An appraisal of emergency medicine clinical practice guidelines: Do we agree?

Clinical Practice Guideline Recommendations For Pediatric Multisystem Trauma Care: A Systematic Review

OBJECTIVE

To systematically review clinical practice guidelines (CPGs) for pediatric multisystem trauma, appraise their quality, synthesize the strength of recommendations and quality of evidence, and identify knowledge gaps.

BACKGROUND

Traumatic injuries are the leading cause of death and disability in children, who require a specific approach to injury care. Difficulties integrating CPG recommendations may cause observed practice and outcome variation in pediatric trauma care.

METHODS

We conducted a systematic review using Medline, Embase, Cochrane Library, Web of Science, ClinicalTrials, and grey literature, from January 2007 to November 2022. We included CPGs targeting pediatric multisystem trauma with recommendations on any acute care diagnostic or therapeutic interventions. Pairs of reviewers independently screened articles, extracted data, and evaluated the quality of CPGs using "Appraisal of Guidelines, Research, and Evaluation II."

RESULTS

We reviewed 19 CPGs, and 11 were considered high quality. Lack of stakeholder engagement and implementation strategies were weaknesses in guideline development. We extracted 64 recommendations: 6 (9%) on trauma readiness and patient transfer, 24 (38%) on resuscitation, 22 (34%) on diagnostic imaging, 3 (5%) on pain management, 6 (9%) on ongoing inpatient care, and 3 (5%) on patient and family support. Forty-two (66%) recommendations were strong or moderate, but only 5 (8%) were based on high-quality evidence. We did not identify recommendations on trauma survey assessment, spinal motion restriction, inpatient rehabilitation, mental health management, or discharge planning.

CONCLUSIONS

We identified 5 recommendations for pediatric multisystem trauma with high-quality evidence. Organizations could improve CPGs by engaging all relevant stakeholders and considering barriers to implementation. There is a need for robust pediatric trauma research, to support recommendations.

The relationship between regional inequalities in the provision of emergency health services and other health services

In this research, it was aimed to examine relationship between regional inequalities in the provision of emergency health services and other health services in Turkey. The values of the number of emergency services and the population per emergency service for the years 2002-2021 were taken from the most up-to-date database published by the Ministry of Health in 2022 and were chosen as the dependent variables of the study. The "regional price level indices for consumption expenditures (PLI)" and "gross domestic product per capita, Statistical Regions Level 2 (PcGDP)" data compiled by TURKSTAT were used as independent variables. Number of emergency stations were significantly correlated with TR31 (İzmir) (r = 0.903; P < .01), TR32 (Aydin, Denizli, Muğla) (r = 0.771; P < .01), TR42 (Kocaeli, Sakarya, Düzce, Bolu, Yalova) (r = -0.798; P < .01), TR62 (Adana, Mersin) (r = 0.837; P < .01), TR63 (Hatay, K.Maraş, Osmaniye) (r = -0.749; P < .01), TR72 (Kayseri, Sivas, Yozgat) (r = -0.719; P < .01), TR83 (Samsun, Tokat, Çorum, Amasya) (r = 0.873; P < .01), TRA2 (Ağri, Kars, Iğdir, Ardahan) (r = -0.873; P < .01), TRB2 (Van, Muş, Bitlis, Hakkari) (r = -0.736; P < .01), TRC2 (Şanliurfa, Diyarbakir) (r = 0.697; P < .01), and TRC3 (Mardin, Batman, Şirnak, Siirt) (r = 0.574; P < .01). In total, 11 of 26 were significantly correlated with inequalities. Although the number of emergency services has increased since 2002 and the population density per emergency room has tended to decrease, regional inequalities also have an impact on the delivery of emergency services today.

Improvement in the diagnosis and practices of emergency healthcare providers for heat emergencies after HEAT (heat emergency awareness & treatment) an educational intervention: a multicenter quasi-experimental study

BACKGROUND

The incidence of heat emergencies, including heat stroke and heat exhaustion, have increased recently due to climate change. This has affected global health and has become an issue of consideration for human health and well-being. Due to overlapping clinical manifestations with other diseases, and most of these emergencies occurring in an elderly patient, patients with a comorbid condition, or patients on poly medicine, diagnosing and managing them in the emergency department can be challenging. This study assessed whether an educational training on heat emergencies, defined as heat intervention in our study, could improve the diagnosis and management practices of ED healthcare providers in the ED setting.

METHODS

A quasi-experimental study was conducted in the EDs of four hospitals in Karachi, Pakistan. Eight thousand two hundred three (8203) patients were enrolled at the ED triage based on symptoms of heat emergencies. The pre-intervention data were collected from May to July 2017, while the post-intervention data were collected from May to July 2018. The HEAT intervention, consisting of educational activities targeted toward ED healthcare providers, was implemented in April 2018. The outcomes assessed were improved recognition-measured by increased frequency of diagnosing heat emergencies and improved management-measured by increased temperature monitoring, external cooling measures, and intravenous fluids in the post-intervention period compared to pre-intervention.

RESULTS

Four thousand one hundred eighty-two patients were enrolled in the pre-intervention period and 4022 in the post-intervention period, with at least one symptom falling under the criteria for diagnosis of a heat emergency. The diagnosis rate improved from 3% (n = 125/4181) to 7.5% (n = 7.5/4022) (p-value < 0.001), temperature monitoring improved from 0.9% (n = 41/4181) to 13% (n = 496/4022) (p-value < 0.001) and external cooling measure (water sponging) improved from 1.3% (n = 89/4181) to 3.4% (n = 210/4022) (p-value < 0.001) after the administration of the HEAT intervention.

CONCLUSION

The HEAT intervention in our study improved ED healthcare providers' approach towards diagnosis and management practices of patients presenting with health emergencies (heat stroke or heat exhaustion) in the ED setting. The findings support the case of training ED healthcare providers to address emerging health issues due to rising temperatures/ climate change using standardized treatment algorithms.

Use of the AGREE II instrument to evaluate critical care practice guidelines addressing pharmacotherapy

RATIONALE, AIMS AND OBJECTIVES

Clinical practice guidelines (CPGs) have been evaluated for reporting transparency and methodological quality in a number of studies in various disciplines, but few studies have focused on critical care and none on pharmacotherapy-related guidelines specifically. The objective of this study was to evaluate the quality of critical care CPGs with a focus on pharmacotherapy using the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument.

METHOD

A cross-sectional study of CPGs published from 2013 through August 2021 was conducted. Following establishment of interrater reliability, guidelines were independently evaluated by three reviewers to rate guidelines on criteria set forth by the AGREE II instrument. Domain scores and item scores were calculated using the AGREE II user manual, and results described with descriptive statistics.

RESULTS

Out of 192 guidelines identified, 73 met inclusion criteria and were screened using the AGREE II instrument. Most guidelines were authored by a professional organization or government agency. Domain quality scores were calculated for each domain as recommended by the AGREE II instrument. Domain 4 (clarity of presentation) had the highest AGREE II domain score with a median score of 87.0% (interquartile range: 79.6%-92.6%). Domain 5 (applicability) received the lowest domain score with a mean score of 41.8 ± 21.1%. The majority of guidelines were recommended for use as published or with modifications, while only six guidelines (8.2%) were not recommended for use.

CONCLUSIONS

The majority of critical care guidelines that include pharmacotherapy recommendations were recommended for use by study authors when the AGREE II instrument was applied. While guidelines generally scored highly in clarity of presentation, additional time and effort should focus on providing solutions to guideline implementation and inclusion of patient preferences.

Augmented Reality for Guideline Presentation in Medicine: Randomized Crossover Simulation Trial for Technically Assisted Decision-making

BACKGROUND

Guidelines provide instructions for diagnostics and therapy in modern medicine. Various mobile devices are used to represent the potential complex decision trees. An example of time-critical decisions is triage in case of a mass casualty incident.

OBJECTIVE

In this randomized controlled crossover study, the potential of augmented reality for guideline presentation was evaluated and compared with the guideline presentation provided in a tablet PC as a conventional device.

METHODS

A specific Android app was designed for use with smart glasses and a tablet PC for the presentation of a triage algorithm as an example for a complex guideline. Forty volunteers simulated a triage based on 30 fictional patient descriptions, each with technical support from smart glasses and a tablet PC in a crossover trial design. The time to come to a decision and the accuracy were recorded and compared between both devices.

RESULTS

A total of 2400 assessments were performed by the 40 volunteers. A significantly faster time to triage was achieved in total with the tablet PC (median 12.8 seconds, IQR 9.4-17.7; 95% CI 14.1-14.9) compared to that to triage with smart glasses (median 17.5 seconds, IQR 13.2-22.8, 95% CI 18.4-19.2; P=.001). Considering the difference in the triage time between both devices, the additional time needed with the smart glasses could be reduced significantly in the course of assessments (21.5 seconds, IQR 16.5-27.3, 95% CI 21.6-23.2) in the first run, 17.4 seconds (IQR 13-22.4, 95% CI 17.6-18.9) in the second run, and 14.9 seconds (IQR 11.7-18.6, 95% CI 15.2-16.3) in the third run (P=.001). With regard to the accuracy of the guideline decisions, there was no significant difference between both the devices.

CONCLUSIONS

The presentation of a guideline on a tablet PC as well as through augmented reality achieved good results. The implementation with smart glasses took more time owing to their more complex operating concept but could be accelerated in the course of the study after adaptation. Especially in a non-time-critical working area where hands-free interfaces are useful, a guideline presentation with augmented reality can be of great use during clinical management.

Methodological quality and transparency of clinical practice guidelines for difficult airway management using the appraisal of guidelines research & evaluation II instrument: A systematic review

BACKGROUND

Complications arising from airway management represent an important cause of morbidity and mortality. Clinical practice guidelines (CPGs) are systematically created documents that summarise knowledge and assist the delivery of high-quality medical care by identifying evidence that supports best clinical care.

OBJECTIVE

Using the Appraisal of Guidelines for Research & Evaluation II instrument, we aimed to evaluate the methodological rigour and transparency of unanticipated difficult airway management CPGs in adults.

DESIGN

Using PUBMED without language restrictions, we identified eligible CPGs between 1 January 1996 and 30 June 2019. All versions of a CPG were included as independent guidelines to assess improvements over time or the methodological limitations of each version. CPGs-related obstetrics or paediatrics or the management extubation in cases of difficult airway were excluded.

RESULTS

Fourteen CPGs were included. Of the six domains suggested by the Appraisal of Guidelines for Research & Evaluation II instrument, 'applicability' had the lowest score (23%) and 'scope and objectives' had the highest score (88%). The remaining domains (stakeholder involvement, editorial independence, rigour of development and clarity of presentation) had scores ranging between 56 and 81%. Overall, the highest scored CPG was the Difficult Airway Society 2015.

CONCLUSION

Future updates of CPGs for difficult airway management in adults and severely ill patients should consider more emphasis on the applicability of their recommendations to real clinical practice.

The structure of the quality of clinical practice guidelines with the items and overall assessment in AGREE II: a regression analysis

Background

The Appraisal of Guidelines for Research & Evaluation (AGREE) II has been widely used to evaluate the quality of clinical practice guidelines (CPGs). While the relationship between the overall assessment of CPGs and scores of six domains were reported in previous studies, the relationship between items constituting these domains and the overall assessment has not been analyzed. This study aims to investigate the relationship between the score of each item and the overall assessment and identify items that could influence the overall assessment.

Methods

All Japanese CPGs developed using the evidence-based medicine method and published from 2011 to 2015 were used. They were independently evaluated by three appraisers using AGREE II. The evaluation results were analyzed using regression analysis to evaluate the influence of 6 domains and 23 items on the overall assessment.

Results

A total of 206 CPGs were obtained. All domains and all items except one were significantly correlated to the overall assessment. Regression analysis revealed that Domain 3 (Rigour of Development), Domain 4 (Clarity of Presentation), Domain 5 (Applicability), and Domain 6 (Editorial Independence) had influence on the overall assessment. Additionally, four items of AGREE II, clear selection of evidence (Item 8), specific/unambiguous recommendations (Item 15), advice/tools for implementing recommendations (Item 19), and conflicts of interest (Item 22), significantly influenced the overall assessment and explained 72.1% of the variance.

Conclusions

These four items may highlight the areas for improvement in developing CPGs.