By Monisha Kumar MD FNCS (left), Molly McNett, PhD, RN, CNRN, FNCS (right)
The development of evidence-based clinical practice guidelines (CPGs) is one of the most valuable and visible functions of the Neurocritical Care Society (NCS) and critical to its mission. As such, the Guidelines Committee (GC) of NCS has experienced tremendous growth and evolution since its inception only ten years ago. Key accomplishments include an increase in the number of guidelines produced on behalf of the society, enhancements to ensure methodological rigor, adherence with best practices in guideline development and streamlining processes for endorsement of NCS and partnering-society guidelines. The GC also has forged critical collaborations with external organizations in producing guidelines and other seminal documents. The aim of this update is to inform NCS members of the new processes created in guideline development and review, solicitation of imprimatur and work product alignment to better serve the NCS community.
Updated Guidelines Process
The goal of a CPG is to generate evidence-based recommendations to guide practice of interdisciplinary teams and highlight areas for future research when a paucity of evidence exists. CPGs require a formal needs assessment, relevant topics, balanced writing groups, a systematic methodology and rigorous review of the literature, generation of unbiased recommendations, internal and external peer review and endorsement prior to external dissemination via publications and presentations. This process generally takes two years to complete, from project inception to completed publication.
The GC has worked on streamlining many aspects of this process over the last two years to increase efficiency and productivity, while ensuring development of quality products. Specific enhancements include the development of a formal needs assessment tool. This web-based survey facilitates the submission of potential topic ideas directly from NCS membership. To enhance methodological rigor, the GC ensures all guidelines have a GRADE coach assigned, and also has also created a leadership position within the committee to train writing committee members on GRADE methodology. With ongoing training, the GC aims to create a large pool of members with skills in GRADE-based methodology to assist in future projects. To further enhance the methodological process, the GC has adopted Distiller SR software to aid in the onerous process of systematic review, which often yields thousands of abstracts for review. The software allows for real-time communication and oversight of progress among members of the writing committee, standardizes the review process for eligibility of studies and extraction of data and creates PRISMA flow charts and evidentiary tables that are a requirement for publication. The GC also has worked to facilitate communication with both the Executive Committee and the Board of Directors, as well as the Neurocritical Care Journal to streamline the final review and approval processes for publication of guidelines within defined timeframes.
Review External Guidelines
In addition to enhancing processes for guideline development, the GC also oversees review of external guidelines from collaborating societies. In addition to committee member review, the GC solicits participation from NCS membership to review guidelines from partnering societies. Approximately 8-12 reviewers at large are chosen based on content expertise, guidelines experience, work environment (clinical or academic) and practice duration; the process also ensures that a heterogeneous group of individuals (age, sex, race, discipline) are invited. Pediatric reviewers often are actively solicited for their expertise and consideration.
To minimize bias and to ensure transparency, the GC formulated a special tool to assist in the review of external guidelines. With this standardized approach, the External Guidelines liaisons, or co-chairs elect, can now collate and analyze these reviews in a formal and systematic fashion. The GC also created a separate endorsement matrix to aid in determining the type of endorsement provided, based on the review criteria. The endorsement matrix accounts for methodological adherence, formal partnership, assigned designee and overall quality. Based on binary outcomes, endorsement, affirmation or a decision not to endorse or affirm is made.
Work with NCS Committees to Assist with Imprimatur
Over the past two years, the GC has provided internal peer review of committee-sponsored documents for consideration of formal NCS imprimatur. To facilitate the review of those documents, the GC created a flow chart (see figure below) to guide the process. For other types of documents generated by society membership, that do not represent an official statement on behalf of the society, a review by the Executive Committee or direct review by journal editors and reviewers may be sufficient.
Working with Other NCS Committees to Ensure Consistency
NCS currently creates various products across many committees. The GC has worked with the committee chairs to establish an internal review process to ensure quality and alignment of content across products and publications released by NCS. Specifically, the GC has initiated a process to ensure consistency of content produced within NCS guidelines, educational products and Emergency Neurological Life Support (ENLS) publications. It is imperative that the practice recommendations and educational content are internally consistent.
The GC has been hard at work over the last two years, and work continues as Herb Fried and Lori Madden transition to GC co-chairs at the Annual Meeting. This year, the GC will introduce presentations for our new guideline, “Medical Management of Cerebral Edema” and an interim update on the Neuroprognostication Guideline conducted in collaboration with the German Neurocritical Care Society (DGNI). Future work includes a comprehensive update to the SAH guideline in 2020, and release of a new guideline on seizure prophylaxis in 2021.