Global guidelines for emergency general surgery: systematic review and Delphi prioritization process

Abstract

Background Existing emergency general surgery (EGS) guidelines rarely include evidence from low- and middle-income countries (LMICs) and may lack relevance to low-resource settings. The aim of this study was to develop global guidelines for EGS that are applicable across all hospitals and health systems. Methods A systematic review and thematic analysis were performed to identify recommendations relating to undifferentiated EGS. Those deemed relevant across all resource settings by an international guideline development panel were included in a four-round Delphi prioritization process and are reported according to International Standards for Clinical Practice Guidelines. The final recommendations were included as essential (baseline measures that should be implemented as a priority) or desirable (some hospitals may lack relevant resources at present but should plan for future implementation). Results After thematic analysis of 38 guidelines with 1396 unique recommendations, 68 recommendations were included in round 1 voting (410 respondents (219 from LMICs)). The final guidelines included eight essential, one desirable, and three critically unwell patient-specific recommendations. Preoperative recommendations included guidance on timely transfers, CT scan pathways, handovers, and discussion with senior surgeons. Perioperative recommendations included surgical safety checklists and recovery room monitoring. Postoperative recommendations included early-warning scores, discharge plans, and morbidity meetings. Recommendations for critically unwell patients included prioritization for theatre, senior team supervision, and high-level postoperative care. Conclusion This pragmatic and representative process created evidence-based global guidelines for EGS that are suitable for resource limited environments around the world.

Introducing re-weighted range voting in clinical practice guideline prioritization: Development and testing of the re-weighted priority-setting (REPS) tool

“…Also, the aim of priority-setting can be different. Existing CPG recommendations or sections can be prioritized for uptake in other CPGs [8], for implementation [9] or for updating [12]. All of such aims might require a different set of relevant priority indicators.…”

“…Multiple systematic reviews were conducted synthesizing priority-setting processes and indicators [1][2][3], including those related to the priority-setting of CPG topics [4], key questions in CPG development [5][6][7], CPG recommendations for uptake [8], and implementation [9]. Although it was stated that there is a need to develop standardized and validated priority-setting tools [5] and some methods have both been developed [6,10,11] and tested [7,12,13], it is important to recognize that different CPG developing organizations may have unique needs and operate in different contexts.…”

“…Priority-setting assessments have relied on Delphi methods [4,5,8], counting [14], or calculating mean scores [6,11,13]. However, some contexts may need other options for initially ranking or selecting items.…”

Why do people die after surgery? A call for research action

“…Several initiatives have attempted to address this, through randomised trials, complex interventional studies, implementation of health technologies and consensus guidelines 9,10,11,12,13 . For example, ASOS-2 was a clusterrandomised trial of enhanced postoperative surveillance versus standard care to reduce mortality among high-risk adult surgical patients across Africa.…”