The “philosophy” of this site:- Perioperative Guidelines for St Elsewhere’s Hospital

Clinical Guidelines have become ubiquitous in medicine, but continue to be unsatisfactory for busy clinicians. Why?

Authoritative Guidelines (such as, perhaps, those from ANZCA, NICE or the ACC/AHA) must be carefully worded, evidence-based, and comprehensive. Inevitably they end up as long, highly referenced, and with detail that may get in the way for quick reference.   Further, if they aim to be universal they may not give advice for a particular be context (hospital), or specify ‘little’ things like drug dilutions, local resources, phone numbers etc.  Authoritative guidelines may ‘set the standard’ where this is possible: Frequently, however, they define what is unknown or uncertain, and then cannot give any further guidance.

Local guidelines started as an individual clinician’s preference list. Evidence-free, but intensely practical. They are akin to a Standard Operating Procedure – something that translates the detailed version for the end user into a form that is useable in the workplace.  As hospitals got bigger, they became Unit protocols; then Departmental, then Hospital, and now (in the Public sector) District, State or National, and (in private) Group or Corporate. They can be used for safety and effectiveness, as well as minimising clinical variation, or just standardisation as an end itself. (Variation erodes quality is one of the catchphrases of the ‘quality’ movement)

A major reason that guidelines become unusable is that they are written by committees that try to deal with all preferences and points of view. At times the task of formatting and finalising guidelines is delegated to non-experts who may be unable to filter the evidence,  weed out the ‘fluff’ from the science.  The final document may fail to prioritise the information in a sensible way.

But a more fundamental influence on the development of institutional guidelines is because of a transformation of purpose. Rather than aiming to assist clinical practice, Institutional guidelines become an instrument to minimise institutional or corporate risk,

All institutions are risk-averse. Whenever a Clinical Guideline has an institutional label, the institution is obliged to ensure that everything in the Guideline can be defended in court or (if a Government) on the floor of the house.  The first task of Government is to defend the legitimacy of itself. (The Minister cannot be seen to have done ‘wrong’.)  This risk aversion is reflected in clinical guidelines, which become so cluttered with precautionary statements that they become unwieldy at best and at times incomprehensible.

But being a clinician requires accepting uncertainty and risk. “If you don’t like gambling, get out of medicine.”  To a clinician, guidelines are an aid to make inevitable risk-taking more effective and efficient. To an institution, guidelines may be a means to avoid risk, ideally by defining a risk-proof system, but if this is not possible, by transferring the unavoidable risk onto a third party (in this case, the clinician who has to make a gamble).  There is an unavoidable tension between the differing goals of the clinician and an institution in the development of guidelines.

Pragmatically, clinicians need guidelines that are easy to find and use, and are uncluttered. The clinician has already accepted that they need to gamble:- they need some quick, simple assistance to help them efficiently and effectively make the gamble that they have to make.  They don’t need unnecessary detail.

Guidelines with an institutional label of any sort expose the institution to risk. Social expectations and changing technology means that even a ‘local’ policy exposes the institution to risk.

Clinicians are caught out – They are the one making the choices and gambles that are inherent part of medicine, but when they attempt to develop guidelines and protocols to assist them in this gamble, they are institutionally constrained to make guidelines that are unwieldy at best.

Thus institutional guidelines, by virtue of their purpose being at odds with the needs of clinicians, are not very useful to the clinician. This has created a void and there remains a need for simple decision support tools.

How to move forward?

Clinicians can be envisioned as independent individuals with special knowledge, skills and status, who are engaged by the institution to accept complex risk. Clinicians must (and should) agree to practice within institutional rules, but the institution is incapable of making guidelines that deal with the complex, undefined and uncertain risk that bothers clinicians on a day-to-day basis.

The risk-acceptors (clinicians) need to develop personal guidelines for their personal complex risk decisions. These should be independent of institutional/corporate labelling, if they are going to be pragmatically useful and useable.  Each clinician will have a personal set of guidelines (either cerebrally or materially).

Can these individual guidelines be shared? – they could be – as a collaborative exercise – as long as they don’t have an institutional label.  They must always belong to ‘St Elsewhere’s Hospital’.   (Although some of the resources on this site have institutional labels, indicating their origin).

This site is thus an endeavour to establish a clinician’s guideline-sharing system, which will be freely available, where any clinician can find resources and advice to develop their own guideline, or use a modification of others. The emphasis on guidelines that are uncluttered, designed to be used, and presume the user is intelligent.  BUT this site is only a storage system, as the risk remains entirely where it must stay – with the practicing clinician.