Grading of recommendations in intensive care unit guidelines: A scoping review of existing methodological approaches
There has been an explosion of ICU guidelines for clinicians to consider in the last decade. Often, several guidelines on one and the same clinical topic, however, appear to come to different conclusions regarding the underlying level of evidence and strength of recommendations.
Objectives: This scoping review assessed methodological approaches used to grade the underlying level of evidence and strength of recommendations within ICU guidelines.
Methods: A systematic search of guideline platforms and medical society databases was performed to identify guidelines for intensive care medicine. Other potentially eligible guidelines were identified by searching reference lists of matching guidelines. A two-stage screening was performed by two reviewers. Data was extracted and inspected for statistical analysis.
Results: We included 91 guidelines with a total of 3.758 recommendations in this scoping review. We grouped relevant guidelines according to their context and contrasted all recommendations and the level of evidence for each recommendation. We found that multiple ICU guidelines exist for the same clinical topic using multiple different grading systems. Most of the included guidelines (n=57) used GRADE to assess the level of evidence and strength of recommendation. Only 10 of 57 guidelines used the GRADE approach correctly. Other grading methods used were the ESC/EACTS grading scale (n=3), SIGN 50 (n=4), a combination of different methods or used a self-developed grading system.
Conclusions: There are too many guidelines for the same clinical topic for a clinician to keep track of them all. This is further complicated by the fact that guideline development is not standardized, and the grading carried out is incorrect, making it difficult to assess which recommendation of which guideline should be followed in daily practice. The use of different grading systems across guidelines limits comparison of recommendations across guidelines.
Patient, public and/or healthcare consumer involvement: Standardization of guideline development process with the use of a uniform grading system will allow clinicians to follow the recommendations of guidelines in their daily work. Patients will benefit from more uniform, guideline-based treatment.