When is a practice guideline not a guideline?

Clinicians must speak same language

Referring to clinical practice guidelines as a standard of care may seem like an insignificant matter of semantics, but confusing these and other terms serves to further muddle the practice of wound care, which often suffers from poorly defined or undefined parameters and routines.

Many clinicians routinely use terms such as "guideline," and "standard of care," interchangeably. Similar mistakes are made with the terms "algorithm" and "critical path." In reality, each has a specific meaning.

The following definitions have been provided by Maryanne McGuckin, DrSc Ed, MT, senior research investigator at the School of Medicine in the Division of Internal Medicine at the University of Pennsylvania in Philadelphia, and her colleagues:1

Consensus statement: Based on existing knowledge, such as is gathered from a search of the medical literature; can include meta-analyses that summarize the literature in a formal manner.

Guideline (or practice guideline): Often based on a consensus statement and always requires some type of peer review to be established. Guidelines are usually developed by professional societies or government agencies. Their impact on health care delivery is often limited and allows practitioners a good deal of decision-making leeway when choosing a course of care. Often, guidelines are incorrectly referred to as standards.

Standard: A guideline that is validated through a prospective, controlled clinical study in which the objective is to confirm that, by following the guideline, clinicians can provide care that is more cost-effective and of higher quality compared with usual practices or previous standards.

Algorithm: Developed from consensus statements and, like guidelines, not validated in clinical trials. Algorithms, too, allow clinicians a great deal of decision-making leeway and generally include only noncontroversial treatment approaches.

Critical pathway (or clinical pathway): Management plans that display goals for patients and provide the corresponding ideal sequence and timing of staff actions to achieve these goals. Critical pathways focus on defining how care decisions should be implemented, not on which diagnostic or treatment procedures should be conducted. As opposed to algorithms, critical pathways contain a time frame within which well-defined patient progress should be witnessed.

Protocol: A policy or guideline for care that is typically specific to an individual institution.

Reference

1. McGuckin M, Steinman M, Goin J, et al. The road to developing standards for the diagnosis and treatment of venous leg ulcers. Ostomy/Wound Management 1996; 42(Suppl):62S-66S. n