IMPORTANCE, SCOPE ANO INVOLVEMENT OF ESA

IN THE PROOUCTION OF GUIDELINES

Maurizio Salca' 359

Clinical practice guidelines have been defined as 'systematically tievelo-

ped statements to assist practitioner and patient decisions about appro-
priote health care for specific clinical circumstances' (1). Their application
in clinica! practice have contoversial effects:
Pro (2):
- reduce variations in practice
- can be used as standards for measurement of clinical performance
- improve the efficacy of healthcare delivery
- raise awareness of a subject
- source of practical advice.
Contra (3):
- don't always apply to an individual patient
-limit doctors' discretion and autonomy
- allow some groups to impose their priorities on others
- resource implications are not always thought through
Do guidelines work in everyday life? Experience has taught us that guide-
IInesare followed when (4,5):
- they are based on evidence
- they are not controversial
- they define precisely the performance improvement sought
- they are tested for feasibility and acceptability
- they do not demand a change in existing practice routines.
Over the past few years, ~istening to the request of its constrtuencv (its
Illernbers) the European Societv of Anaesthesiology (ESA) decided ta pursue

• ESA Guidc/illes Camln/tl('('

Timi>ol,ra 2011
 the preparation and dissemination of clinical practice guidelines. The aims
of guideline development were:
- to make available European guidelines to be used by ESA members and
if agreed, adopted by national societies; ,
- to encourage harmonisation of clinical practice of anaesthesiology
throughout Europe;
- to improve standards of care throughout Europe.
History of guidelines activity within ESA:
- 2007: Council Focus group recommended the formation of permanent,
collaborative group;
- june 2008 Guidelines Committee met for first time;
360 - late 2008 Procedures established;
- first task forces established;
- first guidelines published.
The functions of Guidelines Committee are:
- detine the 'rules' for producing ESA guidelines;
- select topics for guidelines;
- select people and experts for each guideline;
- collect and evaluate currently available documents in Europe;
- establish relationships with necessary societies and groups;
- detine how to implement guidelines.

This is the present composition of the Guidelines Committee:

Chairperson Andrew Smith, UK
Chairperson of SC Benedikt Pannen, DE
EBA Jannicke Mellin-Olsen, NO
ESA Board mernber Maurizio Solca, IT
ESA Council member Josef Wichelewski, IL
NASC representative Geraldine O'Suilivan, UK
Appointed mernbers Jouko Jalonen, SF and Jean-Francois Brichant, BE
ESA Secretariat Anne Dewaegenaere
The vision of ESA and its Guidelines Committee can be condensed in the
acronym 'CoSiTra' for Collaboration, Simplicity and Transparency (6). In detail:

Col/aboration
- between different scientific subcommittees
- with other anaesthetic societies - national and specialist
- between ESA and European Board of Anaesthesiology (UEMS)
- with other European medical organisations e.g. European Society of
Cardiology

Actualităţi ÎI! A nestezie şi Terapie IntellSiv4

l~l' CURSURI DE ANES

 Simplicity
- guidelines as short as Possible
- make guidelines widely and e '1 '
, aSIyavallable
- produce short summanes for everyd
ay use
Transparency
- disagreements between experts made explicit
- declarations of interest should be made
- evidence should be distinguished from opininn

We decided to adopt in the guideline development the following princi-

ples:
- search for existing guidelines and appraise
- update searches for high quality evidence and summarise
- produce guideline, making explicit the level of evidence and strength of
recommendation.

Grading of evidence adopted in the process were:

1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low
risk of bias

1+ Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias

1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++ High quality systematic reviews of case controlor cohort studies

High quality case controlor cohort studies with a very low risk of confounding or
bias and a high probability that the relationship is causal

2+ Well conducted case controlor cohort studies with a low risk of confounding or
bias and a moderate probability that the relationship IS causal

2- Case controlor cohort studies with a high risk of confounding or bias and a signi-
ricant risk that the relationship is not causat

Non-analytic studies, eg case reports, case series

Expert Ol);nion
 The preparation process can be summarized as:
1 Choose topic and scope
2 Find evidence (Cochrane Anaesthesia Review Group)
3 Form task force to translate evidence into guideline and write draft
guideline
4 Circulation, feedback, piloting the draft version
5 Prepare the final version
6 Oissemination and implementation
A major step in producing a quality guideline is assuring a proper review
process. Within the Guidelines Committee it was decided that every gui-
deline would undergo scientific review by members of ESA subcommitte-
362 es, every draft guideline would be posted on ESA website for comment by
members (individual and national societies), and it would be submitted to
relevant external organisations and societies.
In Oecember 2010 the first ESAGuideline has been published (7); althou-
gh its gestation started before the establishment of the Guidelines Commit-
tee, it has been "adopted", and has followed the same reviewing process.
Forthcoming guidelines are on:
• Perioperative fasting - lan Smith (June 2011)
• Preoperative evaluation for adults - Stef de Hert (Autumn 2011)
• Management of severe bleeding - Sibylle Kozek (2012)
• Sedation - (2012/2013).
What is it in the future?
- ESA Clinical Trials Network will help to generate research evidence to
shape guidelines
- ESA will continue to produce high qualitv guidelines
- They are freely available for aii!

You are ALL rnvited to use them!

References

1) Field MJ. Lohr KN (editors). Institute of Medlclne Committee to Advlse the Public Health Service an
Clinical Practice Guidelines. Clinical practice guidellnes: drrections for a new program Washington DC·
National Academy Press: 1990.
2) Woolf Sti, el al. Br Med J 1999; 318: 527-30.
3) Havcox A, et al. Br Med J 1999; 318:391-3.
4) Grrmshaw JM, Ru,sell IT. [((eet of clinical qurdelines an medical practice: a svstematic revll'w of "90"'-
us evatuauons. lancet 1993; 342: 1317-72.
5) Grai R. et al. Br Med J 1998; 317: 858-61.
6) Srruth A, Petosi P. Eur J Anaestheunl 2011; 28: 231-4.
7) Gogarlen W, et al. Neuraxial anaestnesiaand antlcoaqutants: recommend.mnns of tne [SA. Eur J
Anaesthe"oI2010; 27: 999-1015.