Demystifying Clinical Practice Guidelines 

Guidelines Committees, PCNA, and You

It’s no surprise that the role of health care professionals, and specifically of nurses, continues to change. While our primary goal remains focused on maximizing patient outcomes, how that takes place has undergone a seismic shift no matter our work setting. PCNA strives to ensure that every cardiovascular nursing professional is able to work at the top of their credentials; that systemic racism (and other -isms) are addressed to ensure equitable, effective care for all; that health care providers and their patients have access to safe care settings; and that standards of care are developed and implemented through a collaborative and collegial process with the needs of each patient at the forefront. 

To ensure improved outcomes for our patients, it is critical that each of us as health care providers stay current with guidelines and how to apply them into our practice. How is this possible in the era of 12-hour shifts, staffing shortages, shifts in how education is delivered, and the effects of all these that were exacerbated by the COVID-19 pandemic?  

PCNA works to make it as easy as possible for you. (And if you are already committed to getting involved, skip ahead to the section “The involvement of individual nurses like you.” 

Development and Review of Clinical Practice Guidelines 

Let’s start with a brief overview of clinical practice guidelines (sometimes abbreviated as CPGs). How are they developed in the first place, and/or reviewed? What role does PCNA play in the process? How can you and other individuals be involved? 

Clinical practice guidelines (CPGs) are recommendations for best practices in care to achieve optimal patient outcomes. They emanate from a systemic review of research and evidence, an assessment of benefits, costs, and risks, of various approaches to a patient population or clinical practice. 

Professional organizations such as the American Heart Association (AHA) and the American College of Cardiology (ACC) and others have identified processes for the development and review of guidelines. For more than 35 years, the AHA/ACC guidelines have provided actionable and patient-centric recommendations for use in day-to-day practice, utilizing validated methods to evaluate evidence and develop information for cardiology-focused clinicians.1,2,3  

Guidelines writing and review is a collaborative process; selection of members of writing groups will vary with the CPG under development. Frequently, representatives include members of the organizations developing the guidelines, expert clinicians, general cardiologists, pharmacists, advanced nurse practitioners or nurse scientists, and lay/patient representatives. If the guideline involved procedures or surgery, the team may also include specialists such as interventional cardiologists, surgeons, anesthesiologists, and other professionals. Writing group members must declare any conflicts of interest and full transparency of relationships with industry or organizations perceived to create conflict or bias.   

Once drafted, the review process is rigorous. It is usually conducted by a group of similar representations which gives extensive feedback for the original group to use in revisions or refining of the guidelines. The guidelines committees will often meet numerous times over a series of months to review the most recent research and determine how this evidence-based data can be synthesized into recommendations for clinical practice. 

AHA and ACC are not the only organizations involved in guidelines development and review. For broad topics, a large number of organizations may collaborate. For an example of the breadth of organizations that may be involved, we can look to the 2018 cholesterol guideline4 or the 2019 guideline for the prevention of cardiovascular disease.5   

The Role of PCNA

PCNA is committed to ensuring that the perspective of nurses and nursing are included in the development—and implementation—of clinical practice guidelines Frequently this includes recommended patient and family education, and implementation of pharmacological and non-pharmacological best practices.  PCNA partners with organizations such as AHA, ACC, and others to provide nursing representatives to serve on guidelines development and review committees. PCNA representatives are often PCNA board members who are active in clinical practice and/or research. Along with other leaders in the cardiovascular community, these nurses represent nurse clinicians as guidelines are developed and reviewed.  

Once the guidelines are approved and disseminated, PCNA strives to share the information with members and other cardiovascular professionals to ensure that we all are implementing the most currently accepted methods for the prevention and treatment of CVD. PCNA and other organizations develop and share content-area pocket guides to help apply the latest guidelines into practice. Recent pocket resource examples include Heart Failure: A Guide to Prevention and Management, Prevention of Thromboembolism and Stroke in Patients with Atrial Fibrillation, and Guidelines for Managing Cardiovascular Disease Risk in Patients with Diabetes

Classes of Recommendations, Levels of Evidence

AHA guidelines recommendations include classes of recommendations and levels of evidence (2019) vi to assist clinicians in identifying appropriate implantation for specific types of patients. 

Levels (Quality) of Evidence 

There are three levels of evidence that are shared with clinical guidelines. 

LevelSources from which data is derived
Level A
  • High-quality evidence‡ from more than 1 RCT

  • Meta-analyses of high-quality RCTs

  • One or more RCTs corroborated by high-quality registry studies

Level B-R (Randomized)
  • Moderate-quality evidence‡ from 1 or more RCTs

  • Meta-analyses of moderate-quality RCTs
Level B-NR (Nonrandomized)
  • Moderate-quality evidence‡ from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies

  • Meta-analyses of such studies

Level C-LD (Limited Data)
  • Randomized or nonrandomized observational or registry studies with limitations of design or execution

  • Meta-analyses of such studies

  • Physiological or mechanistic studies in human subjects

Level C-EO (Expert Opinion)

  • Consensus of expert opinion based on clinical experience

‡ The method of assessing quality is evolving, including the application of standardized, widely used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee. 

Classes of Recommendations 

The classes of recommendation describe the strength of the recommendation. 


Class of Recommendation


Definition

Suggested Wording to Use in Writing Recommendations
Class 1 (STRONG)Benefit >>> Risk

Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective.
  • Is reccommedned
  • Is indicated/useful/effective/beneficial
  • Should be performed/administered/other
  • Comparative-Effectiveness Phrases†:
    • Treatment/strategy A is recommended/indicated in preference to treatement B
    • Treatment A should be chosen over treatment B

Class 2a (MODERATE)Benefit >> Risk
  • Is reasonable
  • Can be useful/effective/beneficial
  • Comparative-Effectiveness Phrases†:
    • Treatment/strategy A is probably recommended/indicated in preference to treatment B
    • It is reasonable to choose treatment A over treatment B
    Class 3: No Benefit (WEAK)Benefit = Risk
    • Is not recommended
    • Is not indicated/useful/effective/beneficial
    • Should not be performed/administered/other
    Class III: Harm (STRONG)Risk > Benefit
    • Potentially harmful
    • Causes harm
    • Associated with excess morbidity/mortality
    • Should not be performed/administered/other

    † For comparative-effectiveness recommendations (COR I and 2a; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. 

    The Involvement of Individual Nurses Like You 

    Each of us has a role to play in the development and implementation of individual guidelines. Here are some specific ways to be involved: 

    1. Any time a guideline is developed or reviewed, a public comment period allows for professionals outside the writing/review committee to be involved. Here is an example.
    2. Each organization has a specific procedure for reviewing new guidelines and how they should be put into practice at that site. As an example, one organization had several APRNs from the preventive cardiology team, in collaboration with representatives from primary care and endocrinology, develop a protocol to implement new cardio-diabetes guidelines using SGLT2-Is and GLP1-RAs for the patient with cardiovascular disease. The team members led the initial pilot program and roll out to their colleagues and other clinics across the institution.
    3. Apply the latest guidelines in the work you do each day. Keep a pocket card of applicable guidelines that are relevant to the types of patients you care for handy; skim in advance of a visit with a patient for whom the guideline is appropriate, or use during the visit.
    4. Be alert for updates to guidelines that are published as a newly updated guideline or as a brief update when new medications or treatments emerge and help lead in your organization for the implementation.7

    References

    1. Jacobs A.K., Anderson J.L., Halperin J.L. ”The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines”. J Am Coll Cardiol 2014;64:1373-1384.
    2. Anderson J.L., Heidenreich P.A., Barnett P.G., et al. ”ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures”. J Am Coll Cardiol 2014;63:2304-2322. 
    3. Levine G.N., O’Gara P.T., Beckman J.A., et al. ”Recent innovations, modifications, and evolution of ACC/AHA Clinical Practice Guidelines: an update for our constituencies”. J Am Coll Cardiol 2019;73:1990-1998
    4. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139:e1082-e1143. doi: 10.1161/CIR.0000000000000625. 
    5. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the American College of Cardiology/American Heart Association Task Force on the Clinical Practice Guidelines. Circulation. 2019;140:e596-e646. doi: 10.1161/CIR.0000000000000678
    6. Applying Class of Recommendations and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019) https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/tables/applying-class-of-recommendation-and-level-of-evidence Accessed 17 February 2022.
    7. Maddox TM, Januzzi JL, Allen LA, et al. 2021 update to the 2017 ACC Expert Consensus Decision Pathway for optimization of heart failure treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2021;77(6):772-810.

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