Practice guidelines as implementation science: the journal editorsʼ perspective
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We are pleased to present the 2016 edition of the Surviving Sepsis Campaign’s practice guidelines in this issue of our journals [1, 2]. We are also pleased to publish a brief explanatory article intended to facilitate the accurate implementation of the guidelines [3, 4]. These publications fulfill—yet do not explain—the role that journals, their reviewers, and their editors play in bringing actionable information to the bedside. Herein, we offer the editors’ perspective.
Guideline development and refinement are responsibilities of guidelines chairs charged with those tasks by their professional colleges and teaching organizations. The Surviving Sepsis Campaign has evolved to become a multinational and multiprofessional effort organized under the aegis of many professional societies. Guideline chairs and members are charged with weighing published evidence, transforming knowledge into recommendations, discarding outdated or disproven guidance, illuminating areas of continuing controversy, and eventually penning the guidelines document. All of this requires diversity of opinion, deep engagement, and substantial investment of time and of treasure. We editors and our journals are indebted to all who have contributed.
The document is of immediate significance to clinicians. Yet there are many other stakeholders including students in the health professions for whom the guidelines have pedagogical significance. Dissemination of guidelines is commonly interpreted as articulating a “standard of care”, a standard that has political, sociological, and even legal ramifications when compared with day-to-day practice. Implementation of guidelines into practice used to be simply a professional expectation; compliance has become nearly a moral imperative. Yet there are two additional competing imperatives. As clinicians, we are bound to deviate from guidelines when such deviation is reasonably expected to improve an individual patient outcome. As clinical scientists, we are bound to evaluate the prevailing standard against emerging alternatives. These three imperatives are inseparable. We therefore caution against any quality metric or reimbursement policy that mandates slavish adherence to a particular recommendation.
Our journals play key supporting roles. Published guidelines reflect the dedication of many reviewers and editors toward clarification and disambiguation. Foremost in our minds is making the content accessible to—and usable by—the community of caregivers. The final product balances the methods and findings of the guidelines development chairs with the need to provide both concrete recommendations and interpretation to those who care directly for patients. The guidance is necessarily nuanced to reflect reasonable alternatives and approaches when evidence is contradictory or incomplete. Indeed, the guideline authors, our reviewers, and we as editors struggle to balance highlighting uncertainty with actionable recommendations. Guidelines are thus a unique blend of science, method, debate, and art.
Our editorial responsibility does not end with publication of print and electronic versions of the guidelines. We now solicit reports of implementation and of outcomes from those who promptly implement the new version and hopefully improve and save lives. Neither we editors nor our journals will be intermediaries in dialogue or dispute over the validity or framing of specific recommendations within the guidelines. Instead, correspondents are directed to the officials overseeing guideline development. For the Surviving Sepsis Guidelines, correspondence about specific recommendations should be sent to Drs. Andrew Rhodes and Laura Evans at firstname.lastname@example.org and email@example.com.
We editors expect that readers and users will challenge the guidelines by performing additional studies and will thereby generate new evidence for the next version. We look forward to evaluating those manuscripts. We are interested in reviewing correspondence and reports highlighting experience with dissemination, implementation, and clinical effectiveness of the guidelines.
We editors are also interested in learning of the comparative impact, diffusion, and effectiveness of transfer of the guidelines into different forms (such as executive summaries, checklists, order sets, pocket and smartphone guides, electronic alerting systems, videos, podcasts). New guidelines specify new normative behaviors. As such, studies of guideline adoption offer insight not only into the outcomes following the specified treatments but also into the way in which clinical behaviors can be influenced. In other words, we editors are interested in how readers become users. More to the point, we editors are interested in scientific analysis of innovations that appear to accelerate knowledge transfer into clinical practice.
Our collective goal is to facilitate the best patient care today- and even better patient care tomorrow. As editors, we recognize that medical knowledge is inherently volatile. Prior recommendations are modified, replaced, or simply discarded in light of new studies. Well-designed studies that challenge recommendations through comparison with alternate approaches are foundational to the life cycle of practice guidelines. Such studies must extend beyond single institutions and evaluate performance over a wider collection of patients in diverse settings. We note that guidelines aim to promote the greatest good for the greatest number, yet their implementation often requires modification in special settings such as low and middle income countries and during disaster management. We look forward to receiving and reviewing new and generalizable insight that will change thinking and practice.
The guidelines have been developed, written, revised, typeset, and published. The authors, reviewers, and editors have performed their duties. It is now for you, our readers, to implement the guidelines and evaluate their performance in your clinical settings. Thus the cycle of guideline development begins anew.
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