Clinical Practice Guidelines (again)

Clinical Practice Guidelines are recommendations for clinicians caring for patients with specific conditions or ailments. The Institute of Medicine defines clinical practice guidelines (CPGs) as “statements that include recommendations, intended to optimize patient care, that are informed by a systemic review of evidence and an assessment of the benefits and harms of alternative care options”.1

Healthcare entities such as hospitals, clinics, private offices, and birth centers are expected to have CPGs or protocols which provide a specific operating structure within which health care providers are expected to practice. Well-defined CPGs, in any healthcare setting, are essential for quality, safety and continuity of care.

The American College of Nurse-Midwives has emphasized the need for well-developed practice guidelines so that CNMs/CMs can be consistent in the particular care setting, allowing them to defend the quality and safety of their care, if required. ACNM, ACOG, and AWHONN, as examples, publish CPGs which offer parameters of practice for the care of childbearing women. ACNM suggests that CNMs/CMs develop practice guidelines for each specialty of practice, such as primary care, antepartum, intrapartum, postpartum/newborn, family planning, and gynecology.

Clinical Practice Guidelines

Practice guidelines serve to define clinical boundaries. They should include processes for clinical collaboration, consultations, emergencies, and transfer of care. Well-written guidelines will also include an outline for professional relationships with other members of the team, like medicine and nursing. Ideally, practice guidelines should provide enough detail to support independent decisions made in specific situations. For instance, procedures for obstetrical emergencies require an outline of independent actions that a CNM/CM may take prior to, or in conjunction with, seeking assistance and consulting with other members of the practice and health care team.

Specifically, severe hypertension, shoulder dystocia, sepsis, fetal distress, amniotic fluid embolism, and postpartum hemorrhage are examples of situations where the CNM can take first steps while initiating the necessary consultation. Guidelines must clearly define the process of clinical consultations and collaborations. The more detailed the practice guidelines, the higher the chances that they will prevail in the face of medical-legal challenges. 2 Clinical Practice Guidelines are intended for all types of care providers to help them provide the best care possible for their patients.

CPGS In Other Industries

For better or worse, other business entities involved in healthcare also use them. Insurance companies and administrators may borrow CPGs developed for clinical use, in order to set policies on quality and payment for care by transforming guideline recommendations into performance measures that are then used to grade the delivery of care. Medicare and Medicaid have created “pay for performance” programs to link payment to care providers demonstrating “quality of care”, using measurement parameters that have been borrowed from clinical practice guidelines. 3

Clinical Practice Guidelines and Litigation

Attorneys may use well-accepted national guidelines in malpractice litigation, asserting that care providers who have not followed guidelines, without good reason, are negligent. For medical providers, claims of this type have not been particularly successful. The variety of medical specialties and multiplicity of guidelines for the same condition have enough differences from each other that none of them can be argued as representing a community standard of practice.

Clinical Practice Guidelines - CNMs/CMs

In nurse-midwifery, CPGs are derived from ACNM Core Competencies, Ethics, and Standards of Practice which represent a national legal standard for CNMs and CMs, only. Since standards of practice emanate primarily from one certifying body (AMCB), it is very unlikely that nurse-midwifery practice guidelines would significantly differ between practices across the United States. For these reasons, the litigation approach, described above, may prove to be more successful.

Hospital Vested Interests

Hospital and medical practices seeking to develop CPGs involving CNMs will, naturally, want to create documents that will protect their own interests. Be cautious when considering these guidelines. Despite evidence to the contrary, physicians contemplating business arrangements with CNMs/CMs fear that an association places them at increased risk for liability. In an agreement with hospitals and physicians, CNMs should insist on providing input which protects their personal and professional interests, as well as the integrity of their profession. Existing documents published by ACNM are easily accessed to support safe and effective practice guidelines. 4

Concensus report, Institute of Medicine. Clinical practice guidelines we can trust. March 23, 2011. http://www.iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.
King, Takoa; Journal of Midwifery and Women’s Health, Vol. 45, No. 6, p. 448-449; November-December 2000.
Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance:fom concept to practice. JAMA 2005; 294:1788.
ACNM Standards For the Practice of Nurse-Middwifery. Core Competencies, Scope of Practice, and Ethics
http://www.midwivesontrial.com

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