Clinical practice guidelines (CPGs) for trauma have been available since the late 1990s. The Eastern Association for the Surgery of Trauma (EAST) was a pioneer in developing and disseminating these best practices to its members. Many other organizations followed suit, and now all trauma centers have either adopted, copied, or developed their own CPGs.

However, although this is now familiar territory, trauma programs continue to run into predictable barriers to successful implementation.

What are these barriers? What can be done to avoid or counteract them? Here are 13 tips for achieving a smoother implementation of your clinical practice guidelines.

1. Don’t just blindly copy CPGs from major trauma organizations and expect them to work for you

What? Then why do organizations like EAST or the Western Trauma Association bother creating CPGs if you shouldn’t copy them?

The answer: They are not meant to be complete management guidelines for a single clinical condition. These professionally produced CPGs are essentially lists of answers to specific clinical questions. Although some include workable flow diagrams, most cover only the generalities of clinical care.

The EAST Selective Nonoperative Management of Blunt Splenic Injury guideline even has a list of questions it doesn’t answer, including frequency of hemoglobin measurements, time to reinitiating oral intake, necessity of repeat imaging, and eight other important clinical issues.

2. Don’t build trauma clinical guidelines from scratch either…

Many trauma program leaders feel they have to review the literature themselves, convene a committee, and spend months developing their very own CPG. In fact, it’s OK to “borrow” guidelines from other trauma centers, letting them do the initial legwork. Using pre-made guidelines as your starting point will save a lot of time!

Major health systems typically have a few trauma centers among their hospitals. If your center is part of a larger system, begin by reaching out to sister trauma programs within the system to obtain a copy of their CPGs.

Many nationally known Level I and Level II centers post their practice guidelines on public websites, so there is already a virtual library of CPGs available out there. Here are just a few sources:

3. …however, you absolutely must review and revise borrowed guidelines

Every trauma center is different, with varying resources, personnel, and skillsets. What works in LA County will probably not work for you!

For example, your center may not have thromboelastography (TEG) available to incorporate in the massive transfusion protocol. Or you may not have point-of-care INR testing to add to a warfarin reversal CPG. Tweak the existing (borrowed) guidelines to align with your center’s capabilities. Remove the section on TEG or INR testing and rewrite it to match how you do it.

4. Make CPGs as evidence-based as possible

Clinicians, and especially those who are skeptical of CPGs in the first place, will pounce if they see that your new guideline runs counter to current literature. Those skeptics will try to pick apart every one of your guidelines, looking for weak or unsupported components to justify their resistance.

That being said, the literature will only help you so much. It may provide answers to the big questions. But not always. And don’t expect much help with the small stuff.

Even common clinical issues, such as chest tube management, receive virtually no detailed guidance in the literature. Your team will need to fill in the details on things like criteria for pulling a tube, how often tubes should be checked, timing of X-rays, etc.

Much of what we do is really an art, so portions of every guideline will have to be crafted by consensus to some degree. That’s why tip #7 below is so important. In most cases, the best you will be able to achieve is “evidence-informed” guidelines.

5. Make your guidelines “action-oriented” and concise

All too often, a program’s CPGs read like a chapter in a textbook. Pages of text. Hedge words like “consider” or “could.” In a real clinical situation, no one has time to read through all that prose. And the reader wants specific guidance on exactly what to do now, not what to consider.

Ideally, your CPGs should include an easy-to-follow flow diagram. If this, then that. Decision points should be easy to identify and follow. And fewer words are definitely better. Limit your flow diagram to a single page if possible. It should not be completely filled with boxes, triangles and words. It must be very clean and easy to follow. Spend considerable time designing it so the most common flow of care is the most direct and easy to read on the page. Include important information, notes and tips around the edges near the margins.

For examples of clear versus confusing CPGs, see Sample Pediatric Solid Organ Guideline: The Good Vs. The Bad.

6. Create a final “sample” guideline

This is critically important. Creating a guideline via committee is nearly impossible. You must craft a nearly finished CPG to use as a starting point for discussions.

This allows your committee (see tip #7) to discuss and make minor tweaks. They will not need to interpret the literature and build the whole thing from scratch. You’ve done that legwork. The final approved version should look suspiciously like your “sample,” with a few changes the committee recommends here and there.

7. Get buy-in from every department touched by the CPG

This is crucial. Is the laboratory involved? Imaging? Nursing (monitoring, vital signs)? Absolutely every department that is even remotely involved should be at the table. Then take an inventory of every department in the hospital that might even have an interest in the guideline. Invite representatives from all these areas to a meeting to review and discuss the proposed CPG.

This is where your “sample” guideline becomes critically important as the foundation for the final result. It is also a good opportunity to get other eyes looking at the CPG. Other people may see or think of things that you did not. This step will serve to strengthen your guidelines and customize them for your hospital.

8. Make sure there is an “escape valve” for unusual clinical situations

It is impossible to turn clinical care into a cookbook. There are too many variables, making it impossible to include every possibility in a single guideline.

As the guideline creator, you must find that line between too much detail and too little guidance. Craft your guideline to cover 90% of the usual clinical situations encountered. Recognize that some situations may arise in which the guideline will not apply.

Ensure all clinicians understand that, in circumstances not covered by a guideline, they are welcome to use their own expert judgment — however, they must also provide their full rationale in a progress note or a conversation with trauma performance improvement personnel.

As an example, let’s say your spleen and liver injury CPGs dictate that a patient may be monitored in a floor bed for injury grades I-III. However, a patient presents with a grade II spleen and a grade II liver that have an appearance that makes the on-call surgeon nervous. She decides to admit to the ICU for monitoring, and she documents her thought processes in the admission note in the electronic health record.

9. Educate, educate, educate

Don’t just email your CPG to everyone and implement it the next day. Roll out your new guideline slowly and methodically. Send out the final copy to the providers who are most involved or most impacted, and ask for comments. Consider any last-minute tweaks. Set a specific start date, taking into account the time needed to bring everyone up to speed. Then organize a series of educational sessions to ensure everyone involved is aware of the new guideline’s details. Send out regular announcements to all involved, with copies of the CPG attached.

Here is a typical timeline for a relatively simple CPG:

10. Post your CPGs in logical, easy to find locations

One of the biggest problems with new guidelines is that clinicians never seem to have them at hand when (and where) they need them. This practically guarantees that they will not be followed.

Most trauma programs have a website or intranet to house practice guidelines. Some programs have developed smartphone apps to put CPGs directly in providers’ hands. It is also possible to include links in specific areas of the electronic health record software.

Although many hospitals require that practice guidelines be added to their online policy systems, these are rarely easily accessible and should not be relied upon for clinician access.

11. Develop a system for monitoring compliance

Once guidelines are implemented, they absolutely must be monitored. Clinicians occasionally forget or misunderstand specifics, and any digressions need to be caught quickly so that timely feedback can be provided. Without this, overall practice will become sloppy, and the guidelines will fall into disuse.

In smaller trauma centers, the trauma program manager is typically in charge of compliance monitoring. Larger centers may have PI coordinators or nurse clinicians who perform this task.

Records of all patients who did or should have had the guideline applied need to be reviewed each day. Any variances must be identified, and any documented explanations should be reviewed. The trauma medical director must make the final decision on the appropriateness of the care delivered. In addition, basic information on the number of patients involved and the number of variances should be recorded for later performance improvement analysis.

Key performance indicators (KPIs) should be developed for each CPG. Typically, four or five readily identifiable events should be listed on a simple checklist to efficiently use PI personnel’s time. For example, a solid organ management CPG might have the following KPIs:

• Radiologist provided injury grade in the report
• Patient admitted to the appropriate unit based on grade
• Appropriate order set entered into the electronic health record and followed
• VTE prophylaxis started immediately for grade I-III, after 24 hours for grade IV-V
• Post-discharge activity and return to ED instructions documented
• All variances documented in progress notes

12. Maintain a tight feedback loop when a variance occurs

We cannot learn from our errors if there are no consequences. If a provider does not follow the guideline and nothing happens, he or she probably won’t follow it the next time either. The trauma medical director must be notified of every noncompliance incident. The TMD, in turn, must communicate promptly and directly with the provider, ideally within 24 hours of the occurrence.

Either email or direct face-to-face communication can be used. However, it must be done in a way that is non-judgmental and polite yet firm. Remind the clinician that a new CPG has been implemented. Note that it did not appear to have been followed. Provide a copy of the guideline for their “reference” and remind the provider where it can be found. And give the provider an opportunity to explain why he or she didn’t follow it and ask questions about it.

13. And what about “that one doc” who refuses to go along because he or she is already doing it the “right” way?

Some providers don’t believe in a “cookbook” approach to medicine. Others sincerely (and wrongly) believe that their way is the right way, despite what others are doing or what the literature says. There are several ways to deal with them.

• First, make sure that you followed all the points above while designing and implementing your guideline. This serves to make it as sound as possible from the very start.
• If you know or suspect who some of these individuals might be in advance, involve them heavily in the entire process. Once you have designed your “sample” guideline (tip #6), run it by them for comment. Make them part of the group (tip #7) to help customize the hospital’s guidelines.
• Give them feedback (tip #12) every time they don’t follow the CPG, so they get tired of hearing about it.
• And finally, consider circulating a clinician scorecard that shows compliance rates for everyone involved. Even if names are omitted, everyone will be asking who that outlier is. Trauma professionals are a competitive bunch, and none wants to be at the bottom of the list.

One additional tool is the TQIP report provided to all ACS trauma centers. If TQIP data shows your institution is an outlier in an area covered by a CPG, use this as ammunition to share with clinicians and your hospital administrators to bring maximal pressure to bear for guideline compliance.