Leitlinienimplementierung: Wie schließen wir die Lücke zwischen Evidenz und Anwender?

Implementation of a software-based decision support tool for guideline-appropriate preoperative evaluation: a prospective agreement study

BACKGROUND

Guideline adherence in the medical field leaves room for improvement. Digitalised decision support helps improve compliance. However, the complex nature of the guidelines makes implementation in clinical practice difficult.

METHODS

This single-centre prospective study included 204 adult ASA physical status 3-4 patients undergoing elective noncardiac surgery at a German university hospital. Agreement of clearance for surgery between a guideline expert and a digital guideline support tool was investigated. The decision made by the on-duty anaesthetists (standard approach) was assessed for agreement with the expert in a cross-over design. The main outcome was the level of agreement between digital guideline support and the expert.

RESULTS

The digital guideline support approach cleared 18.1% of the patients for surgery, the standard approach cleared 74.0%, and the expert approach cleared 47.5%. Agreement of the expert decision with digital guideline support (66.7%) and the standard approach (67.6%) was fair (Cohen's kappa 0.37 [interquartile range 0.26-0.48] vs 0.31 [0.21-0.42], P=0.6). Taking the expert decision as a benchmark, correct clearance using digital guideline support was 50.5%, and correct clearance using the standard approach was 44.6%. Digital guideline support incorrectly asked for additional examinations in 31.4% of the patients, whereas the standard approach did not consider conditions that would have justified additional examinations before surgery in 29.4%.

CONCLUSIONS

Strict guideline adherence for clearance for surgery through digitalised decision support inadequately considered patients, clinical context. Vague formulations, weak recommendations, and low-quality evidence complicate guideline translation into explicit rules.

CLINICAL TRIAL REGISTRATION

NCT04058769.

Systematic Review of Existing Stroke Guidelines: Case for a Change

Methods

We systematically searched for guideline recommendation on the day-to-day use of peripheral inflammatory markers such as NLR published in the English language between January 1, 2005, and October 2020. Any other evidence of system biology-based approach or recommendation was explored within the selected guidelines for this scoping review. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 4 authors to determine clinical scenarios explained/given, scientific evidence used, and recommendations presented in the context of system biology.

Results

The scoping review found 2,911 titles at the beginning of the search. Final review included with 15 guidelines. Stroke-related organizations wrote sixty-five percent of the guidelines while national ministries wrote a fewer number of guidelines. We were primarily interested in recommendations for acute management in AIS published in the English language. Fifteen eligible guidelines were identified from 15 different countries/regions. None of the guidelines recommended the routine use of peripheral markers of inflammation, such as NLR, among their acute assessment and management recommendations. None of the existing guidelines explored the system biology approach to one of the most complex diseases affecting the human brain, stroke.

Conclusions

This systematic review has identified a significant evidence-practice gap in all existing national stroke guidelines published in English medium as of October 2020. These guidelines included the only current "living stroke guidelines," stroke guidelines from Australia with a real opportunity to modernize the living stroke guidelines with systems biology approach, and provide 2020 vision towards better stroke care globally. Investigation of complex disease such as stroke is best served through a systems biology approach. One of the easiest places to start is simple blood tests such as total white cell count and NLR. Systems biology approach point us towards simple tools such immune-inflammatory index (SII) and serial systemic immune inflammatory indices (SSIIi) which should pave the way for the stroke physician community address the challenges in systems biology approach in stroke care. These challenges include translating bench research to the bedside, managing big data (continuous pulse, blood pressure, sleep, oxygen saturation, progressive changes in NLR, SII, SSIIi, etc.). Working with an interdisciplinary team also provides a distinct advantage. Recent adoption of historic WHO-IGAP calls for immediate action. The 2022 World Brain Day campaign on Brain Health for All is the perfect opportunity to raise awareness and start the process.

[DGPPN pilot study on the implementation of the S3 guideline "Prevention of coercion: prevention and therapy of aggressive behavior in adults"]

Ziel der Arbeit (Fragestellung)

Können die aus der S3-Leitlinie „Verhinderung von Zwang“ abgeleiteten Implementierungsempfehlungen auf akutpsychiatrischen Stationen mittels Implementierungsberater*innen (IB) in der Stationsarbeit umgesetzt werden und führt die Umsetzung zu einem erhöhten Einhalten der von der DGPPN (Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde) verabschiedeten Empfehlungen?

Material und Methoden

Je zwei ärztliche oder pflegerische IB berieten psychiatrische Stationsteams bei der Umsetzung von jeweils drei aus der Leitlinie abgeleiteten, individuell ausgewählten Implementierungsempfehlungen. Die Beratung erfolgte in einem strukturierten Prozess über sechs Monate. Der Grad der Umsetzung der Empfehlungen wurde von den Stationsteams gemeinsam mit den IB mit einem für diesen Zweck entwickelten Instrument (PreVCo-Rating-Instrument) jeweils vor Beginn und nach Ende der Intervention eingeschätzt.

Ergebnisse

Fünf Stationen mit Versorgungsverpflichtung auch für zwangseingewiesene Patient*innen nahmen an der Pilotstudie teil; drei vollendeten die Intervention. Bei den letztgenannten verbesserte sich sowohl die Einschätzung der Umsetzung der von den Stationen ausgewählten Implementierungsempfehlungen als auch die Einschätzung der Umsetzung der nicht ausgewählten Maßnahmen. Die Implementierungsberatung wurde von den Stationen als hilfreich empfunden. Die Anwendung des PreVCo-Rating-Instruments wurde von den IB und Behandlungsteams als gut durchführbar beurteilt.

Diskussion

Die vorliegende Pilotstudie zeigt, dass eine durch IB gestützte Implementierung der 12 Empfehlungen durchführbar ist, von den Behandlungsteams als hilfreich erachtet wurde und zu positiven Veränderungen führen kann. Die Stichprobe der Pilotstudie war mit fünf Stationen unterschiedlichen Profils aussagekräftig. Ob auch die Häufigkeit und Dauer von Zwangsmaßnahmen auf diese Weise reduziert werden kann, wird aktuell in einer randomisiert-kontrollierten Studie mit einer auf dieser Pilotstudie basierenden Intervention an 55 psychiatrischen Stationen in unterschiedlichen Regionen Deutschlands untersucht.

[Implementation of emergency classifications-Where do we stand? : Results of a nationwide survey]

Hintergrund

Ziel der vorliegenden Studie ist eine aktuelle Standortbestimmung im Hinblick auf die Umsetzung der Empfehlungen zur Klassifikation von Notfalloperationen, welche von den Verbänden BDA/DGAI, BDC/DGCH und VOPM im Jahr 2016 veröffentlicht wurden.

Methodik

In Anlehnung an die gemeinsamen Empfehlungen der Fachverbände wurden mithilfe eines Online-Fragebogens verschiedene organisatorische Aspekte der operativen Notfallversorgung untersucht. Hierzu wurden bundesweit OP-Manager/‑Koordinatoren an operativ tätigen Kliniken mit einer Mindestanzahl von 200 Betten befragt.

Ergebnisse

An der Umfrage beteiligten sich 274 der 550 angeschriebenen Kliniken (49,8 %). Die Empfehlungen werden aktuell in 70,7 % der Häuser umgesetzt. Die Auffassung, dass die Notfallklassifizierung die zeitgerechte Notfallversorgung von Patienten verbessert, teilt eine Mehrheit von 78,2 % der OP-Verantwortlichen. 33,6 % sind allerdings auch der Ansicht, dass die definierten Zeitintervalle zur Umsetzung der Notfälle die Möglichkeit einer subjektiven Auslegung bieten. Zusätzliche hausinterne Empfehlungen zu den am häufigsten auftretenden Notfallindikationen würden 80,1 % als hilfreich erachten; in 39,1 % der Häuser sind diese bereits implementiert. 65,2 % der Krankenhäuser halten für die Versorgung von Notfällen keine zusätzliche Notfallkapazität vor, 30,1 % arbeiten hingegen mit definierten Konzepten zur Sicherstellung der bedarfsgerechten Verfügbarkeit von Saalkapazitäten.

Schlussfolgerung

Die Empfehlungen zur Notfallklassifikation sind über alle Versorgungsstufen hinweg in der klinischen Realität Deutschlands angekommen und werden von der großen Mehrheit der OP-Verantwortlichen als hilfreiches Instrument in der OP-Koordination erachtet. Zusätzliche, indikationsbezogene Empfehlungen zur Klassifizierung der am häufigsten auftretenden Notfalleingriffe werden mehrheitlich befürwortet. Das Vorhalten eines definierten Notfallsaales ist entgegen bisherigen Annahmen in der deutschen Krankenhauslandschaft nahezu die Ausnahme.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00101-021-00971-2) enthält den zugrunde liegenden Fragebogen. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

Management of Patients With Venous Leg Ulcers: Challenges and Current Best Practice

Introduction It is well documented that the prevalence of venous leg ulcers (VLUs) is increasing, coinciding with an ageing population. Accurate global prevalence of VLUs is difficult to estimate due to the range of methodologies used in studies and accuracy of reporting. (1) Venous ulceration is the most common type of leg ulceration and a significant clinical problem, affecting approximately 1% of the population and 3% of people over 80 years of age (2) in westernised countries. Moreover, the global prevalence of VLUs is predicted to escalate dramatically, as people are living longer, often with multiple comorbidities. Recent figures on the prevalence of VLUs are based on a small number of studies, conducted in Western countries, and the evidence is weak. However, it is estimated that 93% of VLUs will heal in 12 months, and 7% remain unhealed after five years. (3) Furthermore, the recurrence rate within 3 months after wound closure is as high as 70%. (4) (-6) Thus, cost-effective adjunct evidence-based treatment strategies and services are needed to help prevent these ulcers, facilitate healing when they occur and prevent recurrence. The impact of a VLU represents social, personal, financial and psychological costs on the individual and further economic drain on the health-care system. This brings the challenge of providing a standardised leg ulcer service which delivers evidence-based treatment for the patient and their ulcer. It is recognised there are variations in practice and barriers preventing the implementation of best practice. There are patients not receiving appropriate and timely treatment in the initial development of VLUs, effective management of their VLU and preventing recurrence once the VLU has healed. Health-care professionals (HCPs) and organisations must have confidence in the development process of clinical practice guidelines and have ownership of these guidelines to ensure those of the highest quality guide their practice. These systematic judgments can assist in policy development, and decision making, improve communication, reduce errors and improve patient outcomes. There is an abundance of studies and guidelines that are available and regularly updated, however, there is still variation in the quality of the services offered to patients with a VLU. There are also variations in the evidence and some recommendations contradict each other, which can cause confusion and be a barrier to implementation. (7) The difference in health-care organisational structures, management support and the responsibility of VLU management can vary in different countries, often causing confusion and a barrier to seeking treatment. These factors further complicate the guideline implementation process, which is generally known to be a challenge with many diseases. (8).

Implementation of study results in guidelines and adherence to guidelines in clinical practice

Guidelines were introduced in hospital- and practice-based otorhinolaryngology in the 1990ies, and have been undergoing further development ever since. There are currently 20 guidelines on file at the German Society of Oto-Rhino-Laryngology, Head & Neck Surgery. The society has cooperated in further 34 guidelines. The quality of the guidelines has been continuously improved by concrete specifications put forward by the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V., AWMF). Since increasing digitalization has made access to scientific publications quicker and simpler, relevant study results can be incorporated in guidelines more easily today than in the analog world. S2e and S3 guidelines must be based on a formal literature search with subsequent evaluation of the evidence. The consensus procedure for S2k guidelines is also regulated. However, the implementation of guidelines in routine medical practice must still be considered inadequate, and there is still a considerable need for improvement in adherence to these guidelines.