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Key Point #1: Understand the Prescriptive Nature of the Guidelines
The first step in approaching PAD guidelines implementation is to understand the latitude it offers. One striking difference between the 2013 PAD guidelines and its predecessor is that the nature of prescriptive authority has changed. Instead of recommending drug A versus B versus C for PAD, the opposite occurs. A specific agent is rarely mentioned unless it is known that the agent may cause harm, and then a recommendation against the use is offered. For example, the guidelines do not recommend use of rivistigmine to treat delirium because of the increased risk of mortality. It is suggested that when sedation is indicated benzodiazepines are not used unless the patient is at risk for alcohol withdrawal syndrome. Further, strategies are promoted rather than agents. It is recommended that sedative medications should be titrated to maintain a light rather than a deep level of sedation, but the choice of sedative medication is left to the prescriber. These changes leave a lot of room for variation in practice. The flexibility afforded within these guidelines is a double-edged sword because it is more difficult to create protocols and standards when more than one option is considered a correct choice. Although this may seem optimal to some, this latitude leaves the work group with a dilemma if the goal is to write a standard order set for patients requiring pain management or sedation in the intensive care unit (ICU). The decision will need to be made regarding how many and which choices to allow within the protocol.
No Recommendation versus Suggest versus Recommend
Because no consensus statements were given in the new guideline, the only recommendations made are those with evidence to support them. As already mentioned, the guideline was developed using GRADE methodology where both quality (high, moderate, low/very low) and strength of recommendation (strong or weak) were evaluated. The guideline indicates a strong recommendation by the wording "we recommend," whereas a weak recommendation is phrased, "we suggest." When there was an absence of sufficient evidence or group consensus could not be reached, "no recommendation" was formally made. The PAD guidelines also include 22 statements, which summarize the literature surrounding a specific topic. Each statement is accompanied by a score for the strength of the evidence supporting the statement.
One approach to guideline implementation could be to sort priorities for change based upon an analysis that reveals a gap with recommended versus suggested practices and current practices. It is important to sort out those where the words suggest versus recommend appear within the statement. Suggestions reflect that the practice statement was made from a lower level of evidence. In these cases it would not be wrong to allow individual variation. Further research could actually change the nature of the evidence and recommendation in the future. However, in statements beginning with the words "we recommend" there is strong evidence to support the practice, and it would be harder to justify not addressing practice variation. Where no evidence exists to mandate a practice change, consider allowing for individual practice variation. This approach may decrease dramatically the number of changes needed.
Although the PAD guidelines do not contain a specific protocol per se, it provides some direction as to the development of a protocol or order set. It is conceivable that multiple institutions could develop a different protocol and still be in compliance with the recommendations. Knowing this potential for variability is important as implementation plans are made.
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