Clinical Standards

At Texas Children’s Hospital, we routinely review the scientific evidence and incorporate the evidence into clinical standards. Clinical standards are systematically developed statements that detail the essential steps in the care of patients with a particular clinical condition. They are implemented to minimize unnecessary variation, improve patient outcomes, and decrease costs.

In conjunction with the Evidence-Based Outcomes Center staff, our clinical experts have developed over 90 clinical standards for various conditions. 


Clinical Standards for Pediatrics

Clinical standards are systematically developed statements that detail the essential steps in the care of patients with a particular clinical condition. Their development involves a thorough review of evidence using the GRADE methodology, incorporation of clinical expertise, and an assessment of potential benefits and harms. The aim is to improve the overall quality of care by improving patient outcomes and reducing cost. 

At Texas Children’s Hospital, we develop three types of clinical standards: evidence-based guidelines, evidence summaries, and evidence-informed pathways. All follow a similar process for development but differ in their scope and breadth.

  • Evidence-based guidelines provide comprehensive guidance for a particular disease throughout a continuum of care.
  • Evidence summaries address a smaller number of clinical questions and may only address specific phases or components of care within the continuum.
  • Evidence-informed pathways allow for standardization of care where evidence is sparse.

Clinical standards are reviewed periodically and either reaffirmed, revised, or updated. A clinical standard is reaffirmed if practice has not markedly changed warranting a revision or update. It is revised if some components were changed to reflect current practice. And it is updated if the entire literature search and practice recommendations were updated.

For questions/comments or for requests for literature appraisals, please contact the Evidence-Based Outcomes Center staff at eboc@texaschildrens.org.


Clinical Standards

Category Clinical Standard
Behavioral, Growth and Development Attention-Deficit Hyperactivity Disorder (ADHD): Screening and Diagnosis
Behavioral, Growth and Development Autism Spectrum Disorder: Screening and Diagnosis
Behavioral Second-Generation Antipsychotic Medications: Metabolic Monitoring
Cardiovascular Ablation and Pacemaker Implantation: Postoperative Management
Cardiovascular, Perioperative Fontan: Postoperative Management
Cardiovascular Heart Failure, Acute Decompensated
Care Coordination Nursing Engagement in Rounds
Care Coordination Primary Care Patient Compliance with Appointments
Digestive, Infection Gastroenteritis (Acute Vomiting and/or Diarrhea)
Digestive Gastrostomy Tube: Postoperative Management
Endocrine Diabetes: Continuous Glucose Monitoring in Type 1 Diabetes Mellitus
Endocrine Diabetes: Perioperative Management
Endocrine Non-Classical Congenital Adrenal Hyperplasia: Hydrocortisone Treatment
Endocrine, Perioperative Thyroid Carcinoma (Well-Differentiated): Perioperative Management
Endocrine, Genitourinary Turner Syndrome: Puberty Induction
Genitourinary, Perioperative Hypospadias (Primary Distal Shaft to Midshaft) in Infants <1 Year: Surgical Management
Genitourinary, Infection Urinary Tract Infection, First Febrile
Growth and Development Failure to Thrive
Hematological, Perioperative Red Blood Cell Transfusions
Hematological, Perioperative ROTEM-Guided Goal-Directed Therapy for Bleeding After Cardiopulmonary Bypass in Pediatric Heart Surgery
Hematological Sickle Cell Disease in Vaso-Occlusive Crisis
Infection, Neonatal Antifungal Therapy Prophylaxis in Very Low Birth Weight Infants
Infection Central Line Associated Bloodstream (CLABSI) Infections: Prevention
Infection Central Line Complications
Infection Fever and Neutropenia in Children Receiving Cancer Treatment or with Blood Disorders
Infection Fever Without Localizing Signs, 0-60 Days
Infection Fever Without Localizing Signs, 2-36 Months
Infection, Medications Intravenous Fluid Bags: Frequency of Changing
Infection Intravenous Fluid Lock Therapy
Infection Lymphadenitis, Infectious Cervical
Infection, Musculoskeletal and Integumentary Osteomyelitis, Acute Hematogenous
Infection Peripherally Inserted Central Catheters (PICC): Securement
Infection, Respiratory Pertussis
Infection Rhinosinusitis, Acute Invasive Fungal
Infection Septic Shock: Recognition and Initial Management
Infection Skin and Soft Tissue Infection/Abscess
Medications Acetaminophen with Codeine
Medications Ketamine Subanesthetic Intravenous Infusions for Analgesia
Medications Nitrous Oxide and Fasting
Medications, Neonatal, Respiratory Palivizumab (Synagis) Prophylaxis in Hospitalized Patients
Medications Procedural Sedation
Medications Second-Generation Antipsychotic Medications: Metabolic Monitoring
Musculoskeletal and Integumentary, Trauma Cervical Spine Evaluation and Clearance
Musculoskeletal and Integumentary, Perioperative Spinal Instrumentation: Intraoperative Infection Prevention
Neonatal, Perioperative, Respiratory Congenital Diaphragmatic Hernia: Acute Management
Neonatal Cytomegalovirus Testing
Neonatal, Respiratory Preterm Infant: Respiratory Management in the First Two Weeks of Life
Nervous, Trauma Closed Head Injury: Initial Assessment in the Emergency Center
Nervous Infantile Spasms: Treatment
Nervous Status Epilepticus: Initial Management
Perioperative Acute Appendicitis/Appendectomy
Perioperative Bromage Scale: Assessment of Leg Weakness After Epidural Analgesia
Perioperative Craniosynostosis (Primary Repair): Preoperative Management of Patients
Perioperative Mediastinal Mass (Anterior): Perioperative Management
Perioperative, Respiratory Pneumothorax, Primary Spontaneous
Perioperative Tonsillectomy & Adenoidectomy: Perioperative Medical Management
Respiratory Asthma: Acute Exacerbations
Respiratory Asthma: Chronic Management
Respiratory Bronchiolitis
Respiratory Croup
Respiratory High Flow Nasal Cannula Therapy: Initiation and Escalation for Respiratory Distress
Trauma Snakebites

Clinical Standards for Perinatal/Women’s Health

In addition to our pediatric clinical standards, we have developed a set of standards related to Perinatal/Women's Health. 


Other Quality Work

The Evidence-Based Outcomes Center staff have assisted in the development of clinical standards on the national level. A sample of those projects is listed below.

American Academy of Pediatrics on Emergency Medicine Committee on Quality Transformation


Process for Development of Clinical Standards

Clinical standards (evidence-based guidelines, evidence summaries, and evidence-informed pathways) are prepared by the Evidence-Based Outcomes Center (EBOC) team in collaboration with multidisciplinary content experts at Texas Children’s Hospital (TCH). Once a topic (typically a specific disease) is selected, PICO questions (Patient Intervention Comparison Outcomes) are developed and an evidence search strategy is formed. Both internal and external guidelines are evaluated using the AGREE II (Appraisal of Guidelines for Research and Evaluation) criteria, which evaluate guideline scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence.

An extensive literature search is then carried out and all of the relevant evidence is appraised and summarized using the GRADE (Grade of Recommendations Assessment, Development and Evaluation) criteria. Recommendations with transparency of the strength of evidence are stated for each PICO question. The guideline presents the evidence as in support of or against specific diagnostic strategies or therapeutic interventions and identifies where evidence is lacking/inconclusive. Practice recommendations are formulated based on existing evidence and consensus among the content experts. Evidence may not exist for a small proportion of clinical questions, for which consensus recommendations are made. Patient and family values and preferences are included when possible.

These practice recommendations are the foundation of the clinical standard, algorithm(s), order sets, and any other accompanying documents. Once the documents are complete, they are reviewed and approved by the content expert team and are sent to all TCH Medical Staff for review and comment. All questions during the vetting phase are addressed and archived. After this review period, the clinical standard is approved by hospital committees as deemed appropriate for the guideline’s intended use.

Evidence-based guidelines, evidence summaries, and evidence-informed pathways, all of which constitute “shared baselines” for care delivery, are not intended to apply to all people at all times. They are created with a Pareto principle of intent for application – that they will be used in 80% of that population for which they are intended, as nuances in the other 20% represent a need to apply specific tailored clinical care. Clinicians must use clinical judgment to determine when a guideline is applicable to a patient. Similar judgment must be exercised to determine whether all components of a guideline are applicable to a particular patient.


Disclaimer: Practice recommendations are based upon the evidence available at the time the clinical standard was developed. Clinical standards (guidelines, summaries, or pathways) do not set out the standard of care and are not intended to be used to dictate a course of care. Each physician/practitioner must use his or her independent judgment in the management of any specific patient and is responsible, in consultation with the patient and/or the patient’s family, to make the ultimate judgment regarding care.