Internet guidelines can be the key to improved care

Federal site offers free access to hundreds

As home health care becomes more complex, with nurses caring for more difficult cases, the Internet can be a handy source of clinical information — if, of course, you know where to look.

The federal government, in cooperation with health care organizations, has created an Web site that it hopes will provide health professionals with a trusted source of clinical practice guidelines.

The National Guideline Clearinghouse has been up and running for a year. David Paulus, MD, medical director of Shands HomeCare in Gainesville, FL, says the clearinghouse can be a useful resource for home health agencies.

"One of the difficulties we have in home care is we take care of patients with a broad variety of diseases, with a broad variety of drugs and other therapies, making it difficult for our clinicians to keep up," Paulus says. "I think the guidelines can be helpful, because it does represent the best thinking of the time, which you can use when you do your care plan."

Shands HomeCare, which is affiliated with the University of Florida, is now in the process of equipping its nurses with laptop computers that will be used in the field. While the technology will assist in documentation and collection of OASIS data, it should also provide nurses with a link to the Internet, says Shirley Sleeker, CCRN, CNAA, senior associate with Curran Care and executive director of Shands HomeCare.

"There’s a lot that nurses deal with on a day-to-day basis that they don’t have ready access to from their own knowledge — a pathway or a certain protocol," Sleeker says. "This provides them with information that could be more current, as well as more accessible to them."

Guidelines fill important role

The Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research) of the Department of Health and Human Services developed the clearinghouse in partnership with the American Association of Health Plans and the American Medical Association.

In its first year of operation, it amassed and reviewed more than 650 guidelines in areas ranging from acute care to home care.

Jean Slutsky, MSPH, project officer for the clearinghouse, says her agency’s goal was to fill a void in the area of up-to-date, accessible, peer-reviewed guidelines.

"It’s really hard to capture clinical practice guidelines because they’re not cataloged," she says. "Often, you don’t know who developed them or how old they are. Many are of good quality, but some aren’t. There was no one central repository with exclusion criteria that would set the floor for what would be in it. There was a need that the agency found was important to fill."

While most of the guidelines are available free of charge, there are some developed as proprietary documents for which the agency offers summaries and ordering information.

To date, the site,, has re-ceived more than 800,000 hits. While it’s impossible to know how many home health agencies have used it, Slutsky says there are a number of guidelines in it that would be useful in home health.

"There are guidelines covering chronic illness, as well as geriatric complications," she says. (See related story, below.)

The site is continually updated, and guidelines are revised or removed as more timely information becomes available.

As visitors make suggestions about guidelines they’d like to see, the clearinghouse solicits developers to submit them.

Paulus says the financial pressures on home health agencies can make the Internet an economic resource.

"Home health agencies have a couple of forces on them: One, they’re losing money; and second, they don’t know where to go for help," he says. "They’re unwilling or unable to develop these guidelines and pathways. There are expensive conferences you can go to, but actually most of the information is on the Internet."

Paulus says guidelines can be used by an agency in two ways — to establish and develop an agencywide approach to a particular condition or as a reference for nurses on individual cases.

At Shands HomeCare, Sleeker says education would begin with managers, so that they can be comfortable with the technology and sites such as the clearinghouse that Paulus has identified as being useful and credible.

"Clinical managers would have ready access to it to help support the field in answering their questions," she says. "And then we get those in the field more involved."

She hopes to have staff trained and laptops in use in the field by this summer.

"It [Internet access] can give us some clinical direction in terms of the assessment that we’re providing on the client," Sleeker says.

It can be used to prepare for a visit and provide information on a particular diagnosis. "That helps them focus on their assessment collection; and once they collect it, it helps them in developing their plan of treatment," she says.

Using the clearinghouse

The guideline clearinghouse is similar to other Web-based databases, using a search engine to allow quick access to needed information. You can search based on a keyword found in the document, or by disease, intervention, or submitting organization. Paulus says the results are listed in order of relevance to the keywords typed in.

For each guideline, the site provides a standardized abstract, explaining how the guideline was developed and naming the developers. Contributors include professional organizations such as the American College of Chest Physicians, as well as other research bodies.

The clearinghouse provides access to the full text, if available, and comparisons to guidelines that cover similar topics.

Many of the guidelines are not specifically written for home care, and in some cases, Paulus recommends carving out the portion of a guideline on, say, congestive heart failure, for which the agency can be responsible.

Sleeker says that an agency should work with a medical advisor who can help determine which sites and information are useful to the agency.

"Not just somebody who does record review, but who takes an interest in the development of the staff and the quality of services that they provide and how to keep them moving up the ladder," she says.

Education is also important, she adds, noting that many nurses have never needed computer skills in their work before. "There are many people who are not comfortable with that yet, even using the keyboard," she says. "If they had a computer in their home, then obviously, they’re more skilled. But for some, there is a learning curve."

No money, no excuse

While laptop computers in the field may be out of the reach of many home health agencies, Paulus says budgetary restrictions are no longer an excuse for failing to tap the Internet’s resources.

"Unfortunately, agencies can get themselves into a self-defeating proposition, saying it would be awfully expensive to put computers in every nurse’s car," he says. "But you can buy a cheap system and get access. You can go to the public library, a university library. If I wanted to access the Internet and didn’t want to pay anything, I’d just go to the library and do it.

"It’s pretty hard to argue these days why you don’t have access to the Internet. I think those excuses are going away."

David Paulus, MD, Medical Director, Shands HomeCare, and Professor, Department of Anesthesiology, University of Florida, P.O. Box 100254, Gainesville, FL 32510-0254. Telephone: (352) 846-1309. Fax: (352) 392-7029. E-mail:

Shirley Sleeker, Executive Director, Shands HomeCare, and Senior Associate, Curran Care, 3515 N.W. 98th St., Gainesville, FL, 32606. E-mail:

Jean Slutsky, NGC Project Director, Agency for Healthcare Research and Quality, Center for Practice and Technology Assessment, 6010 Executive Blvd., Suite 300, Rockville, MD 20852. Telephone: (301) 594-4042. Fax: (301) 594-4027. E-mail: