By now, we are sure you’ve seen the latest guidelines from the American Stroke Association on the management of spontaneous intracerebral hemorrhage published in May of 2022. 

Has your program taken the appropriate steps to review the guideline and update your order sets, guidelines and/or clinical pathways to reflect the changes? And how do you handle disparate practice amongst care providers or disagreement with the guidelines? 

The publishing of a significant new guidelines offers an opportunity to reflect on the role guidelines play in your program and how to systematically approach guideline review.  An organized approach ensures you are both optimizing the care of your patients using an evidence-based approach and success during your next stroke program review. 

Guidelines offer a synthesis of the studies published on a certain disease by experts in the field.  Over the past decade, many societies adopted new methodologies to generate guidelines intended to increase the rigor and minimize bias.  This has resulted in both improved guidelines and also changes in guideline recommendations as a result of more rigorous methodology.  However, one of my favorite sayings about guidelines is that they are supposed to be the beginning of the conversation, not the end.  Guidelines are intended to summarize the best evidence applied to the broadest population of individuals.  They are not meant to be rules that are applied indiscriminately to all patients.  Some patients may require a deviation from suggested care in a guideline because the care provider is individualizing care to that individual.  These situations are expected and appropriate, and documentation to justify the decision should be evident in the medical record. 

The best approach to a newly published guideline is to pull all resources (order sets, protocols, pathways, policies, etc) and compare new recommendations against program resources.  When the resource deviates from a published recommendation, this warrants a team discussion with key leaders in the program including physicians, advanced practice providers, nurses, pharmacists and program administrators.  The strength of the recommendation and evidence used to make the recommendation should be reviewed in the context of the population the program serves.  The team must make a decision to either follow the recommendation in the guideline and update program resources, or to deviate from the guideline.  If the choice is made to deviate when planning program resources, the contextual program reasons for the decision should be well documented in meeting minutes or somewhere similar.  Then, program documents should be updated accordingly.  However, providers may still individualize care to patients and should document the reasons why care may differ from program resources and why this is best for the patient. 

Using an organized approach to reviewing and applying clinical practice guidelines is a key skill of a stroke program leader and will minimize the risk of findings on your next certification review.  Most importantly, it will ensure you are providing the best program resources for providers to care for your patients.    


Sarah Livesay, DNP, APRN, ACNP-BC, CNS-BC

Debbie Hill, BS, FAHA

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