Clinical guidelines, clinical pathways and care protocols

Development and implementation according to MBE

Ideally, the guidelines should be developed using the EBM method. But since this requires a great deal of resource consumption, time and means a certain degree of complexity, another possible option is the local adaptation of guides already elaborated with the MBE method and validated. This process has general acceptance and serves to improve the sense of belonging that local professionals will have in front of this instrument. GPC adaptation requires valid GPC search, identification, review, and analysis before deciding which recommendations to adopt and serve as the basis for their implementation at the local level.

The process for the development and evaluation of CPGs should be oriented to results.The scope of the guide will depend on the definition of the population to which it is directed and the objectives that are pursued with the application of the guide.

The development and implementation of CPG, according to the MBE method, requires a systematic approach that considers three phases and 10 stages:

Phase I: development of the guide. Steps I to VII.
Phase II: implantation. Step VIII.
Phase III: evaluation and updating. Stages IX and X.


Importance of standardization in clinical practice

Around clinical management, we have established the importance of standardizing clinical practices. She helps to solve the problems of variability by producing documents based on available scientific evidence.

In the health culture, the importance of standardization of clinical practices has gradually been recognized as dynamic information tools that establish guidelines to optimize the care of each patient. Despite this, there is no common criterion to name them and they are under different names, such as guidelines, routes, guidelines of clinical practices, protocols.

In our environment it is important to establish the conceptual difference between Clinical Practice Guide (GPC), protocol and algorithm, for which the following definitions are presented.

Types of tools for standardization

Guide clinical practice (GPC) is a document that contains systematically developed statements to assist health personnel and patient decisions about appropriate health care for specific clinical picture.

Protocol of medical care: it is a document that describes in brief the set of technical and medical care needed for a specific health situation procedures. The protocols can be part of the CPG and are used especially in critical aspects that require total attachment to the indicated, as it happens in emergencies (resuscitation) or when there is legal regulation, as in forensic medicine.

Algorithm: is a graphical representation in the form of a flow chart of a finite set of steps, rules or logical procedures, successive and well defined, to be followed to solve a specific diagnostic or therapeutic problem. Also called an algorithm is the sequence of ordered steps that lead to solving a problem.

Clinical pathways: are care plans that apply to patients with a given disease, presenting a predictable clinical course. Clinical pathways are also known as care maps, practical guidelines, care protocols, coordinated care, integrated care pathways, care pathways, multidisciplinary, collaborative care programs, early discharge routes, pathways of care or management of clinical cases.

They are a way of adapting clinical practice guidelines or protocols to the actual and concrete exercise of a center. They are the operative version of the clinical guidelines.

The guidelines or protocols define the care or care that the patient should receive. The pathways define when, how and in what sequence the care or care should be provided and also specify the objectives of each phase.

The clinical pathway is a clinical management tool designed to facilitate the systematic and multidisciplinary care of the patient and does not replace the clinical judgment of the professional, but rather complements it.

Clinical Practice Guidelines


“They are a proposal that supports the decision of the physician in the choice of procedures and behaviors that must be followed before a patient in specific clinical circumstances, to improve the quality of medical care, to reduce the use of unnecessary, ineffective or harmful interventions, Facilitate the treatment of patients with maximum benefit and minimize the risk of harm. “Sackett DL, 1985.

“Clinical guidelines are systematic recommendations based on available scientific evidence to guide the decisions of practitioners and patients about the most appropriate and efficient health interventions in addressing a specific health-related problem in specific circumstances.” Field and Lohr, 1990.

“The Clinical Practice Guidelines are technical-medical instruments that describe standard, explicit, reproducible and objective procedures for diagnosis, useful for systematizing the behavior that must be followed in the care of certain health problems and guiding the definition of the health plan. Treatment through protocols and algorithms that allow the provision of correct and open assistance for evaluation. “Mexican Social Security Institute.

“Recommendations systematically developed to assist professionals and patients in making informed decisions about the most appropriate health care, the choice of the most appropriate diagnostic or therapeutic options in the approach to a health problem or a specific clinical picture.” Institute of Medicine, United States.

We can see in these definitions written in different moments of the decades just past, that in their origin the guides appear as orientations limited to the exclusive exercise of medicine. However, with the passage of time they have been expanding to all health care, to the current vision in which it is multiprofessional and, as we will see later, also of multiple processes.


The CPGs are intended to serve as instruments for improving quality, with the aim of:

  • Improve the quality of clinical exercise.
  • Reduce unwanted variation in the clinical exercise.
  • Systematize the focus of the main reasons for medical care that the population presents.
  • Unify within a framework of clinical flexibility, institutional health care criteria.
  • Establish the minimum indispensable criteria for the management of the main reasons for health care based on the institutional organization by levels of care.
  • Guiding clinical decision making.
  • Reordering or, as appropriate, developing and keeping up-to-date the technical-medical criteria of the reference system and against reference between the different levels of care of the organization.
  • To be a substantive element for the objective evaluation of the quality of medical care.
  • Promote the continuous and accessible updating of knowledge in all levels of care.
  • Promote the integral management of the patient with measures at all levels of care.
  • Encourage the appropriate use of medical technologies.


Because clinical guidelines are based on the best available evidence, they should be reviewed regularly to incorporate, as necessary, the results of new research, new technologies and the evaluation of results from other clinical guidelines. The need to meet specific requirements for the interpretation of clinical guidelines is not trivial.Several studies have thoroughly evaluated the quality of interpretation and implementation of clinical guidelines and the need for greater methodological rigor has been demonstrated.

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