Clinical Practice Guideline—or Mandate?
This past month, the Infectious Diseases Society of America (IDSA), in collaboration with the American Geriatrics Society, American Society of Nephrology, American Urological Association, and other organizations in the United States and throughout the world, released their Guidelines for the Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America.1 I read these guidelines with great interest and consider this to be a most welcome addition to other useful guidelines that I now consider when dealing with certain problems.
Clearly stated on the first page is the statement, “Guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient’s individual circumstances.”1
I carefully studied the guidelines, noting the recommendations being made in relation to my current practice and understanding of a given issue. The guidelines are extensive and beyond my ability to list here; however, I suggest that anyone interested in learning what, in my belief, is now the “gold standard” for urinary catheter management obtain a copy for themselves in Clinical Infectious Diseases.
After reading these guidelines, I left my office with new knowledge and enthusiasm and went to the hospital floors to see a patient. I ran into an Infectious Disease colleague and asked him if he had read these new guidelines. He had not seen them, he told me, but he asked me to summarize them for him. I did my best and also gave him the reference. From his comments, however, I soon understood that he had little or no intention of following all of the recommendations, saying that he doubted the “strength” of evidence in favor of some of these, despite the information presented.
I know that the guidelines do state that decisions must be made on an individual basis with the physician and patient as the deciding factor, but “experts” have reviewed all available data, made recommendations as to when evidence supported a specific care plan, and precedent has been set. There is now a document upon which to compare clinical actions. We hear the following question all too frequently in Quality Review and Legal proceedings: “Did the physician follow the guidelines” when treating a specific patient problem? We have long had to justify in writing our decisions, such as when not to use anticoagulation, for example, in a given patient with atrial fibrillation in whom we felt the risk exceeded the potential benefit. This is important not only for proving our quality as physicians when medical review boards look at a physician’s practice in relation to guidelines, but also as a way to avoid future legal problems if a poor outcome develops.
Just as Medicare has begun to institute a penalty for hospitals that have patients with catheter-related infections, physicians will most likely be held to higher standards in this area as well. Was that catheter essential? Was the way in which it was used in accord with standards of care? These and other questions will obviously follow, and as long as guidelines are adhered to, or at least an explanation can be found on the record as to why they were not, physicians can prove that they have followed standards of care.
Guidelines may not be meant as such, but in most cases they serve as mandates and should be taken seriously. True, not all patient situations lend themselves to a specific guideline, and physicians must do what they feel is appropriate in a given situation. I caution all physicians, however, to document more clearly the reasons for using a urinary catheter. They must make sure that they follow guidelines as to their proper use and treatment of infections that may result, or, at a minimum, state why some variance was necessary.
Dr. Gambert is Professor of Medicine and Associate Chair for Clinical Program Development, Co-Director, Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Maryland School of Medicine, Director, Geriatric Medicine, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, and Professor of Medicine, Division of Gerontology and Geriatric Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
1. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50(5):625-663.