evidence used to formulate this guideline also renders the guideline applicable since the outcome has a measurable positive impact. The guideline used in this particular offers a recommendation that increases the quality of life. For example, an elderly may continue living (survival) but will be highly dependent on others to move around, and unable to perform the daily task due to poor eyesight. However, this guideline recommends that they undergo screening since even though they might be seeing, the prevalence of diminishing eyesight with age is on the increase. The evidence of the guideline can, therefore, be said to be strong.
Question 5: Determine the level of evidence used in the EBP identified.
In determining the level of evidence for this guideline, different questions would have to be considered. The questions seek to address the prognostic factors with and without the treatments, the benefits, and harms of different treatments options, and identification of risk factors for the conditions, among other factors. Different study designs provide the most reliable type of evidence for answering these different questions. In reviewing guidelines, these questions ought to be raised and answered, and the outcomes assessed to have a clear understanding of the analytic logic. By developing and analytic logic of the guideline, the evidence is defined.
Some of the questions that are raised in a bid to define this guideline are:
1. What are the benefits and harms of screening compared with no screening for unidentified diminishing visual acuity in children and the elderly?
2. How does those evidence provided, weigh the benefits and harms of screening for diminishing visual acuity?
3. What is the cost-effectiveness of screening for unrecognized visual disorders related to functional limitation in the target groups?
4. What is the accuracy of the screening tests that are recommended by the evidence?
What are some of the benefits and limitations of the screening tests mentioned in the evidence?
Conducting a systematic review of the guidelines seeks to examine whether it meets the criteria set by the questions. The outcome from the evidence could be considered patient-important, thus critical for making a recommendation on screening for diminishing visual acuity.
The level of evidence of the healthcare practice guideline is assessed based on the methods used in developing it, for example, by grading the recommendations. In determining the quality of evidence, one can look at the outcome. High-level ratings are dependent on precise and consistent effect estimate from studies having few limitations in internal validity as well as examining the relevance of factors such as populations, outcomes, interventions, and comparators.
For this guideline, the review may examine the trials from screening programs and their clinical outcomes. Limitations from the scarcity of data can be overcome by focusing on data from non-randomized trials. Moreover, the determination of the level of evidence also faces the limitation of the existence of differences in the studies screening the general population and those focused on specific groups. Moreover, the variation may arise in the adherence to screening, type of testing as well as diagnosis and treatment of the visual disorders identified in the screening studies. From the clinical practice guideline on screening for visual diminishing visual acuity, the evidence would have to adhere to the criteria laid out by the USPSTF and be able to answer the questions asked. From the assessment and adherence to the USPSTF rules, this clinical practice guideline can be termed as being in the medium level.
Question 6: Provide an opinion on how well this guideline is followed by professionals in the system.
Though visual screening is recommended in most studies, many people bypass the screening and are referred directly to an eye care professional. The decision to bypass the screening process is informed by several factors with professional adherence being a critical factor. Many practitioners consider themselves "light users" of the guideline. This assertion is supported in by a study by Wall et al., (2002) who examined the level of compliance to vision-screening guidelines among pediatricians in the US. Of the 1491 pediatricians mailed in their study, 888 of them responded. The analysis of the replies from the pediatricians found that many of them did not follow the visual-screening guidelines, especially in younger children. The research also found that two-thirds did not begin with visual acuity testing at the age of 3, as recommended by the screening.
The vision screening programs are faced with several limitations, which also affect compliance with the guidelines. Though several vision screening tests are recommended, most have stuck y testing for distance visual acuity. This method, as noted in the evidence, does not indicate how well the eyes focus up close or work together. Involving other methods of screening, such as tests for eye coordination, will ensure that there is information on the health of the eyes. The guideline implementation is also faced with inadequately trained personnel, and other practitioners may opt to bypass it. Other challenges revolve the inadequacy of testing equipment. Moreover, a combination of other factors such as room lighting, testing distance, and condition of the testing equipment can also affect the results. This combination led to unwarranted test passes and, which may be discouraging to the professionals.
Question 7: Conclude with a concise overview of the guideline and the discussion in the paper.
Healthcare facilities are increasing adopting clinical practice guidelines aimed at informing how decision concerning the handling of medical cases will proceed. Healthcare practice guidelines are also increasingly becoming evidence-based in a bid to offer well-informed choices rather than dictating decision-based on certain biases. Evidence-based guideline ensures that information concerning certain healthcare practices is up to date. The paper has examined the guideline adopted by the healthcare department I worked for, namely. The instructions for "Screening for Diminishing Visual Acuity" was taken from the USPSTF (2009) and recommends vision disorders. The paper has given an overview of the guideline and examined the level of evidence of the guideline. The paper finds the evidence to be medium as there still exist minor gaps that hinder its adoption and compliance among most practitioners.
References
Centers for Disease Control and Prevention (CDC) and the National Center for Health Statistics (NCHS). (2011). Summary Health Statistics for U.S. Adults: National Health Interview Survey. Retrieved from http://www.cdc.gov/nchs/data/series/sr_10/sr10_256.pdf
Ehrlich, M. I., Reinecke, R. D., & Simons, K. (1983). Preschool vision screening for amblyopia and strabismus. Programs, methods, guidelines, 1983. Survey of Ophthalmology , 28 (3), 145-163. doi:10.1016/0039-6257(83)90092-9
Feldman, W., Sackett, B., Milner, R., & Gilbert, S. (1980). EFFECTS OF PRESCHOOL SCREENING FOR VISION AND HEARING ON PREVALENCE OF VISION AND HEARING PROBLEMS 6-12 MONTHS LATER. The Lancet , 316 (8202), 1014-1016. doi:10.1016/s0140-6736(80)92167-4
Jenkins, P. L., Simon, J. W., Kandel, G. L., & Forster, T. (1985). A Simple Grating Visual Acuity Test for Impaired Children. American Journal of Ophthalmology , 99 (6), 652-658. doi:10.1016/s0002-9394(14)76030-1
Medicine, I. O., & Committee on Clinical Practice Guidelines. (1992). Guidelines for Clinical Practice: From Development to Use . Washington, DC: National Academies Press.
ROSNER, J., & ROSNER, J. (1987). Comparison of Visual Characteristics in Children With and Without Learning Difficulties. Optometry and Vision Science , 64 (7), 531-533. doi:10.1097/00006324-198707000-00008
Sanke, R. F. (1988). Amblyopia. Am Fam Physician , 37 (2), 275-278.
Stults. (1984). Preventive health care for the elderly. Western Journal of Medicine , 141 , 832-45.
Wall, T. C., Marsh-Tootle, W., Evans, H. H., Fargason, C. A., Ashworth, C. S., & Hardin, J. M. (2002). Compliance With Vision-Screening Guidelines Among a National Sample of Pediatricians. Ambulatory Pediatrics , 2 (6), 449-455. doi:10.1367/1539-4409(2002)002<0449:cwvsga>2.0.co;2
