Developing Strategy of Clinical Practice Guidelines for Post-intensive Care Syndrome: A Systematic Review of 14 Practice Guidelines and 10 Consensus Statements


 BackgroundPost-intensive care syndrome (PICS) seriously affects the quality of life of patients and their caregivers. This study systematically evaluates PICS related guidelines and consensuses to provide methodological and strategic guidance for the development and improvement of these guidelines and consensus.MethodsAn Internet search of PICS specific or related guidelines and consensus statements was conducted among academic databases and the websites. The AGREE II was used to evaluate their methodological quality. The themes and contents were evaluated based on the definition of PICS and the “patient-clinical problem-intervention-target” framework.ResultsWe included fourteen guidelines and 10 expert consensuses. The mean AGREE II score for scope and purpose was 86.89% ± 16.12%/ 79.47% ± 11.80%, 55.86% ± 29.17%/16.72% ± 16.39% for stakeholder involvement, 76.35% ± 15.82% /36.09% ±26.05% for rigor of development, 88.03% ± 15.55%/58.84% ± 28.94% for clarity of presentation, 61.79% ± 23.16/32.95% ± 20.91% for applicability, and 66.67% ± 37.96% /28.79% ± 36.54% for editorial independence in Guidelines/Consensus. Most only described a single or series of clinical related issues of PICS; only applicable for critically ill patients with clinical problems of ICUAW, pain, sleep disruption, agitation, and delirium. The interventions included risk assessment, monitoring/diagnosis, prevention, treatment, safety criteria, and home care of one or more symptoms of PICS.ConclusionsOur results suggested that development and improvement of guidelines/consensus should focus on refining the methodology, strengthening quality control, and improving presentation clarity, editorial independence, and applicability. The results may provide new idea for a future guidelines and consensus statements.

The inclusion criteria for the guidelines and consensus statement collection were as follows: (i) Study participants: the participants should be adult patients with a critical illness and experience with critical illness care, including patients that are hospitalized in the ICU, have transferred to a general ward, are recovering at home following discharge from hospital, or have transferred to a community or rehabilitation institution. (ii) Clinical problems: the study covered the physical, psychological, mental, cognitive, and behavioral illnesses of the surviving patients/caregivers that occurred during hospitalization in the ICU, after transfer from the ICU to a general ward, or following discharge from the hospital. Speci cally, the physical dysfunctions should include neuromuscular diseases, acquired weakness, disuse atrophy or fatigue; psychological and mental disorders should include PTSD, tension, anxiety, or depression; and cognitive and behavioral impairment should include delirium, memory loss, inattention, or di culty to return to family, society, and the workplace [5]. (iii) Interventions: The study should be relevant to the monitoring, evaluation, nursing diagnosis, prevention, treatment or management of PICS/PICS-F. Speci cally, physical dysfunction interventions should generally include early mobilization and rehabilitation exercises; interventions for psychological and mental disorders should include ICU diary, mindfulness-based stress reduction (MBSR), or cognitive behavioral therapy and good communication; and interventions for cognitive and behavioral impairment should cover analgesia/sedation or the assessment, monitoring, and management of delirium and environmental management (such as light, sound). (iv) Study type: the study should be clinical practice guidelines or an expert consensus statement.
The exclusion criteria were as follows: First, the titles were reviewed to exclude duplicate records. Second, the titles and abstracts were reviewed to exclude studies of non-ICU patients and studies that were not related to guidelines/consensus statements (such as translations; abstracts, interpretations, and evaluations of guidelines; and applied research and meta-analyses). Last, all studies were reviewed to exclude those that did not cover monitoring, evaluation, diagnosis, prevention, treatment, or management of PICS/PICS-F.

Search strategy
To retrieve all PICS/PCIS-F guidelines and related guidelines, the research team determined that potentially quali ed studies should either contain both terms "PICS/PICS-F" and "guidelines/consensus statement," or the term "ICU"; they should also include one or more clinical problems along with the term "guidelines/consensus statement." Therefore, two strategies were applied: (i) (  Intercollegiate Guidelines Network (SIGN), Medlive.cn, and Registered Nurses' Association of Ontario (l'Association des in rmières et in rmiers autorisés de l'Ontario, RNAO) were also used for acquiring corresponding data (considered supplementary databases). The search range was from the establishment of the corresponding database to May 16, 2020. Then, the bibliography of systematic reviews and clinical evaluations of the corresponding guidelines and consensus statements were further screened for quali ed guidelines and consensus statements.

Data screening
Two reviewers (Min He and Cheng-Qiong Wang) were asked to independently screen the obtained guidelines and consensus statements based on the pre-established inclusion and exclusion criteria. Discrepancies in selection between the evaluators were resolved through discussion, and any further disagreements were resolved by a third party (Zhi-Xia Jiang).
Methodology and reporting quality Two reviewers (Min He and Ying Wang) were asked to independently apply the Appraisal of Guidelines for Research and Evaluation (AGREE II) [6,7] and Reporting Items for Practice Guidelines in Healthcare (RIGHT) [8,9] to evaluate the methodological and reporting quality of the obtained guidelines and consensus statements. Disagreements in the evaluation were resolved through discussion. AGREE contains 23 items from 6 domains. The reviewers rated all items on a 7-point scale ("1" = "strongly disagree" to "7" = "strongly agree") where the score of each domain was calculated according to the following formula: domain score = (obtained score -minimum possible score) / (maximum possible score -minimum possible score) × 100% [6,7]. SPSS 19.0 was employed to calculate the intraclass correlation coe cient (ICC) to ensure that the understanding of the reviewers was consistent. The ICC value should be no less than 0.8 [10]. The total score of each guideline or consensus statement was the weighted sum of the domain scores. Speci cally, the weighting for rigor of development and applicability was 25%, while those for the other domains (i.e. scope and purpose, stakeholder involvement, clarity of presentation, and editorial independence) were 12.5% [11]. A total score greater than 60% indicated that the guideline or consensus statement is highly recommended, a score greater than 30% but less than or equal to 60% indicated that the guideline/consensus statement would be recommended following revision, and a score equal to or less than 30% indicated that the guideline or consensus statement is not recommended [4]. RIGHT includes seven sectors: basic information, background, evidence, recommendations, review and quality assurance, funding, declaration and management of interests, and other information (access, suggestions for future research, and limitations of guidelines), with 22 items in the list. Full conformity of each item equals 1 point, while partial conformity or non-conformity means 0 points. The nal score was calculated as follows: obtained score / maximum possible score × 100%. The results re ect the reporting quality of each evaluation domain and the overall guideline/consensus statement [8].

Data extraction
Two independent reviewers (Min He and Xi-Ying Zhang) were asked to use a pre-developed information extraction table to independently extract and cross-check the data. Disagreements regarding the extraction were resolved through discussion and/or involvement of a third reviewer (Zhi-Xia Jiang). The basic information that was extracted included the rst author, the year of publication/release, region or country of publication, theme, target population, applicable population, and applicable organization. The methodological quality features extracted included basic information, background, evidence, recommendations, review and quality assurance, funding, declaration and management of interests, and other information (access, suggestions for future research, and limitations of guidelines). The reporting quality features extracted included scope and purpose, stakeholder involvement, clarity of presentation, editorial independence, rigor of development, and applicability. The content structure features were extracted that included PICS/PICS-F related clinical problems (physical dysfunctions, psychological and mental disorders, and cognitive and behavioral impairments of patients/caregivers) and the interventions taken (monitoring, diagnosis, prevention, and treatment).

Statistical analysis
According to the AGREE and RIGHT evaluation criteria, each evaluation domain/sector was expressed as a percentage. For the domains/sectors with scores that satis ed a normal distribution, the mean and standard deviation were calculated (); otherwise, the median and quartile values were used for descriptive analysis. The summary of the descriptive analysis was used to analyze the basic information and theme of the guidelines and consensus statements; the "de nitions of PICS/PICS-F" and the "patient-clinical problem-intervention-target" framework were introduced to analyze the content structure; and a combination of the content structure, prevention and treatment measures, and "ICU-general ward-community/family" framework was adopted to visually construct a PICS/PICS-F management model.

Data screening process and results
A total of 1,591 records were extracted from the main databases. Of these, 567 records were removed due to duplication and 986 due to not containing the term "ICU" or lacking guideline and consensus statement content. Four additional records were included following review of the bibliography of the obtained records. A search in the supplementary databases yielded 3 additional guidelines. After excluding records that focused explicitly on medication, as well as all duplicates, 32 research papers were retained for analysis, including 19 guidelines and 11 expert consensus statements ( Figure.1).

Basic characteristics
The systematic search and screening process yielded no PICS-speci c guidelines; in total, 32 guidelines and consensus statements reporting related content, such as risk factors, monitoring, diagnosis, evaluation, prevention, and treatment of PICS and PICS-F were retrieved (Table.1 of the guidelines were developed through multinational cooperation [12][13][14][15], nine were developed by the corresponding state [16][17][18][19][20][21][22][23][24], and one was developed by a hospital [25]. In addition, the guidelines were divided into single and bundled theme guidelines. Single guidelines included the prevention, management and non-pharmacological intervention of delirium [15,16,21], ICUAW diagnosis [20], rest and sleep improvement [25], rehabilitation of critically ill patients [24], and family-centered care [14]. Bundled guidelines included sedation/analgesia [17], management of PAD [12,19,22], and prevention and management of PASDIS [13]. Of these, nine guidelines that covered sedation/analgesia, family-centered care and PAD bundling management [26][27][28][29][30][31] were updated, indicating good continuity and timeliness. Across all guidelines, the main applicable population was critically ill adult patients. Only a few guidelines described the primary disease of the patient or were applicable to caregivers and family members. The main applicable institutions were ICUs, whilst guidelines applicable for standardized general wards, primary and secondary health care institutions, communities, and homecare were limited. The main targeted users were multidisciplinary professional and technical personnel in ICUs, while guidelines for primary health care professionals and community and family caregivers were insu cient.
The screened 10 expert consensus statements were dated between 2013 and 2019, including six evidence-based consensus statements [32][33][34][35][36][37]. The consensus statements that were published by academic organizations focused on critical cardiac, respiratory, and neurological care, from China, New Zealand, Canada, the United Kingdom, and Australia independently. Only the consensus statements that focused on the rehabilitation of discharged patients [34], physiotherapy for ICU patients [35], and safety criteria of active mobilization for mechanically ventilated patients [37] were developed through cross-regional cooperation. The themes covered in the consensus statements included the rehabilitation of ICU or hospital discharged patients [34,[38][39][40][41][42][43], safety criteria for the early mobilization of mechanically ventilated patients [37], sedation/analgesia for ICU patients [33], delirium management [32], and physical therapy [35]. The majority of the consensus statements had individual themes rather than being a bundled theme. Only one consensus statement clearly de ned PICS/PICS-F and provided physical therapy guidelines to prevent PICS/PICS-F [34]. Seven consensus statements clearly de ned the primary disease stages and the applicable population, including patients with severely critical respiratory, cardiovascular, and neurological systems; and mechanically ventilated patients [33,[36][37][38][39][40][41][42][43]. The remaining three consensus statements cited only critically ill patients or patients who survived severe illness. Only one consensus statement identi ed its users as ICU physical therapists [42]. All consensus statements were applicable to the ICU, however; but only one was applicable to patients following discharge from the hospital.
None were developed for in-patients transferred from the ICU.

Methodological quality
The AGREE-II scores of the guidelines were as follows ( Figure.2): (1) The mean for scope and purpose was 86.89% (±16.12%). Speci cally, 13 guidelines clearly described the purpose, speci c clinical problems, and patients targeted; only one guideline did not clearly report its scope and purpose. (2) The mean for stakeholder involvement was 55.86% (±29.17%). Speci cally, seven guidelines described the elds of specialization of the experts involved; 10 introduced the applicable population; ve speci ed the views and choices of the target patients. (3) The mean for rigor of development was 76.35% (±15.82%). Speci cally, four guidelines provided evidence retrieval steps and screening processes; eight clearly speci ed the strengths and weaknesses of the evidence selection process; nine explained how the recommendations were formed and the association between the recommendations and evidence; seven presented the health bene ts, adverse effects, and risks of the recommendations, and 10 provided the comments given by external experts and future updates plans. (4) The mean for the clarity of presentation was 88.03% (±15.55%). Speci cally, the main recommendations of 10 guidelines were clear and identi able and the remaining nine guidelines were clear and provided multiple options for a given clinical problem. (5) The mean for applicability was 61.79% (±23.16%). Speci cally, nine guidelines included likely facilitating and hindering factors during application; eight provided suggestions on ways to apply the recommendations in practice and the support tools required; seven explained the potential resource input issues during application; six speci ed the standards for monitoring the use of guidelines. (6) The mean for editorial independence was 66.67% (±37.96%), where eight guidelines declared the relationship of interest between the sponsors and recommendations and four provided any con icts of interest between the editing team members and recommendations made. According to the overall AGREE-II score, 11 guidelines had satisfactory methodological quality (> 60%) and could be recommended. The scope and purpose, rigor of development, and clarity of presentation of the investigated guidelines were of high quality. However, stakeholder involvement (participially the involvement of patients/caregivers), applicability, and editorial independence required further improvement in quality.
The AGREE-II scores of the 10 expert consensus statements (six of which were evidence-based) were as follows ( Figure.3): (1) The mean for scope and purpose was 79.47% (±11.80%). The investigated consensus statements all described the purpose and targeted clinical problems and patients.
(2) The mean for stakeholder involvement was 16.72% (±16.39%). Only two consensus statements speci ed the applicable population, one considered the viewpoints and choices provided by the target patients, and all 10 provided the authors' professional background. (3) The mean for rigor of development was 36.09% (±26.05%). Only two statements provided evidence of the retrieval and screening processes, three explained the strengths and weaknesses of evidence selection processes, and only one elaborated on the relationship between the supporting evidence and the recommendations and its formulation process. In addition, none of the consensus statements were reviewed by external experts prior to publication, and only two provided an update plan. (4) The mean for clarity of presentation was 58.84% (±28.94%). Speci cally, six included clear and readable recommendations, and three clearly listed different recommendations for a given clinical problem. (5) The mean for applicability was 32.95% (±20.91%). Only four consensus statements explained the potential facilitating and hindering factors during the application process, three provided suggestions and supporting tools for applying the recommendations, two introduced standards for supervision and auditing, and none of the consensus statement explained the impact of recommendations on potential resource allocation. (6) The mean for editorial independence was 28.79% (±36.54%). Speci cally, three consensus statements declared that no con ict of interest existed between the sponsors, editing team members, and the recommendations made. The overall scores revealed that only one consensus statement was methodologically quali ed (> 60%) and could be recommended. The quality in terms of scope and purpose of the investigated consensus statements was high. However, the quality of the remaining domains, such as rigor of development, clarity of presentation, editorial independence, and applicability, was low. It was evident that the methodological quality of the consensus statements required improvement, particularly in their rigor of development and applicability. Moreover, six of the consensus statements were evidence-based, indicating that evidence-based decision-making concepts and techniques have begun to be applied to the development of consensus statements.

Reporting quality
The mean for the overall RIGHT score of the 14 guidelines (35 items) was 58.16% (±30.31%). Speci cally, 23 items were found to have a reporting quality of greater than or equal to 50%. Items with higher reporting quality included 1a, 1b, 4, 7a, and 13a (100.0%), while items with lower reporting quality included 18a and 18b (0%). For quality by domain, basic information, guideline background, evidence, recommendations, and other information had higher reporting ratings, while insu cient information was provided in terms of rationale/explanation for recommendations, reviews and quality assurance, funding source(s), and the role(s) of the funding parties ( Table 2).
An analysis based on the "patient-clinical problem-intervention-target" framework revealed that the guidelines and consensus statements covered patients that suffered cardiac and severe respiratory illnesses and acute respiratory distress syndrome (ARDS), patients that were mechanically ventilated, treated by extracorporeal membrane oxygenation (ECMO), or suffered from brain trauma, as well as ICU survivors and the caregivers of these patients. However, many of the guidelines mentioned critically ill patients without providing information on the primary diseases. Secondly, regarding clinical problem, only one consensus statement provided a de nition of PICS/PICS-F. In addition, the majority of the guidelines and consensus statements provided a clear introduction of ICUAW, pain, anxiety, sleep disorders, depression, agitation, and delirium. Some only described the rehabilitation of critically ill patients without clear provisions of speci c clinical problems. Thirdly, regarding interventions, most of the guidelines and consensus statements clearly illustrated measures such as ICUAW diagnosis, physical therapy, early mobilization and safety criteria, sleep management, sedation/analgesia, anxiety/depression management, risk, monitoring, prevention and management of delirium, and family-centered care. Several guidelines/consensus statements employed bundling strategies to tackle the problems and design interventions. Some guidelines only described the rehabilitation of critically ill patients but did not clarify the speci c rehabilitation interventions utilized. Finally, regarding management target, the majority of the guidelines and consensus statements focused on solving sleep problems, pain (sedation/analgesia), anxiety/depression, and delirium during ICU hospitalization; only one guideline focused on physical therapy to prevent the occurrence of PICS/PICS-F, and no guidelines or consensus statement discussed the patients/caregivers/family members' quality of life or patients' di culty in returning to the family, workplace, and society. Moreover, it was found that the guidelines on the rest and sleep management ICU patients developed by Elliott & McKinley [25], which were formulated using an evidence-based strategy based on internal data collected from their own hospital, could effectively improve the guideline's clinical translational effects (Table.3).

Discussion
PICS/PICS-F seriously affects the quality of life of patients and their caregivers and increases the nancial burden of patients' families [1,2]. Therefore, clinical practice guidelines and expert consensus statements are urgently needed to guide scienti c prevention, standardized diagnosis, and treatment of the syndrome. However, the quality of such guidelines and consensus statements serves as a guarantee and priority to promote high-quality translational effects [4]. Hence, we systematically evaluated PICS/PICS-F related clinical practice guidelines and expert consensus statements and analyzed their methodological and reporting quality. We expected that the ndings could provide methodological guidance for the development and improvement of future guidelines and consensus statements.
Following a pre-designed search and screening method, 14 guidelines [12-25] and 10 consensuses statements [22,32,33,[35][36][37][38][39][40][41][42][43] were obtained. Systematic review of these showed that the majority were evidence-based guidelines (13 of the guidelines) and consensus statements (six of the consensus statements), indicating that evidence-based decision-making techniques have become the main technique for developing guidelines and consensus statements. AGREE-II was introduced to analyze the methodological quality of the obtained documents. The results showed that 11 guidelines could be recommended (>60%). In addition, the scope and purpose, rigor of development, and clarity of presentation of the investigated guidelines were higher quality areas, while stakeholder involvement (the involvement of patients/caregivers), applicability, and editorial independence required further improvement in quality. However, only one of the 10 consensus statements identi ed scored >60% and could be recommended. The quality of the domains such as scope and purpose of the investigated consensus statements was high, while that of the remaining domains such as rigor of development, clarity of presentation, editorial independence, and applicability was generally low. It was evident that the methodological quality of the consensus statements required further improvement, particularly regarding rigor of development and applicability. Six of the consensus statements were evidence-based, indicating that the development of consensus statements also employs evidence-based decision-making. Moreover, detailed and clear reporting of guidelines/consensus statements are important conditions for successful clinical translation. This study used the RIGHT checklist to further evaluate the reporting quality of the included guidelines/consensus statements. The results revealed that the reporting quality was good in terms of basic information, background, evidence, recommendations, and other information regarding the guidelines, while rationale/explanation for recommendations, review and quality assurance, funding source(s), and role(s) of funders were insu ciently reported. The reporting of basic information, background, recommendations, and other information of the consensus statements was of satisfactory quality; however, the reporting of health problems, evidence sources and evaluations, rationale/explanation for recommendations, review and quality assurance, funding and declarations, and management of interests, as well as who had access to the consensus statements, was insu cient. In summary, all analyzed guidelines and consensus statements demonstrated varied limitations. Compared to the guidelines, the core methodological sections of the consensus statements (health problem, evidence sources and evaluations, rationale/explanation for recommendations) were signi cantly incomplete. Both the guidelines and consensus statements had problems regarding the reporting of reviews, quality control, con ict of interest, and accessibility. Therefore, the development and improvement of guidelines/consensus statements should focus on re ning the methodology, strengthening quality control, and improving presentation clarity, editorial independence, and applicability.
Among the retrieved documents, one expert consensus statement covered the use of physical therapy to prevent PICS. No guidelines or consensus statements provided a de nition of PICS/PICS-F. However, based on other 14 PICS/PICS-F related guidelines [12][13][14][15][16][17][18][19][20][21][22][23][24][25] and nine consensus statements, the rehabilitation management of patients suffering from critical respiratory and cardiovascular illnesses (including mechanically ventilated patients) and nervous system diseases, and treatment by prevention and management of PASDIS, ICUAW, early mobilization safety criteria, and provision of family-centered care were the main focuses. Regarding the techniques used, multi-disciplinary cooperation, cross-regional cooperation, and bundling appeared to become prominent characteristics in the development of guidelines and consensus statements.
PICS occurs during ICU hospitalization and continues even after transfer to the general ward or discharge from the hospital. Analysis based on the provided de nitions of PICS/PICS-F suggested that PICS/PICS-F is a multi-disciplinary problem, involving patients, caregivers, and family members, lasting through the entire "ICU-general ward-community/family" period [1,2]. However, existing guidelines and consensus statements generally cover only one or a limited series of clinical problems and do not focus on PTSD, persistent cognitive de cits, and di culties in returning to family, society or workplace caused by PICS/PICS-F. From our analysis, the majority of the guidelines and consensus statements only focused on the ICU hospitalization period and ignored the period in which the patients are transferred to a general ward or discharged from the hospital. There was also insu cient attention given to caregivers/family members. Given that PICS/PICS-F is a multidisciplinary problem, future guidelines/consensus statements should clearly de ne PICS/PICS-F and comprehensively consider measures that cover the periods following discharge from the ICU as well as the interests of the caregivers/family members. PICS/PICS-F is likely to develop among critically ill patients and their caregivers when the patients are in the ICU or have transferred to the general ward following discharge from the ICU. However, the incidence among caregivers can be disregarded. Critically ill patients usually suffer from a primary disease and are in critical status; consequently, patients are likely to be placed in different ICU environments and receive specialized or comprehensive treatment, which affects the incidence of PICS/PICS-F. Moreover, the severity and symptoms of PICS/PICS-F vary signi cantly when the patients are in the ICU, post-ICU, and post-hospitalization periods. The analysis based on the "patient-clinical problem-intervention-target" framework showed that a majority of the guidelines and consensus statements only mentioned critically ill patients instead of clearly reporting the primary disease of the patients. More focus was on the acquired weakness, pain, anxiety, sleep disorder, depression, agitation, and delirium of critically ill patients when they are in the ICU, while less attention was paid to those transferred from ICU to the general ward and community/family. Moreover, the speci c clinical problems of patients were not clearly speci ed. As a result, the existing guidelines and consensus statements are not able to scienti cally guide the management of PICS/PICS-F treatment. Thus, future guidelines and consensus statements should clearly de ne the disease characteristics and ICU characteristics of the applicable population and pay more attention to the differences in patients' clinical problems between ICU, post-ICU, and post-hospitalization periods, as well as the needs of the caregivers/family members.
Based on the characteristics of the target population and clinical problems, recommended intervention measures include prevention, treatment, and quality control and safety precautions. Prevention measures mostly focus on risk assessment, con rmation of risk factors and causes, and implementation of preventive interventions such as pharmacological, non-pharmacological, and physical therapies to reduce the incidence. Treatment measures generally focus on disease monitoring/diagnosis, adopting early detection and treatment as the core principle, and usage of pharmacological, non-pharmacological, and physical therapies to eliminate the disease or reduce its harm. Quality control and safety precautions measures normally emphasized involve strengthening of quality control and elimination/reduction of safety problems to improve the quality of life of patients/caregivers and assist them in returning to family, workplace, and society. The "patient-clinical problem-intervention-target" framework analysis showed that the guidelines/consensus statements only discussed risk assessment, prevention, monitoring/diagnosis, treatment (pharmacological, non-pharmacological, and physical therapies), safety criteria, and family care. The purpose of the guidelines/consensus statements was mostly limited to solving clinical problems during the ICU stage; less attention was paid to the problems that occur in the general wards, the community at large, and the family after discharge from the ICU. The adoption of bundling strategies to integrate issues and interventions were mostly emphasized; however, quite a few of the guidelines and consensus statements did not clearly describe the precise intervention measures used. The majority of the guidelines and consensus statements included two major themes: prevention and treatment. However, the intervention measures tended to be complex and inconsistent, and the goals of the intervention measures were not clear. Therefore, future guidelines and consensus statements should specify the patients' goals, establish clear risk assessment-based interventions with an introduction of risk factors and cause of the diseases, as well as a management system based on monitoring/diagnosis and treatment of PICS/PICS-F. We also found that the guidelines for rest and sleep management of ICU patients developed by Elliott & McKinley adopted an evidence-based strategy [25]. The approach realized a systematic integration of the speci c information on clinical problems and evidence-based strategy, providing new ideas for the development of future guidelines.
Based on the multi-disciplinary and full-process attributes of the applicable population and clinical problems, we propose that multi-disciplinary cooperation, bundling, evidence-based decision-making, and systematic integration of local information should be the core techniques for developing evidence-based PICS/PICS-F prevention and treatment guidelines. The guidelines should cover the clinical problems that occur throughout the entire period from when the patients enter the ICU, to being transferred to the general ward, and returning to community and family. Further, they should consider the interest of both patients and caregivers/family members. Prevention and treatment should be at the core of the guidelines' content.
Prevention systems should focus on critically ill patients (primary diseases) as a starting point, emphasizing the assessment of risk factors/causes, prediction, and prevention (pharmacological, non-pharmacological, and physical therapies), and reducing the incidence of cases. The treatment system should focus on critically ill patients (primary disease) as a starting point, emphasizing monitoring/diagnosis and ensuring early detection and treatment (pharmacological, non-pharmacological, and physical therapies, psychological and behavioral therapy, and family therapy), to eventually alleviate or eliminate the impact of PICS/PICS-F, and improve the quality of care, helping patients to successfully return to their families, workplaces, and society ( Figure 4). From the above analysis, there is currently a shortage of PICS speci c guidelines from both home and abroad, which emphasizes the urgency of developing improved guidelines. Future development of guidelines and consensus statements should focus on re ning the methodology, strengthening quality control, and improving presentation clarity, editorial independence, and applicability. Multidisciplinary cooperation, bundling, and evidence-based decision-making techniques should form the basis of managing guidelines/consensus statements.

Limitations
This study has several limitations: (1) Although two search strategies were employed, certain search biases may remain. (2) This study used the AGREE-and RIGHT checklists to evaluate the guidelines/consensus statements. Although the evaluators received training prior to conducting evaluations, comprehensive and evaluative biases may remain for some items. (3) Application of the AGREE-and RIGHT checklist may have reduced the perceived methodological and reporting quality of the consensus statements. (4) As the information related to the application of the guidelines/consensus statement was not accessible, the effects of implementation were not included in the evaluation.

Conclusion
Currently, there is a lack of PICS speci c guidelines worldwide, necessitating the development of such guidelines. Multidisciplinary cooperation, bundling and evidence-based decision-making techniques, and organic integration of localized information should be the basis for managing the development of corresponding guidelines and consensus statements, focusing on re ning the methodology, strengthening quality control, and improving presentation clarity, editorial independence, and applicability. Developers of future guidelines/consensus statements should focus on prevention and treatment of PICS/PICS-F, integrate multidisciplinary features, and the overall well-being of both patients and caregivers/family members. It is expected that the ndings of this study will serve as a reference for developing future PICS/PICS-F guidelines.

Key messages
We included fourteen guidelines and 10 expert consensuses, but without PICS speci c guidelines worldwide, necessitating the development of such guidelines.
Multidisciplinary cooperation, bundling and evidence-based decision-making techniques, and organic integration of localized information should be the basis for managing the development of corresponding guidelines and consensus statements, focusing on re ning the methodology, strengthening quality control, and improving presentation clarity, editorial independence, and applicability.  The systematic search and screening process yielded no PICS-speci c guidelines; in total, 32 guidelines and consensus statements reporting related content, such as risk factors, monitoring, diagnosis, evaluation, prevention, and treatment of PICS and PICS-F were retrieved.

Author (Years)
Country Organization Topics Target population Types Target users Settings  For quality by domain, basic information, guideline background, evidence, recommendations, and other information had higher reporting ratings, while insu cient information was provided in terms of rationale/explanation for recommendations, reviews and quality assurance, funding source(s), and the role(s) of the funding parties.
The quality of reporting for health problems, evidence sources and evaluations, rationale/explanation for the recommendations, reviews and quality assurance, funding sources and declarations, management of interest, and funder's access to the consensus statements was insu cient. An analysis based on the "patient-clinical problem-intervention-target" framework revealed that the guidelines and consensus statements covered patients that suffered cardiac and severe respiratory illnesses and acute respiratory distress syndrome (ARDS), patients that were mechanically ventilated, treated by extracorporeal membrane oxygenation (ECMO), or suffered from brain trauma, as well as ICU survivors and the caregivers of these patients. Familycentered care The experiences and needs of families , strategies for action and hospital resources EBG Note: PASDIS: Pain, Agitation/ Sedation, Delirium, Immobility, and Sleep Disruption; PAD: pain, agitation, and delirium ; EBG: evidence-based guideline; ICUAW: ICU acquired weakness ARDS: Acute respiratory distress syndrome; ECMO: Extracorporeal membrane oxygenation. Figure 1 Articles retrieved and assessed for eligibility After excluding records that focused explicitly on medication, as well as all duplicates, 32 research papers were retained for analysis, including 19 guidelines and 11 expert consensus statements.

Figure 3
Methodological characteristics for expert consensuses The quality in terms of scope and purpose of the investigated consensus statements was high. However, the quality of the remaining domains, such as rigor of development, clarity of presentation, editorial independence, and applicability, was low.