Evaluation of a COVID-19 Surgical Scheduling Guideline using the Appraisal of Guidelines for Research and Evaluation AGREE II Instrument



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Introduction/Background Since the beginning of the SARS-COVID-19 pandemic in February 2020, the operating room and surgical care has undergone vast change. At its start, COVID-19 infection caused many elective surgeries to be canceled, operating room schedules to be altered, and inquiries of how healthcare should change in order to continue providing the best care during unprecedented circumstances. Hospital administration, healthcare workers, and patients began searching for valid information to guide best practice. COVID-19 has been found to severely affect the physiology of the circulatory and pulmonary systems of patients. With new discovery of pathophysiologic consequences of COVID-19 infection, the need for well-founded guidelines to assist clinicians in managing surgical and anesthetic care is realized. Guidelines surrounding the treatment of surgical patients infected with COVID-19 were formed during a time of crisis when evidence was limited and instability in healthcare delivery occupied much of healthcare team efforts. This period of uncertainty, paired with the volume of patients infected with COVID-19, may have contributed to the development of unclear guidelines as well as inconsistencies in following established guidelines that were meant to direct surgical and anesthesia care during times of peak infection of the COVID-19 pandemic. Method: The main purpose of this Doctor of Nursing Practice (DNP) final project was to evaluate a clinical practice guideline (CPG) designed to be used by anesthesia providers to guide timing of surgery for patients diagnosed with COVID-19 in a major midwestern hospital in Michigan. The surgical scheduling guideline was evaluated for overall quality, development, and reporting using the AGREE II instrument and following instructions from AGREE Enterprise. The quality improvement methodology for this project followed the Agency for Healthcare Research and Quality’s “Plan-Do-Study-Act'' model for testing an implemented change. The appraisal team consisted of four appraisers that examined the CPG guideline. All items within the AGREE II instrument were given a score on a Likert scale ranging between 1-7 (strongly disagree = 1 and strongly agree = 7). Quality scores corresponding to six domains of the AGREE II instrument were calculated in addition to a compilation of the overall quality of guideline scores. Results The guideline received low appraisal scores for the domain categories contained in the AGREE II instrument. All quality scores for the six appraised domains were low except for Domain 4: Clarity of Presentation (65.28%). In addition, the guideline received an overall low guideline quality rating of 25%. Although all domain scores and the final appraisal score were low, three out of four appraisers would recommend the guideline for use with modifications. Discussion Large contributors of poor appraisal scores were the lack of available supporting evidence and explicit language needed for continual use and improvement. In developing future practice guidelines that will assist in upholding the delivery of safe surgical and anesthesia care even during an unprecedented crisis such as the COVID-19 pandemic, it is essential to include source materials to lend transparency for clinician use. Additionally, guidelines intended to influence patient care outcomes should include explicit evidence and language that states the desired outcomes. Additions such as these would better ensure the assessed guideline would contribute to positive change in patient care.



COVID-19, guidelines, Agree II Instrument, anesthesia, surgery