This annex provides further details on the process and methods used in the development of the clinical recommendations in Chapter 6. This followed the process and methods outlined in the WHO Handbook for Guideline Development, 2nd edition, with oversight of the WHO Guideline Review Committee.
Evidence synthesis and assessment
The priority questions to be addressed by the clinical recommendations were identified by the GDG. These were formulated into PICO-structured review questions by the systematic review team with input from the methodologist, clinical chair, GDG and technical members of the WHO Steering Group. The important outcomes of interest were rated and selected by the GDG. The systematic reviews were conducted in accordance with pre-defined protocols and the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The available evidence was synthesized with outcome-based intervention effect estimates, where amenable, and evidence certainty assessed using GRADE methodology. These were presented to the GDG using GRADE summary of findings tables.
Formulation of recommendations
The GRADE approach was used to formulate recommendations. GDG deliberations on the direction and strength of recommendations were facilitated by the methodologist and clinical chair. In their formulation, the GDG considered the balance of benefits and harms (with reference to the GRADE summary of findings tables, including effect estimates and confidence intervals), certainty of evidence, values and preferences, resource implications, and other considerations such as equity, acceptability, and feasibility. As recognized in the limitations of the GRADE approach, there were circumstances in which the GDG was unable to issue a GRADE-formulated recommendation, particularly due to lack of direct evidence, but for which actionable statements were deemed necessary for health practice and where there were certainty of benefits outweighing undesirable effects supported by indirect evidence. In such circumstances, an ungraded Best Practice Statement was issued in accordance with the five criteria set out by the GRADE Working Group (48). Decisions and recommendations were made by consensus. Pre-defined rules for decision-making had specified a voting process in case consensus could not be reached: 80 % of GDG members was required to formulate a strong recommendation, and a simple majority for conditional recommendations. However, in the end, voting was not needed for any of the recommendations. The final recommendation statements were drafted by the responsible technical officer according to the GDG’s decisions and formulations, approved by the GDG, and shared with the WHO Steering Group.
External review
The clinical recommendations (and full document) were reviewed by an external review group composed of members of the EMT Strategic Advisory Group, with balanced representation of geographical regions and gender. Any feedback and comments were considered by the GDG, and incorporated as appropriate by the responsible technical officer. The clinical recommendations section (Chapter 6) of the final document was then reviewed and approved by the WHO Guideline Review Committee.
Contributors and affiliations
GDG clinical chair:
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Stuart Watson, Canniesburn Plastic Surgery and Burns Unit, Glasgow Royal Infirmary, United Kingdom of Great Britain and Northern Ireland
GDG guideline methodologist:
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Srinivas Murthy, University of British Columbia, Canada
GDG members:
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Mercy Ama Amuah Agtuahene, University of Ghana, Ghana
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Pauline Convocar, Philippines College of Emergency Medicine, Philippines
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Heike Geduld, University of Capetown, South Africa
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Minoru Hayashi, Red Cross Maebashi Hospital, Japan
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Omar Hussein, Ministry of Health, Palestinian Authority
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Tom Potokar, International Committee of the Red Cross, Switzerland
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Alberta Rockson, University of Ghana/Interburns, Ghana
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Richard Wong She, NZMAT, New Zealand
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Rojina Shilpkar, Sushma Koirala Memorial Hospital, Nepal
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Ziphilly Sichinga, Interburns, Malawi
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Barclay Stewart, University of Washington, United States of America
External Review Group members (as part of EMT Strategic Advisory Group):
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Gabriel Garcia, Ministry of Health, Mexico
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Alegnta Gebreyesus, Permanent Mission of the Federal Democratic Republic of Ethiopia to the United Nations Office and other international organizations in Geneva, Ethiopia
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Gregory Hynes, International Federation of Red Cross and Red Crescent Societies, Switzerland
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Ridzuan Isa, Ministry of Health, Malaysia
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Len Notaras, National Critical Care and Trauma Response Centre, Australia
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Florian Schwoebel, Robert Koch Institute, Germany
Management of conflicts of interest
All contributors were required to complete and return the standard WHO Declaration of Interests forms for experts along with their CVs. These were evaluated by the responsible technical officer for relevance of any declared interests, and for significance of any potential conflicts of interest based on their nature, number and value, scope of relationship, and extent of discretion. The approach to managing any significant conflicts of interest was partial or total exclusion from participation, assessed and/or consulted on a case-by-case basis. The contributing experts’ names and their brief biographies were compiled and made publicly available.
