Quality in rheumatoid arthritis care

While most rheumatology practices are characterized by strong commitment to quality of care and continuous improvement to limit disability and optimize quality of life for patients and their families, the actual step toward improvement is often difficult. This is because there are still barriers to be addressed and facilitators to be captured before a satisfying and cost-effective practice management is installed. Therefore, this review aims to assist practicing rheumatologists with quality improvement of their daily practice, focusing on care for rheumatoid arthritis (RA) patients. First we define quality of care as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge". Often quality is determined by the interplay between structure, processes, and outcomes of care, which is also reflected in the corresponding indicators to measure quality of care. Next, a brief overview is given of the current treatment strategies used in RA, focusing on the tight control strategy, since this strategy forms the basis of international treatment guidelines. Adherence to tight control strategies leads, also in daily practice, to better outcomes in patients with regard to disease control, functional status, and work productivity. Despite evidence in favor of tight control strategies, adherence in daily practice is often challenging. Therefore, the next part of the review focuses on possible barriers and facilitators of adherence, and potential interventions to improve quality of care. Many different barriers and facilitators are known and targeting these can be effective in changing care, but these effects are rather small to moderate. With regard to RA, few studies have tried to improve care, such as a study aiming to increase the number of disease activity measures done by a combination of education and feedback. Two out of the three studies showed markedly positive effects of their interventions, suggesting that change is possible. Finally, a simple step-by-step plan is described, which could be used by rheumatologists in daily practice wanting to improve their RA patient care.

Development of a Consensus Statement for the Definition, Diagnosis, and Treatment of Acute Exacerbations of Idiopathic Pulmonary Fibrosis Using the Delphi Technique

INTRODUCTION

There is a lack of agreed and established guidelines for the treatment of acute exacerbations of idiopathic pulmonary fibrosis (AE-IPF). This reflects, in part, the limited evidence-base underpinning the management of AE-IPF. In the absence of high-quality evidence, the aim of this research was to develop a clinician-led consensus statement for the definition, diagnosis and treatment of AE-IPF.

METHODS

A literature review was conducted to obtain published material on the definition and treatment of AE-IPF. The results of this review were circulated to an online panel of clinicians for review. Statements were then shared with ten expert respiratory clinicians who regularly treat patients with IPF. A Delphi technique was then used to develop a consensus statement for the definition, diagnosis and treatment of AE-IPF. During the first round of review, clinicians rated the clarity of each statement, the extent to which the statement should be included and provided comments. In two subsequent rounds of review, clinicians were provided with the group median inclusion rating for each statement, and any revised wording of statements to aid clarity. Clinicians were asked to repeat the clarity and inclusion ratings for the revised statements.

RESULTS

The literature review, online panel discussion, and face-to-face meeting generated 65 statements covering the definition, diagnosis, and management of AE-IPF. Following three rounds of blind review, 90% of clinicians agreed 39 final statements. These final statements included a definition of AE-IPF, approach to diagnosis, and treatment options, specifically: supportive measures, use of anti-microbials, immunosuppressants, anti-coagulants, anti-fibrotic therapy, escalation, transplant management, and long-term management including discharge planning.

CONCLUSION

This clinician-led consensus statement establishes the 'best practice' for the management and treatment of AE-IPF based on current knowledge, evidence, and available treatments.

Best Practices for Effective Clinical Partnerships with Indigenous Populations of North America (American Indian, Alaska Native, First Nations, Métis, and Inuit)

This article presents a review of the literature to identify best practices for clinical partnerships with indigenous populations of North America, specifically American Indian/Alaska Native, First Nations, Métis, and Inuit of Canada. The authors have identified best practices and lessons learned from collaborating with indigenous populations, presented in 2 categories: conceptual guidelines and health care delivery guidelines. Major themes include the importance of trust and communication, the delivery of culturally congruent health care, and the necessity of working in partnership with tribal entities for successful delivery of health care. Best practices in health care delivery with indigenous populations are presented.

How nurses contribute to medicines reconciliation

The process of obtaining an up-to-date and accurate patient medication list, medicines reconciliation (MedRec), is vital to ensuring patient safety. Despite its high status as a patient safety issue, and the efforts made to drive and implement robust MedRec processes, further efforts are required to identify and disseminate best practice (Greenwald et al 2010). This article outlines some of the principles involved in conducting effective MedRec and invites interested nurses to join a working group that aims to develop a best-practice toolkit.

Anterior eye health recording

AIMS

To survey eye care practitioners from around the world regarding their current practice for anterior eye health recording to inform guidelines on best practice.

METHODS

The on-line survey examined the reported use of: word descriptions, sketching, grading scales or photographs; paper or computerised record cards and whether these were guided by proforma headings; grading scale choice, signs graded, level of precision, regional grading; and how much time eye care practitioners spent on average on anterior eye health recording.

RESULTS

Eight hundred and nine eye care practitioners from across the world completed the survey. Word description (p<0.001), sketches (p=0.002) and grading scales (p<0.001) were used more for recording the anterior eye health of contact lens patients than other patients, but photography was used similarly (p=0.132). Of the respondents, 84.5% used a grading scale, 13.5% using two, with the original Efron (51.6%) and CCLRU/Brien-Holden-Vision-Institute (48.5%) being the most popular. The median features graded was 11 (range 1-23), frequency from 91.6% (bulbar hyperaemia) to 19.6% (endothelial blebs), with most practitioners grading to the nearest unit (47.4%) and just 14.7% to one decimal place. The average time taken to report anterior eye health was reported to be 6.8±5.7 min, with the maximum time available 14.0±11 min.

CONCLUSIONS

Developed practice and research evidence allows best practice guidelines for anterior eye health recording to be recommended. It is recommended to: record which grading scale is used; always grade to one decimal place, record what you see live rather than based on how you intend to manage a condition; grade bulbar and limbal hyperaemia, limbal neovascularisation, conjunctival papillary redness and roughness (in white light to assess colouration with fluorescein instilled to aid visualisation of papillae/follicles), blepharitis, meibomian gland dysfunction and sketch staining (both corneal and conjunctival) at every visit. Record other anterior eye features only if they are remarkable, but indicate that the key tissue which have been examined.

Development and implementation of guidelines in neurosurgery

Although it is intuitive that any neurosurgeon would seek to consistently apply the best available evidence to patient management, the application of evidence-based medicine (EBM) principles and clinical practice guidelines (CPGs) remains variable. This article reviews the origin and process of EBM, and the development, assessment, and applicability of EBM and CPGs in neurosurgical care, aiming to demonstrate that CPGs are one of the valid available options that exist to improve quality of care. CPGs are not intended to define the standard of care but to compile dynamic advisory statements, which need to be updated as new evidence emerges.

The European patient advocacy perspective on specialist breast units and accreditation

Europa Donna--The European Breast Cancer Coalition has been advocating for all women to have access to care in specialist breast units since 2003. Two European Parliament Resolutions, (2003 and 2006) as well as the Written Declaration against breast cancer in the EU of 2010 called on member states to ensure that all women in the European Union have access to treatment in such units set up in accordance with the "European Guidelines for quality assurance in breast cancer screening and diagnosis," by 2016. Once mammography screening implementation according to EU Guidelines commenced, it became evident that it would be essential to have high-quality units where women would receive specialised treatment upon diagnosis. Europa Donna was a member of the revision committee for Chapter 9 of the 4th edition of these Guidelines (2006) which provided a detailed description of these services as previously defined by EUSOMA. Moreover, the 2010 Written Declaration on the fight against breast cancer in the EU called on the Commission "to develop a certification protocol for specialist breast units in accordance with EU Guidelines by 2011". The most important thing for a woman diagnosed with breast cancer to know is where to go to get the best treatment, i.e. she needs to know that the clinic or unit is accredited as having implemented appropriate quality standards that meet EU Guidelines thus ensuring provision of high level breast services, and that her national health system will pay for it. Progress on accomplishing this has not moved quickly, nor has it been accepted by all stakeholders involved.

Outcome quality assessment by surgical process compliance measures in laparoscopic surgery

OBJECTIVE

The effective and efficient assessment, management, and evolution of surgical processes are intrinsic to excellent patient care. Hence, in addition to economic interests, the quality of the outcome is of great importance. Process benchmarking examines the compliance of an intraoperative surgical process to another process that is considered as best practice. The objective of this work is to assess the relationship between the course and the outcome of surgical processes of the study.

MATERIALS AND METHODS

By assessing 450 skill practices on rapid prototyping models in minimally invasive surgery training, we extracted descriptions of surgical processes and examined the hypothesis that a significant relationship exists between the course of a surgical process and the quality of its outcome.

RESULTS

The results showed a significant correlation with Person correlation coefficients >0.05 between the quality of process outcome and process compliance for simple and complex suturing tasks in the study.

CONCLUSIONS

We conclude that high process compliance supports good quality outcomes and, therefore, excellent patient care. We also showed that a deviation from best training processes led to a decreased outcome quality. This is relevant for identifying requirements for surgical processes, for generating feedback for the surgeon with regard to human factors and for inducing changes in the workflow in order to improve the outcome quality.

Smart Program Design Through a Common Information Model

Although much information is already available publically from information-sharing initiatives such as ClinicalTrials.gov, information about clinical programs is unstructured, inconsistent, and incomplete. Clinical research within bioscience companies, health care, academia, and governmental agencies could benefit from easier access to best practices, historical information, and improved information sharing. Facilitating information sharing requires a standardized information model. Information standards today focus on individual clinical trials and the representation of clinical trial data. Although work is ongoing to expand standards to cover the protocol, these are insufficient to capture the objectives, rationale, and design thinking behind clinical programs. An information model is proposed to cover the rationalization and decision-making aspects of designing a clinical program and its associated trials. This paper is the output of a newly formed multicompany working group that examines the merits of a clinical program-level information standard. An example information model is presented to explain the concept.

Evidence synthesis and its role in evidence-based health care

The central role of evidence synthesis (or the systematic review of evidence) in evidence-based health care is often poorly understood. There are numerous examples in the literature of poorly conceived and/or executed systematic reviews and of a lack of awareness of the international standards developed by the international leaders in systematic reviews. The Cochrane Collaboration has played a critical global role in developing and refining systematic review methods in relation to evidence of effects and of diagnostic accuracy.

Production patterns of packaging waste categories generated at typical Mediterranean residential building worksites

The construction sector is responsible for around 28% of the total waste volume generated in Europe, which exceeds the amount of household waste. This has led to an increase of different research studies focusing on construction waste quantification. However, within the research studies made, packaging waste has been analyzed to a limited extent. This article focuses on the packaging waste stream generated in the construction sector. To this purpose current on-site waste packaging management has been assessed by monitoring ten Mediterranean residential building works. The findings of the experimental data collection revealed that the incentive measures implemented by the construction company to improve on-site waste sorting failed to achieve the intended purpose, showing low segregation ratios. Subsequently, through an analytical study the generation patterns for packaging waste are established, leading to the identification of the prevailing kinds of packaging and the products responsible for their generation. Results indicate that plastic waste generation maintains a constant trend throughout the whole construction process, while cardboard becomes predominant towards the end of the construction works with switches and sockets from the electricity stage. Understanding the production patterns of packaging waste will be beneficial for adapting waste management strategies to the identified patterns for the specific nature of packaging waste within the context of construction worksites.

Evaluation of a dementia care learning programme

This article reports on an evaluation of the Dementia Services Development Centre's Best Practice in Dementia Care Learning Programme for hospitals, care homes including day centres and domiciliary care settings. A multi-method qualitative and quantitative evaluation was undertaken using 100 course participant feedback questionnaires, 60 course participant reflective exercises and 89 online responses to a service manager survey. Participants' increased awareness and understanding of dementia in practice were evidence that the learning outcomes had been successfully met. Improved practice supported these results demonstrating a more expansive use of interventions and effective interactions between staff, families and people with dementia in multiple settings. With this training, practitioners can provide evidence-based and best practice care and support to families and people with dementia in hospitals, care homes, day centres and domiciliary care settings.

Subcutaneous injection technique: an evidence-based approach

Injections are routinely administered by nurses in acute care settings and in the community. Nurses require a thorough understanding of anatomy and physiology, pharmacological principles and equipment, and potential risks to the patient of injections. Nurses should also take an active approach to patient assessment before injecting medicines. This article, the first of two, provides an evidence-based review of injection administration, with particular reference to subcutaneous injections, and suggests a framework for best practice.

Clinical audit of leg ulceration prevalence in a community area: a case study of good practice

This article presents the findings of an audit on venous leg ulceration prevalence in a community area as a framework for discussing the concept and importance of audit as a tool to inform practice and as a means to benchmark care against national or international standards. It is hoped that the discussed audit will practically demonstrate how such procedures can be implemented in practice for those who have not yet undertaken it, as well as highlighting the unexpected extra benefits of this type of qualitative data collection that can often unexpectedly inform practice and influence change. Audit can be used to measure, monitor and disseminate evidence-based practice across community localities, facilitating the identification of learning needs and the instigation of clinical change, thereby prioritising patient needs by ensuring safety through the benchmarking of clinical practice.

The application of implementation science for pressure ulcer prevention best practices in an inpatient spinal cord injury rehabilitation program

OBJECTIVES

To implement pressure ulcer (PU) prevention best practices in spinal cord injury (SCI) rehabilitation using implementation science frameworks.

DESIGN

Quality improvement.

SETTING

SCI Rehabilitation Center.

PARTICIPANTS

Inpatients admitted January 2012 to July 2013.

INTERVENTIONS

Implementation of two PU best practices were targeted: (1) completing a comprehensive PU risk assessment and individualized interprofessional PU prevention plan (PUPP); and (2) providing patient education for PU prevention; as part of the pan-Canadian SCI Knowledge Mobilization Network. At our center, the SCI Pressure Ulcer Scale replaced the Braden risk assessment scale and an interprofessional PUPP form was implemented. Comprehensive educational programing existed, so efforts focused on improving documentation. Implementation science frameworks provided structure for a systematic approach to best practice implementation (BPI): (1) site implementation team, (2) implementation drivers, (3) stages of implementation, and (4) improvement cycles. Strategies were developed to address key implementation drivers (staff competency, organizational supports, and leadership) through the four stages of implementation: exploration, installation, initial implementation, and full implementation. Improvement cycles were used to address BPI challenges.

OUTCOME MEASURES

Implementation processes (e.g. staff training) and BPI outcomes (completion rates).

RESULTS

Following BPI, risk assessment completion rates improved from 29 to 82%. The PUPP completion rate was 89%. PU education was documented for 45% of patients (vs. 21% pre-implementation).

CONCLUSION

Implementation science provided a framework and effective tools for successful pressure ulcer BPI in SCI rehabilitation. Ongoing improvement cycles will target timeliness of tool completion and documentation of patient education.

State of the art regarding the management of multiligamentous injuries of the knee

Multiligamentous knee injuries are rare but serious injuries that can threaten limb viability. As such, they require careful management to give patients the best chance of immediate and ultimate functional recovery. However, as these injuries are rare, there is paucity in prospective comparative studies large enough to provide high level evidence for best practice. This lack of comprehensive and convincing evidence has made the management of multiligamentous knee injuries an area of active debate and controversy. The debate on whether surgical management leads to better outcomes than non-operative management, the optimal timing of surgery after injury and whether repair is better than reconstruction is still ongoing. Using the Oxford Levels of Evidence, this review summarises the latest high level evidence to provide answers to these issues. Recommendations for practice have also been offered and assigned a grade using a published scale.

The "Princess Mirror": Exemplars of the Use of the Mirror in Nursing Practice

PROBLEM

Incorporating mirrors into nursing is a relatively new field of research and practice. The focus of two studies was to explore (a) the meaning of women's mirror experiences following a mastectomy and (b) the experience of viewing self in the mirror for women who were terminally ill. The goal of the research was to establish a conceptual foundation for the development of nursing mirror interventions.

METHODS

Open-ended questions and dialogical engagement in one-to-one audio-taped interviews were used in both studies. Ricoeur's hermeneutic phenomenology was used to analyze the findings.

FINDINGS

Four concepts were uncovered in the experience of viewing self in the mirror: decision, seeing, understanding, and consent.

CONCLUSION

Exemplar composite case studies across the care continuum are provided as examples of the way in which mirrors may be utilized in nursing practice.

Preparing to work with big data in proteomics - a report on the HUPO-PSI Spring Workshop: April 15-17, 2013, Liverpool, UK

The Human Proteome Organisation Proteomics Standards Initiative (HUPO-PSI) was established in 2002 with the aim of defining community standards for data representation in proteomics and facilitating data comparison, exchange and verification. The 2013 annual spring workshop was hosted by the University of Liverpool, UK and concentrated on updating and refining the existing standards in the light of new methodologies and technologies. To control the inflation of file sizes, strategies for file compression, particularly for mzML files, were explored. Best practices for encoding information such as protein grouping and PTM localisation were refined and documented. Additional example files for the mzQuantML format were designed to provide support for selected reaction monitoring techniques. Enhancements to the PSI Common Query Interface (PSICQUIC) and PSI-MI XML were discussed. Finally, the group engaged in discussion on how the existing work of the HUPO-PSI can be leveraged by the Metabolomics Standards Initiative to improve the capture of metabolite data.

Recruitment, selection and retention of nursing and midwifery students in Scottish Universities

BACKGROUND

High attrition rates from pre-registration nursing and midwifery programmes have been reported in both the UK and in other countries.

OBJECTIVES

A study was conducted to identify best practice in recruitment, selection and retention across Scottish Universities providing pre-registration programmes.

DESIGN

A survey of all universities providing pre-registration programmes in Scotland was conducted. Semi-structured interviews were conducted with key personnel in each university. Documentary evidence was collected to supplement interview data and evidence recruitment, selection and retention practices.

SETTINGS

All universities in Scotland providing pre-registration nursing and/or midwifery programmes.

PARTICIPANTS

All 10 identified universities agreed to take part and a total of 18 interviews were conducted.

METHODS

Semi-structured face to face and telephone interviews were conducted. Relevant documentary evidence was collected. All data were subject to thematic analysis.

FINDINGS

Universities are predominantly concerned with recruiting to the institution and not to the professions. Interviews are widely used, and are a requirement in the United Kingdom. However, there is no evidence base within the literature that they have predictive validity despite creating scales and scoring systems which are largely unvalidated. The study identified initiatives aimed at addressing attrition/retention, however most had not been evaluated often due to the multi-factorial nature of attrition/retention and difficulties with measurement.

CONCLUSIONS

Recruitment selection and retention initiatives were rarely evaluated, and if so, adopted a relatively superficial approach. Evidence from existing studies to support practices was mostly weakly supportive or absent. The study highlights the need for a coordinated approach, supporting the development of a robust evidence base through the evaluation of local initiatives, and evaluation of new strategies. Evaluation strategies must take account of the local context to facilitate transferability of findings across different settings.

Suggestions for a Web based universal exchange and inference language for medicine

Mining biomedical and pharmaceutical data generates huge numbers of interacting probabilistic statements for inference, which can be supported by mining Web text sources. This latter can also be probabilistic, in a sense described in this report. However, the diversity of tools for probabilistic inference is troublesome, suggesting a need for a unifying best practice. Physicists often claim that quantum mechanics is the universal best practice for probabilistic reasoning. We discuss how the Dirac notation and algebra suggest the form and algebraic and semantic meaning of XML-like Web tags for a clinical and biomedical universal exchange language formulated to make sense directly to the eye of the physician and biomedical researcher.

Presentation rubric: improving faculty professional presentations

PURPOSE

This article describes the content of a presentation evaluation rubric for use in the development and improvement in faculty performance to enhance learning.

CONCLUSIONS

Lectures or professional presentations require skills that can be learned through the use of evidence-based practices for all forms of public speaking.

PRACTICE IMPLICATIONS

A core competency of nursing faculty is to serve as a role model in skilled oral communication. The use of an evaluation presentation rubric can increase faculty competency in this area.

Screening for sexually transmitted infection pathogens in semen samples

The transmission of sexually transmitted infection (STI) pathogens from an infected donor to the recipient of a semen donation in assisted conception may result not only in acute infection but also in long-term reproductive complications or adverse outcomes of pregnancy, including infection of the offspring. Screening for bacterial STI pathogens, Chlamydia trachomatis and Neisseria gonorrhoeae is strongly recommended because these pathogens can cause serious reproductive complications in the recipients of semen donations and infection in their offspring. Screening for these pathogens should be performed using the most sensitive methods, such as nucleic acid amplified tests. False-negative results due to inhibitory substances in the semen sample should be monitored using amplification controls. Where specimen transport is not a problem and culture facilities are available, N gonorrhoeae can also be detected by culture. Laboratories performing screening should subscribe to proficiency programs and have strict quality controls. Although Trichomonas vaginalis, group B streptococcus and genital mycoplasmas have been associated with adverse outcomes of pregnancy, the frequent finding of these organisms in healthy individuals brings into question the validity of mandatory inclusion of these organisms in the screening panel. Although viral STI pathogens and Treponema pallidum - the causative agent of syphilis - may be detected in semen, their presence may be more sensitively detected through antibody testing of the donor. Screening donors for HIV, hepatitis B and syphilis by serology is uniformly recommended in all of the guidelines, but the value of screening either donors or semen samples for cytomegalovirus, herpes simplex viruses and human papilloma viruses is less clear.

PET/CT in Gynecologic Cancer: Present Applications and Future Prospects-A Clinician's Perspective

This article briefly reviews the epidemiology, diagnosis, and treatment of the common gynecologic malignancies, with an emphasis on the shortcomings of current clinical practice. The persistent need to achieve early diagnosis, adjust proper treatment, enhance surveillance, and improve the outcome of these patients has led to the development of new diagnostic modalities. Novel tools such as 18F-fluorodeoxyglucose PET/CT should aim at enhancing the clinician's ability to make critical decisions in treating difficult scenarios.