AORN Changes Guideline Rating Systems

AORN has officially launched changes to the way evidence is rated in AORN’s Guidelines for Perioperative Practice. The changes appear for the first time in AORN’s updated draft guideline for Surgical Attire, which is currently up for public comment.

This evidence rating change will impact the way the guidelines look, and deeper than look alone, the changes will alter how AORN makes perioperative practice recommendations, according to Amber Wood, MSN, RN, CNOR, CIC, editor-in-chief of AORN Guidelines for Perioperative Practice and Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, AORN director of evidence-based perioperative practice.

Why change?
AORN’s commitment to providing high-quality, trustworthy guidelines that support the clinical decision-making of perioperative nurses is seen in its constant review of new evidence and in the manner in which the evidence is presented. In 2011, the Institute of Medicine (now the National Academy of Medicine) published a report on the best practices for development of clinical practice guidelines. AORN adopted these standards at their inception, and we are continually improving our processes. From the time when AORN first embarked on this endeavor, many major professional organizations and even federal agencies such as the CDC have also changed their recommendations ratings giving AORN new insight into how we can further improve our guidelines.

Recently, organizations have begun scoring guidelines to determine how well the guideline meets the IOM standards for trustworthy guidelines. This work began with the National Guidelines Clearinghouse, which is currently seeking funding to be reinstated. In November 2018, the ECRI Institute launched the Guidelines Trust, which is a publically-accessible database for guidelines that meet the IOM standards. The ECRI Guidelines Trust has accepted 27 AORN guidelines into this database, which each include a brief summary and scorecard.

“We want to improve the quality of the guidelines to meet the standards for guideline development—it’s not just about improving the score but meeting the latest criteria that define best practice,” Wood adds.

What are the changes at a glance?

1. Evidence-rating model changes:

   The process of making a practice recommendation has changed. “When the guideline team is developing a practice recommendation, we rate the evidence quality and consistency of results, assess benefits and harms, evaluate the resources needed for implementation, and then we rate the strength of the recommendation based on these factors,” Wood says.

   This change can be seen in the way evidence is rated at the end of a practice recommendation in an AORN guideline.

   Where a recommendation used to have these five rating levels …

   -[1: Strong Evidence]
   -[2: High Evidence]

   -[3:Moderate Evidence]

   -[4: Limited Evidence]

   -[5: Benefits Balanced With Harms]

   There are now three evidence rating levels, which can be found in the rationale discussing the evidence for the recommendation...

   -High-quality evidence

   -Moderate-quality evidence

   -Low-quality evidence

   The recommendation itself will also now have its own rating, separate from the evidence quality rating. There are three levels of recommendation strength rating:

   -[Recommendation]

   -[Conditional recommendation]

   -[No recommendation]




2. Formatting changes:

   With a new rating process, AORN has decided to also change up the format of the guidelines to make them easier to read and find information with a simplified format that includes:

   -Sorting recommendations by topic

   -Numbering recommendations numerically as 1, 2, 3, 4 ….

   -Starting recommendation statements with action verbs

   “With this new format, it will be easier to quickly identify the information you are looking for in a guideline,” Wood explains.




3. Implementation changes:

   With this new approach to rating, the implication for practice will be clearer and easier to tailor to your individual practice:

   • [Recommendation]: Perioperative team members “should” implement the recommendation, unless a clear and compelling rationale for an alternative approach is present.
   • [Conditional Recommendation]: Perioperative team members “may” implement the intervention, although the degree of implementation may vary depending on the benefit-harm assessment for the specific setting.
   • [No Recommendation]: Perioperative team members will need to evaluate whether or not to implement the practice issue.

On the rare occasion that perioperative practices are rated as “no recommendation,” there may not be enough evidence to make a recommendation. In this case, it is up to individual health care organization and perioperative team to make their own decision about how to implement a safety practice, Spruce notes.

“Guidelines are developed using the available scientific evidence, the experience of health care practitioners and an assessment of benefits and harms to patient,” Spruce acknowledges. “Health care practitioners need to learn how to implement guideline recommendations into their practice setting, form interdisciplinary teams to make decisions and base those decisions on the needs of individual patients.”

When will the changes begin?

Now. That means that throughout 2019 as AORN guidelines are being revised, each will be written with the new evidence-rating and formatting changes.

Check out the new guideline changes in the draft updated Surgical Attire guideline up for public comment through Feb. 22.

Additional Resources

Share this graphic depicting the new evidence-rating model to help your team understand what the guideline changes look like.

Review ECRI scorecards for AORN guidelines. (Free registration is required)

Learn more about revisions to the AORN evidence-model in this webinar, free for AORN members only.

Get additional help implementing AORN guidelines easily and effectively with the members-only Guideline Essentials. Access implementation steps, instructional videos, policy and procedure templates, audit tools, and more.