In the situation where we have clear evidence-based practice guidelines, should a provider be able to order outside of the guidelines?”
1) The short answer is yes, but qualified. A doctor should always be able to practice medicine as they see fit which would mean they should be able to order something other than what the guidelines say. If the change cannot be shown to be harmful to the patient while also offering a potential benefit, the doctor should be allowed to enter the order.
However, the guidelines exist so that the best possible care is consistently provided to all patients. A well-written order set that is part of a systematic review process should seldom be ignored. I would want the doctor to be given the opportunity to justify the change and for the hospital to explain why they discourage making modifications to the orders in an approved care set. The creation and implementation of effective order sets can take months (Nolin & Hatton, 2015). If a given provider chooses to ignore those researched and tested orders in favor of their own, a discussion between administration and that provider must take place. The doctor’s reasoning must be heard and perhaps the order set in question should be changed. If the doctor’s change order is a better way to address an issue, it should be added to a future version of the order set.
Additionally, the hospital system should run reports on who creates their own orders and the frequency with which this happens. If the percentage of deviation falls outside some pre-defined limit, the hospital administration must then do the work of addressing those providers individually. Perhaps it is simply a need for education; the doctor was not aware of the care set’s details. Perhaps the doctor’s change is a better way to address a problem and should be incorporated into future versions of the care set. At the worst, the doctor is well aware of the care set and the reason for its use but refuses to use it for personal reasons. In such a case the hospital should treat the continued use of the personal orders as a potential malpractice situation. The doctor is effectively practicing medicine that goes against the known and accepted standard of care.
Reference
Nolin, J., & Hatton, K. W. (2015). The four essential steps to effective order set management and their implementation at University of Kentucky healthcare. Elsevier. https://www.elsevier.com/__data/assets/pdf_file/0003/150429/The_Four_Essential_Steps_to_Effective_Order_Management.pDr
2) Good evening everyone,
When considering whether or not a provider should be able to order outside of evidence-based practice guidelines, we must first understand the circumstances of the situation, and why the provider would want to deviate. Most providers are aware of how much effort and research it takes to create evidence-based guidelines, but I would first verify with the provider if there was a particular component that they disagreed with, or the entire guideline itself. Perhaps the provider simply wants to substitute an alternative antibiotic in a SCIP protocol due to a patient allergy, and this request has led to a discovery that the guideline should be updated to allow for other providers to make this substitution when appropriate as well. But if the provider disagreed with major components of the guideline, further discussion should be made. I would mention that evidence-based practice is important because medical knowledge and practice change rapidly and the volume of research continues to expand exponentially, therefore integrating the evidence into practice makes it easier to assess and treat patients with up-to-date knowledge (Duke University and University of North Carolina at Chapel Hill, 2019). It is difficult for providers to stay abreast of all the newest medical information. According to the Agency for Healthcare Research and Quality, there were about 35 systematic reviews, 59 randomized or controlled clinical trials, and 166 observational studies published daily in 2017 (Chang & Borsky, 2019). However, “evidence on its own, is never sufficient to make a clinical decision” (Dotson, 2008). Anjum and Mumford debated evidence-based medicine and policy philosophically, and argued that this can be a form of utilitarianism, because it requires the provider to follow the evidence that brings the most benefit, but in doing so, there is an acknowledgement that in some cases it may not bring a benefit and may result in harm (2017). They further studied Hooker and the thought that an evidence-based approach could be considered a rule of consequentialism, and his view that rules are there to tell you what you can do, not what you should do, also that rules can include additional rules for when to break them (Anjum & Mumford, 2017). Certainly providers should be able to raise concern based upon their expertise and thoughtful responses should be provided, with escalation to an ethics panel if warranted.
References
Anjum, & Mumford, S. D. (2017). A philosophical argument against evidence‐based policy. Journal of Evaluation in Clinical Practice, 23(5), 1045–1050
Dotson, W. D. (n.d.). Evidence-Based Practice: What It Is and Why It Matters [PowerPoint slides]. Centers for Disease Control and Prevention.
https://www.cdc.gov/genomics/about/file/print/Evidence-Based_Practice_508.pdf
