Rapid Guidelines Research Articles

Quality Assessment of 45 Guidelines on Management of Critical Care Patients with COVID-19: A Systematic Review and AGREE II Instrument Assessment

Background: In response to the COVID-19 pandemic, a host of rapid guidelines (RGs) have been published to inform clinicians and decision-makers on best management for people with COVID-19. We assessed the quality of RGs for management of critically ill patients with COVID-19. Methods: We performed a rapid systematic review of RGs for the critical care patients with COVID-19. Medline (OVID), CINAHL (EBSCO), EMBASE, CNKI, CBM, WanFang, and relevant databases and websites were systematically searched through 31 st July 2020. The AGREE II instrument was used to assess the quality of included RGs and summarize relevant therapeutic interventions. Results: A total of 45 RGs for critically ill patients with COVID-19 were included. Ten were multinational and the remaining from individual countries. The clinical topics included in each RG varied: 41 were for general critical care unit management, two covered patients with tracheostomy, six covered children, four covered women, five covered cardiovascular diseases, 12 covered emergencies, 19 covered patients with pneumonia, and one was for patients receiving renal replacement therapy. Average scores for the six domains of the AGREE II instrument were 70%, 40%, 26%, 74%, 28%, 41% for the scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, editorial independence, respectively. Recommendations for therapeutic interventions were summarized. Interpretation: Most of the RGs for critical care in response to COVID-19 included in the review showed a low overall quality (less than 40%). Future RGs for COVID-19 need to rely, for their development, on standard evidence-based methods and tools.Funding Statement: This work was supported by the Research Chair for Evidence-Based Health Care and Knowledge Translation, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.Declaration of Interests: None.

Development of rapid guidelines: 1. Systematic survey of current practices and methods

BackgroundGuidelines in the healthcare field generally should contain evidence-based recommendations to inform healthcare decisions. Guidelines often require 2 years or more to develop, but certain circumstances necessitate the development of rapid guidelines (RGs) in a short period of time. Upholding methodological rigor while meeting the reduced development timeframe presents a challenge for developing RGs. Our objective was to review current practices and standards for the development of RGs. This is the first of a series of three articles addressing methodological issues around RGs.MethodsWe conducted a systematic survey of methods manuals and published RGs to identify reasons for the development of RGs. Data sources included existing guideline manuals, published RGs, Trip Medical Database, MEDLINE, EMBASE and communication with guideline developers until February 2018.ResultsWe identified 46 guidelines that used a shortened timeframe for their development. Nomenclature describing RGs varied across organisations, wherein the United States Centers for Disease Control and Prevention produced ‘Interim Guidelines’, the National Institute for Health and Care Excellence in the United Kingdom developed ‘Short Clinical Guidelines’, and WHO provided ‘Rapid Advice’. The rationale for RGs included response to emergencies, rapid increases in cases of a condition or disease severity, or new evidence regarding treatment. In general, the methods to assess the quality of evidence, the consensus process and the management of the conflict of interest were not always clear. While we identified another 11 RGs from other institutions, there was no reference to timeframe and reasons for conducting a RG. The three organisations mentioned above provide guidance for the development of RGs.ConclusionsThere is a lack of standardised nomenclature and definitions regarding RGs and there is inconsistency in the methods described in manuals and in RG. It is therefore important that all RGs provide a detailed and transparent description of their methods in order for readers and end-users to be able to assess their quality and validate their findings.

Development of rapid guidelines: 2. A qualitative study with WHO guideline developers

BackgroundSituations such as public health emergencies and outbreaks necessitate the development and publication of high-quality recommendations within a condensed timeframe. For example, WHO has produced examples of and guidance for the development of rapid guidelines (RGs). However, more information is needed to understand the experiences and perceptions of guideline developers. This is the second of a series of three articles addressing methodological issues around RGs. This study describes the perceptions and experiences of guideline developers at WHO about RGs.MethodsWe conducted interviews consisting of open- and closed-ended questions with guideline developers at WHO. Our analysis described the definition and rationale of RGs, the differences from regular guidelines with regard to timelines from topic definition until publication, barriers to identifying the evidence and the lack of a standard methodology to develop RGs.ResultsWe interviewed 10 participants, the majority of whom were comfortable with the current WHO definition of RGs. Most stated that the rationale for developing RGs should be in response to new evidence about efficacy, cost-effectiveness or safety. Respondents differed with regards to the amount of time RGs should take. While the majority of participants agreed that guidelines should be based on a systematic review, this step in the process was considered the most time and resource intensive. Challenges for developing RGs included limited personnel and financial resources as well as the lack of evidence. Facilitators, in turn, that may improve RG development include additional financial and personnel resources as well as the use of virtual meetings.ConclusionsWhile our study suggests a strong need and rationale for the development of RGs, standardisation of timelines and guidance on panel composition, peer-review process, conduct of meetings and sources of permissible evidence require further research.

Development of rapid guidelines: 3. GIN-McMaster Guideline Development Checklist extension for rapid recommendations

BackgroundPractice guidelines require a substantial investment of resources and time, often taking between 1 and 3 years from conceptualisation to publication. However, urgent situations require the development of recommendations in a shorter timeframe. In this third and final article in the series exploring challenges and solutions in developing rapid guidelines (RGs), we propose guiding principles for the development of RGs.MethodsWe utilised the Guideline International Network-McMaster Guideline Development Checklist (GDC) as a starting point for elements to consider during RG development. We built on those elements using the findings from a systematic review of guideline manuals, a survey of international organisations conducting RGs, and interviews of guideline developers within WHO. We reviewed initial findings and developed an intermediate list of elements, as well as narrative guidance. We then invited experts to validate the intermediate list, reviewing for placement, brevity and redundancy. We used this iterative process and group consensus to determine the final elements for RG development guidance.ResultsOur work identified 21 principles within the topics of the Guideline International Network-McMaster GDC to guide the planning and development of RGs. Principles fell within 15 of the 18 checklist topics, highlighting strategies to streamline and expedite the guideline development process.ConclusionsWe defined principles to guide the development of RGs, while maintaining a standardised, rigorous and transparent process. These principles will serve as guidance for guideline developers responding to urgent situations such as public health urgencies. Integration of these principles within currently disseminated guideline development standards will facilitate the use of those tools in situations necessitating RG recommendations.