Rapid guideline development in an ever-changing environment
Professor George Braitberg shares the challenges of accurate information and dissemination faced by Melbourne Health in the COVID-19 crisis and what strategies were implemented to mitigate the risk of misinformation.
How to develop reliable and evidence-based guidelines rapidly in an ever-changing environment (listen from 00:02:08).
Moving away from traditional guideline and policy development processes, Melbourne Health established a COVID-19-specific clinical practice guideline committee. The committee sent out an expression of interest to all units for authoring clinical practice guidelines about how they are going to operate. These would be sent to the committee to review and publish across multiple systems. These documents were colour coded for instant topic recognition and were developed using Google Docs to ensure real-time collaboration between committee members (listen from 00:07:00, view templates from 00:09:42).
The enthusiasm and uptake of the system from staff members has meant that information is being disseminated rapidly. Staff members from different departments are also working collaboratively (listen from 00:18:55).
Professor George Braitberg
George Braitberg is a practicing emergency physician and toxicologist of 35 years. George is the Head of the Emergency Medicine Stream for the Centre for Critical Care Medicine at the University of Melbourne and Executive Director of Strategy, Quality and Improvement at Melbourne Health.
George is a Fellow of the American College of Medical Toxicology, the Australasian College for Emergency Medicine (ACEM) and the Royal Australasian College of Medical Administrators. He holds a Masters in Bioethics and Health Services Management (Monash University) and is a member of the Victorian Clinical Council, a Board member of St Johns Ambulance (Victoria) and Medical Advisor to Ambulance Victoria. George’s research interests include toxicology, pre-hospital care, clinical governance and health system redesign and the management of acute emergencies.
George is involved in the development of emergency medicine in Israel and has published over 70 peer-reviewed papers and authored more than 20 book chapters. George was awarded the Australasian College for Emergency Medicine Service Award in 2018 and became a member of the Order of Australia (AM) in 2018 and an Officer of the Order of St John (OStJ) in 2019. And lastly, George is a proud grandfather of 5+.
Welcome to the Australasian Institute of Clinical Governance ‘Connecting Clinicians’ COVID-19 Clinical Governance series. The COVID-19 pandemic is causing unprecedented challenges for our healthcare workforce. We've watched as organisations and clinicians have had to mobilise at speed, making changes to systems and processes in response to COVID-19. Health professionals are developing practical solutions in record time to adapt and keep people safe, so sharing these practical solutions as they have been developed is invaluable. Unfortunately we can't wait for these improvements to be written up in papers or shared at conferences, we need to learn from these experiences now.
So that's what we're aiming to do with the series, to ‘connect clinicians’. Each episode we'll interview a clinician across Australasia to discuss three things; the first is a safety and quality challenge that COVID-19 has presented. Secondly, the solution they implemented to address this challenge, and lastly, the impact seen from these changes. Our clinicians have generously agreed to share any relevant material that they might have developed in addressing this challenge, which will result in a repository of practical quality improvement COVID-19 resources for others to utilise in their own practices.
Today we are welcoming Professor George Braitberg, who is a practicing emergency physician and toxicologist of 35 years. George is the head of the Emergency Medicine Stream for the Centre for Critical Care Medicine at the University of Melbourne, and Executive Director of Strategy, Quality and Improvement at Melbourne Health. Today, George will be sharing with us the challenge of rapid guideline development in an ever changing environment. So George, thanks so much for joining us today.
(00:02:08) Thank you for having me, I appreciate the opportunity to talk about this. From our perspective, as you've said in your introduction, this once in a hundred year event has caused many challenges, and one of the major challenges that evolved early in the preparation for the pandemic was the tension, the natural tension between people wanting information about how to manage patients, and making sure that information that is provided is as robust and as evidence-based as possible. And that tension plays out very much between the need to know basis and, I guess, the conservative nature of not providing misinformation. That also, in a sense, causes people who don't feel they're getting the information in a timely way to go to other sources, and some of those sources are not as reliable as others.
There's also at the beginning of this, I think a little delay in the Commonwealth and state government putting out guidelines. They too were going through their own processes, and so there's this idea of living guidelines which the Cochrane Collaborative has defined, started to come into our vernacular, started coming to our thinking that we needed to have a rapid process of developing guidelines so that we could get information out, but would have the caveat that as living guidelines these guidelines would be subject to change, that they're only as good as the information that we have currently, and that we build up the expectation in the people that are using the guidelines that it's okay that these guidelines are updated frequently because the information that we get changes frequently as well.
So that was our challenge, how do we move away from our tried and true method of guideline and policy development into this new world of dissemination of information while maintaining a good governance structure around the way this information is crafted, the way that information is disseminated, and the way the information is monitored and audited so that when there are changes we could then provide those, that updated information, to our clinicians?
It was also about making sure this information was broadly available. We have a policy document system within the hospital, it's available within our intranet, within our server, our internal server, but we recognise that clinicians may want to access this information, these guidelines, from home outside our internal server. And we do have a communication platform called Workplace, which was actually developed by Facebook and is used now by quite a number of organisations, including some healthcare organisations, and it is an outward facing program that allows people to look at what's going on inside the hospital from outside the hospital, and there are some closed and open groups, so you've got some security around who can access information. So we wanted to create a COVID-19 guideline process that would be available within our iPolicy, which is our official policy platform document system available on our intranet, but also available through Workplace, and trying to get that coordinated has its challenges. Certainly has challenges in terms of uploading and version control, and how do we link all the documents together to make sure that everyone is reading the right document?
So we had to look at a number of things. Firstly, how do we author and endorse the documents, how do we do that rapidly, and how do we work with public affairs and others in the organisation to provide notification that there is a new guideline that people should be looking at, or that we've changed a guideline that people have been looking at? And so this was really the challenge, and we did come up with some solution and a process, and that's now been embedded and seems to be working well.
That's great. Please definitely talk us through that process and the solution, and I know that you're also able to share something with us, some documentation which will be great to see also.
(00:07:00) Thank you. So we as part of the Emergency Operations Centre that had been established to deal with the pandemic credited a clinical council. That clinical council was initially trying to do two things. It was trying to understand the nature of the documentation and evidence that was coming out through official channels, through the department, through everyone reading what was going on initially in places like China but then Italy, and everyone had their own craft group connections and there was lots of dissemination of information within craft groups and across health systems, but we wanted to control that. So the clinical council tried to do that in the beginning, but it became too much of a job for a council that was also looking at other aspects of clinical care across the organization. So we decided that we would actually break away and have a clinical practice guideline group that would be responsible for running that process. And we wanted this to be simple, rapid, and we had in mind, because we were thinking about redeploying staff, and we had in mind what does someone who doesn't normally work in this area need to know to successfully manage patients in an environment that they're not familiar with? And I actually looked at the Ambulance Victoria clinical practice guidelines, which paramedics are using which are very succinct and, if you like, action orientated. There are other places to go if you want to read the detail and the science behind the actions, but it was predominantly about what you have to do in the circumstance and when you have to do it.
We looked at those documents and we also started looking at how we were going to divide the hospital up into various wards, some would be COVID positive wards, some would be non-COVID wards, and when we started looking at all the wards in the hospital, someone, for some reason which I cannot fathom, allocated orange to the COVID wards. So we decided then that the templates that we would develop would all have this orange colour associated to it, so whenever anyone wanted to know something about COVID, if it was orange, that was where they would be looking.
(00:09:42) So what I'll do is I'll share my screen, and so this is really the procedure and I'll just go through this using the diagram. So as I said, we developed a COVID-19 specific clinical practice guideline committee, which would then authorise the documents. The committee consisted of three medical staff from the COVID clinical council, which is the group I mentioned earlier. We had our medical administration registrar, we had a nursing representative from nursing education, we had an Allied Health representative, we had our director of Medical Services. We had our policy document system manager who would normally do our policies ordinarily, and who was very important in terms of making sure that we were linking to existing policy where it was referenced, and myself as the chair of that committee. We sent out an expression of interest to all our units and said, "If you're going to practice differently during COVID, we want you to author a clinical practice guideline about how you're going to operate, and then that would be sent to us and we would then take it into this template, work with it, send it back if we needed to, to the primary author, but otherwise if it was fairly straightforward we would just authorise it and then upload it into those three systems I mentioned, intranet, our iPolicy documents system, and Workplace.
We also established terms of reference for the committee, and we said we would try and have a turnaround time of three business days from time of arrival of a template to time of final approval. And so these are the documents that we developed. The first thing was when we see a document... And we use Google Docs, which was the first time I've used Google Docs, because then you could actually do version control by one source of truth. And so people were in there and editing, and it was quite interesting to see you're editing a document and three other people are editing it. Sometimes what you've changed they change back, and it was all very interesting. But it was real time, and it's actually quite an interesting experience. And then we said, "How do we know when everyone is finished doing the reviewing, because you can only tell when people are in there?" You can do an audit trial, but we thought we'd just develop this template, and so most of it was about minor formatting. Someone has asked questions, but all the members of the steering committee would finish this template when everyone has made their comments I knew that the document was ready to go.
So this is our standard orange template. On top of this would be a heading which would be what the template was about, what the guideline was about, I should say, and then underneath that would be these headings. So stop, always ensure correct PPE prior to screening the patient or entering their room, that's on every single template. Special considerations, actually some language that's there that I haven't included, which talks about making sure that even in these circumstances we are mindful of our patients, consumers, and carers, their needs are always paramount, so there's something about that. But then there are also special considerations that the clinical team would have put in about the way they need to manage their patients, their conditions during COVID, and what are the special considerations in assessment, management, and disposition of the patient. So a fairly simple template. We asked people to do two pages maximum, and a flow chart would be appended if there was one necessary to do that. It was authored by the subject matter experts, it was authorised by the committee and the issue date became the version date. And as you can read in the disclaimer below that it says, "This document has been through a rapid review process, but is acknowledged that there may be questions or issues that require updating. If in reading this you identify an update required, please email," and we developed our own email address so that we could constantly get feedback from people where they felt the documents needed to be improved, and we're scanning the literature and do some of that ourselves, too. When we sent out the request to heads of units and to our divisional directors, this was the template that we asked them to use.
So this was about outline why you need a COVID-19 specific clinical requirement, and there had been one or two which had been sent to us that we've actually not uploaded because we couldn't actually find the change in the management. There was, I think, just some enthusiasm that people had that they wanted to have something in a terrible orange template. List the key related policies and procedures and guidelines. Who is your key contact, i.e. the primary author, has it been sponsored by the right person? Who were the people that you consulted with to make this document widely accepted by stakeholders? And then once that's done, with your orange template and with this checklist, please email them both to our email address. So these are some of the COVID related clinical practice guidelines that we've developed. The ones that are in yellow on your screen, if that's yellow or green, are the ones that have been put into circulation, and the ones below that are the ones that we're still going through, and on average most of them have gone in within about two or three days. There's a couple down here that we have... Actually, this isn't all the list that have also gone up, there's about 11 that have gone up already, and there's some that have been referred back to their authors because we had questions, or we didn't feel that they were consistent with our model of carers, or we couldn't work out why they wanted them uploaded under the COVID-19 clinical practice guideline page, and so we just sought some additional information.
One of the things I think that I keep saying to people when I asked about how we've done things and how we prepared is I refer them to the House of God. Now if you're younger than me you may not know the House of God, but the House of God was a book written by an author called Howard Shem, and it was in the 80s, and it was basically a survival guide for the first year of being an intern, and the House of God was the reference to the hospital in which this person worked. And at the end of the book there are 10 guides or 10 rules of the House of God. And one of the first rules, and this is a rule that I've always reflected on as an emergency physician, one of the rules is that the first thing to do with a cardiac arrest is take your own pulse. In other words, before you rush in, do a situational awareness check and work out what you need to do. And I think one of the things that happened earlier on with COVID is because there was such a sense of urgency, guidelines were being developed by departments and units which were not vetted and weren't linking different guidelines together, and so we needed to have that sense of governance. Very important to have sense of governance so that there is no difference between craft groups, no difference between units about how they were going to manage a condition, and that there was a place to go to look for these guidelines.
So I think in the early stages, as I said, we were trying to do things on the run too much. And so you do need to step back a little bit and set your structure up so that then you can bolt things onto it, and that was probably one of the early key learnings. And in some ways luckily, because of the way the pandemic has unfolded in Australia, we've had time to make sure our structures are tight and our governance is in place.
I think it's really interesting George, just in terms of the speed at being able to develop what you've referenced or called the living guidelines and understand that wider impact of going through that process. So have the staff embraced it, and do you think that it's something that you might look at adopting post-COVID-19?
00:18:55 Well it's very intense, doing it this way. I must say that the people on the clinical guidelines committee are really enthusiastic, and we can put up a document five o'clock in the evening and I can see from home at seven o'clock that there's already been someone in there doing stuff. We want to get out an updated PPE guide today, and that was given to us by the subject matter experts yesterday at about six o'clock, 6:00 PM, and we got it posted today at midday because there was a real need for the organisation to have the updated guidelines. So I think the intensity makes it difficult to sustain, but I do like the fact that we've simplified our templates, because a lot of our hospital policies and procedures are very verbose and are probably too detailed, and we need to make sure that practice guidelines and evidence and information supporting them are in different places.
We might leave it there with the interview, and thank you so much for joining us today. And also we'd just like to take a moment to thank you for all the hard work that you are doing during this time, and that of your team and the staff at Melbourne Health.
Thank you, I certainly appreciate that. I think one of the pleasing things about what's been happening is how healthcare workers have really rallied together. And this is, as I said before, a once in a hundred-year event, and when we are tested like this it's just amazing to be able to watch how people do come together. And I think also the community support that we've had as well has been really uplifting, and I think if there's something positive to take out of this it's that we can show that we can innovate, we can show that we can respond to a crisis such as this. And I guess thank God that we don't have to respond, or hopefully won't have to respond to the crisis in the magnitude that we have seen our colleagues overseas respond to, but I still think that we can celebrate our successes.
Yeah, I agree, there are some positives that have come out of this situation. I know there's been a lot of community support for Melbourne Health and the team, so that's been fantastic. So as mentioned, the material that you spoke through today will be made available post-interview, and it will accompany George's interview on our website. Next week we'll be speaking to Professor Harvey Newnham, who is Director of General Medicine and Clinical Program Director of Emergency and Acute Medicine at Alfred Health. And look, I'm going to encourage anyone out there, our clinicians out there, if you would like to become involved in the Connecting Clinicians COVID-19 series, then we'd really love to hear from you. So the faster that we can share the great work that's taking place, like we've heard today at Melbourne Health, both here and in New Zealand, then the better. So please drop us an email at firstname.lastname@example.org. So before we leave George, before we say goodbye I thought is there anything, any final note that you'd like to share with your fellow colleagues and clinicians, both here and in New Zealand?
Look, again, I'd just like to echo how wonderful it is to see the cooperation that has come about. We were struggling to get tele-health outpatient appointments, and that's now just exploded using technology like Zoom, we hope will become everyday practice. What has been really good here is the way that the teams that are normally separate units have come together to work out from a patient-centered or patient perspective which clinicians need to be working together to manage the problem. So we've got respiratory, general medicine, and infectious diseases coming together to form team COVID. So it's a unit that has been formed for a particular condition and we haven't had that really before, and I'm hoping that next year we might have team flu, or something else that we bring together the experts to deal with a particular problem, and not so siloed as we often are in our separate units. So lots of innovation, lots of good things that we can keep going. I guess the only concern we have is that when it's over those good ideas go away with it, and we don't want that to happen.
No, this is so true. So hopefully we can be a part of bringing all those things together. And thank you once again, George, for your time today, and for also sharing those last few words. So on that note, until next time, stay safe and Kia Kaha.