Clinical Practice Guidelines: Phase 5 – New Methods Same Goals

The American Association for Respiratory Care (AARC) has published clinical practice guidelines (CPGs) crafted by respiratory therapists and our physicians and nursing colleagues in Respiratory Care since 1991. Several editorials have documented the evolution of the AARC CPGs from expert opinion (1991) to referenced-based guidelines (2013); to a university evidenced-based practice center creating CPGs for the AARC (2014); and to 2021 using the patient, intervention, comparison, and outcome (PICO) format.^1-4 The respiratory care profession owes great gratitude and appreciation to those who have worked to publish CPGs since 1991. But as history shows, clinical practice continues to change, as does the methodology and our understanding of guideline development.

In 2021, I began my journey to direct the CPG development process for the AARC. My one-day orientation was at the AARC executive office. Throughout the day, Dean Hess filled my mind with terms such as methods; evidence; tools; INGUIDE; data extraction; Grading of Recommendations Assessment, Development, and Evaluation (GRADE); bias; and more. Reflecting on that October day, I now see that Dean was explaining the next iteration of the CPG process. The CPG published in this issue of the Journal is the first publication based on phase 5 methods. Roberts et al⁵ spent nearly 2 years on the creation of this CPG. This CPG follows the INGUIDE program developed at McMasters University (https://inguide.org) for developing CPGs based on GRADE methodology (https://www.gradepro.org). These sources are based on international standards and criteria that include scientific rigor, transparency, and inclusivity.⁶ Furthermore, the most current tools to judge the literature and interpret evidence were used. Roberts et al provided 4 recommendations to assist clinicians to liberate adult patients more rapidly from mechanical ventilation in acute care settings. This CPG complements previously published CPGs related to ventilator liberation.

What to Expect from New Methodology

By the end of 2024, there will be 9 different teams working to create CPGs. Those guidelines accepted and published in Respiratory Care will follow a standardized format that includes a definition of the topic under review. The goal is to define the population, the patient setting, and why the practice is important. Enhanced methods will detail full disclosures of team members so that readers can adjudicate any conflicts of interest. Systematic reviews are registered with PROSPERO (https://www.crd.york.ac.uk/PROSPERO) to prevent replication, examine the literature search terms created by the librarians, and assess Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow and checklists (https://www.prisma-statement.org) for information on the number of articles reviewed. Additionally, details on how team members screened the literature, how the evidence was graded based on a review of bias, and an assessment via GRADEpro-GDT will be available. When the writing begins, PICO questions will structure the format of the paper and will include a background section of why the question is relevant and important to respiratory care practice. A summary of the evidence by patient outcomes is followed by recommendations. A section on justification and implementation is provided as well as future research opportunities that are needed to fill gaps in the literature. Lastly, one can expect a steady stream of CPG publications in the Journal. For instance, a second CPG paper has been accepted and will be published by year’s end;⁷ a third guideline is in the writing stage, and a fourth is beginning the writing process.

Presentations to cover CPG recommendations and implementation strategies at AARC meetings are planned. Team members can be expected to provide presentations at state society meetings. Protocols and best practice statements are planned to assist with implementation strategies. A system of updating CPGs every 5 years can be expected to meet INGUIDE standards. AARC webcasts and podcasts are planned as well.

What Not to Expect

CPGs will not answer all questions. The evidence may not provide sufficient guidance, or clinical practice may necessitate a new approach as practice evolves. In many cases, the patient drives appropriate clinical practice based on severity and trajectory of illness. Conversely, some current practices may need a de-implementation plan.⁸ New recommendations may require managers and clinicians to acquire more education for implementation and to change practice.

Do not expect AARC CPGs to dictate the details of what to do. For example, CPGs will not inform how often to do procedures or when. This is determined at the local level. In other words, the respiratory care department in cooperation with the physicians, administrators, and others determines implementation. However, the AARC is committed to providing CPGs to support best patient outcomes. Implementation will always be dictated by factors such as local culture and available resources. Armed with the recommendations from CPGs, a skilled respiratory therapist will provide clinical leadership through improvements in practice to guide evidence-based practice and improve patient outcomes.

In summary, the AARC has a history of publishing CPGs and will continue to do so. Phase 5 of the development process is based on evidence-based medicine and the clinical decision-making of team members using tools that meet accepted respiratory care practice and international clinical practice.