Clinical practice guidelines (CPGs) are intended to improve the quality of clinical care by promoting evidence-based care, reducing inappropriate variation, and producing optimal outcomes for patients.

The Royal Children's Hospital (RCH) in Melbourne, Australia, has a long history of developing and implementing CPGs to ensure the provision of high quality care for children and young people. A CPG committee was established in 1996 with the aim of developing guidelines for management of common and important paediatric conditions.

The original RCH CPG committee comprised senior and junior doctors and nurses from the departments of general medicine and emergency medicine. Development of the CPGs has evolved, but the core processes and principles remain the same. A member of the committee reviews the available evidence related to the condition in question, its diagnosis, the value of investigations, and the role of interventions. This review starts with published systematic reviews and other national and international guidelines, including Australian Therapeutic Guidelines (https://www.tg.org.au/). A draft CPG is prepared and reviewed by a second committee member, before consultation with appropriate subspecialists and other relevant health care professionals. A final draft is then presented at a CPG committee meeting. The aim of meetings is to endorse content that is based on clear evidence and to achieve consensus recommendations where the evidence is poor or lacking. Content and style are reviewed to ensure that recommendations are clear and practicable.

An important principle is that CPGs are generally point-of-care guidelines with emphasis on assessment and management, and as such, they are kept brief and focused. Key points and red flags are highlighted, and advice on disposition, including admission, discharge, escalation and transfer, is provided. Levels of evidence are not provided for individual recommendations; however, references and all those consulted in the development of the CPG are documented. The emphasis is on an appropriate balance between detailed evidence appraisal and pragmatic and timely translation of evidence into CPGs. It is felt by the CPG committee and users of the CPGs that the adoption of a formal GRADE or similar approach to developing guidelines would not add to the utility of the CPGs and would hinder the process. Between 30 and 40 new and updated CPGs are published each year.

Although the CPGs have always been freely available online, they were originally focused on practice at RCH. In 2011, the RCH CPG group partnered with Safer Care Victoria's Paediatric Clinical Network to adapt CPGs for use across the state. Given their free availability and accessibility, the CPGs were being used in many other settings in Australia and even overseas. The CPGs have been widely available via an app since 2015, and a new app was launched in 2022 (https://www.rch.org.au/rch/apps/Clinical_practice_guidelines_app/).

CPGs have historically been produced by each state (and even individual hospitals) in Australia. The production and maintenance of CPGs is a costly and time-consuming process. Moreover, use of and adherence to local guidelines in other states has not been optimal. A study examining use of CPGs in ten emergency departments in rural and regional New South Wales found that only 22% of medical officers reported that they used the CPGs frequently when managing sick children.¹ Major barriers to the use of CPGs were a lack of awareness of their existence, a lack of training in their use, and poor access to the guidelines in printed or electronic format. The CareTrack Kids study measured adherence to CPG recommendations for 17 common childhood conditions and identified barriers that prevent appropriate delivery.² Overall adherence was 59.8%, with substantial variation across conditions. Some of the factors leading to poor adherence include redundancy, lack of currency, inconsistent structure and content, voluminous documents, and concerns about the quality of evidence on which CPGs are based. While there is no direct evidence of harm occurring because of poor adherence to CPGs (or lack of national CPGs), it is increasingly clear that reducing variation in care is an important step in improving patient health outcomes through appropriate care.³

In an effort to reduce variation in care, avoid duplication of work and reduce cost, a collaborative between RCH, Clinical Excellence Queensland, the NSW Agency for Clinical Innovation, and Safer Care Victoria was formed in 2018. The aim of this Paediatric Improvement Collaborative (PIC) was to adapt the CPGs so that they would be appropriate for use in NSW, Queensland and Victoria. To this end, several part-time CPG fellows, two part-time consultants and a CPG manager were appointed with funding from Clinical Excellence Queensland, the NSW Agency for Clinical Innovation, and Safer Care Victoria. The CPG committee was expanded to include a broad group of clinicians from general paediatrics, emergency medicine and general practice, including doctors (consultants and trainees), nurses, allied health practitioners and pharmacists from health services across the three states. The development of PIC CPGs is guided by a set of principles, including the use of evidence-based recommendations and the involvement of relevant stakeholders. Details are provided on the RCH website.⁴ One hundred and thirty PIC CPGs are currently available with a further 170 CPGs which will be revised and adapted into PIC CPGs. PIC CPGs are reviewed every three years.

A PIC steering committee was formed, comprising representatives from each partner organisation. This group provides governance to ensure that the process for development and revision of PIC CPGs is robust and responsive. It is responsible for setting the strategic direction of the PIC and ensuring that the activities of the collaborative align with the needs and priorities of stakeholders. To this end, state-based information is still provided for a few topics such as escalation and retrieval, child protection, and antimicrobial prescribing.

In 2020, the PIC commissioned the Assessment and Evaluation Research Centre at the University of Melbourne to evaluate PIC processes and development of PIC CPGs. Three main barriers to successful collaboration and stakeholder satisfaction were identified: inadequate time for CPG committee members to review drafts, a sense from some that their feedback was not being sufficiently addressed, and the technology used for dissemination and feedback. As a result, the platform for communication and collaboration was changed to Microsoft Teams, the timelines for review were extended, and minutes are now circulated shortly after each meeting with specific details regarding the way in which feedback has been addressed.

More recently, the PIC has engaged with the Australian Institute of Health Innovation at Macquarie University to undertake evaluation of the impact and use of PIC CPGs. A national survey investigating the views and experiences of the CPGs has recently been conducted; responses are currently being analysed and follow-up qualitative interviews have been completed. The results will be published shortly, and further studies are planned. CPGs are accessed frequently around Australia and internationally; Google Analytics data showed over 5.8 million visitors in the past 12 months, 3.2 million (55%) from Australia, not including app usage.

South Australia and Western Australia have recently joined the PIC, and it is likely that Tasmania, the Northern Territory and the Australian Capital Territory will follow shortly. Plans are underway to rebadge the CPGs as the Australian Paediatric CPGs. It is anticipated that the Royal Australasian College of Physicians and the Australasian College for Emergency Medicine will help advocate for use of these CPGs. Leads in each state have a role in ensuring that they are used in preference to local guidelines. While development of evidence-based national guidelines is a priority, the goal is also to ensure that CPGs are applicable to local contexts. This will require a sustained commitment from key stakeholders, including health care professionals and government, to ensure that the guidelines are developed, implemented and evaluated effectively. A 2021 article entitled “The silent crisis of pediatric clinical practice guidelines” considered the issues facing CPG development in the United States and internationally.⁵ Recommendations made by the authors included centralised topic prioritisation and development process, regular review of CPGs, and centralised financial support. A survey of general paediatricians in the US regarding use of paediatric CPGs found that guidelines are most likely to be followed if they are simple, flexible, rigorously tested, not used punitively, and motivated by desires to improve quality and not reduce costs.⁶

The PIC CPGs fulfil most of these criteria. They are now developed by a committee that includes members from five of the eight Australian states and territories. Centralised and reliable financial support is required to sustain the process. Excitingly, we are almost at the point of having truly national paediatric CPGs in Australia.

临床实践指南 (CPG) 旨在通过促进循证护理、减少不适当的变异并为患者提供最佳结果来提高临床护理质量。

澳大利亚墨尔本皇家儿童医院 (RCH) 在开发和实施 CPG 方面有着悠久的历史，以确保为儿童和青少年提供高质量的护理。 CPG 委员会成立于 1996 年，旨在制定常见和重要儿科疾病的管理指南。

原RCH CPG委员会由全科医学科和急诊医学科的资深和初级医生和护士组成。 CPG 的开发不断发展，但核心流程和原则保持不变。委员会成员审查与相关病症、其诊断、调查的价值以及干预措施的作用相关的现有证据。本综述以已发表的系统综述和其他国家和国际指南开始，包括澳大利亚治疗指南 (https://www.tg.org.au/)。 CPG 草案由第二位委员会成员准备和审查，然后与适当的专科专家和其他相关医疗保健专业人员协商。最终草案将提交给 CPG 委员会会议。会议的目的是认可基于明确证据的内容，并在证据不足或缺乏的情况下达成共识建议。对内容和风格进行审查，以确保建议清晰且可行。

一个重要的原则是，CPG 通常是强调评估和管理的现场护理指南，因此，它们保持简短且重点突出。重点强调了要点和危险信号，并提供了处理建议，包括入院、出院、升级和转移。没有为个别建议提供证据级别；然而，参考文献以及在 CPG 开发过程中咨询的所有内容均已记录。重点是在详细的证据评估与务实且及时地将证据转化为 CPG 之间取得适当的平衡。 CPG 委员会和 CPG 用户认为，采用正式的 GRADE 或类似方法来制定指南不会增加 CPG 的效用，而且会阻碍这一进程。每年发布 30 到 40 个新的和更新的 CPG。

尽管 CPG 一直可以在网上免费获取，但它们最初主要用于 RCH 的实践。 2011 年，RCH CPG 小组与 Safer Care Victoria 的儿科临床网络合作，调整 CPG 以供全州使用。鉴于其免费可用性和可访问性，CPG 已在澳大利亚甚至海外的许多其他环境中使用。自 2015 年以来，CPG 已通过应用程序广泛提供，并于 2022 年推出了新应用程序 (https://www.rch.org.au/rch/apps/Clinical_practice_guidelines_app/)。

历史上，CPG 是由澳大利亚每个州（甚至个别医院）生产的。 CPG 的生产和维护是一个成本高昂且耗时的过程。此外，其他州对当地指南的使用和遵守也不是最佳的。一项对新南威尔士州农村和地区 10 个急诊室使用 CPG 的研究发现，只有 22% 的医务人员表示，他们在管理患病儿童时经常使用 CPG。¹使用 CPG 的主要障碍是缺乏对其存在的认识、缺乏使用培训以及难以获取印刷或电子格式的指南。 CareTrack Kids 研究测量了对 17 种常见儿童疾病的 CPG 建议的遵守情况，并确定了妨碍适当分娩的障碍。²总体依从率为 59.8%，但不同条件下存在很大差异。导致依从性差的一些因素包括冗余、缺乏流通、结构和内容不一致、大量文件以及对 CPG 所依据的证据质量的担忧。虽然没有直接证据表明由于对 CPG 的依从性差（或缺乏国家 CPG）而造成伤害，但越来越明显的是，减少护理差异是通过适当护理改善患者健康结果的重要一步。³

为了减少护理差异、避免重复工作并降低成本，RCH、昆士兰州临床卓越中心、新南威尔士州临床创新机构和维多利亚州安全护理机构于 2018 年成立了合作组织。该儿科改善合作组织的目标是 ( PIC）的目的是调整 CPG，使其适合新南威尔士州、昆士兰州和维多利亚州使用。为此，在昆士兰州临床卓越中心、新南威尔士州临床创新机构和维多利亚州安全护理机构的资助下，任命了几名兼职 CPG 研究员、两名兼职顾问和一名 CPG 经理。 CPG 委员会扩大到包括来自普通儿科、急诊医学和全科医学的广泛临床医生，其中包括来自三个州卫生服务部门的医生（顾问和实习生）、护士、专职医疗从业人员和药剂师。 PIC CPG 的开发遵循一系列原则，包括使用基于证据的建议和相关利益相关者的参与。详情请参阅 RCH 网站。⁴目前有 130 种 PIC CPG，另外 170 种 CPG 将经过修订并适应 PIC CPG。 PIC CPG 每三年审查一次。

PIC 指导委员会成立，由各合作伙伴组织的代表组成。该小组提供治理，以确保 PIC CPG 的开发和修订流程稳健且响应迅速。它负责制定 PIC 的战略方向，并确保协作活动符合利益相关者的需求和优先事项。为此，仍然为一些主题提供基于状态的信息，例如升级和检索、儿童保护和抗菌药物处方。

2020年，PIC委托墨尔本大学评估与评估研究中心评估PIC流程和PIC CPG的开发。确定了成功合作和利益相关者满意度的三个主要障碍：CPG 委员会成员审查草案的时间不足、一些人认为他们的反馈没有得到充分处理以及用于传播和反馈的技术。因此，沟通和协作平台改为 Microsoft Teams，审查时间延长，现在每次会议后不久就会分发会议记录，其中包含有关处理反馈的方式的具体细节。

最近，PIC 与麦考瑞大学澳大利亚健康创新研究所合作，对 PIC CPG 的影响和使用进行评估。最近进行了一项全国调查，调查中央人民政府的观点和经验；目前正在对答复进行分析，后续定性访谈也已完成。结果将很快发表，并计划进一步研究。 CPG 在澳大利亚和国际上经常被访问； Google Analytics 数据显示，过去 12 个月内有超过 580 万访问者，其中 320 万 (55%) 来自澳大利亚，不包括应用程序使用情况。

南澳大利亚州和西澳大利亚州最近加入了 PIC，塔斯马尼亚州、北领地和澳大利亚首都领地很可能很快也会加入。目前正在计划将 CPG 重新命名为澳大利亚儿科 CPG。预计澳大利亚皇家医师学院和澳大利亚急诊医学学院将帮助倡导使用这些 CPG。每个州的潜在客户都有责任确保优先使用它们而不是当地的指导方针。虽然制定基于证据的国家指南是当务之急，但目标也是确保 CPG 适用于当地情况。这需要包括医疗保健专业人员和政府在内的主要利益相关者的持续承诺，以确保有效地制定、实施和评估指南。 2021 年一篇题为《儿科临床实践指南的无声危机》的文章考虑了美国和国际上 CPG 发展面临的问题。⁵作者提出的建议包括集中的主题优先级和开发流程、定期审查 CPG 以及集中的财政支持。一项针对美国普通儿科医生关于儿科 CPG 使用情况的调查发现，如果指南简单、灵活、经过严格测试、不以惩罚性方式使用，并且出于提高质量而不是降低成本的愿望，则最有可能被遵循。⁶

PIC CPG 满足大部分标准。它们现在由一个委员会制定，该委员会的成员来自澳大利亚八个州和地区中的五个。维持这一进程需要集中且可靠的财政支持。令人兴奋的是，我们即将在澳大利亚拥有真正的全国儿科 CPG。