Developing a Thai national critical care allocation guideline during the COVID-19 pandemic: a rapid review and stakeholder consultation

Background At the height of the COVID-19 pandemic, Thailand had almost depleted its critical care resources, particularly intensive care unit (ICU) beds and ventilators. This prompted the necessity to develop a national guideline for resource allocation. This paper describes the development process of a national guideline for critical resource allocation in Thailand during the COVID-19 pandemic. Methods The guideline development process consisted of three steps: (1) rapid review of existing rationing guidelines and literature; (2) interviews of Thai clinicians experienced in caring for COVID-19 cases; and (3) multi-stakeholder consultations. At steps 1 and 2, data was synthesized and categorized using a thematic and content analysis approach, and this guided the formulation of the draft guideline. Within step 3, the draft Thai critical care allocation guideline was debated and finalized before entering the policy-decision stage. Results Three-order prioritization criteria consisting of (1) clinical prognosis using four tools (Charlson Comorbidity Index, Sequential Organ Failure Assessment, frailty assessment and cognitive impairment assessment), (2) number of life-years saved and (3) social usefulness were proposed by the research team based on literature reviews and interviews. At consultations, stakeholders rejected using life-years as a criterion due to potential age and gender discrimination, as well as social utility due to a concern it would foster public distrust, as this judgement can be arbitrary. It was agreed that the attending physician is required to be the decision-maker in the Thai medico-legal context, while a patient review committee would play an advisory role. Allocation decisions are to be documented for transparency, and no appealing mechanism is to be applied. This guideline will be triggered only when demand exceeds supply after the utmost efforts to mobilize surge capacity. Once implemented, it is applicable to all patients, COVID-19 and non-COVID-19, requiring critical care resources prior to ICU admission and during ICU stay. Conclusions The guideline development process for the allocation of critical care resources in the context of the COVID-19 outbreak in Thailand was informed by scientific evidence, medico-legal context, existing norms and societal values to reduce risk of public distrust given the sensitive nature of the issue and ethical dilemmas of the guiding principle, though it was conducted at record speed. Our lessons can provide an insight for the development of similar prioritization guidelines, especially in other low- and middle-income countries.

Guidelines and Safety Practices for Improving Patient Safety

This chapter explains why clinical practice guidelines are needed to improve patient safety and how further research into safety practices can successfully influence the guideline development process. There is a description of the structured process by which guidelines that aim to increase the likelihood of a higher score are created. Proposals are made relating to (a) the live updating of individual guideline recommendations and (b) tackling challenges related to the improvement of guidelines.

Knowledge translation of the Canadian 24-Hour Movement Guidelines for Adults aged 18–64 years and Adults aged 65 years or older: a collaborative movement guideline knowledge translation process

Establishing a step-by-step process that provides practitioners with a blueprint for translating movement guidelines into action stands to optimize the investment in guideline development, improve guideline promotion and uptake, and ultimately enhance population health. The purpose of this paper is to describe how the Knowledge-to-Action framework and integrated knowledge translation were operationalized to systematically inform our knowledge translation (KT) efforts for the Canadian 24-Hour Movement Guidelines for Adults aged 18–64 years and Adults aged 65 years or older. In October 2018, the need for a KT Process, operating in tandem with the Guideline Development Process, led to the establishment of a KT team with a specific structure and terms of reference. The KT team collaboratively agreed on decision-making principles prior to selecting target audiences to focus their efforts. We undertook formative research to assess the local context and determinants of guideline dissemination and implementation efforts among target audiences. Plans for the subsequent steps and research are outlined. We highlight recommendations and lessons learned for applying the process in other settings. Novelty We outline a collaborative and systematic process and research program for the knowledge translation of movement guidelines. This paper provides an innovative and replicable blueprint to optimize future movement guideline knowledge translation efforts.

Developing a Thai national critical-care allocation guideline during the COVID-19 pandemic: a rapid review and stakeholders’ consultation

Background: At the height of the COVID-19 pandemic, Thailand had almost depleted its critical care resources, particularly ICU beds and ventilators. This prompted the necessity to develop a national guideline for resource allocation. This paper describes the development process of a national guideline for critical resource allocation in Thailand during the COVID-19 pandemic. Methods: The guideline development process consisted of three steps (1) rapid review of existing rationing guidelines and literature; (2) interviews of Thai clinicians experienced in caring for COVID-19 cases; and (3) multi-stakeholder consultations. At steps 1 and 2, data was synthesized and categorized using a thematic and content analysis approach and this guided the formulation of the draft guideline. Within Step 3, the draft Thai critical care allocation guideline was debated and finalized before entering the policy-decision stage. Results: Three-order prioritization criteria consisting of (1) clinical prognosis using four tools (Charlson Comorbidity Index, Sequential Organ Failure Assessment, Frailty Assessment, and Cognitive Impairment Assessment); (2) number of life years saved; and (3) social usefulness, were proposed by the research team based on literature reviews and interviews. At consultations, stakeholders rejected using life years as a criterion due to potential age and gender discrimination, as well as social utility due to a concern it would foster public distrust as this judgment can be arbitrary. It was agreed that attending physician is required to be the decision maker in the Thai medico-legal context while a patient review committee would play an advisory role. Allocation decisions are to be documented for transparency and no appealing mechanism is to be applied.This guideline will be triggered only when demand exceeds supply after the utmost efforts to mobilize surge capacity. Once implemented, it is applicable to all patients, COVID-19 and non-COVID-19, requiring critical care resources prior to ICU admission and during ICU stay.Conclusions: The guideline development process for the allocation of critical care resources in the context of the COVID-19 outbreak in Thailand was informed by scientific evidence, medico-legal context, existing norms and societal values to reduce risk of public distrust given the sensitive nature of the issue and ethical dilemmas of the guiding principle though it was conducted at recorded speed. Our lessons can provide an insight for the development of similar prioritization guidelines, especially in other LMICs.

Understanding international variation in national low-risk drinking guidelines: health policy report

Background The harmful use of alcohol is associated with adverse health, social, and economic consequences. National low-risk drinking guidelines provide evidence-based advice on how to reduce the risks associated with alcohol consumption and provide a basis for other alcohol-control interventions. There is substantial variation between guidelines and no international consensus on what constitutes 'low-risk' drinking. These discrepancies may lead to misinterpretation of the guidance, and such variation may undermine public confidence in experts and be exploited by the alcohol industry. Methods This project had two main components: (i) a literature review, to identify any new evidence from January 2016 to August 2019 suggesting a recommended threshold for 'low-risk' drinking; (ii) the analysis of six examples of national guidelines. Those from the UK, Ireland, Australia, New Zealand, Canada, and USA were examined for information about the utilisation of evidence to inform guidance, as well as details of the guideline development process. Thematic analysis of the UK, Canadian and Australian guidance explored wider influences on the guidelines. Results The literature review highlighted that all alcohol consumption carries some degree of risk. Content analysis of the guidelines emphasised the substantial variation in national guidance. Differences in the use of evidence and guideline development process may have given rise to at least some of the observed variation. Thematic analysis suggested that wider influences, such as differences in societal values, may also have contributed to disparities in the guidelines. Conclusions It may be possible to standardise certain areas of the development process, such as agreeing what constitutes an 'acceptable' level of alcohol-attributable risk. Further research is required to verify whether these results are generalisable to other countries, and to determine the most appropriate statistical model for risk calculations. Key messages The factors which determine guideline development are manifold and complex. Any level of alcohol consumption carries some degree of risk.