Development of practice guidelines relevant to patient characteristics and local imperatives

Systematic reviews are essential to summarize research evidence about decision options for diagnosis and patient management [1]. Clinical practice guidelines recommendations are based on systematic reviews [2]. However, individual patients differ because of their unique biological characteristics, comorbidities, cultures and preferences [3]. In addition, local health care resources, facilities, and personnel experiences vary in different geographical settings. Therefore, to facilitate a more cost effective care, clinical practice guidelines must be modified and updated to accommodate individual and local imperatives [4].

Panjasawadwong et al. [5] mounted a prospective multicenter observational study to update guidelines to improve perioperative anesthetic safety in Thailand (PAAd Thai study as reported in this volume). Anonymous incident reporting using a standardized incident report form and the main anesthetic techniques used were documented and analyzed [5]. This will lead to more refined guidelines that are developed, modified, and updated. Charuluxananan et al. [6] showed that the group was able to ascertain a dramatic reduction of perioperative cardiac arrests and difficult intubations. The most common contributing factors for critical incidents were inexperience, emergency conditions, inadequate preanesthetic evaluation and preparation, inappropriate decision making, inadequate vigilance, and inappropriately skilled assistants [6].

The development of updated guidelines has been conducted by a process that involved representatives with a full range of expertise; an unbiased review of local imperatives (feasibility, harms, costs, and patient preferences) combined with the ongoing use of systematic reviews. This is to ensure transparency, avoid conflicts of interest, and with due concerns for local imperatives. Guidelines also lead to systems enhancements, other quality improvement, decision support tools, and outcomes of measurement and feedback relevant to local institutions. Once updated guidelines are available, health providers should be encouraged to use them. Strategies to enhance the use of clinical guidelines by physicians are available [7].

Because of variable clinical settings in different countries, local providers and their institutions are encouraged to organize groups to develop guidelines that respond better to their unique patient characteristics and health care imperatives. Standards for developing trustworthy clinical practice guidelines have been suggested by the Institute of Medicine [8]. These standards can be adapted for local use.