Factors impacting on the implementation of clinical management guidelines (CMGs) for high consequence infectious diseases (HCIDs) during outbreaks globally: a systematic review
Authors: Dahmash Dania Talaat , Michelen Melina , Rigby Ishmeala , Piotrowski Helen , Nartowski Robert , Cheng Vincent , Dagens Andrew , Harriss Eli , Hart Peter , Jacobs Shevin , Gedela Keerti , Horby Peter W , Pilbeam Caitlin , Sigfrid Louise 
Published: November 2024

Background

High consequence infectious disease (HCID) outbreaks are a threat to societies globally. Evidence-based clinical management guidelines (CMGs) are important tools for translating evidence into clinical practice. However, developing guidelines is resource-intensive and guidelines must remain responsive to new evidence while being accessible to clinicians. This review aims to identify factors that impact the implementation of HCID CMGs across different contexts during health emergencies.

Methods

A systematic review. Four databases (Ovid MEDLINE, Ovid Embase, Ovid Global Health, and Scopus) were searched until November 2021, complemented by a grey literature search conducted on November 2021. Studies that explored implementation of HCID guidelines were included, without language restriction. Two reviewers screened articles and extracted data. Data was analysed using qualitative inductive thematic analysis.

Results

Of 12,512 records, 28 studies were included, with most (61%, 17/28) set in high-income countries. Three overarching themes impacting HCID CMG implementation were identified: 1) Development and characteristics of CMGs, 2) Organisational and logistical factors, and 3) Realities of Implementing guidelines. Key recommendations included engaging all relevant representatives in CMG development, including those in endemic countries; integrating mechanisms for regular updates; supporting implementation by ensuring access to necessary resources (e.g., equipment, pharmaceuticals), and training; and enabling intra- and inter-organisational collaboration and communication channels. Importantly, recognising the challenges faced by staff in implementing new guidance is crucial, as is understanding the impact of a supportive environment on the effective implementation of care during emergencies.

Conclusion

These findings highlight the need to bridge the gap between HCID CMGs development and their real-world implementation amid health emergencies. The complex factors impacting effective implementation should be addressed beginning at the development stage, with training focused on implementation during inter-epidemic times, and ongoing implementation monitored during outbreaks. Further research to guide implementation frameworks are recommended.

Key messages of the article:

What is already known on this topic:

- Clinical management guidelines (CMGs) are important tools to guide clinical decision-making and optimise care and outcome.

- The COVID-19 pandemic showcased the need for CMGs to be rapidly responsive to new emerging evidence.

- HCID CMGs are scarce and often of low quality, and when available they frequently contain inconsistent therapeutic recommendations.

- Most CMGs are developed by high-income countries while the burden is often the largest in resource deprived settings.

What this study adds:

- This study highlights the gap between HCID CMGs development and their implementation in real world within emergency setting.

- The review explores the potential factors that influence the implementation process of HCID CMGs such as time, information and resource constraints.

- Key recommendations to stakeholder and CMGs developers were explored within this study such as the use of “living guidelines” to make CMGs updates more efficient, and the availability of viable alternative options for different-resourced healthcare settings to bridge the gap between the ideal situation and the local realities.

- There is a need for a clear communication and consensus on HCP expectations and obligations during health emergencies within CMGs as well as the practicalities of delivering training during emergencies need to be addressed within CMG development and implementation.

How this study might affect research, practice or policy:

- HCID implementation research should consider these factors impacting effective implementation when planning, from the development stage through ongoing monitoring.

- Further research and funds are needed to guide implementation frameworks.