September 1999
Volume 63 |
Number 9
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| Practice Parameters:
Some New; Others Under Development or Revision |
James F. Arens, M.D.,
Chair
Committee on Practice Parameters
The process of developing rigorous and useful practice parameters
continues at a strong pace, under the direction of the Committee
on Practice Parameters.
Practice Parameters Recently Published
Two practice guidelines were approved by the ASA House of Delegates
in 1998 and published in the spring of 1999. According to task
force members, both guidelines have been very well-received by
the practicing community.
• Guidelines
for Preoperative Fasting. Anesthesiology. 1999; 90:896-905.
Mark A. Warner, M.D., at the Mayo Clinic, Rochester, Minnesota,
chaired the task force. These guidelines provide a succinct synthesis
of available scientific evidence, with emphasis on a rational
and cost-effective approach to management.
• Guidelines
for Obstetrical Anesthesia. Anesthesiology. 1999; 90:600-611
Joy L. Hawkins, M.D., of the University of Colorado Medical
Center, Denver, Colorado, chaired the task force. These guidelines
provide a rigorous and balanced analysis of current scientific
literature and practitioner opinion.
Suggested Revision of ASA Policy Statement on Practice Parameters
The Committee on Practice Parameters is recommending a
minor revision of the ASA Policy Statement on Practice Parameters.
As previously reported to the Board of Directors, the committee
has determined that adequate scientific evidence is difficult
to obtain for many aspects of clinical practice that might be
considered appropriate topics for practice parameters. To meet
the need for guidance in the absence of sufficient scientific
evidence, the committee has developed a new type of practice parameter
called a practice advisory.
Practice advisories are systematically developed
reports that are intended to assist decision-making in areas of
patient care where scientific evidence is insufficient. Advisories
provide a synthesis and analysis of expert opinion, clinical feasibility
data, open forum commentary and consensus surveys. Advisories
are not intended as standards or guidelines. They may be adopted,
modified or rejected according to clinical needs and constraints.
Practice parameters are developed to provide guidance
or direction for the diagnosis, management and treatment of specific
clinical problems. The term "practice parameter" may refer to
Standards, Guidelines or Advisories.
Practice standards are rules or minimum requirements
for clinical practice. They represent generally accepted principles
for sound patient management. They may include statements of practice
policy and protocol or specific recommendations for patient management.
Standards evolve through a variety of processes that draw upon
broad-based consensus and the consideration of scientific evidence.
Standards may be modified under unusual circumstances, e.g., extreme
emergencies, unavailability of equipment, etc.
Practice guidelines are systematically developed
recommendations for patient care that describe a basic management
strategy or a range of basic management strategies. Guideline
recommendations are supported by analysis of the current literature
and by a synthesis of expert opinion, open forum commentary, clinical
feasibility data and consensus surveys. Guidelines are not intended
as standards or absolute requirements. They may be adopted, modified
or rejected according to clinical needs and constraints.
Variances from practice parameters may be acceptable based
upon the judgment of the responsible anesthesiologist. Practice
parameters are intended to promote beneficial or desirable outcomes
but cannot guarantee any specific outcome. Practice parameters
are subject to periodic revision as warranted by the evolution
of medical knowledge, technology and practice.
The ASA Board of Directors and House of Delegates recommends
subjects for practice parameters. Committees that develop practice
parameters are not empowered to define interpretations for specific
institutions, organizations or practices.
Members of the Society are responsible for interpreting
and applying practice parameters in their own institutions and
practices. The practice parameters developed by ASA are not intended
as unique or exclusive indicators of appropriate care. An individual
physician should be able to show that the care rendered, even
if departing from the parameters in some respects, satisfies the
physician's duty to the patient under all the facts and circumstances.
In addition to Standards, Guidelines and Advisories, the
ASA House of Delegates has approved a number of documents variously
titled Statements, Positions or Protocols. These documents represent
opinions of the House on a variety of subjects, but have not necessarily
been subjected to the same level of formal scientific review as
Standards, Guidelines or Advisories. Variances from the opinions
expressed in these documents may also be acceptable, based on
sound judgment of the responsible anesthesiologist.
Practice Parameters Under Development
The new practice parameters are as follows:
Advisory on Patient Positioning: Dr. Warner chairs this
task force. A practice advisory for Patient Positioning in Anesthesia
will be ready for consideration by the House of Delegates in October
1999.
The Task Force on Patient Positioning has completed its draft
and intentionally limited its scope to peripheral nerve injuries.
However, ASA and Dr. Warner have been asked by several members
to address the issue of perioperative blindness (ischemic optic
neuropathy). Therefore, I have recommended that this task force
develop a practice advisory on the subject of Perioperative Blindness.
Dr. Warner feels this can be done in two meetings, one of which
can be held in Dallas at the Annual Meeting.
Advisory on Preanesthesia Evaluation: In response to
continued interest from the ASA membership, the Task Force on
Preoperative Testing has reconvened under the direction of L.
Reuven Pasternak, M.D. Due to the lack of sufficient scientific
evidence, the task force will develop a practice advisory rather
than a practice parameter. The task force will endeavor to develop
a document that recognizes the diversity of evaluation needs and
capability in different practice settings and emphasizes the importance
of individualized judgments. This advisory should be ready for
consideration by the House of Delegates in October 2000.
Advisory on Recovery from Anesthesia: In response to
the rapid growth in ambulatory and outpatient anesthesia, the
committee has recommended a practice advisory on recovery from
anesthesia. Jeffrey H. Silverstein, M.D., will chair this task
force. The task force will hold its first meeting toward the end
of 1999, and a completed product is anticipated in 2000 or 2001.
Advisory on Basic Expectations for Anesthesia Practice: The
intent of this advisory is to articulate a set of fundamental
and mutually compatible expectations about the practice of anesthesia
as an individual or as part of an anesthesia care team. The advisory
would focus on the basic or minimum expectations regarding such
features of care as the preoperative evaluation, intraoperative
conduct of anesthesia, medical direction ratios and postoperative
care. This advisory would be highly dependent upon consensus formation
and broad-based opinion surveys. The committee believes that this
task force should be composed of senior-ranking members of ASA.
Carl C. Hug, Jr., M.D., has agreed to serve as chair. Members
of the committee who have volunteered to serve with Dr. Hug include
David Glass, M.D., Michael A. Ashburn, M.D., and Dr. Silverstein.
Dr. Silverstein wishes to serve as a consultant. Drs. Arens and
Hug will develop a final list of task force members. This task
force will convene in 2000
Parameters Undergoing Revision
Existing practice parameters are subject to periodic review
and revision about once every five years. At the request of the
committee, the Guidelines for Management of the Difficult Airway
and the Guidelines for Pulmonary Artery Catheterization (both
initially approved in 1992) are now undergoing review.
Robert A. Caplan, M.D., of the Virginia Mason Medical
Center, Seattle, Washington, will chair the task force for the
review of the Guidelines for Management of the Difficult Airway;
Michael F. Roizen, M.D., of the University of Chicago, will chair
the task force for review of the Guidelines for Pulmonary Artery
Catheterization. Both task forces will perform a systematic re-evaluation
of all guideline objectives, evidence and content. Specific emphasis
will be placed on the examination of recent changes in knowledge,
technology and patterns of practice.
An Open Forum on the proposed revisions for the Guidelines
for Management of the Difficult Airway will be held on October
9, 1999, in Dallas from 2 to 5 p.m., at the Adam's Mark Hotel
in conjunction with the ASA Annual Meeting (page 28). Revisions
of both guidelines should be ready for consideration by the House
of Delegates in October 2000.
A revision of the Guidelines for Sedation and Analgesia
by Nonanesthesiologists will commence in 2000, and a revision
of the three guidelines for pain management (Acute Pain Management,
Cancer Pain Management, Chronic Pain Management) will be considered
in 2001.
Brief Update on Practice Parameter Development
A detailed description of the development process for
practice parameters can be found in the 1997 committee's Annual
Report. A few highlights are mentioned here.
A member of the committee closely monitors each practice parameter.
Monitoring assures that parameters are appropriate in scope and
purpose.
The extensive technical and analytic aspects of practice
parameter development have been successfully consolidated into
a single, efficient methodology unit. This unit is composed of
two experienced health service analysts and a research librarian.
These individuals utilize state-of-the-art techniques for literature
searching, clinical surveys and scientific analysis of the available
evidence. The extensive bibliography associated with practice
parameter development is now continuously stored and updated in
CD format. The activities of the methodology unit are directly
supervised by a member of the committee, Dr. Caplan. The cost
of parameter development remains low compared to that of other
specialties, primarily due to the policy of voluntary (uncompensated)
participation by task force members and the efficiencies of the
methodology unit.
Of special note, the process of developing practice parameters
creates an extensive and valuable repository of information for
the ASA membership. A technique for archiving this information
on CD-ROM has recently been developed and successfully deployed.
This technology also includes a "search engine" that facilitates
the recovery of specific data.
Approved parameters are published in Anesthesiology
and reprints are available from the ASA Executive Office. Practice
parameters are also available for inspection and downloading
at the ASA Web site.
The Committee on Practice Parameters gratefully acknowledges
the valuable contributions of task force chairs, task force members,
consultants and other members of ASA who have participated in
the development of evidence-based guidelines. The committee welcomes
suggestions for new parameter topics and for ways to improve the
development process.
James F. Arens, M.D., is Vice President
for Clinical Affairs, Chief Executive Officer and Professor of
Anesthesiology at the University of Texas Medical Branch, Galveston,
Texas. He served as ASA President in 1989.
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