Week 3 Critical Appraisal Of Practice Guidelines

While there are several tools to critically appraise practice guidelines, the most comprehensively validated appraisal tool is the AGREE II Instrument. The AGREE II Instrument can be used by individual practitioners to critically appraise health guidelines and by decision makers to inform policy decisions. The purpose of the AGREE II Instrument is to provide a framework to:

Assess the quality of guidelines.
Provide a methodological strategy for the development of guidelines.
Inform what information and how the information ought to be reported in guidelines.
Overall assessment includes rating the overall quality of the guideline and whether the guideline would be recommended for use in practice.

Items are rated on a 7-point scale from 1 (Strongly Disagree) to 7 (Strongly Agree). A score of 1 is given when there is no information on that item or if it is poorly reported. A score of 7 is given if the quality of reporting is excellent and when full criteria have been met (Score explanations found in the AGREE II-GRS Instrument).

A quality score is calculated for each of the six domains, which are independently scored. Domain scores are calculated by summing up all the scores of the items in the domain and by scaling the total as a percentage of the maximum possible score for that specific domain.

For this assignment, you will choose a guideline and assess the overall quality and whether the guideline would be recommended for use in practice.

General Requirements:

Use the following information to ensure successful completion of this assignment:

Download the AGREE II instrument.
Doctoral learners are required to use APA style for their writing assignments. The APA Style Guide is located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please Review the rubric prior to the beginning to become familiar with the expectations for successful completion.
You are not required to submit this assignment to Turnitin.
Directions:

Perform the following tasks to complete this assignment:

Using the AGREE II instrument as your guide, create a table that discusses a practice guideline in which you might have questioned the recommendations. (Note: You may be able to copy and paste the instrument into a new Word document and complete the information.)
Each domain must have its own cell (similar to the one shown in the manual) and add domain scores and an overall guideline assessment. Be sure to include comments and additional considerations that influenced your rating decision and cite any sources used.
3. Apply Rubrics

Running Head: Critical Appraisal of Practice Guidelines Page1

Critical Appraisal of Practice Guidelines

Critical Appraisal of Practice Guidelines

DNP 820

Date

CHECKLIST ITEM AND DESCRIPTION

REPORTING CRITERIA

Page #

DOMAIN 1: SCOPE AND PURPOSE

1. OBJECTIVES

Report the overall objective(s) of the guideline. The expected health benefits from the guideline are to be specific to the clinical problem or health topic.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 6

Nurses are not recognized and are underutilized in this program

Health intent(s):

Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care (Barlam et al, 2016).

The purpose of this guideline is to comprehensively evaluate the wide range of interventions that can be implemented by ASPs in emergency department, acute inpatient, and long- term care settings as they determine the best approaches to influence the optimal use of antibiotics within their own institutional environments. In addition, this guideline addresses approaches to measure the success of these interventions (Barlam et al, 2016).

The guidelines emphasize the importance of physician and pharmacist leadership for an ASP, the need for infectious diseases expertise, and the role of measurement and feedback as critical components of ASPs (Barlam et al, 2016).

Expected benefit(s) or outcome(s)

The benefits of antibiotic stewardship include improved patient outcomes, reduced adverse events including Clostridium difficile infection (CDI), improvement in rates of antibiotic susceptibilities to targeted antibiotics, and optimization of resource utilization across the continuum of care (Barlam et al, 2016).

Target(s) (e.g., patient population, society

Health Professionals in the following areas: internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties (Barlam et al, 2016).

2. QUESTIONS

Report the health question(s) covered by the guideline, particularly for the key recommendations.

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Strongly Disagree

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Strongly Agree

COMMENTS: 7

Antibiotic stewardship is strongly needed in all health care settings

Health care setting or context:

Guideline for Implementing an Antibiotic Stewardship Program in inpatient populations including long-term care (Barlam et al, 2016).

3. POPULATION

Describe the population (i.e., patients, public, etc.) to whom the guideline is meant to apply.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 7

· Target population, sex and age Clinical condition (if relevant) Severity/stage of disease (if relevant) Comorbidities (if relevant) Excluded populations (if relevant)

For Health care professionals who work with inpatient populations including long-term care (Barlam et al, 2016).

DOMAIN 2: STAKEHOLDER INVOLVEMENT

4. GROUP MEMBERSHIP

Report all individuals who were involved in the development process. This may include members of the steering group, the research team involved in selecting and reviewing/rating the evidence and individuals involved in formulating the final recommendations.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 6

Nurses are not recognized and are underutilized in this program

· Name of participant

· Discipline/content expertise

· Institution

· Geographical location

· A description of the member’s role in the guideline development group

Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (Barlam et al, 2016).

Led by Co-chairs Tamar Barlam and Sara Cosgrove, a panel of 18 multidisciplinary experts in the management of ASPs was convened per the IDSA Handbook on Clinical Practice Guide- line Development in 2012. In addition to members of IDSA and the SHEA, representatives from diverse geographic areas, pediatric and adult practitioners, and a wide breadth of specialties representing major medical societies were included among the panel’s membership (American College of Emergency Physicians [ACEP], American Society of Health-System Pharmacists [ASHP], American Society for Microbiology [ASM], PIDS, Society for Academic Emergency Medicine [SAEM], Society of Infectious Diseases Pharmacists [SIDP], and the Surgical Infection Society [SIS]). A guideline methodologist and member of the GRADE Working Group and a medical writer were added to assist the panel (Barlam et al, 2016).

5. TARGET POPULATION PREFERENCES AND VIEWS Report how the views and preferences of the target population were sought/considered and what the resulting outcomes were.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 7

· Statement of type of strategy used to capture patients’/publics’ views and preferences (e.g., participation in the guideline development group, literature review of values and preferences)

· Methods by which preferences and views were sought (e.g., evidence from literature, surveys, focus groups)

· Outcomes/information gathered on patient/public information

· How the information gathered was used to inform the guideline development process and/or formation of the recommendations

The expert panel followed a process used in the development of other IDSA guidelines, which included a systematic weighting of the strength of recommendation and quality of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system (IDSA, 2015).

PubMed, which includes Medline (1946 to present), was searched to identify relevant studies for each of the antibiotic stewardship guideline PICO (population/patient, intervention/ indicator, comparator/control, outcome) questions. Search strategies were developed and built by 2 independent health sciences librarians from the Health Sciences Library System, University of Pittsburgh. For each PICO question, the librarians developed the search strategies using PubMed’s command language and appropriate search fields. Medical Subject Headings terms and keywords were used for the main search concepts of each PICO question Barlam et al, 2016).

6. TARGET USERS

Report the target (or intended) users of the guideline.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 6

Nurses are not recognized and are underutilized in this program

· The intended guideline audience (e.g. specialists, family physicians, patients, clinical or institutional leaders/administrators)

· How the guideline may be used by its target audience (e.g., to inform clinical decisions, to inform policy, to inform standards of care)

For Health care professionals who with inpatient populations including long-term care. That is considered for use in pediatrics, oncology, community hospitals, small hospitals, and nursing home and long-term care environments, and not limited to acute care facilities Barlam et al, 2016).

This guideline discusses a broad range of possible ASP interventions. They emphasized the need for each site to assess its clinical needs and available resources and individualize its ASP with that assessment in mind Barlam et al, 2016).

DOMAIN 3: RIGOUR OF DEVELOPMENT

7. SEARCH METHODS

Report details of the strategy used to search for evidence.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 7

· Named electronic database(s) or evidence source(s) where the search was performed (e.g., MEDLINE, EMBASE, PsychINFO, CINAHL)

· Time periods searched (e.g., January 1, 2004 to March 31, 2008)

· Search terms used (e.g., text words, indexing terms, subheadings)

· Full search strategy included (e.g., possibly located in appendix)

PubMed, which includes Medline (1946 to present), was searched to identify relevant studies for each of the antibiotic stewardship guideline PICO (population/patient, intervention/ indicator, comparator/control, outcome) questions. Search strategies were developed and built by 2 independent health sciences librarians from the Health Sciences Library System, University of Pittsburgh. For each PICO question, the librarians developed the search strategies using PubMed’s command language and appropriate search fields. Medical Subject Headings terms and keywords were used for the main search concepts of each PICO question. A data supplement that includes search strings can be found following publication on the IDSA website. Articles in all languages and all publication years were included. Initial searches were created and confirmed with input from the guideline committee chairs and group leaders from February through mid-July 2013. The searches were finalized and delivered between late July and September 2013. After the literature searches were performed, authors continued to review the literature and added relevant articles as needed Barlam et al, 2016).

8. EVIDENCE SELECTION CRITERIA

Report the criteria used to select (i.e., include and exclude) the evidence. Provide rationale, where appropriate.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 7

· Target population (patient, public, etc.) characteristics

· Study design

· Comparisons (if relevant)

· Outcomes

· Language (if relevant)

· Context (if relevant)

To evaluate evidence, the panel followed a process consistent with other IDSA guidelines. The process for evaluating the evidence was based on the IDSA Handbook on Clinical Practice Guideline Development and involved a systematic weighting of the quality of the evidence and the grade of re- commendation using the GRADE system. Unless otherwise stated, each PICO comparator was usual practice Barlam et al, 2016).

9. STRENGTHS & LIMITATIONS OF THE EVIDENCE

Describe the strengths and limitations of the evidence. Consider from the perspective of the individual studies and the body of evidence aggregated across all the studies. Tools exist that can facilitate the reporting of this concept.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 7

· Study design(s) included in body of evidence

· Study methodology limitations (sampling, blinding, allocation concealment, analytical methods)

· Appropriateness/relevance of primary and secondary outcomes considered

· Consistency of results across studies

· Direction of results across studies

· Magnitude of benefit versus magnitude of harm

· Applicability to practice context

Panel members were divided into 5 subgroups: (1) interventions, (2) optimization of antibiotic administration, (3) micro- biology and laboratory diagnostics, (4) measurement and analysis, and (5) antibiotic stewardship in special populations. Each author was asked to review the literature, evaluate the evidence, and determine the initial strength of the re- commendations along with an evidence summary supporting each recommendation in his/her assigned subgroup. The evidence was graded based on the effectiveness of the antibiotic stewardship intervention, not the underlying data that provided the groundwork for the intervention. The panel reviewed all recommendations, along with their strength and the quality of the evidence. Discrepancies were discussed and resolved, and all panel members are in agreement with the final recommendations (Barlam et al, 2016).

10. FORMULATION OF RECOMMENDATIONS

Describe the methods used to formulate the recommendations and how final decisions were reached. Specify any areas of disagreement and the methods used to resolve them.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 7

· Recommendation development process (e.g., steps used in modified Delphi technique, voting procedures that were considered)

· Outcomes of the recommendation development process (e.g., extent to which consensus was reached using modified Delphi technique, outcome of voting procedures)

· How the process influenced the recommendations (e.g., results of Delphi technique influence final recommendation, alignment with recommendations and the final vote)

The panel met face to face on 3 occasions and conducted numerous teleconferences to complete the work of the guideline. The purpose of the meetings and teleconferences was to develop and discuss the clinical questions to be addressed, assign topics for review and writing of the initial draft, and develop recommendations. The whole panel reviewed all sections. The guide- line was reviewed and approved by the IDSA Standards and Practice Guidelines Committee (SPGC), the IDSA Board of Di- rectors, the SHE Guidelines Committee, and the SHEA Board of Directors, and was endorsed by ACEP, ASHP, ASM, PIDS, SAEM, SIDP, and SIS (Barlam et al, 2016).

11. CONSIDERATION OF BENEFITS AND HARMS

Report the health benefits, side effects, and risks that were considered when formulating the recommendations.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 1

No information available.

· Supporting data and report of benefits

· Supporting data and report of harms/side effects/risks

· Reporting of the balance/trade-off between benefits and harms/side effects/risks

· Recommendations reflect considerations of both benefits and harms/side effects/risks

12. LINK BETWEEN RECOMMENDATIONS AND EVIDENCE

Describe the explicit link between the recommendations and the evidence on which they are based.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 7

· How the guideline development group linked and used the evidence to inform recommendations

· Link between each recommendation and key evidence (text description and/or reference list)

· Link between recommendations and evidence summaries and/or evidence tables in the results section of the guideline

A powerful way to support antibiotic stewardship is to improve the scientific basis for ASP interventions. As outlined in Section XIII, ASPs can successfully intervene to reduce the duration of therapy for many infections because well-constructed, randomized controlled clinical trials have demonstrated that clinical outcomes are equivalent. Rigorous published evidence is often needed to convince clinicians to alter well-established, albeit suboptimal, practice Barlam et al, 2016).

13. EXTERNAL REVIEW

Report the methodology used to conduct the external review

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 7

· Purpose and intent of the external review (e.g., to improve quality, gather feedback on draft recommendations, assess applicability and feasibility, disseminate evidence)

· Methods taken to undertake the external review (e.g., rating scale, open-ended questions)

· Description of the external reviewers (e.g., number, type of reviewers, affiliations)

· Outcomes/information gathered from the external review (e.g., summary of key findings)

· How the information gathered was used to inform the guideline development process and/or formation of the recommendations (e.g., guideline panel considered results of review in forming final recommendations)

To evaluate evidence, the panel followed a process consistent with other IDSA guidelines. The process for evaluating the evidence was based on the IDSA Handbook on Clinical Practice Guideline Development and involved a systematic weighting of the quality of the evidence and the grade of re- commendation using the GRADE system (Barlam et al, 2016).

14. UPDATING PROCEDURE

Describe the procedure for updating the guideline.

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Strongly Disagree

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Strongly Agree

COMMENTS: 7

· A statement that the guideline will be updated Explicit time interval or explicit criteria to guide decisions about when an update will occur

· Methodology for the updating procedure

At annual intervals, the panel chair, the SPGC liaison advisor, and the chair of the SPGC will determine the need for revisions to the guideline based on an examination of current literature. If necessary, the entire panel will reconvene to discuss potential changes. When appropriate, the panel will recommend revision of the guideline to the IDSA SPGC and SHEA guidelines committees (IDSA, 2015).

DOMAIN 4: CLARITY OF PRESENTATION

15. SPECIFIC AND UNAMBIGUOUS RECOMMENDATIONS Describe which options are appropriate in which situations and in which population groups, as informed by the body of evidence.

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Strongly Disagree

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Strongly Agree

COMMENTS: 7

· A statement of the recommended action

· Intent or purpose of the recommended action (e.g., to improve quality of life, to decrease side effects)

· Relevant population (e.g., patients, public)

· Caveats or qualifying statements, if relevant (e.g., patients or conditions for whom the recommendations would not apply)

· If there is uncertainty about the best care option(s), the uncertainty should be stated in the guideline

The benefits of antibiotic stewardship include improved patient outcomes, reduced adverse events including Clostridium difficile infection (CDI), improvement in rates of antibiotic susceptibilities to targeted antibiotics, and optimization of resource utilization across he continuum of care (Barlam et al, 2016).

16. MANAGEMENT OPTIONS

Describe the different options for managing the condition or health issue.

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Strongly Disagree

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Strongly Agree

· Description of management options Population or clinical situation most appropriate to each option

17. IDENTIFIABLE KEY RECOMMENDATIONS

Present the key recommendations so that they are easy to identify.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 7

· Recommendations in a summarized box, typed in bold, underlined, or presented as flow charts or algorithms

· Specific recommendations grouped together in one section

· Preauthorization and prospective review of antibiotics are among the many recommendations to ensure antibiotic stewardship programs are most effective, suggest new guidelines from IDSA/SHEA.

· Antibiotic stewardship programs should be led by physicians and pharmacists, including ID specialists, who have the expertise and education to ensure the right drug is being prescribed at the right time for the right diagnosis.

· Antibiotic stewardship programs must be based on the specific problems identified by the healthcare facility and a realistic examination of available resources to ensure interventions are performed with consistency.

· These programs have been shown to improve patient outcomes, reduce antibiotic resistance and save money (IDSA& SHEA, 2016).

DOMAIN 5: APPLICABILITY

18. FACILITATORS AND BARRIERS TO APPLICATION Describe the facilitators and barriers to the guideline’s application.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 7

· Types of facilitators and barriers that were considered

· Methods by which information regarding the facilitators and barriers to implementing recommendations were sought (e.g., feedback from key stakeholders, pilot testing of guidelines before widespread implementation)

· Information/description of the types of facilitators and barriers that emerged from the inquiry (e.g., practitioners have the skills to deliver the recommended care, sufficient equipment is not available to ensure all eligible members of the

· population receive mammography) How the information influenced the guideline development process and/or formation of the recommendations

Additional clinical trials that incorporate consideration of antibiotic stewardship in their design are critically needed. Another significant gap is the dearth of implementation re- search in this area Wagner et al. 2014). Although the National Action Plan for Combating Antibiotic-Resistant Bacteria will require the institution of ASPs across healthcare facilities, little effort and limited research funding have been allocated to study how best to achieve large-scale implementation (The White House, 2015).

Qualitative assessments that can examine the impact of factors such as organizational culture, prescriber attitudes, and the self- efficacy of the antibiotic steward (ie, the extent to which he/she believes his/her goals can be reached) are lacking and are important to establish the context in which ASP implementation occurs (Pakyz et al, 2014).

19. IMPLEMENTATION ADVICE/TOOLS

Provide advice and/or tools on how the recommendations can be applied in practice.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 6

Additional materials to support the implementation of the guideline in practice. For example:

o Guideline summary documents o Links to checklists, algorithms o Links to how-to manuals o Solutions linked to barrier analysis(see Item 18) o Tools to capitalize on guideline facilitators (see Item 18) o Out come of pilot test and lessons learned

Despite the recognition that much more research is needed, this guideline identifies core interventions for all ASPs as well as other interventions that can be implemented based on facility- specific assessments of need and resources. Every healthcare facility is able to perform stewardship, and institution of an ASP is attainable and of great importance to public health (Barlam et al, 2016).

20. RESOURCE IMPLICATIONS

Describe any potential resource implications of applying the recommendations.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 6

· Types of cost information that were considered (e.g., economic evaluations, drug acquisition costs)

· Methods by which the cost information was sought (e.g., a health economist was part of the guideline development panel, use of health technology assessments for specific drugs, etc.)

· Information/description of the cost information that emerged from the inquiry (e.g., specific drug acquisition costs per treatment course)

· How the information gathered was used to inform the guideline development process and/or formation of the recommendations

Support for these guidelines was provided by the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (Barlam et al, 2016).

21. MONITORING/ AUDITING CRITERIA

Provide monitoring and/or auditing criteria to measure the application of guideline recommendations.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 7

· Criteria to assess guideline implementation or adherence to recommendations

· Criteria for assessing impact of implementing the recommendations

· Advice on the frequency and interval of measurement

· Operational definitions of how the criteria should be measured

The American Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), the Surgical Infection Society (SIS), and the Society for Healthcare Epidemiology of America (SHEA). Plus Centers for Medicare and Medicaid Services (CMS), Joint Commission on Accreditation of Healthcare Organizations (JACHO) and Center for Disease Control and Prevention (CDC) (Barlam et al, 2016).

DOMAIN 6: EDITORIAL INDEPENDENCE

22. FUNDING BODY

Report the funding body’s influence on the content of the guideline.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 7

· The name of the funding body or source of funding (or explicit statement of no funding)

· A statement that the funding body did not influence the content of the guideline

Financial support for these guidelines was provided by the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (Barlam et al, 2016).

23. COMPETING INTERESTS

Provide an explicit statement that all group members have declared whether they have any competing interests.

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Strongly Disagree

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Strongly Agree

COMMENTS: Rate 7

· Types of competing interests considered

· Methods by which potential competing interests were sought

· A description of the competing interests

· How the competing interests influenced the guideline process and development of recommendations

Potential conflicts of interest. A list of the reflection of what was reported to IDSA was provided. To provide thorough transparency, IDSA requires full disclosure of all relationships, regardless of relevancy to the guide- line topic. Evaluation of such relationships as potential conflicts of interest is determined by a review process that includes assessment by the Standards and Practice Guidelines Committee (SPGC) chair, the SPGC liaison to the development panel, and the board of directors liaison to the SPGC, and, if necessary, the Conflicts of Interest (COI) Task Force of the Board (Barlam et al, 2016).

Maximum possible score = 7 (strongly agree) x 3 (items) x 1 (appraisers) = 21

Minimum possible score = 1 (strongly disagree) x 3 (items) x 1 (appraisers) = 3

The scaled domain score will be:

Obtained score – Minimum possible score

Maximum possible score – Minimum possible score

OVERALL GUIDELINE ASSESSMENT

1. Rating the overall quality of this guideline. 6

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Lowest possible quality

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5

6

7

Highest possible quality

2. I would recommend this guideline for use. YES

Yes

Yes, with modifications

No

NOTES:

The overall quality of this guideline is 6 and I would recommend them for use for Health Professionals in the following areas: internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties.

I gave it a 6 because Nurses are kind of ignored or overlooked or unrecognized /underutilized in the Antimicrobial Stewardship Programs. My question is that, Are the staff nurses being underutilized and not recognized as members of the antimicrobial/antibiotic stewardship program team related to the rise in health care associated c-diff? “Focused consideration to empower and educate staff nurses in antimicrobial management is needed to strengthen collaboration and build an inter professional stewardship workforce” (Monsees, E. et al., 2017).

References

Barlam, T., F., Cosgrove, S., E., Abbo, L., M., MacDougall, C., Schuetz, A., N, … & Trivedi,

K., K. (2016). Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America.

https://watermark.silverchair.com/api/watermark?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAdcwggHTBgkqhkiG9w0BBwagggHEMIIBwAIBADCCAbkGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMtgHaCXY6dtLfrTfPAgEQgIIBii_Vh27ywlLtT-idNtyo35gc6nrg82pilVGebZq5ITivnrk747DXbqOT7lq0bkXiTyK0oQYc5M8zRqJmRoQA1-Eiji8H69AbwZmEQGE92jUSiyuN48xkHYMaNZNjGjZcOrfPTLqj0__NxMG7bVGh5a3zgEy2B2ZJlwHWgkoxxO9oP97xSN5kVCB6SPshQ_nuEmCklC_Pig37IdHglC4R0Rrgdl_MNIGoHhECflm3ZJ6QWSiH0YayXVh1vVmbHcWrTi5awDg4rNFcxzpbyvHLYwc9jMQlRSkE6wmsgt_YF_CBxwv2EPs6omJInMvNiD6RD6TVvI7ZzMCnSR15yZglWwpxgYGfZWpBGh05snfYFegMtoNFiWMTouQs7mZcHBNH1T2MGvNCKntdeWhiLGi4g15vLUN7n7GHcFXNkbHfII4oJ44bMwQ-UFcMpcjV-eiBpW7rgaW2zTK-jdJiPdN1nX5v6dWvKW_sCrRcbf_u2Eyf3iAMz6m2-K1ue_SBwV9vgVe7uQIlzxNVYg8

Brouwers, M., C., Kerkvliet, K., Spithoff, K. (2016). On behalf of the AGREE Next Steps

Consortium. The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines. BMJ 2016;352:i1152. doi: 10.1136/bmj.i1152. www.agreetrust.org. ttp://www.agreetrust.org/wp-content/uploads/2013/10/AGREE-II-Users-Manual-and-23-item-Instrument_2009_UPDATE_2013.pdf

Charani E, Castro-Sanchez E, Sevdalis N, et al. (2013). Understanding the determinants

of antimicrobial prescribing within hospitals: the role of “prescribing etiquette.”

Clin Infect Dis 2013; 57:188–96.

Infectious Diseases Society of America (IDSA) (2015). Handbook on clinical practice guideline

development. Available at: http://www.idsociety.org/uploadedFiles/IDSA/ Guidelines-Patient_Care/IDSA_Practice_Guidelines/IDSA%20Handbook% 20on%20CPG%20Development%2010.15.pdf

Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of

America (SHEA) (2016). New Antibiotic Stewardship Guidelines Focus on Practical Advice for Implementation. http://www.idsociety.org/New_Antimicrobial_Stewardship_Guideline_2016/

Monsees, E., Goldman, J & Popejoy, L. (2017). Staff nurses as antimicrobial stewards: An

integrative literature review. American Journal of Infection Control 2017 August 1, 45 (8): 917-922

Pakyz, A., L., Moczygemba, L.,R., VanderWielen, L., M., Edmond, M., B., Stevens, M., P,

Kuzel, A., J. (2014). Facilitators and barriers to implementing antimicrobial stewardship strate- gies: results from a qualitative study. Am J Infect Control 2014; 42(suppl 10): S257–63.

The White House (2015). National action plan for combating antibiotic-resistant bacteria, 2015.

Available at: https://www.whitehouse.gov/sites/default/files/docs/ national_action_plan_for_combating_antibotic-resistant_bacteria.pdf.

Wagner B, Filice GA, Drekonja D, et al. (2014). Antimicrobial stewardship programs in

inpatient hospital settings: a systematic review. Infect Control Hosp Epidemiol 2014; 35:1209–28.

Week 3 Assignment Instructions

Details:

While there are several tools to critically appraise practice guidelines, the most comprehensively validated appraisal tool is the AGREE II Instrument. The AGREE II Instrument can be used by individual practitioners to critically appraise health guidelines and by decision makers to inform policy decisions. The purpose of the AGREE II Instrument is to provide a framework to:

1. Assess the quality of guidelines.

2. Provide a methodological strategy for the development of guidelines.

3. Inform what information and how the information ought to be reported in guidelines.

Overall assessment includes rating the overall quality of the guideline and whether the guideline would be recommended for use in practice. Items are rated on a 7-point scale from 1 (Strongly Disagree) to 7 (Strongly Agree). A score of 1 is given when there is no information on that item or if it is poorly reported. A score of 7 is given if the quality of reporting is excellent and when full criteria have been met (Score explanations found in the AGREE II-GRS Instrument). A quality score is calculated for each of the six domains, which are independently scored. Domain scores are calculated by summing up all the scores of the items in the domain and by scaling the total as a percentage of the maximum possible score for that specific domain.

For this assignment, you will choose a guideline and assess the overall quality and whether the guideline would be recommended for use in practice.

General Requirements:

Use the following information to ensure successful completion of this assignment:

· Download the AGREE II instrument.

· Doctoral learners are required to use APA style for their writing assignments. The APA Style Guide is located in the Student Success Center. An abstract is not required.

· This assignment uses a rubric. Please Review the rubric prior to the beginning to become familiar with the expectations for successful completion.

· You are not required to submit this assignment to Turnitin.

Directions:

Perform the following tasks to complete this assignment:

1. Using the AGREE II instrument as your guide, create a table that discusses a practice guideline in which you might have questioned the recommendations. (Note: You may be able to copy and paste the instrument into a new Word document and complete the information.)

2. Each domain must have its own cell (similar to the one shown in the manual) and add domain scores and an overall guideline assessment. Be sure to include comments and additional considerations that influenced your rating decision and cite any sources used.

Apply Rubrics

Critical Appraisal of Practice Guidelines

 

1 Unsatisfactory 0.00%

2 Less Than Satisfactory 74.00%

3 Satisfactory 79.00%

4 Good 87.00%

5 Excellent 100.00%

70.0 %Content

 

20.0 %Discuss a practice guideline in which you might have questioned the recommendations.

Discussion of the practice is not presented.

Discussion of the practice is presented but incomplete.

Discussion of the practice is presented but at a cursory level.

Discussion of the practice is clearly presented and convincing. Sources cited are from current scholarly but some outdated sources.

Discussion of the practice is clearly presented and perceptive. Sources cited are from current scholarly sources.

25.0 %Create a table for each domain (similar to the one shown in the manual) and add domain scores and an overall guideline assessment.

A table with each domain is not presented.

A table with each domain is presented but incomplete.

A table with each domain is presented but at a cursory level.

A table with each domain is clearly presented. Scores are present for each domain and justification is beyond surface understanding.

A table with each domain is clearly presented. Scores are present for each domain and justification is insightful.

25.0 %Create a table for the overall guideline assessment.

A table for the overall guideline assessment is not presented.

A table for the overall guideline assessment is presented but incomplete.

A table for the overall guideline assessment is presented but at a cursory level.

A table for the overall guideline assessment is clearly presented and convincing.

A table for the overall guideline assessment is clearly presented and perceptive.

20.0 %Organization and Effectiveness

 

7.0 %Thesis Development and Purpose

Paper lacks any discernible overall purpose or organizing claim.

Thesis and/or main claim are insufficiently developed and/or vague; purpose is not clear.

Thesis is apparent and appropriate to purpose.

Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose.

Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.

8.0 %Argument Logic and Construction

Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources.

Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility.

Argument is orderly, but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis.

Argument shows logical progressions. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative.

Clear and convincing argument that presents a persuasive claim in a distinctive and compelling manner is present. All sources are authoritative.

5.0 %Mechanics of Writing (includes spelling, punctuation, grammar, language use)

Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction are used.

Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, and/or word choice are present.

Some mechanical errors or typos are present, but are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used.

Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used.

Writer is clearly in command of standard, written, academic English.

10.0 %Format

 

5.0 %Paper Format (Use of appropriate style for the major and assignment)

Template is not used appropriately or documentation format is rarely followed correctly.

Appropriate template is used, but some elements are missing or mistaken. A lack of control with formatting is apparent.

Appropriate template is used. Formatting is correct, although some minor errors may be present.

Appropriate template is fully used. There are virtually no errors in formatting style.

All format elements are correct.

5.0 %Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)

Sources are not documented.

Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors.

Sources are documented, as appropriate to assignment and style, although some formatting errors may be present.

Sources are documented, as appropriate to assignment and style, and format is mostly correct.

Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.

100 %

Guideline Evaluation using the Agree II Instrument

Student Name

Grand Canyon University: DNP 820

Date

Guideline Evaluation using the Agree II Instrument

The following table outlines a critical appraisal of the guideline written by Kalil et al. (2016) on “Management of Adults with Hospital-Acquired and Ventilator-Associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society” using the AGREE II Instrument (2009). Pneumonia that occurs greater than 48 hours after admission to the hospital (HAP) or greater than 48 hours after endotracheal intubation (VAP) has special considerations, separate from the considerations for community-acquired pneumonia, and this guideline was written to address these specific considerations and circumstances (Kalil et al., 2016). This guideline includes 25 recommendations outlining how to best diagnose and treat HAP and VAP. Serum and microbiology laboratory testing option recommendations related to HAP and VAP are outlined, and then antibiotic selection and duration recommendations make up the majority of recommendations included in the guideline (Kalil et al., 2016).

Domains with Questions:

Score (1-7):

Comments:

Domain 1: SCOPE AND PURPOSE

1. The overall objective(s) of the guideline is (are) specifically described.

7

Kalil et al.’s (2016) overall objectives are found on the first page where an abstract would normally be found.

2. The health question(s) covered by the guideline is (are) specifically described.

6

While not introduced overtly as the health questions covered in this guideline, it is very easy to tell from the introduction summary that Kalil et al. are answering the questions how to diagnose and how to treat HAP and VAP. In the scope and purpose section it is even more clear.

3. The population (patients, public, etc.) to whom the guideline is meant to apply is specifically described.

7

Kalil et al. explain in great detail who the target population of patients is to whom the guideline is meant to apply.

Domain 1 total: 20/21 calculates to 94.4%

Domain 2: STAKEHOLDER INVOLVEMENT

4. The guideline development group includes individuals from all relevant professional groups.

7

Professionals from a multitude of relevant groups (e.g. pulmonary, critical care, infectious disease, pathology, and microbiology medicine groups) who are from at least six countries are part of the Kalil et al. author group. Comment by Lane, Kari: Who is missing from this group/

5. The views and preferences of the target population (patients, public, etc.) have been sought.

2

In their table on interpretation of strong and weak (conditional) recommendations, Kalil et al. take patient preference into consideration, but the patient preference is assumed rather than explicitly sought. This is likely because evidence on patient preferences for how HAP and VAP are diagnosed and treated is scarce and not very applicable as patients are grossly uninformed on the topic.

6. The target users of the guideline are clearly defined.

7

Kalil et al. clearly define the target audience for the guidelines on page nine in the scope and purpose section.

Domain 2 Total: 16/21 calculates to 72.2%

Domain 3: RIGOUR OF DEVELOPMENT

7. Systematic methods were used to search for evidence.

7

Kalil et al. describe their methodology employed for developing the guideline, including that two health science librarians who are experts in searching for evidence developed the literature searches, and more details on the searches can be found in supplementary material.

8. The criteria for selecting the evidence are clearly described.

3

Kalil et al. write that the literature search results were reviewed by panelists who then selected and reviewed the articles. More details are available on how the search was conducted and how the evidence was evaluated after selection than on how the articles were selected. Comment by Lane, Kari: Where are they available from? How did you decide on a score of 3 here, justify your decision.

9. The strengths and limitations of the body of evidence are clearly described.

7

A summary of the evidence with the strengths and limitations is included after every recommendation Kalil et al. give. Comment by Lane, Kari: What limitations do you see? Often the creators do not see limitations in their own work, so really look for downfalls.

10. The methods for formulating the recommendations are clearly described.

7

Kalil et al. include a rationale for the recommendation section after the summary of evidence that accompanies every recommendation.

11. The health benefits, side effects, and risks have been considered in formulating the recommendations.

7

This is thoroughly discussed by Kalil et al. in the rationale for the recommendation section. Comment by Lane, Kari: What is missing?

12. There is an explicit link between the recommendations and the supporting evidence.

DOMAIN 3. RIGOUR OF DEVELOPMENT continued

7

Kalil et al. give their recommendation and then detail the evidence and their rationale, clearly linking every recommendation with the evidence.

13. The guideline has been externally reviewed by experts prior to its publication.

7

Per Kalil et al., external peer reviewers gave feedback, and then the guideline was reviewed and endorsed by the Society of Critical Care Medicine and the Society for Healthcare Epidemiology of America before final review and approval was obtained from the boards of directors of the Infectious Diseases Society of America and the American Thoracic Society.

14. A procedure for updating the guideline is provided.

2

Kalil et al. describe how this guideline is an update from their 2005 guidelines, but they do not address a procedure for future updating.

Domain 3 Total: 47/56 calculates to 81.3%

Domain 4: CLARITY OF PRESENTATION

15. The recommendations are specific and unambiguous.

7

Each recommendation summary is written clearly and precisely by Kalil et al..

16. The different options for management of the condition or health issue are clearly presented.

7

Kalil et al. specify options when appropriate and also include room for provider judgment in individual patients or special situations.

17. Key recommendations are easily identifiable.

DOMAIN 5. APPLICABILITY

7

Kalil et al. do an excellent job in how they present the concise recommendation summaries in the beginning and also how they re-present their recommendations clearly in the more detailed section later.

Domain 4 Total: 21/21 calculates to 100%

Domain 5: APPLICABILITY

18. The guideline describes facilitators and barriers to its application.

4

Barriers to application of the guideline are described by Kalil et al. in a few applicable places. Comment by Lane, Kari: And facilitators? What is missing here, can you see any gaps or loopholes, where this might not work in your setting?

19. The guideline provides advice and/or tools on how the recommendations can be put into practice.

5

Tables are given that can be used as tools to implement the guideline recommendations in specific situations.

20. The potential resource implications of applying the recommendations have been considered.

6

Kalil et al. are aware of resources necessary for diagnosing and treating HAP and VAP, and they address resource considerations. Comment by Lane, Kari: Do they offer resources to assist with implementation?

21. The guideline presents monitoring and/or auditing criteria.

7

Several of Kalil et al.’s recommendations address monitoring patients’ response to treatment. Comment by Lane, Kari: Would these be easily applied? How so?

Domain 5 Total: 19/28 calculates to 75%

Domain 6: EDITORIAL INDEPENDENCE

22. The views of the funding body have not influenced the content of the guideline.

7

The content of Kalil et al.’s guideline is very clearly based on researched evidence, and no apparent other influences were noted. Comment by Lane, Kari: Does the guideline specifically declare conflicts of interest or state no conflicts of interest were declared?

23. Competing interests of guideline development group members have been recorded and addressed.

7

Kalil et al. include both a “discloser and management of potential conflicts of interest” section in the body of their guideline and a potential conflicts of interest list at the end.

Domain 6 Total: 14/14 calculates to 100%

Total Domain scores:

1. 20/21 calculates to 94.4%

2. 16/21 calculates to 72.2%

3. 47/56 calculates to 81.3%

4. 21/21 calculates to 100%

5. 19/28 calculates to 75%

6. 14/14 calculates to 100%

Overall Total: 137/161 calculates to 82.6%

Overall Rating of Quality:

6

Using this Agree II Instrument (2009) to structure this evaluation, the guideline by Kalil et al. (2016) performs very well in the areas of scope and purpose, clarity of presentation, and editorial independence, obtaining scores of greater than 90% in all three of those domains. Scores in the other three domains are all over 70%. The lowest score is in the domain of stakeholder involvement, and this area is low partially due to the low applicability of patient preferences in how HAP and VAP is diagnosed and treated.

Recommended for use:

YES

I see no reason why the guideline by Kalil et al. should not be followed in the vast majority of HAP and VAP diagnoses or suspected diagnoses, and the rigor with which the authors evaluated evidence to build the guideline makes it an excellent reference for finding best practices. The clarity with which the recommendations are presented makes it easy to use for all providers.

Running head: GUIDELINE EVALUATION 1

6

GUIDELINE EVALUATION USING THE AGREE II INSTRUMENT

References

AGREE Next Steps Consortium (2009). The AGREE II Instrument [Electronic version]. Retrieved from: http://www.agreetrust.org

Kalil, A. C., Metersky, M. L., Klompas, M., Muscedere, J., Sweeney, D. A., Palmer, L. B., & … Brozek, J. L. (2016). Management of adults with hospital-acquired and ventilator- associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clinical Infectious Diseases, 63(5), e61-e111. doi:10.1093/cid/ciw353

I, student name, verify that I have completed ## clock hours in association with the goals and objectives for this assignment. I have also tracked said practice hours in the Typhon Student Tracking System for verification purposes and will be sure that all approvals are in place from my faculty and practice mentor.

Mandatory Discussion Question