The On-Call Reality: NICE Is Not a Single Source
At 3 a.m., the medical registrar bleeps. A patient on a surgical ward has a potassium of 6.8 mmol/L. The FY1 is concerned. The registrar’s immediate mental checklist includes ECG changes, calcium resonium, and insulin/dextrose. But the surgical team wants to know: "What’s the NICE threshold for treatment?" This is where the instruction "just check NICE" fails. There is no single NICE guideline titled "Management of Hyperkalaemia." The relevant advice is fragmented across chronic kidney disease guidelines, hyperkalaemia drug management pathways, and potentially other disease-specific documents. In the minutes that matter, searching NICE.org.uk is not a viable strategy.
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The assumption that NICE is a monolithic, easily searchable database of all clinical thresholds is dangerously incorrect. It is a sprawling library of condition-specific guidance, technology appraisals, and quality standards. Knowing a piece of information exists within NICE is not the same as being able to retrieve it under pressure.
Access Failure Modes: When the Digital Door is Locked
Even if you know the exact guideline, access is not guaranteed. Trust IT systems are notoriously fragile, especially out-of-hours. Common failure modes include:
- Expired Session Timeouts: You log into the trust desktop, open a browser, navigate to NICE, and authenticate with your OpenAthens credentials. Then you get bleeped. Ten minutes later, your session has expired, and you must restart the entire process.
- VPN Issues: Accessing NICE from a trust computer often requires the VPN to be connected. If the VPN is down or requires a complex re-authentication, the resource is inaccessible.
- OpenAthens Failures: Password forgotten? Account locked? These are routine occurrences that render the entire NICE website inaccessible during a clinical emergency.
I have personally spent over seven minutes during a night shift simply trying to get a NICE webpage to load, only to give up and call a senior colleague for a verbal threshold. Seven minutes is a long time when a patient is deteriorating.
The Problem of the "Internal Shared Drive"
Many trusts attempt to mitigate access issues by maintaining a shared drive with local guidelines and "important NICE summaries." This creates a second layer of risk.
These drives are often chaotic. File names are cryptic ("NICE_CVD_2019_final_v2_JB_amends.docx"). The most recent version is impossible to discern. I have seen folders containing five different versions of the same summary, all with different modification dates. Relying on a junior doctor to find the correct, current version in this digital junkyard is unsafe.
Furthermore, these summaries are static. They are PDFs or Word documents created months or years ago. They do not update automatically when NICE updates its guidance. A trust might be operating on a summary of NG28 (Type 1 Diabetes) from 2020, completely missing critical updates made in 2022. This creates a silent, system-wide knowledge gap.
The WhatsApp Gambit: A Sign of System Failure
When digital systems fail, clinicians resort to human networks. The most common tool for this is WhatsApp. A typical message: "Does anyone know the NICE threshold for starting antibiotics in COPD exacerbation?"
This practice is ubiquitous because it works. Someone usually replies within 30 seconds. But it is high-risk. The answer is only as good as the memory of the person on the other end. It is unverifiable in the moment and leaves no audit trail. I have received incorrect thresholds via WhatsApp on at least three occasions that I can recall, fortunately catching the error before acting. This is not a failure of individual clinicians; it is a failure of the system to provide reliable, immediate point-of-care information.
The Illusion of the Screenshot
Another common workaround is the "trusty screenshot." A registrar takes a screenshot of a NICE flowchart during a quiet moment and saves it to their phone. This seems like a prudent backup.
The problem is one of context and currency. A screenshot is a fragment. It lacks the surrounding text, caveats, and footnotes that are essential for safe application. More importantly, it has no version control. That screenshot from six months ago is now obsolete, but there is no alert to tell you so. You are making a decision based on historical data, believing it to be current. This is particularly dangerous for rapidly evolving areas like antimicrobial stewardship or anticoagulation.
The Need for Integrated, Point-of-Care Access
The solution is not to abandon NICE guidance but to integrate it directly into the clinical workflow. The concept of a point-of-care view is critical. This means the information is available within the electronic patient record (EPR) or on a dedicated clinical device without requiring separate logins, VPNs, or browser searches.
Imagine the hyperkalaemia scenario again. The registrar opens the EPR, navigates to the patient's lab results, and next to the potassium result is a small, clickable icon. One click opens a concise, trusted summary of the hyperkalaemia management pathway, including ECG indications and treatment thresholds, directly referenced to the current NICE-derived trust policy. The search is eliminated. The access barriers are removed. The decision is supported within the same environment where the data is reviewed.
This is not a theoretical improvement. In environments where such systems are piloted, the time to access critical guidance drops from minutes to seconds. It reduces cognitive load and prevents the dangerous drift towards informal, unverified sources like WhatsApp.
Beyond Hyperkalaemia: The Breadth of Thresholds
The problem extends far beyond acute biochemistry. Consider these common on-call queries where "checking NICE" is impractical:
- Sepsis: What is the specific threshold for lactate in the NICE sepsis guideline? Is it 2.0 mmol/L? The answer is buried within a complex algorithm.
- Acute Kidney Injury (AKI): What actions are mandated by NICE for AKI stage 2? The guidance is spread across multiple sections.
- Blood Transfusion: While there are national guidelines, many trusts create local adaptations based on NICE principles. Finding the local 70g/L vs. 80g/L threshold for stable patients can be a frantic search through a shared drive.
Each of these requires navigating a different part of the NICE website or a different local folder. There is no centralised, searchable repository for the specific numerical thresholds that drive immediate clinical action.
Building a Reliable Clinical Thresholds Index
The ultimate safeguard against access failure and information fragmentation is a maintained clinical thresholds index. This is not a shared drive full of PDFs. It is a dynamic, searchable database of key numerical values and decision points, each linked directly to its source guideline and version number.
A well-constructed threshold index allows a clinician to search for "potassium" or "COPD exacerbation" and immediately retrieve the trust-mandated threshold, the date it was last updated, and a direct link to the full guideline for context. It functions as a rapid-reference tool to be used before or during a decision, ensuring that the most basic, critical data is instantly available.
This eliminates the guesswork and the frantic searches. It provides a single source of truth that is accessible from any clinical workstation without complex authentication. Governance leads should view the creation and maintenance of such an index as a fundamental patient safety activity, as critical as maintaining a drug formulary.
In summary, instructing a junior colleague to "just check NICE" is an abdication of responsibility. It ignores the realities of on-call work: time pressure, IT fragility, and information overload. Safe practice requires systems that deliver verified guidance directly to the point of care, bypassing the barriers that make "just checking NICE" an unsafe and unreliable instruction.