TRAUMA: making trauma clinical guidance more implementable

Abstract

Introduction: Trauma clinical guidance (guidelines, protocols, algorithms, etc) has been shown to improve patient outcomes; however, it is only used in about half of the patients to whom it applies. Guidance implementation is affected by intrinsic factors (eg, guidance format) as well as extrinsic factors (eg, the clinical environment). Recommendations and frameworks have been created to aid in the development of implementable guidance. We hypothesize that existing trauma clinical guidance lacks elements important for implementation.

Methods: The Framework for Guideline Implementability by Gagliardi, which consists of 22 elements arranged into eight domains, was used to evaluate trauma clinical guidance. A sample of 20 pieces of guidance, crafted by 11 professional organizations, were reviewed. Data were extracted to identify the presence or absence of each implementability element.

Results: All guidance provided a clear objective and 85% allowed for individualized application of recommendations based on clinical scenario. Approximately half of the guidance included formatting elements, such as graphic aids, to enhance usability, and 50% incorporated formal evidence grading. Patient-friendly tools accompanied 10% of guidance, and few discussed implementation strategies (25%) or quality metrics (30%) to evaluate guidance implementation.

Discussion: Clinical guidance exists on a spectrum, from narrative (eg, written documents) to executable tools (eg, automated decision support based on patient context). While integration of computable guidance into clinical workflows may be the ultimate goal in high-resource settings, there are other more feasible and even cost-free modifications developers may integrate into new guidance to improve implementation across settings.

Conclusion: Utilization of trauma clinical guidance is crucial for improving healthcare quality. To achieve this, guidance developers might leverage the elements in the new TRAUMA (Transparency, Robust inclusivity, Adaptability, Usability, Measurability, Accessibility) framework that enhance implementability. Future research is needed to validate this theoretical new framework's impact on clinical implementation and patient outcomes.

Level of evidence: IV.

Keywords: guidelines; implementation.

Figure 1. Knowledge levels. CDS, clinical decision support; CQM, clinical quality measure.

Figure 2. Redesigning guideline development and implementation: the integrated process. CDS, clinical decision support; CQM, clinical quality measure.

Figure 3. TRAUMA (Transparency, Robust inclusivity, Adaptability, Usability, Measurability, Accessibility) framework for guideline implementability.