Adapt or perish

Many events have coloured the year 2020, such as the fires in the Amazon rainforest and Australia, the incredible explosion in Lebanon and the Black Lives Matter movement. However, we cannot forget the dramatic floods in Indonesia and the year of the nurse and the midwife. Although these events have occurred in different parts of the world, the coronavirus disease 2019 (COVID-19) crisis has braided every country in a single thread, entwining these historic moments inextricably together. The experience of the COVID-19 crisis has left a mark on the scientific community and has revealed some of its limitations. Current structures inherently imply that, from the time a stimulus reaches the surface until a response is produced, a considerable amount of time elapses. One of the most daunting challenges for medical societies and regulatory bodies in the last year has been adapting to the global crisis associated with COVID-19. How should I treat my patients? This question has popped up constantly in every hospital and clinic. Physical fatigue has embraced mental exhaustion and an ‘infodemic’ surge (WHO definition of too much information including false or misleading information in digital and physical environments during a disease outbreak) has slapped us hard with endless exponential graphs, new genetic variants, predictive studies of the new upcoming wave and the prevalence of antibodies in the population. The overwhelming production and publication of studies in a very short period of time has been the awakening stimulus to start reacting swiftly to COVID-19 external shock. The rationale for the development of focused guidelines Other significant changes occurred in our surroundings: the renaming of the Society, which now includes Intensive Care in its name, the new open-access journal, European Journal of Anaesthesiology and Intensive Care, the creation of a Methodology Group and the recent loss of a much appreciated and relevant member, Pr. Andreas Hoeft. Generally, in clinical practice, we rely on aggregated evidence to increase precision, avoid unnecessary costs and decrease care variation. In addition to the synthesis of evidence, clinical recommendations (Guidelines) should also contribute to a better quality of treatment through a comprehensive evaluation of the evidence. Until now, the process comprising the initiation, development and publication of a set of clinical guidelines could take up to 2 years. Clearly, this strategy cannot be accomplished in health crises and emergent situations. Both clinicians and guideline developers have been overwhelmed by the quantity of evidence during the COVID-19 crisis, but how do we interpret the quality of this massive pile of documents? Focused guidelines and the modern concept of clinical guidelines For this reason, major players worldwide, such as Cochrane,1 Centers for Disease Control2 and academic journals such as the British Medical Journal,3 adapted their procedures to new circumstances almost a decade ago. Therefore, the Guidelines Committee of the European Society of Anaesthesiology and Intensive Care (ESAIC) has created a transparent and reproducible structure capable of responding to the urgent needs arising from health crises and other questions that require quick and consolidated answers based on the best available evidence. In addition, we have improved our procedures to successfully face specific areas, for example, when there is an increased likelihood of evolving evidence in hot topics or cutting-edge treatments, or when the scope of the guideline is more specific and delimited. We would like to introduce the three formats of recommendations and Clinical Guidelines of the ESAIC. They aim to respond to a gap in the methodological scheme in view of recent events. (1) Extended Guidelines or traditional Clinical Guidelines. These are the majority of all guidelines developed so far.4–8 They usually take longer to develop and update. (2) Focused Guidelines or clinical guidelines on a narrower topic. Focused Guidelines require less time from inception to publication. They adhere to the same methodological structure as traditional Clinical Guidelines with an expedited systematic review process. (3) Rapid Statements or expert recommendations. These are equivalent to expert opinions that aim to provide a unified response to a health crisis or emergency. These new procedures were developed in parallel with the GRADE working group's methodology,9 McMaster group10 and Cochrane methodology group, which has also published its methods.1 However, the new paradigm in developing Clinical Guidelines still has several problems that concern even the name of this novel concept. Last but not least, the new nomenclature led to the misunderstanding that Focused Guidelines were restricted guidelines of inferior quality.11,12 The optimal time span for the publication process of modern Clinical Guidelines with a reduced scope is also not yet clear.13 All Clinical Guidelines follow rigorous methodology and quality standards in terms of recommendations.14 However, Focused Guidelines deal with a more specific topic, are easier to read and use, and allow more efficient implementation and updating process.15 In this regard, recommendations from traditional Clinical Guidelines were compared with those from Focused Guidelines.16 They did not differ substantially, the main difference being that the Focused Guidelines reported clinical outcomes, social and economic factors less often. Focused Guidelines incorporate targeted and systematic reviews, along with an expedited process of synthesis and wording of evidence.17 To the future and beyond: the living guideline approach Nonetheless, the WHO goes further and developed an ambitious initiative defined as the ‘living guideline approach’. This vision is based on recommendations that are constantly being updated. Two Clinical Guidelines have been developed so far: for the treatment18 and the prevention19 of COVID-19. The icing on the cake will be the use of automation technology in the systematic review process, where there is a clear potential for artificial intelligence20 and software that will help perform this task more easily. By adopting these new strategies, we believe that we will respond more adequately to the purposes of Clinical Guidelines, the need to assist patients and practitioners, educate individuals or groups, assess and ensure the quality of care, allocate healthcare resources and reduce the risk of legal liability.21 Conclusion Progressive migration towards a living model of Clinical Guidelines is a desirable shift to improve the quality of care and has a clear impact in specific situations. It is our obligation to ensure that the production of Clinical Guidelines is adapted to the current times and the needs of their users, whether they are physicians who will follow them in their daily clinical practice, policy makers who in this way can advance the allocation of resources in a well founded manner, or patients who will benefit from an accelerated streamlined process. What is new? The new format will put ‘knowledge into action’ faster to assist patients and clinicians. Several well known evidence-based groups worldwide have adopted a most pragmatic guideline production without compromising the quality of the recommendations. The ESAIC guidelines committee is working to transform the production of Clinical Guidelines to respond to new circumstances, and healthcare providers’ and patients’ needs.