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ICU TopicsStatistics & evidence-based medicine

ICU · Statistics & evidence-based medicine

Guidelines, Evidence-Based Medicine & Quality-Improvement Methodology

Also known as Evidence-based medicine · GRADE · GRADE Evidence to Decision · Clinical guidelines · Guideline development · Quality improvement · PDSA cycle · AGREE II · PICO · Care bundles · Evidence hierarchy · Systematic review · Critical appraisal · CASP · CONSORT · PRISMA · STROBE · Bias · Implementation science · Knowledge translation · CFIR · PARIHS

Guidelines, EBM and quality improvement for the ICU First Part: evidence-based medicine as the integration of best evidence, clinical expertise and patient values; the PICO question and the evidence hierarchy; the GRADE approach to evidence quality (high/moderate/low/very low), recommendation strength (strong/weak), downgrading and upgrading domains, and the Evidence to Decision framework; the guideline-development pipeline from PICO to systematic review to evidence profile to graded recommendation; guideline appraisal (AGREE II); critical appraisal tools (CASP checklists) and reporting guidelines (CONSORT, PRISMA, STROBE); implementation science (knowledge-to-action, CFIR, PARIHS); and QI methodology - PDSA cycles, care bundles, audit and feedback, and the structure-process-outcome framework.

high23 referencesUpdated 26 July 202642 min readVerification in progress

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Meet the patient — the guideline you are asked to trust

You are the ICU representative on the hospital antimicrobial stewardship committee. A new national guideline recommends procalcitonin-guided antibiotic discontinuation as a weak recommendation, moderate-quality evidence. The committee chair asks: should we adopt this? Before you can answer, you need to know what those words mean, how the guideline was built, and whether you can trust it.[1][2]

Evidence-based medicine is the integration of the best research evidence with clinical expertise and patient values. It is not cookbook medicine — your judgment and the patient in front of you are explicit, weighted components. The pipeline runs from asking the right question (PICO), through finding and grading the evidence (GRADE), to appraising the guideline (AGREE II), to closing the gap between guidance and practice (PDSA, care bundles, audit). The whole chain is examinable end to end.[1][2]

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  1. [1]Evidence-Based Medicine Working Group (Guyatt G, Cairns J, Churchill D, et al.) Evidence-based medicine. A new approach to teaching the practice of medicine JAMA, 1992.PMID 1404801
  2. [2]Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS Evidence based medicine: what it is and what it isn't BMJ, 1996.PMID 8555924
  3. [3]Richardson WS, Wilson MC, Nishikawa J, Hayward RSA The well-built clinical question: a key to evidence-based decisions ACP J Club, 1995.PMID 7582737
  4. [4]Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, Guyatt GH, Harbour RT, Haugh MC, Henry D, Hill S, Jaeschke R, Leng G, Liberati A, Magrini N, Mason J, Middleton P, Mrukowicz J, O'Connell D, Oxman AD, Phillips B, Schünemann HJ, Edejer TT, Varonen H, Vist GE, Williams JW Jr, Zaza S; GRADE Working Group Grading quality of evidence and strength of recommendations BMJ, 2004.PMID 15205295
  5. [5]Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ; GRADE Working Group GRADE: an emerging consensus on rating quality of evidence and strength of recommendations BMJ, 2008.PMID 18436948
  6. [6]Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables J Clin Epidemiol, 2011.PMID 21195583
  7. [7]Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, Vist GE, Falck-Ytter Y, Meerpohl J, Norris S, Guyatt GH GRADE guidelines: 3. Rating the quality of evidence J Clin Epidemiol, 2011.PMID 21208779
  8. [8]Guyatt GH, Oxman AD, Montori V, Vist G, Kunz R, Brozek J, Alonso-Coello P, Djulbegovic B, Atkins D, Falck-Ytter Y, Williams JW Jr, Meerpohl J, Norris SL, Akl EA, Schünemann HJ GRADE guidelines: 4. Rating the quality of evidence--study limitations (risk of bias) J Clin Epidemiol, 2011.PMID 21247734
  9. [9]Guyatt GH, Oxman AD, Kunz R, et al. GRADE guidelines 6. Rating the quality of evidence--imprecision J Clin Epidemiol, 2011.PMID 21839614
  10. [10]Andrews J, Guyatt G, Oxman AD, et al. GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations J Clin Epidemiol, 2013.PMID 23312392
  11. [11]Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation's direction and strength J Clin Epidemiol, 2013.PMID 23570745
  12. [12]Alonso-Coello P, Schünemann HJ, Moberg J, et al. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction BMJ, 2016.PMID 27353417
  13. [13]Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L; AGREE Next Steps Consortium AGREE II: advancing guideline development, reporting and evaluation in health care CMAJ, 2010.PMID 20603348
  14. [14]Schulz KF, Altman DG, Moher D; CONSORT Group CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials BMJ, 2010.PMID 20332509
  15. [15]Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement PLoS Med, 2009.PMID 19621072
  16. [16]Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D The PRISMA 2020 statement: an updated guideline for reporting systematic reviews BMJ, 2021.PMID 33782057
  17. [17]von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies PLoS Med, 2007.PMID 17941714
  18. [18]Greenhalgh T How to read a paper. Getting your bearings (deciding what the paper is about) BMJ, 1997.PMID 9253275
  19. [19]Grol R, Grimshaw J From best evidence to best practice: effective implementation of change in patients' care Lancet, 2003.PMID 14568747
  20. [20]Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science Implement Sci, 2009.PMID 19664226
  21. [21]Kitson A, Harvey G, McCormack B Enabling the implementation of evidence based practice: a conceptual framework Qual Health Care, 1998.PMID 10185141
  22. [22]Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021 Crit Care Med, 2021.PMID 34605781
  23. [23]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 Intensive Care Med, 2021.PMID 34599691

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