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Ruth M. Kleinpell, RN-CS, PhD, FCCM
In this article, Society President Ruth M. Kleinpell, RN-CS, PhD, FCCM, discusses the importance of guidelines to clinical practice and to improving care in the intensive care unit.
Guidelines are important to clinical practice and to improving care in the intensive care unit (ICU). The general purpose of clinical practice guidelines (CPGs) is to improve the quality of patient care and health outcomes, as well as to summarize related research to facilitate clinical decisionmaking. Yet guidelines are not binding as by definition they are “guides.” The Institute of Medicine (IOM) describes CPGs as “statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”1
The IOM describes the characteristics of a “clinical practice guideline we can trust” as one that has clarity, specificity, strength of the evidence, perceived importance and relevance to practice.” According to the IOM, to be trustworthy, guidelines should 1) be based on a systematic review of the existing evidence; 2) be developed by a knowledgeable, multidisciplinary panel of experts and representatives from key affected groups; 3) be based on an explicit and transparent process that minimizes distortions, biases and conflicts of interest; 4) provide a clear explanation of the logical relationships between alternative care options and health outcomes and provide ratings of both the quality of evidence and the strength of recommendations; and 5) be reconsidered and revised as appropriate when important new evidence warrants modifications of recommendations.
The Society of Critical Care Medicine (SCCM) has a long history of developing and supporting CPGs. In a 1973 Critical Care Medicine article titled “The Society of Critical Care Medicine, Its History and Its Destiny,”2 Max Harry Weil, MD, PhD, SCCM’s first president, highlighted the first guidelines adopted by the Society, “Guidelines for Organization of Critical Care Units,” 3 which addressed the centralization and regionalization of critical care, organization of critical care services, and general concepts of ICU design. John J. Downes, MD, served as chair of the 26-member guideline committee for these first guidelines. Dr. Weil stressed, “I do not know of any one enterprise of the Society which is more important than the development of our policy statements in the guidelines.”
Subsequent early guidelines dealt with training of critical care unit personnel, design and structure of critical care units, and equipment for critical care units. In 1988, the American College of Critical Care Medicine (ACCM) was created to emphasize quality management in the practice and administration of critical care through the development of CPGs. The ACCM has continued to foster the development of new CPGs. In 2016 alone, several guidelines were published, including “ICU Admission, Discharge, and Triage Guidelines,”4 “Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients,”5 and “Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient.”6
At this year’s 2017 SCCM Congress, two new CPGs were released: “Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016” 7 (codeveloped by SCCM and the European Society of Intensive Care Medicine) and “Guidelines for Family- Centered Care in the Neonatal, Pediatric, and Adult ICU.”8
By definition, these guidelines meet the criteria for being trustworthy. Yet this does not ensure their uptake.
The literature on CPGs in healthcare indicates that, on average, 60% of clinicians follow guideline recommendations. In John A. Daly’s book Advocacy: Championing Ideas and Influencing Others, he states that the economist Joseph Schumpeter famously said in 1939, “It was not enough to produce satisfactory soap, it was also necessary to induce people to wash.”9 Indeed, putting guidelines into practice is not a simple task.
Implementing new guidelines involves change. In healthcare, this involves having to change some aspects of clinical care—and change can be quite difficult. A cartoon I came across recently captured some of the essence of the difficulty of change. Two characters are shown having a conversation, and one states “Implementing these changes won’t be easy. We’re pretty set in doing things the wrong way.”10 This aptly highlights one of the key challenges with implementing guidelines, or for that matter, anything new!
The IOM identifies that “effective multifaceted implementation strategies targeting both individuals and healthcare systems should be employed by implementers to promote adherence to trustworthy clinical practice guidelines.”1 Strategies for promoting uptake of guidelines include education, use of information and decision support systems, including reminders, alerts, and decision assistance and embedded controls such as computer order entry guides. Other strategies include performance gap assessment, audit and feedback, infrastructure support and leadership support.
As organizational barriers and clinician attitudes toward change and toward implementing guidelines can influence their uptake, it may help to highlight that the ACCM/ SCCM guidelines adhere to the IOM’s criteria for being trustworthy. Additionally, both the updated Surviving Sepsis Campaign (SSC) and family-centered care guidelines integrate resources for implementation.
Unique to the SSC guidelines is a comprehensive appendix that provides a comparison of the 2012 SSC recommendations and the updated 2016 recommendations. Complementary publications to the SSC guidelines including a user’s guide to the new guidelines, a video comparing the two sets of recommendations, and a slide deck reviewing the new guidelines. See the SSC website (www.survivingsepsissurvivingsepsis.org) for these resources.
Unique to the family-centered care guidelines is an accompanying supplement with a gap analysis tool to assist clinicians in identifying ICU practice differences, an instructional video on using the gap analysis tool, and implementation tools, including teaching slides. See the SCCM guidelines website (sccm.org/guidelines) for these and other resources.
Developing CPGs is no small feat. Collectively the two most recent guidelines were developed by more than 80 expert clinicians, researchers and methodologists in the field, and countless others who served as peer reviewers, along with editorial staff support. We thank them for their time, efforts and dedication to advancing care in the ICU!
We All Play a Role
Individually and collectively as critical care clinicians, we all have a role in promoting these new clinical guidelines at our institutions; for topic-related regional, national and international initiatives; to key stakeholders such as the World Health Organization, Centers for Disease Control and Prevention, National Quality Forum, Centers for Medicare and Medicaid Services and others; and to advocacy groups, including patients, families and quality advocates. CPGs really only have value if they are utilized to improve the quality of care.
David Ganz, in his article on implementing guidelines in organizations, says that, even when there is evidence of benefit, healthcare providers may not always be convinced that it is good for their patients or that a new guideline will work in their environment.11 He outlines several strategies to build a robust case to promote implementation. For example, if you suspect there is a need for improvement in care, have you evaluated how well your organization is complying with what the guideline recommends? An organization’s readiness to change will determine what will be needed for implementation. Assessing the availability of resources needed, identifying who will serve on the implementation team, and how guideline implementation progress will be measured is also important. Other strategies include securing support from change champions who can help colleagues understand the reasons for changes that are being made and to understand the evidence behind new CPG recommendations.
Let’s all do our part to reduce inappropriate practice variation, enhance translation of research into practice, and improve care for critically ill patients. SCCM guidelines are open access to help ensure that critical care patients are receiving consistent, evidence-based care. Members and nonmembers can access the SCCM guidelines for free by visiting www.sccm.org/guidelines and Critical Care Medicine online or by downloading the guidelines app.
If you find a novel or exceptionally successful way that you or your organization is implementing these new guidelines, please let me know. I’d love to hear about your experiences! E-mail me at email@example.com.
1. Institute of Medicine. Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press; 2011.
2. Weil MH. The Society of Critical Care Medicine, its history and its destiny. Crit Care Med. 1973 Jan-Feb;1(1):1-4.
3. [No authors listed]. Guidelines for organization of critical care units. JAMA. 1972 Dec 18;222(12):1532-1535.
4. Nates JL, Nunnally M, Kleinpell R, et al. ICU admission, discharge, and triage guidelines: a framework to enhance clinical operations, development of institutional policies, and further research. Crit Care Med. 2016 Aug;44(8):1553-1602.
5. Levitov A, Frankel HL, Blaivas M, et al. Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part II: cardiac ultrasonography. Crit Care Med. 2016 Jun;44(6):1206-1227.
6. Murray MJ, DeBlock H, Erstad B, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med. 2016 Nov;44(11):2079-2103.
7. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med. 2017 Mar;45(3):486-552.
8. Davidson JE, Aslakson RA, Long AC, et al. Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Crit Care Med. 2017 Jan;45(1):103-128.
9. Daly JA. Advocacy: Championing Ideas and Influencing Others. New Haven, CT: Yale University Press; 2012.
10. Carpenter D. Cartoons by Dave Carpenter. #9850.
11. Ganz DA. Implementing Guidelines in Your Organization: What Questions Should You be Asking? Rockville, MD: Agency for Healthcare Research and Quality. National Guideline Clearinghouse; 2015. https://www.guideline.gov/expert/expert-commentary/49423/implementing-guidelines-in-your-organization-what-questions-should-you-be-asking. Accessed April 10, 2017.