Special Editorial
Practice Guidelines as Implementation Science:
The Journal Editors’ Perspective*
Timothy G. Buchman, MD, PhD, MCCM
Editor-in-Chief, Critical Care Medicine
Elie Azoulay, MD, PhD
Editor-in-Chief, Intensive Care Medicine
W
e are pleased to present the 2016 edition of the Sur-
viving Sepsis Campaign’s practice guidelines in this
issue of our journals (1, 2). We are also pleased to
publish a brief explanatory article intended to facilitate the
accurate implementation of the guidelines (3, 4). These publi-
cations fulfill—yet do not explain—the role that journals, their
reviewers, and their editors play in bringing actionable infor-
mation to the bedside. Herein, we offer the editors’ perspective.
Guideline development and refinement are responsi-
bilities of guidelines chairs charged with those tasks by their
professional colleges and teaching organizations. The Surviv-
ing Sepsis Campaign has evolved to become a multinational
and multiprofessional effort organized under the aegis of
many professional societies. Guideline chairs and members
are charged with weighing published evidence, transforming
knowledge into recommendations, discarding outdated or dis-
proven guidance, illuminating areas of continuing controversy,
and eventually penning the guidelines document. All of this
requires diversity of opinion, deep engagement, and substan-
tial investment of time and of treasure. We editors and our
journals are indebted to all who have contributed.
The document is of immediate significance to clinicians.
Yet there are many other stakeholders including students in the
health professions for whom the guidelines have pedagogical
significance. Dissemination of guidelines is commonly inter-
preted as articulating a “standard of care”, a standard that has
political, sociological, and even legal ramifications when com-
pared with day-to-day practice. Implementation of guidelines
into practice used to be simply a professional expectation;
compliance has become nearly a moral imperative. Yet there
are two additional competing imperatives. As clinicians, we are
bound to deviate from guidelines when such deviation is rea-
sonably expected to improve an individual patient outcome. As
*See also p. 486.
This editorial is be co-published in Intensive Care Medicine and
­Critical Care Medicine.
Copyright © 2017 by the Society of Critical Care Medicine and the
­European Society of Intensive Care Medicine. All Rights Reserved.
DOI: 10.1097/CCM.0000000000002256
Critical Care Medicine www.ccmjournal.org 553
Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
clinical scientists, we are bound to evaluate the prevailing stan-
dard against emerging alternatives. These three imperatives are
inseparable. We therefore caution against any quality metric
or reimbursement policy that mandates slavish adherence to a
particular recommendation.
Our journals play key supporting roles. Published guidelines
reflect the dedication of many reviewers and editors toward
clarification and disambiguation. Foremost in our minds is
making the content accessible to–and usable by–the commu-
nity of caregivers. The final product balances the methods and
findings of the guidelines development chairs with the need to
provide both concrete recommendations and interpretation to
those who care directly for patients. The guidance is necessar-
ily nuanced to reflect reasonable alternatives and approaches
when evidence is contradictory or incomplete. Indeed, the
guideline authors, our reviewers, and we as editors struggle to
balance highlighting uncertainty with actionable recommen-
dations. Guidelines are thus a unique blend of science, method,
debate, and art.
Our editorial responsibility does not end with publication of
print and electronic versions of the guidelines. We now solicit
reports of implementation and of outcomes from those who
promptly implement the new version and hopefully improve
and save lives. Neither we editors nor our journals will be inter-
mediaries in dialogue or dispute over the validity or framing of
specific recommendations within the guidelines. Instead, cor-
respondents are directed to the officials overseeing guideline
development. For the Surviving Sepsis Guidelines, correspon-
dence about specific recommendations should be sent to Drs.
Andrew Rhodes and Laura Evans at andrewrhodes@nhs.net
and Laura.Evans@nyumc.org.
We editors expect that readers and users will challenge the
guidelines by performing additional studies and will thereby
generate new evidence for the next version. We look forward to
evaluating those manuscripts. We are interested in reviewing cor-
respondence and reports highlighting experience with dissemina-
tion, implementation, and clinical effectiveness of the guidelines.
We editors are also interested in learning of the comparative
impact, diffusion, and effectiveness of transfer of the guide-
lines into different forms (such as executive summaries, check-
lists, order sets, pocket and smartphone guides, electronic
alerting systems, videos, podcasts). New guidelines specify new
normative behaviors. As such, studies of guideline adoption
offer insight not only into the outcomes following the specified
treatments but also into the way in which clinical behaviors
can be influenced. In other words, we editors are interested in
Special Editorial
how readers become users. More to the point, we editors are
interested in scientific analysis of innovations that appear to
accelerate knowledge transfer into clinical practice.
Our collective goal is to facilitate the best patient care
today−and even better patient care tomorrow. As editors,
we recognize that medical knowledge is inherently volatile.
Prior recommendations are modified, replaced, or simply dis-
carded in light of new studies. Well-designed studies that chal-
lenge recommendations through comparison with alternate
approaches are foundational to the life cycle of practice guide-
lines. Such studies must extend beyond single institutions and
evaluate performance over a wider collection of patients in
diverse settings. We note that guidelines aim to promote the
greatest good for the greatest number, yet their implementa-
tion often requires modification in special settings such as low
and middle income countries and during disaster manage-
ment. We look forward to receiving and reviewing new and
generalizable insight that will change thinking and practice.
554 www.ccmjournal.org March 2017 • Volume 45 • Number 3
Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
The guidelines have been developed, written, revised,
typeset, and published. The authors, reviewers, and editors
have performed their duties. It is now for you, our readers, to
implement the guidelines and evaluate their performance in
your clinical settings. Thus the cycle of guideline development
begins anew.
REFERENCES
1. Rhodes A, Evans LE, Alhazzani W, et al: Surviving Sepsis Campaign:
International Guidelines for the Management of Sepsis and Septic
Shock: 2016. Crit Care Med 2017; 45:486–552
2. Rhodes A, Evans LE, Alhazzani W, et al: Surviving Sepsis Campaign:
International Guidelines for the Management of Sepsis and Septic
Shock: 2016. Intensive Care Med 2017; 2017 Jan 18. doi: 10.1007/
s00134-017-4683-6. [Epub ahead of print]
3. Dellinger RP, Schorr CA, Levy MM: A Users’ Guide to the 2016
Surviving Sepsis Guidelines. Crit Care Med 2017; 45:381–385
4. Dellinger RP, Schorr CA, Levy MM: A Users’ Guide to the 2016
Surviving Sepsis Guidelines. Intensive Care Med 2017; 2017 Jan
18. doi: 10.1007/s00134-017-4681-8. [Epub ahead of print]