Elsevier

Australian Critical Care

Volume 21, Issue 4, November 2008, Pages 200-215
Australian Critical Care

Using consensus methods to develop clinical practice guidelines for intensive care: The Intensive Care Collaborative project

https://doi.org/10.1016/j.aucc.2008.08.003Get rights and content

Summary

Background

Clinical practices or procedures based on the best available evidence are an essential resource within an intensive care unit (ICU). Maintaining the currency of a local clinical practice manual is challenging however, particularly in relation to the time required, other workload pressures and the availability of staff with relevant skills to interrogate the literature. The aim of the Intensive Care Collaborative (ICC) project was to use the synergism of group processes to develop state-based clinical guidelines for six common intensive care practices - eye care, oral care, endotracheal tube management, suctioning, arterial line management, and central venous catheter (CVC) management.

Methods

Participants were 55 senior nurse clinicians from all nine area health services in NSW, seven academic facilitators, and staff from the Intensive Care Coordination and Monitoring Unit (ICCMU). A range of approaches were used to develop the six clinical practice guidelines (CPG) and related systematic literature reviews, including a preparatory educational seminar for participants, formation of working groups of clinicians, with subsequent teleconferences, e-mail and online forums to identify the scope of each guideline and review the literature. A consensus development conference (CDC) was conducted to finalise the reviews with a nominal group technique (NGT) used to develop recommendations for practice. External Validation Panels (EVP) verified the recommendations in each clinical practice guideline. Group voting was undertaken using a Likert scale (1–3 disagree, 4–6 neutral, 7–9 agree) with consensus agreement set as a median of at least seven.

Results

Eighty-three recommendations for practice were developed for the six Clinical Practice Guidelines; 50% were based on research literature evidence (23% with high levels of evidence). The balance were based on consensus opinion of the panel members. Only five recommendations were not validated by external validation.

Conclusion

This project has demonstrated a method for guideline development that is robust, incorporating evidence from research and clinical expertise utilising an objective egalitarian framework.

Section snippets

Background

Clinical practices or procedures based on the best available evidence are essential resources within an intensive care unit (ICU).1 Maintaining the currency of a local clinical practice manual is challenging however, particularly in relation to the time required, other workload pressures and the availability of senior nursing staff with relevant skills to interrogate the literature. The Intensive Care Coordination and Monitoring Unit (ICCMU) was established in 2003 to collect information

Method

The aim of the Intensive Care Collaborative project was to develop CPGs for six common intensive care practices using a group process approach. This entailed: synthesising the current evidence base around each practice; and developing recommendations for practice incorporating the research evidence and expert opinion where evidence was lacking. The models used to assist development of the methods included: the AGREE Collaboration;12 and Promoting Action on Research Implementation in Health

Results

In total, 55 participants from all nine Area Health Services in NSW attended the seminar (15 Clinical Nurse Consultants; 18 clinical/nurse educators; 8 Nurse Managers; 14 Clinical Nurse Specialists). Twenty-nine pre-seminar surveys (response rate 49%) were returned with 171 requests for potential topics. These were categorised into eight groups: (1) routine care of the critically ill (n = 53); (2) ventilation (n = 49); (3) speciality areas (n = 27); (4) haemodynamic monitoring (n = 25); (5) drug

Discussion

This Intensive Care Collaborative project conducted by the NSW Intensive Care Coordination and Monitoring Unit enabled the development of six clinical practice guidelines using a mixed-method group consensus approach—using electronic communications in the initial development phases of guideline scope identification and literature review, utilising a NGT at a consensus conference, and then seeking external validation using Delphi panels. While the project was coordinated centrally, the impetus

Conclusion

This paper described a project where the tools of evidence-based practice (systematic reviews) were combined with structured group techniques (nominal group, Delphi panel and CDC) to develop CPGs and their related literature reviews for six common clinical nursing practices in intensive care. Other related papers will report the specific details for each guideline, including the recommendations for clinical practice based on the available body of research evidence or expert consensus. All

Financial disclosure

The Intensive Care Collaborative project was primarily funded from internal funding of ICCMU, NSW Health. Participants in the GDNs were supported by their employing units. Three rural participants were supported by the Rural Education fund to attend the CDC. Travel and accommodation costs of the academic facilitators were paid by ICCMU. Elsevier Publications attended the Education seminar. No trade sponsorship was solicited for the CDC and no industry representatives were involved in any aspect

Acknowledgements

The Authors acknowledge the invaluable involvement of all GDN and EVP members. Panel participants are acknowledged in each of the full guideline documents available at the ICCMU website (http://intensivecare.hsnet.nsw.gov.au).

Academic facilitatorsArterial guideline: Dr. Tina Jones Manager, Australian Centre for Evidence-Based Clinical Practice, Flinders Medical Centre and Senior Lecturer, Faculty of Health Sciences, Flinders University. CVC guideline: Dr. Judy Currey Senior Lecturer, School of

References (55)

  • S. Keeney et al.

    A critical review of the Delphi technique as a research methodology for nursing

    International Journal of Nursing Studies

    (2001)
  • K.L. Dowling et al.

    Asynchronous implementation of the nominal group technique: is it effective?

    Decision Support Systems

    (2000)
  • A. Gardner et al.

    Best practice in stablisation of oral endotracheal tubes: a systematic review

    Australian Critical Care

    (2005)
  • M. Pogorzelska et al.

    Assessment of attitudes of intensive care unit staff toward clinical practice guidelines

    Dimensions of Critical Care Nursing

    (2008)
  • K. Rolls et al.

    Building a statewide knowledge network for clinicians in intensive care units: knowledge brokering and the NSW Intensive Care Coordination and Monitoring Unit

    Australian Critical Care

    (2008)
  • S. Nagy et al.

    Nurses’ beliefs about the conditions that hinder or support evidence-based nursing

    International Journal of Nursing Practice

    (2001)
  • A.M. Hutchinson et al.

    Beyond the BARRIERS scale: commonly reported barriers to research use

    Journal of Nursing Administration

    (2006)
  • Cochrane. The Cochrane Collaboration. No date [cited 8 May 2008]; Available from:...
  • JBIEBNM. The Joanna Briggs Institute [cited 8 May 2008]; Available from:...
  • NICE. Welcome to the National Institute for Health and Clinical Excellence. No date [cited 8 May 2008]; Available from:...
  • SIGN. Scottish Intercollegiate Guidelines Network. No date [cited 8 May 2008]; Available from:...
  • J. Rycroft-Malone

    Formal consensus: the development of a national clinical guidelines

    Quality and Safety in Health Care

    (2001)
  • SIGN. What is SIGN—what are guidelines? 2008 [cited 9 May 2008]. Available from:...
  • J.E. Heffner

    Does evidence-based medicine help the development of clinical practice guidelines

    Chest

    (1998)
  • AGREE. Development and validation of an international appraisal instrument for assessing the quality of clinical...
  • D. Elliott

    Reviewing the literature

  • D.J. Cook et al.

    Systematic reviews: synthesis of best evidence for clinical decisions

    Annals of Internal Medicine

    (1997)
  • JBIEBNM. An introduction to systematic reviews, changing practice Sup. 1. In: Changing practice: evidence based...
  • R. Whittemore et al.

    The integrative review: updated methodology

    Journal of Advanced Nursing

    (2005)
  • B. McCormack et al.

    A realist synthesis of evidence relating to practice development: findings from the literature analysis

    Practice Development in Health Care

    (2007)
  • D. Sackett et al.

    Evidence based medicine: what it is and what it isn’t

    BMJ

    (1996)
  • P. Fulbrook

    Developing best practice in critical care nursing: knowledge, evidence and practice

    Nursing in Critical Care

    (2003)
  • J. Rycroft-Malone et al.

    What counts as evidence in evidence-based practice?

    Journal of Advanced Nursing

    (2004)
  • J.T.P. Higgins et al.

    Cochrane handbook for systematic reviews of interventions version 5.0.0

    (2008)
  • NHMRC. How to use the evidence: assessment and application of scientific evidence. Canberra, NHMRC 2000. In: Australian...
  • C. Pagliari et al.

    Impact on group structure and process on multidisciplinary evidence-based guideline development: an observational study

    Journal of Evaluation in Clinical Practice

    (2002)
  • Straker D. Nominal group technique. In: Straker D, editor. The Quality Toolbook. Syque,...
  • Cited by (19)

    • Clinical effectiveness and safety of salvia miltiorrhiza depside salt combined with aspirin in patients with stable angina pectoris: A multicenter, pragmatic, randomized controlled trial

      2021, Phytomedicine
      Citation Excerpt :

      Therefore, consistent recommendations can be reached through strict expert consensus in the absence of high-quality evidence. There are three specific methods of expert consensus commonly used in the medical field: Delphi method, Nominal Group Technique (NGT) and Consensus Development Conference (CDC) (Coster et al., 2018; Rolls and Elliott, 2008). Based on the results of this study, we will use the CDC method and Delphi method to form an expert consensus of SMDS combined with aspirin in the treatment of SAP to guide clinical practice (Liao and Xie, 2008).

    • A retrospective study showing the extent of compliance with perioperative guidelines in patients with coronary stents with regard to double antiplatelet therapy

      2016, Journal of Clinical Anesthesia
      Citation Excerpt :

      Recently, the University of Alabama at Birmingham Health System established an Anticoagulation Task Force to create 2 evidence-based and expert opinion–supported protocols with the goal to standardize perioperative management of antiplatelet agents in patients with previously placed coronary stents [4]. Such protocols use a consensus decision-making approach and facilitate decision making in complex clinical situations [11,12]. At the Vanderbilt University Medical Center (VUMC), antiplatelet management decisions in the perioperative setting are made by our surgeons in partnership with the physician prescribing the antiplatelet agent, typically a cardiologist.

    • Developing a context appropriate clinical guideline for post-operative pain management in Ghana: A participatory approach

      2015, International Journal of Africa Nursing Sciences
      Citation Excerpt :

      Formal consensus method involves a process of group decision-making that ensures that decisions made are representative of the group’s ideas or concerns. The process ensures that each member is given an opportunity to make a comment (Rolls & Elliott, 2008). The emphasis on group decisions in a consensus process is to enhance ‘ownership’ of research outcome.

    • The perioperative management of patients with coronary artery stents: Surveying the clinical stakeholders and arriving at a consensus regarding optimal care

      2012, American Journal of Surgery
      Citation Excerpt :

      Consensus decision making is one form of group decision making that does not require unanimity but instead seeks the majority agreement of participants and the resolution or mitigation of minority objections.15,16 Consensus decision making is applicable to the development of clinical practice guidelines and clinical care pathways involving a variety of health care providers.17–19 The Consensus-Oriented Decision-Making (CODM) model20 was specifically applied here.

    View all citing articles on Scopus
    View full text