6. Grades of recommendation

It has long been known that clinical practices based on scientific evidence can only be "as good as" the underlying evidence and judgments [124]. Parallel to the assessment of LSE discussed in previous sections of this manuscript, the need arose for the ability to grade the corresponding recommendations—a necessary step for reconciliation of all of the components of, and internal consistency of, EMB practices [124]. Grading of recommendations has been pioneered by the Scottish Intercollegiate Guidelines Network (SIGN), with subsequent worldwide embrace and adoption of this powerful healthcare quality improvement paradigm [129, 130]. As outlined in Table 2, recommendations are graded on a scale from A (highest) to C (lowest), with the overall goal of careful consideration and weighing of objective and


Table 3. Quality of evidence assessment definitions, as utilized in the GRADE approach [138].

actual implementation of evidence into practice, especially within organizations where expert opinion and hierarchical decision-making impose "glass ceilings" toward evidence-based approaches. Moreover, numerous methodological and ethical complexities make research in clinical safety particularly challenging, as patients cannot be subjected to blinding or random-

It is important to reiterate that EBM is not purely about conducting RCTs and implementing their context-appropriate results into clinical practice. Evidence-based medicine extends to critical decision-making regarding treatment and practices that stem from carefully and thoughtfully considering and weighing "best evidence" [123–125]. Well-designed case-control and cohort studies can prove to be equally effective tools and should be considered for areas where RCTs are simply not feasible or impractical. Lastly, it is every practitioner's obligation to provide the best available care for their patients and that will continue to be driven by the increasing wealth of available literature [126], hopefully characterized by better LSEs and overall quality of both methodology and data. Practitioners and champions of patient safety must therefore be encouraged to thoroughly search and evaluate published research and thoughtfully consider "best evidence" in an unbiased, holistic manner before committing to

Clinical pathways and guidelines are used by practitioners to provide a framework of care for specific patient populations to improve outcomes [107]. Clinical guidelines are evidence-based care recommendations for defined populations and assist the clinician in decision-making regarding the patient care plan. Clinical pathways are used to implement the guidelines into practice and represent what has been determined to be the best evidence-based care for most patients [127]. They are typically a written tool and may be facility specific with an overarching goal of minimizing variability and optimizing outcomes. Rotter et al. [128] reviewed 27 studies involving 11,398 participants. Twenty of those studies compared clinical pathways with usual care. Their review identified a reduction in complications and improved documentation. Most studies also reported significant reductions in patient length of stay and thus a favorable

It has long been known that clinical practices based on scientific evidence can only be "as good as" the underlying evidence and judgments [124]. Parallel to the assessment of LSE discussed in previous sections of this manuscript, the need arose for the ability to grade the corresponding recommendations—a necessary step for reconciliation of all of the components of, and internal consistency of, EMB practices [124]. Grading of recommendations has been pioneered by the Scottish Intercollegiate Guidelines Network (SIGN), with subsequent worldwide embrace and adoption of this powerful healthcare quality improvement paradigm [129, 130]. As outlined in Table 2, recommendations are graded on a scale from A (highest) to C (lowest), with the overall goal of careful consideration and weighing of objective and

any clinical decisions or programmatic implementations.

impact on associated costs [128].

6. Grades of recommendation

ization [102].

64 Vignettes in Patient Safety - Volume 3

subjective components of both the available evidence and its corresponding interpretation. It is important to note that different other GOR paradigms have been devised, with the topic being so vast as to warrant its own dedicated chapter and/or book [124]. Finally, another matter that is beyond the scope of the current discussion is the advent of various reporting requirements for different types of studies. The reader is referred to external resources for additional information on this important and increasingly complex subject [131–134].

Another important development in the area of translating evidence into practice was the introduction of the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach [135, 136]. In the GRADE paradigm, evidence is assessed in terms of both its certainty (e.g., quality) and strength of the corresponding clinical recommendation(s) [135, 137]. In terms of practical applicability of the GRADE system, quality of evidence and the corresponding definitions are provided in Table 3 [138]. A multi-tiered system, examining specific evidence-related factors and criteria in the context of their influence on the direction and strength of the recommendation, is then employed to help with clinical implementations and translations of research data [139]. Since its introduction, the GRADE paradigm provides a well-organized and objectivized framework for evaluating the relative importance of research outcomes and alternative clinical approaches, and summarizing evidence for systematic reviews and clinical practice guidelines [139].
