Intensive care medicine rapid practice guidelines (ICM-RPG): paving the road of the future

Over the past decade, clinical practice guidelines (CPGs) have undergone extensive and rapid development. The credibility of CPGs is proportional to the methodological rigour, effective management of conflict of interest (COI), incorporation of patients’ values and preferences, and transparency of judgments. With the emergence of the Grading of recommendations, assessment, development and evaluation (GRADE) approach, CPG development has become systematic, transparent, and based on explicit judgments. The GRADE approach is an essential component of trustworthy CPGs. GRADE has been adopted by more than 100 organisations worldwide, including the Cochrane Collaboration, the World Health Organization, UpToDate, and many professional societies within critical care [1]. Intensive care medicine (ICM) now joins this list. Here, we provide an introduction and overview of the new series in ICM rapid practice guidelines (ICM-RPGs).

Most CPGs, including in the field of critical care, are at best updated every 3–5 years [2]. Between updates, new and potentially practice-changing evidence may emerge, but guidelines will not incorporate it until their next iteration, potentially delaying evidence dissemination and implementation in clinical practice. Outdated recommendations may also undermine CPGs’ credibility. It is a priority to speed the integration of new evidence in guidelines.

With the ICM-RPGs, we aim to ensure timely production of trustworthy clinical practice recommendations on topical questions related to critical illness diagnosis and/or management. The ICM-RPGs are intended for clinicians and other healthcare professionals caring for critically ill patients.

The process for developing ICM-RPGs is summarised as follows:

Academic critical care clinicians and methodologists experienced in CPG development from the ICM-RPG steering committee (Fig. 1). This committee receives alerts when new randomised clinical trials (RCTs) and systematic reviews in the field are published. When a study may impact clinical practice, i.e. may change practice or introduce equipoise, the steering committee will propose a new ICM-RPG to the ICM editorial board. After ICM-RPG approval, the steering committee will gather a panel, aiming for appropriate gender and geographic balance; the panel will be comprised of key stakeholders including experienced methodologists, academic clinicians, content experts (i.e. leading researcher(s) on this topic), frontline clinicians, allied health professionals, and patient representative(s). The steering committee will also assign a Clinical Chair and a Methods Chair, both of which should not have financial or academic conflicts of interest. Methodologists and statisticians from the Guidelines in intensive care development and evaluation (GUIDE) group will support the panel. Panel members’ disclosed conflicts of interest will be adjudicated and managed as previously outlined [3, 4]. The panel will formulate the specific components of the guideline question(s), including the population, interventions, and outcomes in the PICO format [5]. When appropriate, an independent systematic review team from GUIDE will conduct a rapid systematic review and meta-analysis [6], with input from the panel and the methods team. The methods team, in collaboration with the panel, will assess the certainty of evidence (also referred to as the quality of evidence or the confidence in the effect estimates) using the GRADE approach [7]. In brief, the certainty of evidence will be categorised as very low, low, moderate or high based on risk of bias, imprecision, indirectness, inconsistency, and publication bias [8]. In general, RCTs start as high certainty evidence, while observational studies start as low certainty evidence [7]. We will present transparent and explicit ratings of the certainty of evidence for each outcome in an evidence profile table with the judgements for each GRADE domain and the relative and absolute effects for each outcome [9].

Fig. 1

This figure summarises the ICM-RPG development process

To ensure maximal guideline relevance in clinical practice, the ICM-RPG panel will aim to issue a recommendation whenever possible. Recommendations will be presented as either strong (phrased as “we recommend”) or conditional (also known as weak and phrased as “we suggest”). The strength of recommendation will depend on the certainty of evidence across all outcomes, the balance of benefits and harms, patients’ values and preferences, cost and resource utilisation, feasibility, and acceptability. In the recommendation formulation phase, we will use the Evidence-to-Decision framework to evaluate these factors [10].

When appropriate, visual decision aids will accompany published ICM-RPGs to facilitate guideline implementation. In addition, the panel will provide suggestions to implement the ICM-RPGs in various contexts (e.g. low–middle-income countries/high-income countries) using existing adaptation frameworks [11].

ICM is the sponsoring organisation and is responsible for forming and overseeing the ICM-CPR steering committee. The GUIDE Group will support methodological and statistical aspects of the ICM-RPG development. All ICM-RPGs will undergo peer and editorial review through ICM.

The British Medical Journal Rapid Recommendation Group developed a similar process and successfully generated several recommendations on different topics in medicine [12]. They have demonstrated the feasibility of conducting high-quality systematic reviews and trustworthy guidelines within a short period of time.

We hope the ICM-RPGs will hasten the translation of evidence in clinical practice. Stay tuned for the first ICM-RPG addressing the use of neuromuscular blocking agents in moderate–to-severe acute respiratory distress syndrome, planned publication in the near future.



Clinical practice guidelines


Evidence to decision


Guidelines in intensive care development and evaluation


Grading of recommendations, assessment, development and evaluation


Intensive care medicine


Rapid practice guidelines


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Correspondence to Waleed Alhazzani.

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WA and EB is the chairs of the GUIDE Group that is supporting this initiative; MHM is a GUIDE Group member. GC has no conflicts related to this topic.

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Alhazzani, W., Møller, M.H., Belley-Cote, E. et al. Intensive care medicine rapid practice guidelines (ICM-RPG): paving the road of the future. Intensive Care Med 45, 1639–1641 (2019).

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