Behind the Scenes: What is a Clinical Practice Guidline with Dr. Lynda Goodfellow

Recorded live at the 2024 AARC Congress, this episode of AARC Perspectives chats with AARC Clinical Practice Guidelines (CPG) Director, Dr. Lynda Goodfellow, about what a CPG is, why it's important, and what new guidelines are on the horizon. 

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Transcript

SPEAKER_00 0:00

And welcome to today's American Association for Respiratory Care's Perspectives podcast, live from Congress today with Linda Goodfellow, AARC Director of Clinical Practice Guidelines. Thanks, Linda, for joining me today to talk about AARC's CPGs. So to begin, can you tell me a little bit about what roles do clinical practice guidelines play in respiratory care and why it's important for respiratory therapists to be familiar with them?

SPEAKER_01 0:22

Sure, and thank you, Lisa, and I appreciate being here today. Clinical practice guidelines are really essential tools for clinicians in any health care role. Clinical practice guidelines provide guidance that's related to the most current evidence that's found in the medical literature. What this means for respiratory therapists is that the AERC clinical practice guidelines can inform respiratory care evidence-based practice. We think of evidence-based medicine, but for our CPGs, they are informing respiratory care evidence-based practice. And this is important for respiratory therapists so that we are aware that we are that we have credible resources available to us. Because when we have these resources that are credible, then we can have confidence that we are looking for the best choice for our patients whenever they have situations that are different from other patients. In other words, we are familiar with sort of the 80-20 rule where 80% of photocalls can be followed, but there's about 20% chance that this patient or a patient that you're seeing will not follow that 80% rule. In other words, you have 20% of the time where you need to actually do your own investigation. And so you look for evidence that can be your guide in these situations. So clinical practice guidelines are very important, and I hope that you will take a look and be seeking out these guidelines as they're published in respiratory care.

SPEAKER_00 1:55

Thanks for that explanation. How does the ARC develop and update its CPGs? And what is the process for ensuring they reflect current evidence-based practices?

SPEAKER_01 2:04

So the process that we're using today to develop clinical practice guidelines is based on an in-guide methodology. EndGuide was developed by McMaster University. There's a group of epidemiologists that have developed this, and it is one method to use for developing, and it is really becoming the gold standard in terms of methods for clinical practice guidelines. So I'm very happy that the AERC has embraced the EN-Guide methodology. These methods follow a logical approach so that the recommendations are based on current evidence. It's no longer based on our expert opinion. Expert opinion is okay, but let's say my expert opinion on a situation could be different from your expert opinion. And so we really need a consensus, and with expert opinion, at times it's difficult to have a consensus on the right way. So expert opinion is really low evidence, and we're looking for high evidence. So for example, questions are created following a framework called PICO. That the PICO is T for population, I for intervention, C for comparator, and O for outcomes. This is one of the very first step in developing the clinical practice guideline. So let's look at a question, a potential question. It may be that patients, and here I'm I'm going to go with the P here, patients in acute care settings receiving non-invasive ventilation. The intervention is going to be does the use of a critical care ventilator versus a comparator, which is a affordable ventilator, how does that affect clinical outcomes? So that's the language of a CPG question, and it is formed from this particular PICO framework. So going forward, the question like for this and others like this one, it does provide a framework to assist in creating a literature review. Because the librarians, they will look at our question, really pick it apart in terms of using, you know, NIV or outcomes or uh acute care. These are all words that go into a literature review or a literature search so that we have a robust literature review that addresses the question that we're actually trying to find answers for. So going forward, CPGs to answer the question about when they'll be updated. We will be planning to update CPGs every five years. And that's this will either be an update of a previous CPG, or if the evidence tells us or leads us to retiring CPGs, then we will do that if the evidence is uh telling us that this the retired the the current CPG is no longer relevant, so then we will discard it at that point. We still post everything to the AERC website, the current ones, and we also have our retired ones our archived CPGs still posted. But once we start on a a rigorous five-year schedule, the archived ones will probably go away and then we'll just keep the current ones or those that are still usable on our website going forward.

SPEAKER_00 5:20

Sounds like you're gonna be busy for a while then. Uh to be. So can you discuss a few key CPGs that have had a major impact on the practice of respiratory therapy in recent years?

SPEAKER_01 5:32

Yes, and this is one of the exciting things here. So two CPGs were published in 2024. One was the Spontaneous Breathing Trials for Ventilator Liberation Clinical Practice Guideline. This came out in July, and so far, for the rest of 2024, it has been one of the most downloaded papers from respiratory care. This clinical practice guideline addressed the use of spontaneous breathing trials when compared to other measures for determining extirbation. So, one notable finding from the literature and from the evidence was that the use of a RISB or a rapid shallow breathing index test is not needed to determine readiness for a spontaneous breathing trial. In other words, we've were seeing in the literature that some were doing a RISB procedure and then they would use the whatever the value may be, whether it was normal or the patient was not ready, then they would then do a spontaneous breathing trial. So they were really doing two different tests to determine readiness for extubation. And the evidence does not support that. There's moderate certainty that you only need to do the spontaneous breathing trial. And it is becoming more and more anecdotally known that the RISB really is not effective or predictive in determining extubation. So you can see how just this one minor change in practice can really impact the respiratory therapist workload. In fact, the evidence indicates that the RISB, if you still do it, can prolong time on the ventilator. So we suggest that there is no need to determine readiness for an SVT. Another recommendation suggested not to use or not to increase the FIO2 during the SVT. There's low evidence, but the rationale for not doing the SVT with increasing the FI2 is because you cannot determine which parameter actually led to the change to either have the patient pass the SBT or for failure. When you're doing research in the lab, the best thing, one of the best practices in that type of research is you only change one parameter at a time. Because if you add two things, like in this case here, where you increase the FIO as well as do the SVT procedure, you really don't know which one is changing and which one is not. So because one will have to change the results there. So those were two examples of how just one paper, and there were four recommendations, and this is just two that I went over, just how impactful this one paper has already shown to us. And I can understand now why it's one of the most downloadable papers in respiratory care today.

SPEAKER_00 8:21

Wow, that's that's amazing. How can respiratory therapists use CPGs to improve patient outcomes and ensure high quality care? Yes, so we all want high quality care.

SPEAKER_01 8:33

I mean, all of us want high quality care. And actually, the clinical practice guidelines should be incorporated into respiratory therapy-driven protocols. That's the answer here to how do you improve patient outcomes and ensure high-quality care, is when respiratory therapists are practicing by protocols. The best method to improve and ensure high-quality care. If you don't have a respiratory therapy-driven protocol, then another option is a care pathway. It's a good option if there are no RT-driven protocols, and many facilities have incorporated RT protocols with great success. However, if your facility does not or has not embraced protocols or adapted them, there are many other examples on the AE AERC website for a protocol so that you could download those and then tailor-make those for your facilities. You have to be careful though, because for protocols, these are all institution specific. In other words, your organizational culture will determine how robust by protocol you're actually practicing, or maybe how weak you are practicing by protocol. So it's important to have good clinical practice guidelines that can be developed or incorporated into your protocol so that you can show actually that you are providing high quality care.

SPEAKER_00 9:59

That's really interesting. The ARC collaborate with other healthcare organizations to align its CPGs with broader healthcare guidelines and initiatives? Yes, we do.

SPEAKER_01 10:10

And um, in fact, two years ago, after I'd only really been in this row for almost a year, a physician group approached me. And this was, like I said, two years ago, I was at the New Orleans meetings, and uh a physician from the PLC network, which is the Pediatric Acute Lung Injury and Sepsis Intervention Network, um, a physician who is a member there wanted to partner or asked to partner with the AERC for a C for a clinical practice guideline on pediatric critical asthma. This is a specific population of P of pediatric patients who have severe asthma and are regularly in the emergency department or admitted to the uh uh PICU uh for severe asthma. And so it is a subspecialty or a subtopic of just pediatric asthma overall. This is critical, pediatric critical asthma. And so we uh sat down there in New Orleans, had a long talk about what uh uh involvement the respiratory therapist would have, what involvement the pediatric intensivist would have, and uh to this day we have we are in the final stage of the manuscript for the clinical practice guideline, and so it should be uh submitted for peer review to respiratory care by the end of this year. So the publication is most likely to be published in the first half of 2025. And so, yes, we have an example where another organization has approached us, and um, it's been a very good partnership. I think all have learned a lot through this process. There were eight questions that we have reviewed, uh PICO questions, and some of the literature was very strong, some was of low certainty, but that's what you find in when you're looking or trying to make recommendations for clinical practice guidelines. Some of the questions that we all ask, well, they're questions because there's been no research out there. And so what little we're able to find, sometimes it's not, well, it's just low value because of the methods used in the studies that have been published. And so my plug here is that all of us should engage in quality improvement projects in your institutions or participate in high-level clinical practice guideline teams so that the evidence can be found and then recommendations, and then also future research can fill in even more of the gaps that we're trying to find.

SPEAKER_00 12:48

So, I guess kind of along that same way, how are CBGs incorporated into respiratory therapy education and training to ensure that the new practitioners that are coming in stay up to date?

SPEAKER_01 12:58

So, this is a great question because many students are exposed to clinical practice guidelines in their respiratory therapy education. I can speak firsthand from being at a university where the baccalaureate and the master's students would have an assignment on a clinical practice guideline. Those in the entry-to-level associate programs, they may not have any exposure other than maybe, you know, one lecture on those. So my point is all programs should be exposed to clinical practice guidelines. And the way to incorporate these into the curriculum is to have the students have a group of students or even just one, but I would say have a group project where the students are given a clinical practice guideline, but yet they are to make a protocol out of this guideline. I think that at the educational level was would be very productive. They may not see practice uh clinical practice guidelines in their future employment, just depends on if their facility uses protocols. If they use protocols, most likely they are looking at protocol uh clinical practice guidelines. But if there are no protocols being used, then the students will say, hey, here is an option for when I go to work and there's no protocols, here's a clinical practice guideline, let's let's make one here. Well, it's it's not as easy as I just stated, of course. You need a champion and you need lots of uh things to fall into place to fully implement a clinical practice guideline, but a protocol is not as daunting of a ask uh facilities. So, yes, students should be exposed to clinical practice guidelines. They should have an assignment, whether it be a protocol or maybe they're gonna create some PICO questions, that's a good a good exercise as well because they're using some of their critical thinking skills to determine what the population would be, what the intervention and comparison as well as the outcomes that uh they may find. Yes, all schools should be involved in assigning clinical practice guidelines to our students. Because if we don't, they will not most likely use them because they won't know about them. So it's our job as educators to tell them and then find a way for them to use these.

SPEAKER_00 15:19

Great. So what upcoming CBGs or updates can we expect from the ARC in the near future and how will they shape the field? Sure.

SPEAKER_01 15:27

Well, I just started one the day before Congress started on airway clearance. And uh it was very interesting because, you know, airway clearance is just not very sexy to me. I just don't know. Suctioning is uh it's better than the other, you know, from being a nurse, I'll say it. My peers here will know exactly what I'm talking about. But the conversation that we had on Tuesday with with this new team that was started, they had a passion for this airway clearance, because they have seen firsthand over and over with children who have mucus plugs and they're not detected in time. So at at some point in the the adult population where there are so many airway clearance devices, and so which one do you use? So I was very happy to see a topic that I was kinda you know, we're updating one uh from 2013, so it wasn't again my favorite, but they really had some passion. I was I was really just inspired by their enthusiasm, and they they they were very productive. In fact, they came up with 12 different questions, and that was unusual. Yeah, but I'm very proud for them. So that's coming up in the future. And 2025, one new thing that I'm going to do, many times the topics themselves just sort of fall in my lap, or uh, you know, I've really not had to really pick or choose. I mean, they've again they just kind of hit me, and you know, I've been very fortunate. But going forward, I thought, you know, I need to get input from other people, not just those that have been sort of advising me over and over. So in 2025, I will most likely have a CPG, and this is not decided completely just yet, but probably will have one on humidification, maybe another one on respiratory telehealth, because I think that's COVID to us that's here for s for good now, and so uh we don't have any guidance on that. Uh so those are some likely choices, but uh also with this application here, uh I would ask anyone, and you'll have I'll have a request for applications come out in 2025. But if you're interested in joining a team, then uh I would ask for a CD or a resume for you, why you would like to be on a team, uh, and any suggestions for uh a team that you would like to be on. So if you do make an application, and let's say I don't have the team that you have requested, then you know don't fret because it may be later in 2025 or even 2026 when we do get to all topics at some point.

SPEAKER_00 18:06

So that's what's coming up in the near future. What's one of the, just as an add-on question to that, I guess, what's one of the benefits of being on a CPG team?

SPEAKER_01 18:15

So I have a variety of practitioners on the team. I have people who are, say, within the first 10 years of their career, five to ten years. I have junior faculty, I have mid-level career practitioners, I have nurses, I have patients, uh, two patients who are very much advocates for their COPD, uh, and their perspective has been invaluable. There are physicians on almost all the teams, not all, but I I understand and see the value of their expertise at their level and how they can be part of respiratory therapy team uh to interact with us. So we we're building some relationships there. But the point is I am trying to elevate the profession by training some of the junior and newer practitioners of the profession to have an interest in research. Most of them do already whenever they come onto a team, but it could be that they've had an abstract or two and they want to do more. And so this is a I think a valuable experience, but be uh be aware that it takes us about two years to start to finish. This is not, you know, an ad hoc task force that does their thing and then goes away. You know, I mentioned five years we'll update everything. My plan is those who are on the first team, they have first right of refusal to come to the update. But if they don't, then of course we'll, you know, sprinkle in some some new thinking. Uh, but you know, I'm looking for diversity of location, diversity of your role in respiratory therapy, diversity of color, diversity of you name it, you know, diversity of thought. Because I don't want this group think where we're all, you know, one channel here. No, we need to hear from everyone. And so it's worked out quite well, I'll say, thus far, because we have good conversations. These are not, you know, drag out beat down conversations. We all are in this swimming in the same direction, but you know, we all have a voice and it's all we're going to hear them. Yes.

SPEAKER_00 20:30

That's great. Sounds like a good opportunity for people to get involved with. So, kind of to wrap up here a little bit, where where can people find the latest CPGs?

SPEAKER_01 20:39

Well, the two publications I mentioned earlier, they are in respiratory care. So that's where you will find all of the AERC CPGs once they're published. Now, once they are published, then they are posted to the AERC website under clinical practice guidelines. There's a uh, you have to go to resources, and then you'll see clinical practice guidelines, and so it'll flip to the next page. And they also are on PubMed. Uh, you can probably find them in uh best uh Mbase. That's another data search engine. And so there are multiple multiple places where they are located, but the main source is respiratory care because the AURC owns these clinical practice guidelines.

SPEAKER_00 21:27

So, any other last thoughts you'd like to add in as we finish up on our podcast today?

SPEAKER_01 21:31

Yes, I want to say right now I have over 70 people on teams, and so this is a way to get involved with the AURC. Yes, it's just been a lovely experience for me. I've gotten to know more people than ever before with the AURC on these teams, and so I'm going to continue that. And I mentioned the application process. There's probably going to be two to three papers coming out in 2025, so a lot to

SPEAKER_00 22:00

look forward to. It's greet. Thanks Linda so much for joining us today for this informative podcast on CPGs and what's next. We'll talk to you next time.