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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 3  |  Page : 299-308

Extent and feasibility of the application of the clinical pathway, clinical guideline, and practice protocol in eastern province Saudi Arabian Hospitals: A cross-sectional survey study


1 Pharmaceutical Affairs, Intensive Care Unit, Dammam Health Network, Eastern Health Cluster, Dammam, Kingdom of Saudi Arabia
2 AlNahdi Medical Company, Dammam, Kingdom of Saudi Arabia
3 Health Information Department-Coding Section, King Fahad Specialist Hospital, Eastern Health Cluster, Dammam, Kingdom of Saudi Arabia

Date of Submission19-Jan-2022
Date of Decision17-Apr-2022
Date of Acceptance18-Apr-2022
Date of Web Publication08-Jul-2022

Correspondence Address:
Zahra AL Qamariat
Pharmaceutical Affairs, Intensive Care Unit, Dammam Health Network, Eastern Health Cluster, Dammam
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsm.jnsm_9_22

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  Abstract 


Background: Diversity in clinical practice may become a problem and increase the risk of errors. Several tools have been suggested to reduce this diversity and improve unification in clinical practice. These tools include the clinical pathway, clinical guidelines, and practice protocol. They have been proven effective. However, there are different barriers to their application. Methods and Data Analysis: A cross-sectional survey in the Eastern Province of the Kingdom of Saudi Arabia aimed to identify the availability of the clinical pathway, clinical guidelines, and practice protocol and their benefits, as well as barriers in their development and utilization. Both quantitative and qualitative analyses were used to evaluate the study results. Findings are presented as numbers and percentages. Results: Clinical pathway, clinical guidelines, and practice protocol are available to a large extent in the Eastern Province. The study showed some difficulties in the development and implementation of these tools, such as insufficient training and leader support. It also provided some suggestions to overcome these barriers. Conclusion: The availability of clinical pathway, clinical guidelines, and practice protocol has helped unify practice and reduce errors in the clinical setting. The barriers can be overcome by different solutions.

Keywords: Application, barrier, clinical guidelines, clinical pathway, practice protocol


How to cite this article:
AL Qamariat Z, Alkhalifah K, Alqarni S. Extent and feasibility of the application of the clinical pathway, clinical guideline, and practice protocol in eastern province Saudi Arabian Hospitals: A cross-sectional survey study. J Nat Sci Med 2022;5:299-308

How to cite this URL:
AL Qamariat Z, Alkhalifah K, Alqarni S. Extent and feasibility of the application of the clinical pathway, clinical guideline, and practice protocol in eastern province Saudi Arabian Hospitals: A cross-sectional survey study. J Nat Sci Med [serial online] 2022 [cited 2022 Aug 17];5:299-308. Available from: https://www.jnsmonline.org/text.asp?2022/5/3/299/350307




  Introduction Top


Background

The existence of diversity may be problematic in the work area, especially in clinical practice, as it may cause medication errors.[1] Thus, different tools have been utilized to eliminate this variation, reduce errors, minimize miscommunication, and standardize clinical practice. Clinical pathways, clinical guidelines, and practice protocols are examples of these tools. The clinical guideline is a set of general recommendations developed based on best updated and/or available research or expert consensus. It aims to guide clinicians' and patients' decisions regarding care for certain medical conditions.[2] While the clinical pathway is a detailed, structured multidisciplinary action plan. It translates clinical guidelines and evidence into clinical processes. It includes interventions and actions performed in a specific order and timeframes to manage a particular group of patients with a certain disease.[3] On the other hand, practice protocols is an agreed documented plan to operate clinical process of care. It identifies responsibilities and when and where to be performed.[4] Although these tools are used and explained differently, they share the same objective. They use evidence from clinical trials and research to inform clinicians regarding the best methods of care.[5] The use of these tools has been proven effective in various aspects. For example, the incidence of adverse events significantly declined in the past 25 years via standardization of patient monitoring, dispensing of inhaled gases, and medication administration in anesthesia.[1] Moreover, the use of weaning protocol by respiratory therapists and nurses decreased the mechanical ventilation time.[6] Another example is shown in the field of obstetrics, in which standardization of antenatal testing for Group B streptococci, combined with standardization of antibiotic prophylaxis, reduced the incidence of Group B streptococcal infection in neonates.[1] Furthermore, the compliance with clinical guidelines is found to reduce mortality factors and health cost each by third, and improve practice. This impact encouraged the development of a new system known as “Grades of Recommendation Assessment, Development, and Evaluation system,” which grades recommendations strength.[7] Furthermore, a recent systemic survey classified clinical guidelines into four classes to help developers when designing, reporting, and assessing this tool. The first class called “standard original (or de novo)” and uses systemic review and guidelines to develop an original recommendations document. The second class is the “rapid original (or de novo)” that develops original documents using specific criteria such as developing checklist from the existed guideline. “Adapted or adopted” is the third class and it develops clinical guidelines using the recommendations of other guidelines. Finally, the “Updated” class which utilizes the new evidence to update current recommendations. This systemic survey suggested that developers need to understand these classes and know which meets their practice need.[8]

However, various barriers have been reported regarding the use of clinical pathways, clinical guidelines, and practice protocols. First, most clinicians have large workloads and cannot keep up with new research and trial results, while some do not have the skills to appraise these results. This leads to what is known as “knowledge-practice gap.”[9] As a consequence, biased research may be used and ends with fatal outcomes, like when hormonal replacement therapy was used to reduce cardiovascular risk in healthy women and resulted in high rate of breast cancer.[7] Moreover, there are insufficient knowledge for guideline implementation and inadequate experience to interpret the guideline recommendation.[10] Furthermore, it could be difficult to apply a single protocol for all patients.[6]

In Saudi Arabia, available data showing the barriers and facilitators of the clinical pathway, clinical guidelines, and practice protocols used in clinical practice are scarce and have mainly dealt with evidence-based medicine adaptation and mostly focused on a specific guideline or protocol.[11] Thus, there may be a need to have focused data that can identify the main barriers faced by clinicians and suggest solutions to eliminate them and help institutions target these barriers and plan their development and implementation.

Objectives

This study aimed to achieve number of objectives to determine extent and feasibility of the application of clinical pathways, clinical guidelines and practice protocols in hospitals in the Eastern Province of Saudi Arabia. The first objective was to assess the extent of availability of clinical pathways, clinical guidelines, and practice protocols and to assess whether health-care providers were aware of the difference between them. The second objective was to illustrate health-care provider's (i.e., physician, pharmacist, nurse, respiratory therapist) opinions and suggestions regarding barriers and benefits of these tools if they have already applied them and their expectations if not. Another important objective was to identify the health-care personnel involved in the process of institutionalization of clinical pathways and guidelines and protocols development. Last objective was to examine the effect of the COVID-19 pandemic on the availability of clinical pathways, guidelines, and practice protocols and the health-care provider's perspective toward their need in clinical practice.


  Methods Top


Study design

Literature was searched using PubMed, Google Scholar, and Imam Abdulrahman University Library Summon, and a survey was developed by the study investigators. The validity and reliability of the survey were ensured through a pilot study. During the pilot study, three participants from each of the targeted specialties were asked to complete the survey. A review of the pilot study results showed that the survey did not require modifications. The results from the pilot study were excluded from the data analysis step.

An electronic survey form was developed [Appendix 1] using Google Forms. It was attached to the study participation invitation and sent to the target health-care providers via E-mail or distributed through social media applications such as WhatsApp and Twitter. Recruits were also asked to send the invitation link to individuals they knew who met the inclusion criteria. The recruitment and data collection were performed between February 1, 2021, and March 15, 2021. Thus, this study was based on a cross-sectional survey.

Setting

The study targeted participants working in either Ministry of Health (MOH) or non-MOH (non-MOH) hospitals in the Eastern Province in Saudi Arabia.

Participants

The study population consisted of physicians, pharmacists including clinical pharmacists, nurses, and respiratory therapists.

Variables

The study used one group of participants to assess different variables as follows:

  1. The extent of the availability of clinical pathways, clinical guidelines, and practice protocols
  2. Participants' perception toward different aspects:


    1. Awareness of the difference between clinical pathways, clinical guidelines, and practice protocols
    2. Impact of COVID-19 on the availability of clinical pathways, clinical guidelines, and practice protocols and awareness of their importance
    3. Benefits of clinical pathways, clinical guidelines, and practice protocols application
    4. Barriers for clinical pathways, clinical guidelines, and practice protocols application and suggestions to eliminate the barriers.


Data source/measurement

Variables in this study were assessed using questions on the electronic survey. Close answer questions were used to assess all variables except for benefits, barriers, and suggestions to eliminate the barriers, in which open answer questions were used.

Bias

No source of bias was expected. Participant specialty, work setting, and region were clearly identified to overcome any possibility of selection bias. Also, to avoid interview bias, the survey was distributed electronically and self-filled by participants.

Study size

The snowball sampling technique was used in the recruitment of participants. This technique is a common sampling method in which one recruited participant will lead the research team to other participants.[12] As this study is based on a larger geographical region, it would have been extremely difficult to identify relevant health-care professionals and contact them for participation in the study, which would have also limited the sample size. Therefore, with the use of this technique, a sample size of 417 was obtained.

Quantitative and qualitative variables

Data from this study were mostly quantitative, and others were qualitative, including barriers, benefits, and suggestions presented by the participants. Quantitative variables were directly analyzed. However, thematic analysis was used for qualitative data.

Statistical methods

After sufficient data were obtained; Microsoft Excel was used in the data analysis, and data were presented as numbers and percentages.

Ethical consideration

This study was approved on January 12, 2021, by the Institutional Review Board of the King Fahad Specialist Hospital (KFSH) (approval number: EXT0379). KFSH IRB requires the investigator to follow National Committee of Bioethics regulations, Good Clinical Practice guidelines, ethical guidelines of the Declaration of Helsinki, and the policies and procedures of KFSH.

Researchers have used the absolute data without any manipulation of responses from the selected participants. Moreover, no personal data were obtained from the participants during the completion of the form; thus, informed consent was not required.


  Results Top


Participants

A total of 417 participated in this study. Investigators ensured participants' eligibility for the study by reviewing participants' answers to questions that identified the inclusion criteria; that is to be physicians, pharmacists including clinical pharmacist, nurses, or respiratory therapists working in hospitals in the eastern region in Saudi Arabia.

Descriptive data

A total of 417 participated in this study (134 males, 284 females). The highest percentage of participants aged between 20 and 35 years old (95.7%), followed by participants aged between 36 and 45 years old (27.3%) and the rest aged between 46 and 55 years old. Participants qualified with bachelor degrees accounted for the highest percentage (56.6%) of the study participants, followed by participants qualified with diploma degrees (13.4%). Similar percentages for other qualifications (fellowship; 9.1%, residency; 8.9%, master; 7.9%) and the lowest for PhD qualified participants (4.1%). More than half of the study participants were Saudi (69.8%) and about three-quarter of the total participants were MOH employees.

Outcome data

Extent of availability of clinical pathways, clinical guidelines, and practice protocols

The study findings showed that clinical pathways, clinical guidelines, and practice protocols are available to a great extent. Practice protocol accounted for the highest percentage in both MOH and non-MOH sectors.

Development of the clinical pathways, clinical guidelines, and practice protocols

Participants were asked to choose any of three identified sources of development of the clinical pathways, clinical guidelines, and practice protocols in their workplaces, which are participants' institutions, MOH, international institutions, or organizations. MOH was the main identified source by participants working in MOH hospitals. However, MOH was the lowest source chosen by non-MOH participants.

Regarding personal involved in the development process, physicians and pharmacists were opted by the highest number of participants (323 and 307 respectively), while more than half and less than three-quarter of participants opted for nurses and respiratory therapists.

Awareness of the difference between clinical pathways, clinical guidelines, and practice protocols

Participants' perception toward awareness of the difference between clinical pathways, clinical guideline, and practice protocol was evaluated. They were asked about their belief and then instructed to select the correct definition for practice protocol and clinical guidelines.

When evaluating this objective, we were not concerned about the workplace, if it is MOH or non-MOH, and calculated the percentage using the total number from each profession. Thus, more than 75% of participants believed to be aware of the difference. The high percentage of the total number of participants was able to choose the correct meaning for clinical guidelines (71.70%). However, less than half of the total number of participants were able to choose the correct meaning for practice protocol.

Impact of the COVID-19 pandemic on the availability of the clinical pathways, clinical guidelines, and practice protocols

The majority of participants answered that COVID-19 pandemic has impacted the availability of clinical pathways, clinical guidelines and practice protocol positively. Results showed that more than 95% of participants understand these tools need and importance in clinical practice.

Opinions and suggestions regarding barriers and benefits of clinical pathways, clinical guidelines, and practice protocols

An open answer questions were asked to identify benefits for clinical pathways, clinical guidelines, and practice protocols and barriers to applying them and also, another question for suggestions to eliminate those barriers. The main determined benefit was practice standardization and conflict elimination. Nearly 50% of participants identified lack of training as a barrier for application and a similar percentage suggested training to eliminate this barrier.

Main results

The absolute results of the collected data were reported as numbers and percentages. No confounders were included or adjusted.

Other analysis

There was no other analysis for the data.


  Discussion Top


Key results

There were several objectives for this study. The first objective assessed the extent of availability of clinical pathways, clinical guidelines, and practice protocols and evaluated healthcare providers' awareness toward the difference between them. Great percentage of participants stated that these tools are available. For example, more than 90% of participants stated that practice protocols are available in their institutions. Although more than 75% of participants believed they are aware of the difference between the tools, only half of them were able to define practice protocol. The second objective was to list health-care provider's opinions and suggestions regarding barriers and benefits of these tools. The most common documented barrier was lack of training to use the tools and consequently, continuous training and education suggested by 44.26% of participants. About 70% of participants stated that these tools help standardize practice and reduce conflict occurrence. One objective was to know the health-care personnel involved in the development process of the tools. The results showed that physicians, pharmacists, and nurses are greatly involved, followed by respiratory therapists which were chosen by about 50% of the participants. Finally, the results of the last objective showed that the COVID-19 pandemic impacted the availability of the tools and the health-care provider's opinion regarding their importance in clinical practice positively.

Limitation

Both selection and interview bias were overcome by using self-filled electronic survey with no identification for participants. However, the eastern province is a large geographic area which requires data from a larger sample size to come with more representative findings.

Interpretation

There are difficulties limiting the use of evidence-based practice despite recommendations on its application. The main difficulties are “knowledge-practice gap” and the clinician's ability to deal with and apprise research findings.[1] One study showed that more than three-quarters of its participants lack the skills to assess the quality of research.[10] Thus, tools have been introduced to overcome these difficulties.[1] Clinical pathways, clinical guidelines, and practice protocols are examples of these tools.

This was a cross-sectional survey study in the Eastern Province in the Kingdom of Saudi Arabia (KSA) with a total of 417 participants. The study results showed that practice protocols in in the Eastern Province in KSA are available to a great extent (MOH, 90.68%; non-MOH, 94.3%). This was followed by a high extent of availability of clinical guidelines (MOH, 81.35%; non-MOH, 80.2%). Conversely, there was less availability of clinical pathways, as reported by <70% of participants [Table 1].
Table 1: Extent of availability of clinical pathway, clinical guideline, and practice protocol

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Nearly 80% of participants believed that they are aware of the difference between clinical pathways, clinical guidelines, and practice protocol. Although a similar percentage in each specialty selected the correct definition for clinical guidelines, the results showed that participants were less familiar with the meaning of practice protocols, with the lowest percentage among nurses (33.58%) and the highest among respiratory therapists (71.7%) [Table 2]. Moreover, the study results showed that 50% of participants were unaware of the personnel involved in the development process of these tools. A large percentage pointed to physicians and pharmacists as the involved personnel. However, respiratory therapists were pointed out by only half of the study participants [Table 3]. This may be because respiratory therapists' specialty limits their involvement in other areas. These findings may suggest the need for increasing clinician awareness of the basics of these terms and not only how to use them.
Table 2: Perception of participants toward awareness of the difference between clinical pathway, clinical guideline, and practice protocol

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Table 3: Personnel involved in the development of the clinical pathway, clinical guideline, and practice protocol

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Regarding the source of the clinical pathway, clinical guideline, and practice protocol, there was a clear difference between MOH and non-MOH participants when considering the three identified sources (participant institution, MOH, international institution/organization). MOH participants indicated that MOH is the major source of these tools, which was pointed out by approximately 70% of participants for each tool. Less than half of MOH participants pointed to their institutions as a source. Conversely, less than a quarter of non-MOH participants pointed MOH as a source of these tools, and 50% pointed to their institutions as a source [Table 4]. These findings may reflect the effort of the MOH in KSA toward implementing these tools in their hospitals. In addition, it may indicate the low capability of MOH hospitals to develop their own tools or low interest to take a role in developing them. Moreover, it may suggest the lack of awareness of their importance by leaders in MOH hospitals.
Table 4: Clinical pathway, clinical guideline, and practice protocol development sources

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Seven barriers [Table 5] in the development, implementation, or application of the clinical pathway, clinical guideline, and practice protocol were identified by this study results. The two main barriers were the lack of training and insufficient resources and support. Consequently, orientation for new staff and continuous training and education were recommended by nearly half of the participants. Others suggested support from leaders as a facilitator. One study indicated the importance of leadership support in enhancing physicians' adherence to clinical guideline implementation.[11] Moreover, leaders' interest and awareness of the need for these tools may help enforce them in the orientation programs and encourage frequent staff training for their utilization. These barriers were followed by the lack of awareness of the availability, which was identified by 39.13% of study participants. Thus, some participants suggested maintaining availability and easy access. These barriers may be overcome by training, in which staff will practice how to access available resources and maintain awareness of any changes. A comparable percentage of participants pointed to language barriers and structural complexity as obstacles (36.45%). This minor percentage may support a recent systemic review findings, in which an average of 80% of evaluated clinical guidelines scored with high presentation clarity.[13] Approximately a quarter of participants reported time constraints and heavy workload, and lack of access as barriers. However, continuous training in utilizing clinical pathways, clinical guidelines, and practice protocols may help enhance familiarity with them, ease their use, and eliminate complexity to understand them. As a result, this may save time needed to review literature and provide more time for patient care. Finally, a small percentage identified staff resistance as a barrier (6.69%). Another barrier stated by another study was fear that expert clinicians may stick rigidly to these tools at a time deviation. An example of this scenario is identified in a semi-structured interview for physicians on the use of a mechanical ventilation weaning protocol, in which physiological parameters of a normal patient may mislead the interpretation of subjective data and harm the patient.[6] The variety of barriers may suggest to assess available barriers and target them with diverse strategies instead of focusing on one barrier.[14]
Table 5: Benefits listed by the participants on the use of clinical pathway, clinical guideline, and practice protocols and barriers faced by the practitioner in their development, implementation, and application and suggestions to overcome the barriers

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Three benefits of the development, implementation, or application of the clinical pathway, clinical guideline, and practice protocol were indicated in this study. High participants' percentage stated that these tools help standardize practice and eliminate conflict. Thus, this may be a factor for the time efficiency of the clinician. Moreover, about half of the participants stated that these tools improve the quality of care and patient safety. This has been also mentioned in other studies.[15] Moreover, participants suggested that these tools may help avoid errors. Consequently, they may be a reason for reducing health-care costs and spending.[15]

Finally, in this study, approximately 96% of participants indicated that the COVID-19 pandemic showed the need of these tools in practice, and approximately 85% stated that the COVID-19 pandemic has enhanced their availability [Table 6]. This surely would be obvious, particularly at the time were no identified treatment is available for COVID-19, and hopefully reflect the improvement in the awareness of these tools' importance.
Table 6: Impact of the COVID-19 pandemic on the availability of the clinical pathway, clinical guideline, and practice protocol

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Future research recommendation

It is suggested to conduct studies with a large sample size, including different regions in the country. This may help evaluate national guidelines, clinical pathways, and practice protocols feasibility at a national level. It may also aid MOH in identifying strategies to facilitate the implementation of these tools. Researchers may study the applicability of using MOH tools in non-MOH sectors and investigate their benefits and drawbacks.

Generalizability

The study results may image the current clinical practice status in terms of the extent and feasibility of the application of clinical pathways, clinical guidelines, and practice protocols. Furthermore, it may provide helpful overview data for barriers and suggestions to overcome them to hospitals. However, the study sample size compared to the population and number of hospitals in the targeted geographic area would necessitate a larger sample size for generalizability.


  Conclusion Top


This cross-sectional survey assessed the level of availability of the clinical pathway, clinical guidelines, and practice protocol in Eastern Province hospitals. It measured the awareness of clinicians of these tools and listed their opinions regarding these tools' advantages. It also identified some barriers in the development, implementation, or applications with suggestions to overcome them.

Data availability

The authors declare that data supporting the findings of this study are available within the article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Appendix Top


Appendix 1: Study Survey

Dear health care practitioner you are kindly invited to fill in this survey which aim to measure the Extent and Feasibility of Clinical Pathway, Guideline and Practice Protocols Application in Eastern Province Saudi Arabian Hospitals

Gender □Male □Female

Nationality

□ Saudi

□ Non-Saudi/Arabic country

□ Non-Saudi/European country

□ Non-Saudi/Asian country

□ Non-Saudi/the Americas

□ Non-Saudi/African

□ Non-Saudi/Oceania

Age

□ 20-35

□ 36-45

□ 46-55

□ >55

Speciality

□ Physician/Consultant

□ Physician/Specialist

□ Physician/Resident

□ Pharmacist

□ Clinical Pharmacist

□ Nurse

□ Respiratory therapist

Academic qualification

□ Diploma

□ Bachelor

□ Residency

□ Master

□ PhD

□ Fellowship

Work at

□ MOH hospitals

□ Non MOH governmental hospital (National Guard Hospital, Military Hospital, Security Forces Hospital, University Hospital)

□ Private Hospital

□ Other, please specify

I am aware of the difference between clinical pathway, guideline and practice protocol

□Yes □No

Choose the correct terminology; agreed frameworks outlining the care that will be provided to patients in a designated area of practice is

□ Clinical pathway

□ Clinical guideline

□ Practice protocol

Choose the correct terminology; sets of evidence-based recommendations that aid decision-making about care in specific health systems and resource settings is

□ Clinical pathway

□ Clinical guideline

□ Practice protocol

Clinical pathways are available in my institution

□Yes and I apply them □Yes but I do not apply them usually □No they are not available

Clinical guidelines are available in my institution

□Yes and I apply them □Yes but I do not apply them usually □No they are not available

Practice protocols are available in my institution

□Yes and I apply them □Yes but I do not apply them usually □No they are not available

Available clinical pathways developed by (click as many as it applicable to your institution)

□My institution □MOH □International institution/organization

Available clinical guidelines developed by (click as many as it applicable to your institution)

□My institution □MOH □International institution/organization

Available Practice protocols developed by (click as many as it applicable to your institution)

□My institution □MOH □International institution/organization

Having clinical pathways, guidelines and protocols available in my institution

□Very important □Important □Partially important □Not important

People involved in therapeutic clinical pathways, guidelines and practice protocols development in my institution (click as many as involved):

□ Physician

□ Pharmacist

□ Nurse

□ Respiratory therapist

□ I do not know

Illustrate at least three barriers to clinical pathways, guidelines and practice protocols application



Illustrate at least three suggestions to eliminate barriers to clinical pathways, guidelines and practice protocols application



Illustrate at least three benefits to clinical pathways, guidelines and practice protocols application



COVID 19 pandemic has enhance the availability of clinical pathways, guidelines and/or practice protocols in my institution

□Yes □No

COVID 19 pandemic has shown the need of clinical pathways, guidelines and/or practice protocols availability in my institution

□Yes □No



 
  References Top

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Clinical guidelines and standardization of practice to improve outcomes: ACOG Committee Opinion, Number 792. Obstet Gynecol 2019;134:e122-5.  Back to cited text no. 1
    
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Khalifa M, Alswailem O. Clinical pathways: Identifying development, implementation and evaluation challenges. Stud Health Technol Inform 2015;213:131-4.  Back to cited text no. 3
    
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Paul S. Developing practice protocols for advanced practice nursing. AACN Clin Issues 1999;10:343-55.  Back to cited text no. 4
    
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Betit P. Guidelines, pathways, bundles, and protocols: Clinical recipes for success. Respir Care 2015;60:469-70.  Back to cited text no. 5
    
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Blackwood B, Wilson-Barnett J, Trinder J. Protocolized weaning from mechanical ventilation: ICU physicians' views. J Adv Nurs 2004;48:26-34.  Back to cited text no. 6
    
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Djulbegovic B, Guyatt GH. Progress in evidence-based medicine: A quarter century on. Lancet 2017;390:415-23.  Back to cited text no. 7
    
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Yao X, Xia J, Jin Y, Shen Q, Wang Q, Zhu Y, et al. Methodological approaches for developing, reporting, and assessing evidence-based clinical practice guidelines: A systematic survey. J Clin Epidemiol 2022;146:77-85.  Back to cited text no. 8
    
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Amer YS, Wahabi HA, Abou Elkheir MM, Bawazeer GA, Iqbal SM, Titi MA, et al. Adapting evidence-based clinical practice guidelines at university teaching hospitals: A model for the Eastern Mediterranean Region. J Eval Clin Pract 2019;25:550-60.  Back to cited text no. 9
    
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Mahmoud MH, Mohamed Abdelrasol ZF. Obstacles in employing evidence-based practice by nurses in their clinical settings: A descriptive study. Front Nurs 2019;6:123-33.  Back to cited text no. 10
    
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Alnaim L, Almaz S. A study of barriers and facilitators of clinical practice guidelines implementation among physicians. Indian J Pharm Sci 2017;79:923-9.  Back to cited text no. 11
    
12.
Kirchherr J, Charles K. Enhancing the sample diversity of snowball samples: Recommendations from a research project on anti-dam movements in Southeast Asia. PLoS One 2018;13:e0201710.  Back to cited text no. 12
    
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Almazrou SH, Alsubki LA, Alsaigh NA, Aldhubaib WH, Ghazwani SM. Assessing the quality of clinical practice guidelines in the Middle East and North Africa (MENA) Region: A systematic review. J Multidiscip Healthc 2021;14:297-309.  Back to cited text no. 13
    
14.
Almazrou SH, Alfaifi SI, Alfaifi SH, Hakami LE, Al-Aqeel SA. Barriers to and facilitators of adherence to clinical practice guidelines in the Middle East and North Africa Region: A systematic review. Healthcare (Basel) 2020;8:564.  Back to cited text no. 14
    
15.
Prior M, Guerin M, Grimmer-Somers K. The effectiveness of clinical guideline implementation strategies – A synthesis of systematic review findings. J Eval Clin Pract 2008;14:888-97.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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