Guidelines Review and Update

The dynamic environment of critical care nursing is both interesting and challenging. Research findings, new medications, technological advances, and, yes, even new diseases are discovered with amazing frequency. The challenge to do the right thing at the bedside is made easier with clinical practice guidelines that are evidence based. According to the Institute of Medicine (IOM),¹  more than 3700 clinical practice guidelines are available from 39 countries. The IOM outlined standards for the best practices of guideline development in Clinical Practice Guidelines We Can Trust.¹  These standards include transparency, management of conflict of interest, guideline development group composition, systematic review processes, rating recommendations using levels of evidence, and external review and updating.¹  This symposium includes reviews of recently released guidelines to assist clinicians in providing and implementing evidence-based care to vulnerable, and frequently unstable, acute and critically ill patients.

Cardiovascular disease and its complications are major contributors to mortality and morbidity rates. Although the Advanced Cardiac Life Support guideline has been the criterion standard for decades for resuscitation of patients with cardiac arrest, it might not be appropriate in the early postoperative period for patients undergoing cardiac surgery. Cheryl Herrmann, a cardiac surgery clinical nurse specialist, addresses the new Cardiac Advanced Life Support–Surgery guideline, which is being utilized and discussed globally. Stroke is a serious emergency care concern for adults living with cardiovascular disease, and Sarah Live-say, an associate professor and nurse practitioner, offers a scholarly review of the American Heart Association 2013 stroke guidelines. Helen Brown, who is dually credentialed as an acute care and a family nurse practitioner and works in a busy emergency department, outlines the 2013 American Heart Association updated guidelines for the care of ST-segment elevation myocardial infarction. Advances in cardiovascular care have led to increased survival rates from ST-segment elevation myocardial infarction and stroke, which has, in turn, increased the number of older adults living with heart failure. Nurse practitioners Denise Buonocore and Elizabeth Wallace discuss the comprehensive guidelines for the treatment of heart failure.

The last 2 articles in this symposium are not specifically related to cardiac care. Sepsis and ventilator-associated complications are unfortunately ubiquitous in critical care practice. Nancy Munro and Margaret Ruggiero, acute care nurse practitioners at the National Institutes of Health in Maryland, outline and evaluate the ventilator-associated pneumonia bundle and articulate a strong case for reconstruction. The final article focuses on the Surviving Sepsis Campaign guidelines. In addition to introducing the changes contained in the updates, Ruth Kleinpell and Christa Schorr offer readers an insightful discussion of performance improvement and the role of nurses in the care of patients with sepsis.

Clinical practice guidelines are meant to be recommendations not mandates. Guidelines that meet the criteria established by the IOM have undergone a rigorous development process.¹  Each recommendation comes with a grade or strength assigned to it, typically referred to as level of evidence. A detailed discussion and review of the different grading systems are beyond the scope of this introduction and the articles within this symposium. Recommendations that are assigned the highest levels have the strongest research supporting their implementation and those with lower-level grades have less, inconclusive, or contradictory research support. Each member of the team who bears the responsibility for decision making in the care of acute and critically ill patients must consider the patient, the guidelines, and the strength of the evidence for each recommendation during the critical thinking process to do the right thing.