Trauma Service Guidelines-Introduction
Introduction
The clinical mission of the Division of Acute Care Surgery is to provide outstanding patient-centered care.* To fulfill this mission, the Division aims to create a learning health care system, in “which science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the care process… and new knowledge captured as an integral by-product of the delivery experience.”**
Acute Care Surgery Clinical Practice Policies, Clinical Practice Guidelines, and Clinical Care Algorithms will facilitate the delivery of evidence-based medicine and optimize patient outcomes at a greater value by:
- Disseminating best practices,
- Reducing unwarranted variations in practice, and
- Identifying gaps in knowledge to target further studies.
That being said, learning health care systems consider agility is a virtue. Experimentation is required for continuous improvement. Learning health care systems value agility and experimentation as long as there is a consensus on aims and a culture free of fear.
Tools***
Clinical Practice Policies (policies) – information for physicians and ancillary staff regarding trauma center functions (e.g. triage instructions, blood procurement, operating room utilization) to minimize disruption in patient care processes
Clinical Practice Guidelines (guidelines) – a care pathway designed to guide medical decision making around a particular disorder based upon systematic review, synthesis of medical literature, and expert opinion
Clinical Practice Algorithms (algorithms) – a branching delivery of care aide comprised of multiple decision points utilizing guidelines or other best available evidence to support medical decision making at the decision points (if algorithms are the item on the menu, guidelines are the ingredients)
Clinical Practice Policies
Policies are to be drafted by consensus of the stakeholders involved in the particular clinical area. Policies will be posted on the website of the Division of Acute Care Surgery and updated continuously as needed to reflect real-time changes in clinical processes.
Clinical Practice Guidelines
Guidelines will be written utilizing an iterative process in following pattern: (1) systematic review of the literature or limited review if a recent systematic review has already been performed, (2) comprehensive evaluation of the evidence, and (3) determination of a strength of recommendation based upon expert opinion.
Systematic reviews use rigorous methodologic principles and inclusion criteria determined a priori to ensure comprehensiveness and limit bias. The systematic review is research of the medical literature and does not consider expert opinion or make recommendations. A systematic review precisely states one or more clear questions, identifies the relevant studies, critically appraises the studies, and combines studies, if appropriate, into a meta-analysis.
For the Division of Acute Care Surgery guidelines, evidence will be critically appraised using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Strength of recommendations will be based upon the United States Preventative Services Task Force method considering level of evidence and net benefit.
Guidelines are published by many organizations (e.g. the Cochrane Collaboration, the Eastern Association for the Surgery of Trauma, the Agency for Healthcare Research and Quality) and incorporation of existing guidelines can facilitate the adoption of best practices. Guidelines written by other organizations should be critically evaluated using the GRADE criteria. Any guidelines older than 3 years should be accompanied with a thorough literature search (as described above) to ensure that no new evidence has been published since guideline creation. Additionally, published guidelines adopted by the Division of Acute Care Surgery may need modification to ensure that they are congruent with the mission of the division, policies, and local culture (including stakeholder input).
Algorithms
Algorithms for common diseases and injuries will be built by combining best practices from adopted policies and guidelines and consensus among involved stakeholders. The algorithms will specify decision points along the continuum from diagnosis to ultimate treatment. Ideally, decision points will be based both upon high quality evidence and available resources.
Importantly, algorithms will be updated periodically to reflect changes in evidence and available resources at the institution. Algorithms are also published by national organizations and can be duplicated at UT Health as long as the decision points are (1) consistent with the mission of the Division of Acute Care Surgery, (2) congruent with our policies and guidelines, and (3) adapted to local culture based upon involved stakeholder input.
Conclusion
Utilizing a learning health care system to fulfill the mission of the Division of Acute Care Surgery, service line processes and the treatment of diseases and injuries will be standardized via Clinical Practice Policies, Guidelines, and Algorithms. For therapies in which high quality evidence and a substantial net benefit exists, adherence to these tools will be enforced.
For therapies in which the quality of evidence is weak or insufficient and the net benefit is small or unknown, variation and innovation will be encouraged in an environment free of fear. Ideally, this agility will then be used to further inform best practices.
All of these tools will be judged by the available evidence and recommendations determined by strength of evidence and expert opinion. Post-implementation evaluations will be triaged based upon strength of recommendation and supporting evidence to minimize
References
* https://med.uth.edu/about-us/
** Roundtable on Value & Science-Driven Health Care. The Roundtable. Washington, DC: Institute of Medicine; 2012.
*** Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons, Chapter 16, page 118.