When COVID-19 struck, Scottish Intercollegiate Guidelines Network (SIGN) had an obligation to support healthcare professionals in Scotland with contextualised guidance on the diagnosis and treatment of a new and emerging disease. Angela Timoney, Chair of SIGN, explains the challenge of developing evidence-based guidance with very little high-quality evidence.

The scale and pace of the COVID-19 pandemic has presented numerous challenges to healthcare professionals. It has also presented a new type of problem for people who seek to aid health and care professionals by making sense of evidence. The so-called infodemic is almost a virus in its own right – the endless circulation of information and misinformation from many different sources and experts causing hope and confusion on an almost daily basis, and spreading with great speed through social media and 24-hour news. In fact, the World Health Organization has said that the infodemic around COVID-19 is almost as dangerous as the pandemic itself.

“The so-called infodemic is almost a virus in its own right – the endless circulation of information and misinformation from many different sources and experts causing hope and confusion on an almost daily basis, and spreading with great speed through social media and 24-hour news. In fact, the World Health Organization has said that the infodemic around COVID-19 is almost as dangerous as the pandemic itself.”

Some steady voices, including the Centre for Evidence-based Medicine and Cochrane, have helped filter this information overload, and Healthcare Improvement Scotland’s Evidence Directorateis providing expertise in evaluating evidence and highlighting the most reliable sources. Internationally, SIGN has been involved in a COVID-19 taskforce as part of Guidelines International Network to reduce duplication of effort. There’s lots of information – but is there evidence?

The need to adapt

Indeed, there is plenty of evidence – it comes thick and fast. But it’s not the robust evidence we need for clinical guidance. We like large, randomised controlled trials; currently, most evidence related to COVID-19 is retrospective and observational at best. It’s fast-moving, incomplete and often from populations that don’t always match with ours. This rapid pace of change means that, even with the best of intentions, outdated clinical guidance can actually do more harm than good.

Over the past 27 years, SIGN has developed an international reputation in producing highly regarded clinical guidelines. We have worked to a robust methodology during this time, but quickly realised that the lack of high-quality evidence related to COVID-19 wouldn’t fit this mould. Uncomfortable as it was, we had to adapt to ensure that our contribution would be meaningful and timely.

Initially, we worked with the National Institute for Health and Care Excellence (NICE) to learn from their development of rapid ‘living’ guidelines within one week. We also collaborated with the University of Glasgow to develop a rapid review to support colleagues in general practice.

“Over the past 27 years, SIGN has developed an international reputation in producing highly regarded clinical guidelines. We have worked to a robust methodology during this time, but quickly realised that the lack of high-quality evidence related to COVID-19 wouldn’t fit this mould. Uncomfortable as it was, we had to adapt to ensure that our contribution would be meaningful and timely.”

We are also supporting the Scottish Government’s COVID-19 Clinical Guidance Cell, a large multidisciplinary group acting on behalf of the Chief Medical Officer, Dr Gregor Smith, to develop rapid, high-quality guidance. Dr Smith recently acknowledged our role: “your willingness to collaborate has resulted in a process that is responsive to clinicians’ need for guidance. It will also ensure that Scotland’s clinical guidance will continue to be highly regarded, and provide our healthcare professionals with much needed support.”

Learning for the future

There’s a common word in all of this: ‘rapid’. In a short space of time, we’ve learned a great deal that we can apply to future guideline development, while retaining our reputation. It is easy to state that we must not ignore the good in search of the perfect, but in the middle of the storm the real challenge was determining not if it was good but ‘good enough’. History will determine if we got that balance right, but it feels that we have and this is reflected in feedback from others.

We’ve seen how guidance can be developed more quickly and without physical meetings, and we’ve also seen how our methodology remains valid; it is still necessary to have debate among multidisciplinary healthcare professionals and involvement from patient and public involvement groups and representatives.

Whether it is producing rapid guidelines, pinpointing where more research is needed or highlighting the most reliable resources, SIGN’s role in Scotland’s response to COVID-19 is vital –by sticking to our founding principles and robust methodology, we aim to continue to be a guiding light for healthcare professionals in Scotland throughout the crisis. We look forward to finding ways that we can take this knowledge and experience to benefit other areas of our work in the future.

Angela Timoney is Chair of Scottish Intercollegiate Guidelines Network (SIGN)

More information

Weekly updates on SIGN’s work throughout the pandemic can be found on the Healthcare Improvement Scotland website.

Visit the Healthcare Improvement Scotland website for information on our response to COVID-19.