Recent years have seen a proliferation of documents aimed at standardising and improving medical care. These are variously known as standards, guidelines and protocols and are developed at local, national and even international level. There are no firm, accepted definitions of these terms, and in practice they are often used interchangeably. However, the term ‘minimum standards’ tends to be used for establishing general standards of services and care to which practitioners and units should aspire, while ‘protocols’ tends to refer to specific management of a particular condition or group of conditions. ‘Guidelines’ is commonly used in both contexts.
Such documents are increasingly used throughout medicine. They are seen as an efficient way of maintaining good practice, although they may have some disadvantages (Table 172.1). They are generally seen as an important part of risk management.
Current national standards and guidelines
In the UK, the Association of Anaesthetists of Great Britain and Ireland (AAGBI) has produced a series of standards and guidelines over the past 20 years. In the field of obstetric anaesthesia, the Obstetric Anaesthetists’ Association (OAA) produced its Recommended Minimum Standards for Obstetric Anaesthesia Services in 1994. In 1998, both organisations jointly produced Guidelines for Obstetric Anaesthesia Services, which was most recently updated in 2013. This important document specifies recommendations for staffing levels; acceptable response times; monitoring during regional analgesia and caesarean section; theatre, recovery, high-dependency and intensive care unit facilities; availability of blood; consent; support services; assistance and departmental guidelines. In addition, it has a section on professional relationships with midwives and obstetricians.
The Royal College of Anaesthetists (RCoA) produces an online document, Guidelines for the Provision of Anaesthetic Services (GPAS), which has a chapter dedicated to obstetric service provision. This covers staffing requirements, equipment and support services, training, governance, organisation and areas of special requirement such as the acutely unwell or obese parturient. The RCoA has also produced an audit recipe book (with an obstetric section) that details standards of care for trusts to measure themselves against, as a method of maintaining and improving quality of service.
In 1999, the Royal Colleges of Midwives and Obstetricians and Gynaecologists published Towards Safer Childbirth - Minimum Standards for the Organisation of Labour Wards, setting out recommendations for organisational aspects of maternity services and risk management, which was updated in 2007.
Table 172.1 Advantages and disadvantages of minimum standards, guidelines and protocols
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Advantages |
Can support local departments/units in their argument for adequate resources/facilities Encourage practitioners/units to examine their own practice and establish good risk-management procedures Represent an overview from established authorities Increase uniformity of practice, especially where there is a large turnover of staff Allow better adherence to evidence-based practice Improve management of rare but serious conditions, e.g. anaphylaxis, major haemorrhage Can be used for teaching and training of staff May reduce the risk of medicolegal claims Required by most accreditation/assessment authorities as an indicator of good risk management |
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Disadvantages |
Require continuous updating and removal when obsolete Lay the organisation or individuals open to potential criticism if not adhered to or if badly written May be ignored if the targets set are seen as unrealistic May restrict clinical freedom May result in blind adherence to a set management path, even though it may be inappropriate in certain circumstances May remove the incentive to 'think for oneself’ Rely on consensus; if opinions vary widely the resultant protocol may be too loose to be useful |
The National Institute for Health and Care Excellence (NICE) aims to produce evidence-based guidance on best practice, and it has an extensive section on obstetric care that covers topics such as midwifery staffing, use of intraoperative cell salvage and maternal request for caesarean section.
In the USA, the American Society of Anesthesiologists (ASA) produced its Guidelines for Regional Anesthesia in Obstetrics in 1988 and amended them in 1991. Practice Guidelines for Obstetrical Anesthesia, the report by the ASA’s Task Force on Obstetrical Anesthesia, was produced in 1999 and most recently updated in 2016; it aims to be evidence-based, covering most aspects of obstetric anaesthetic practice. The ASA’s Guidelines for Regional Anesthesia in Obstetrics and Optimal Goals for Anesthesia Care in Obstetrics (the latter produced jointly with the American College of Obstetricians and Gynecologists, ACOG) were published in 2000, and were subsequently replaced by a new document published in 2009 by ACOG and ASA entitled Optimal Goals for Anesthesia Care in Obstetrics.
Local protocols and guidelines
It is important that these are written clearly and unambiguously. Once a protocol has been written, it becomes an important legal document (e.g. in future claims that negligence occurred) even if it has not yet been formally introduced, since merely by existing it demonstrates that any other management is suboptimal. This potential exposure to criticism and possibly legal action has deterred some clinicians from utilising protocols more widely.
Each version of a protocol should be dated and previous ones removed in order to maintain consistency throughout the unit. Obsolete ones should be stored, since subsequent legal actions may refer to guidelines that were in force at the time of the supposed mismanagement.
Although there have been calls for national protocols that can be used by all units, most prefer to alter basic schemes to suit the local circumstances.
Writing a protocol requires the clinical problem or procedure to be carefully defined at the start. It is important that protocols are written by multidisciplinary groups and that all individuals involved are consulted before their introduction, since the protocols must be willingly followed by all clinicians unless specific exclusion criteria are met. Management of cases meeting exclusion criteria should also be covered. It is equally important that adherence to the protocol is audited to ensure consistency of management.
Medicolegal considerations
As a method of protecting the practitioner from legal actions for negligence, documents of this type are obviously a double-edged sword, since they could be a useful weapon for lawyers when the stated standards have not been achieved.
In practice, however, standards and guidelines have not been afforded a great deal of weight in courts of law in the UK or USA. This is partly because, although they may reflect the views of a group of senior and respected practitioners, they are rarely firmly based on good scientific evidence, and there is often an equally respectable opinion that would support a different course of action or standard of care. Furthermore, since such documents and their authors cannot be cross-examined in court, greater weight is often attached to the evidence given directly by expert witnesses. Finally, guidelines and protocols cannot cover every clinical scenario, and expert clinical judgement must be applied to determine the most appropriate management of individual patients.
Key points
• Minimum standard documents provide a useful reference when developing local protocols and are an impetus to improving and maintaining the quality of medical care.
• Local protocols and guidelines can improve clinical management and form an important part of risk management.
• Many potential problems can be avoided by careful writing and achieving consensus.
• Each copy should be dated, and obsolete versions removed from all clinical sites and kept for future reference.
Further reading
ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 433: optimal goals for anesthesia care in obstetrics. Obstet Gynecol 2009; 113: 1197-9.
American Society of Anesthesiologists. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2016; 124: 270-300.
McGarrity L, O’Connor R, Young S. A national survey of obstetric anaesthesia guidelines in the UK. Int J Obstet Anesth 2008; 17: 322-8.
National Institute for Health and Care Excellence. Fertility, pregnancy and childbirth. NICE guidance. www.nice.org.uk/guidance/conditions-and-diseases/fertility-pregnancy-and-childbirth (accessed December 2018).
Obstetric Anaesthetists’ Association, Association of Anaesthetists of Great Britain and Ireland. OAA/
AAGBI Guidelines for Obstetric Anaesthetic Services, 3rd edn. London: AAGBI, 2013. www .aagbi.org/sites/default/files/obstetric_anaesthetic_services_2013.pdf (accessed December 2018).
Royal College of Anaesthetists, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, Royal College of Paediatrics and Child Health. Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour. London: RCOG Press, 2007. www.rcog.org.uk/globalassets/documents/guidelines/wprsaferchildbirthreport2007.pdf (accessed December 2018).
Royal College of Anaesthetists. Guidelines for the Provision of Anaesthesia Services for an Obstetric Population 2018. GPAS, Chapter 9. London: RCoA, 2018. www.rcoa.ac.uk/system/files/GPAS-20 18-09-OBSTETRICS.pdf (accessed December 2018).
Royal College of Anaesthetists. Raising the Standard: a Compendium of Audit Recipes, 3rd edn. London: RCoA, 2012. www.rcoa.ac.uk/ARB2012 (accessed December 2018).