Strategies to improve compliance with evidence-based clinical management guidelines

An approach to rapidly assess sepsis through multi-biomarker host response using machine learning algorithm

Sepsis is a life-threatening condition and understanding the disease pathophysiology through the use of host immune response biomarkers is critical for patient stratification. Lack of accurate sepsis endotyping impedes clinicians from making timely decisions alongside insufficiencies in appropriate sepsis management. This work aims to demonstrate the potential feasibility of a data-driven validation model for supporting clinical decisions to predict sepsis host-immune response. Herein, we used a machine learning approach to determine the predictive potential of identifying sepsis host immune response for patient stratification by combining multiple biomarker measurements from a single plasma sample. Results were obtained using the following cytokines and chemokines IL-6, IL-8, IL-10, IP-10 and TRAIL where the test dataset was 70%. Supervised machine learning algorithm naïve Bayes and decision tree algorithm showed good accuracy of 96.64% and 94.64%. These promising findings indicate the proposed AI approach could be a valuable testing resource for promoting clinical decision making.

A Simple Way to Improve DVT Protocol Compliance

Objective:

To assess the impact on deep vein thrombosis (DVT) protocol violations of the introduction of a label attached to the patient's drug chart, which specifically allows low-dose subcutaneous heparin or thromboembolic deterrent stockings (TEDS) to be prescribed as appropriate.

Design:

An audit study.

Setting:

Department of General Surgery of a District General Hospital in the United Kingdom.

Method:

All adult general surgical inpatients on a Weekday were studied. Staff were not forewarned of the studies. Patient details and risk factors for DVT were noted. Details of administered DVT prophylaxis were recorded. In total four separate studies were undertaken, namely: with original protocols (I), with refined protocol 1 and 3 years later (II, III) and finally after introduction of the label (IV).

Results:

Protocol violations were defined as being ‘acceptable’ or ‘unacceptable’. Raising awareness between studies I and II reduced acceptable violations to zero. There was no statistically significant reduction in unacceptable violations (24 in 80 patients, 1; 17 in 75, II; 13 in 60, III). In study IV, following introduction of the label, there were only 6 violations in 51 patients ( p<0.02).

Conclusion:

Combining increased awareness with the attachment of a label to the drug chart reduced unacceptable violations by 63%.

Associations between workplace affiliation and phlebotomy practices regarding patient identification and test request handling practices in primary healthcare centres: a multilevel model approach

Background

Clinical practice guidelines aim to enhance patient safety by reducing inappropriate variations in practice. Despite considerable efforts to enhance the use of clinical practice guidelines, adherence is often suboptimal. We investigated to what extent workplace affiliation explains variation of self-reported adherence to venous blood specimen collection regarding patient identification and test request handling practices, taking into consideration other primary healthcare centre and individual phlebotomist characteristics.

Methods

Data were collected through a questionnaire survey of 164 phlebotomy staff from 25 primary healthcare centres in northern Sweden. To prevent the impact of a large-scale education intervention in 2008, only baseline data, collected over a 3-month period in 2006–2007, were used and subjected to descriptive statistics and multilevel logistic analyses.

Results

In two patient identification outcomes, stable high median odds ratios (MOR) were found in both the empty model, and in the adjusted full model including both individual and workplace factors. Our findings suggest that variances among phlebotomy staff can be largely explained by primary healthcare centre affiliation also when individual and workplace demographic characteristics were taken in consideration. Analyses showed phlebotomy staff at medium and large primary healthcare centres to be more likely to adhere to guidelines than staff at small centres. Furthermore, staff employed shorter time at worksite to be more likely to adhere than staff employed longer. Finally, staff performing phlebotomy every week or less were more likely to adhere than staff performing phlebotomy on a daily basis.

Conclusion

Workplace affiliation largely explains variances in self-reported adherence to venous blood specimen collection guidelines for patient identification and test request handling practices among phlebotomy staff. Characteristics of the workplace, as well as of the individual phlebotomist, need to be identified in order to design strategies to improve clinical practice in this and other areas.

Deviations from venous blood specimen collection guideline adherence among senior nursing students

BACKGROUND

Despite considerable efforts to increase patient safety by supporting the use of best practice medical and nursing guidelines by healthcare staff, adherence is often suboptimal. Swedish nurses often deviate from venous blood specimen collection (VBSC) guideline adherence. We assessed the adherence to national VBSC guidelines among senior nursing students.

METHODS

We conducted a cross-sectional, self-reported questionnaire survey among 101 out of 177 senior nursing students consisting of web-based students in their fifth semester and campus-based students in their fifth or sixth semester out of six. In regard to the VBSC procedures, we asked about adherence to the patient identification, test request handling, and test tube labelling protocols that the students had learned during their second semester and practiced thereafter.

RESULTS

Guideline adherence to patient identification was reported by 81%, test request handling by 74%, and test tube labelling by 2% of the students. Students with no prior healthcare education reported to a higher extent that they operated within the guidelines regarding labelling the test tube before entering the patient's room compared to students with prior healthcare education. Using multiple logistic regression analysis, we found that fifth semester web-based program students adhered better to VBSC guidelines regarding comparing patient ID/test request/tube label compared to campus-based students.

CONCLUSIONS

Senior nursing students were found to adhere to VBSC guidelines to a similar extent as registered nurses and other hospital ward staff in clinical healthcare. Thus student adherence to VBSC guidelines had deteriorated since their basic training in the second semester, and this can impact patient safety during university/clinical studies. The results of our study have implications for nursing practice education.

Interventions for implementation of thromboprophylaxis in hospitalized medical and surgical patients at risk for venous thromboembolism

BACKGROUND

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in hospitalized patients. Numerous randomized controlled trials (RCTs) show that using thromboprophylaxis in hospitalized patients at risk for VTE is safe, effective and cost-effective. Despite this, prophylactic therapies for VTE are underutilized. System-wide interventions may be more effective to improve the use of VTE prophylaxis than relying on individual providers' prescribing behaviors.

OBJECTIVES

To assess the effects of interventions designed to increase the implementation of thromboprophylaxis in hospitalized adult medical and surgical patients at risk for venous thromboembolism (VTE), assessed in terms of: 1. Increase in the proportion of patients who receive prophylaxis and appropriate prophylaxis 2. Reduction in risk of symptomatic VTE3. Reduction in risk of asymptomatic VTE4. Safety of the intervention.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Group's Specialised Register (last searched July 2010) and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) 2010, Issue 3. We searched the PubMed, EMBASE, and SCOPUS databases (19 April 2010) as well as the reference lists of relevant review articles.

SELECTION CRITERIA

We included all studies whose interventions aimed to increase the use of prophylaxis and/or appropriate prophylaxis, decrease the proportion of symptomatic VTE, or decrease the proportion of asymptomatic VTE in hospitalized adult patients. We excluded studies that simply distributed published guidelines and studies whose interventions were not clearly described.

DATA COLLECTION AND ANALYSIS

We collected the following outcomes: the proportion of patients who received prophylaxis (RP), the proportion of patients who received appropriate prophylaxis (RAP) (primary outcomes), and the occurrence of symptomatic VTE, asymptomatic VTE, and safety outcomes such as bleeding. We categorized interventions into education, alerts, and multifaceted interventions. We meta-analyzed RCTs and non-randomized studies (NRS) separately by random effects meta-analysis, and assessed heterogeneity using the I(2)statistic and subgroup analyses. Before analysis, we decided that results would be pooled if three or more studies were available for a particular intervention. We assessed publication bias using funnel plots and cumulative meta-analysis.

MAIN RESULTS

We included a total of 55 studies. One of these reported data in patient-days and could not be quantitatively analyzed with the others. The 54 remaining studies (8 RCTs and 46 NRS) eligible for inclusion in our quantitative synthesis enrolled a total of 78,343 participants. Among RCTs, there were sufficient data to pool results for one primary outcome (received prophylaxis) for the 'alert' intervention. Alerts, such as computerized reminders or stickers on patients' charts, were associated with a risk difference (RD) of 13%, signifying an increase in the proportion of patients who received prophylaxis (95% confidence interval (CI) 1% to 25%). Among NRS, there were sufficient data to pool both primary outcomes for each intervention type. Pooled risk differences for received prophylaxis ranged from 8% to 17%, and for received appropriate prophylaxis ranged from 11% to 19%. Education and alerts were associated with statistically significant increases in prescription of appropriate prophylaxis, and multifaceted interventions were associated with statistically significant increases in prescription of any prophylaxis and appropriate prophylaxis. Multifaceted interventions had the largest pooled effects. I(2) results showed substantial statistical heterogeneity which was in part explained by patient types and type of hospital. A subgroup analysis showed that multifaceted interventions which included an alert may be more effective at improving rates of prophylaxis and appropriate prophylaxis than those without an alert. Results for VTE and safety outcomes did not show substantial benefits or harms, although most studies were underpowered to assess these outcomes.

AUTHORS' CONCLUSIONS

We reviewed a large number of studies which implemented a variety of system-wide strategies aimed to improve thromboprophylaxis rates in many settings and patient populations. We found statistically significant improvements in prescription of prophylaxis associated with alerts (RCTs) and multifaceted interventions (RCTs and NRS), and improvements in prescription of appropriate prophylaxis in NRS with the use of education, alerts and multifaceted interventions. Multifaceted interventions with an alert component may be the most effective. Demonstrated sources of heterogeneity included patient types and type of hospital. The results of our review will help physicians, nurses, pharmacists, hospital administrators and policy makers make practical decisions about local adoption of specific system-wide measures to improve prevention of VTE, an important public health issue. We did not find a significant benefit for VTE outcomes; however, earlier RCTs assessing the efficacy of thromboprophylaxis which were powered to address these outcomes have demonstrated the benefit of prophylactic therapies and a favourable balance of benefits versus the increased risk of bleeding events.

Medication chart intervention improves inpatient thromboembolism prophylaxis

BACKGROUND

Inpatient VTE prophylaxis is underused. This study evaluated the effectiveness of the low-cost, multifaceted Australian National Inpatient Medication Chart (NIMC) intervention on improving the quality of VTE prophylaxis and reducing disease. The NIMC intervention incorporated (1) a VTE risk stratification and appropriate prophylaxis guidance tool, (2) a prophylaxis contraindication screening instrument, and (3) a prophylaxis prescription prompt.

METHODS

Retrospective analysis of 2,371 consecutive medical and surgical admissions was performed at a regional referral hospital over 1 year both before and after the intervention. Outcomes measured included the frequency of prophylaxis use, timing of prophylaxis initiation, adherence of the prescribed prophylaxis regimen to guidelines, incidence of VTE disease, and prophylaxis-related complications.

RESULTS

Following NIMC intervention, prophylaxis use increased from 52.7% to 66.5% in medical patients and from 77.5% to 89.1% in surgical patients (P < .001). This increase was still evident 12 months postintervention. After intervention, prophylaxis initiated on admission increased from 65.0% to 83.6% in medical patients and from 60.7% to 78.0% in surgical patients (P < .01); adherence rates to recommended guidelines increased from 55.6% to 71.0% in medical patients and from 53.6% to 75.6% in surgical patients (P < .01). More VTE risk factors independently triggered prophylaxis usage postintervention. The improved quality of prophylaxis did not significantly reduce VTE incidence (risk ratio, 0.88; 95% CI, 0.48-1.62). The rate of prophylaxis-related complications remained similar before and after intervention.

CONCLUSIONS

The multifaceted NIMC intervention resulted in a sustained increase in appropriate and timely VTE prophylaxis in medical and surgical inpatients.

Overview of the quality assurance movement in health care

This chapter aims to describe the origin and current status of quality assurance (QA) in health care and to provide a background of similar developments in other industries, which have provided a major impetus for QA initiatives in health care. The interest in quality and safety in the health care sector has rapidly risen over the past decade. Without important lessons learnt from other industries, the interest and obtained improvements would have been far less fast. Knowledge on basic principles and challenges faced by other industries like the airline, car, and nuclear energy industry, that drove quality improvement projects, is of major relevance to understand the evolutions taking place in health care. To fully appreciate the QA movement, and design or implement quality improvement projects, its basic principles need to be understood. This chapter aims to give insights in basic principles underlying QA, and to discuss historical lessons that have been learnt from other industries. Furthermore, it discusses how to implement and assure a sustainable QA program.

Is upper extremity trauma an independent risk factor for lower extremity venous thromboembolism? An 11-year experience at a Level I trauma center

INTRODUCTION

Venous thromboembolism (VTE) is an important problem in orthopedic trauma patients. An association between VTE and upper extremity injury has not been reported. The purpose of this investigation was to determine whether upper extremity trauma is an independent risk factor for lower extremity VTE. This study also attempted to identify associations between VTEs and demographic and injury variables in patients that sustained upper extremity trauma.

METHODS

Eleven years of data from the trauma registry at our Level I trauma center was retrospectively reviewed in an injury-matched cohort study. From an initial pool of 646 patients who sustained upper extremity trauma, 32 subjects (4.95%) were identified as having major upper extremity injuries as well as thromboembolic complications. Thirty-two injury-matched controls were randomly selected from the 646 patients with major upper extremity injuries. Regression analysis was performed to determine variables that were significantly associated with lower extremity thromboembolic complications.

RESULTS

Overall incidence of VTE in patients sustaining upper extremity injury was 4.95% (deep vein thrombus 4.64%, pulmonary embolism 0.31%) and was similar to the 4.95% VTE rate in patients without upper extremity injury. Major head injury (p = 0.022) occurred at increased frequency in the VTE group. Patients with increased length of hospital stay (p < 0.001) and length of time on a ventilator (p = 0.002) were at significantly higher risk for thromboembolic complications. No patient with isolated upper extremity trauma had complications from VTE.

CONCLUSION

Lower extremity VTE occurs at similar rates in patients sustaining upper extremity injury compared to those patients that do not. Major upper extremity orthopedic trauma is not an independent risk factor for lower extremity VTE, and current clinical management guidelines for VTE prophylaxis are adequate for patients sustaining major upper extremity trauma.

Hospitals with percutaneous coronary intervention capability have greater adherence to established myocardial infarction guidelines

The American College of Cardiology/American Heart Association guidelines for acute myocardial infarction related to process of care aim to decrease morbidity and mortality and provide a standard of care for patients with acute myocardial infarction (AMI). Currently, there are limited data comparing adherence between centers providing fibrinolytic therapy alone and those that provide percutaneous coronary intervention (PCI). Reported compliance with AMI performance measures was analyzed using data from the United States Department of Health and Human Services Hospital Compare Web site from 2007, including aspirin administration, beta-blocker administration, angiotensin-converting enzyme or angiotensin receptor blocking agents, and smoking cessation counseling. Adherence to all reported measurements was significantly higher (P < 0.0001) in hospitals that reported PCI capability, compared with hospitals that reported only fibrinolytic use in AMI patients.

Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs

BACKGROUND

Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency.

OBJECTIVES

To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs.

SEARCH STRATEGY

We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care.

MAIN RESULTS

Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups.

AUTHORS' CONCLUSIONS

Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

Hormone therapy, dilemmas, medical decisions

The decision for women to go on hormone therapy (HT) remains controversial. An historical oscillation of beliefs exists related in part to expectations of the medicinal value of HT over longer-term use beyond the initial peri-menonpausal period. Studies thought to resolve issues surrounding the efficacy of HT were perhaps overstated as confusion still permeates the decision making with regard to HT. Overzealous advertising and exaggerated understanding of the results (negative or positive) undermine patient and physician decision making. There remains no magic bullet with regard to HT. What remains is still the possibility of HT longer-term efficacy on diverse end organ systems with pockets of clinical and scientific ambiguity while working to engender reasonable expectations.

The Accident and Emergency Department Virtual Consulting Room

The goal was to describe the development of the Virtual Consulting Room (VcR), a unique intranet-based guidance application providing direct access to local specialist knowledge, and to evaluate its usability and whether it has the potential to educate staff while working in the Accident and Emergency (A&E) department. Duty staff of the A&E Department, The Royal Free Hospital, London, participated in a prospective observational study. Two hundred and twenty consecutive patients were identified from the triage section of their casualty card as having a presenting complaint that featured in the VcR. These casualty cards were highlighted with a red sticker alert and a short questionnaire attached. Members of staff were invited to consult with the VcR after assessing each patient by clicking on an icon located on the department's computer desktops. No prior training was provided. The questionnaire was completed in 103 of 220 (46.8%) patients. The VcR was used in the management of 38 of 220 (17.3%) patients. In 21 of 38 (55.3%), users reported the VcR supported clinical decision making, in 20 of 38 (52.6%) the VcR improved knowledge and in 11 of 38 (28.9%) the VcR helped directly influence the decision to discharge the patient. In 2 of 38 (5.3%) users changed their decision to refer and in 1 of 38 (2.6%) investigations were altered. This evaluation indicates that A&E clinicians accessing the VcR found it easy to use and educational in the workplace.

The Current Status of Thromboprophylaxis after Trauma: A Story of Confusion and Uncertainty

It is difficult to support a standard of care for venous thromboprophylaxis after trauma when there is no convincing research that any of the currently used methods is consistently effective. Because many conclusions from the nontrauma literature have been misleadingly extrapolated to trauma patients, this review focuses exclusively on trauma articles. These articles present variable results. The rates of deep venous thrombosis and pulmonary embolism are widely different even among similar trauma populations. The heparin-unfractionated or low-molecular-weight and calf compression methods fail to show a reproducible effect in decreasing venous thromboembolic events. The current methods of venous thromboprophylaxis after trauma are inadequate and further research in this area is direly needed.

The use of retrievable inferior vena cava filters in trauma: implications for the trauma team

Prevention of venothromboembolic complications remains a challenge in trauma care. Guidelines for prophylaxis published by the Eastern Association for the Surgery of Trauma stratify patients by risk and recommend therapies based on scientific evidence. New innovations such as retrievable inferior vena cava filters are being used by trauma surgeons for patients at risk for pulmonary embolism but in whom anticoagulation is contraindicated. Some available devices offer a limited timeframe for retrieval beyond which the device becomes permanent. The increased utilization of this technology presents case management challenges to trauma teams. Patients who are unreliable or may be difficult to track posthospitalization (homeless, migrant workers, prison system, etc.) run the risk of not having their filters removed as initially intended. Nurses can play a critical role in helping to manage and direct the discharge plan and case management of trauma patients with retrievable inferior vena cava filters.

TRAUMA RECEPTION AND RESUSCITATION

The hospital reception phase of major trauma management requires a great number of expedient decisions. However, despite widely taught programmes advocating a standardized, algorithmic approach to decision-making, there is an ongoing rate of human errors contributing to adverse outcomes. It is now time for a fundamental change in our approach to trauma resuscitation. Point-of-care computer technology linked to real-time decision-making and trauma team coordination may achieve error reduction through standardized decision-making and a corresponding reduction in preventable mortality and morbidity.

Brief report: Reducing inappropriate usage of stress ulcer prophylaxis among internal medicine residents. A practice-based educational intervention

BACKGROUND

Many inpatients receive stress ulcer prophylaxis (SUP) inappropriately. This indiscriminate usage increases costs and avoidable side-effects. Practice-based learning and improvement (PBLI) methodology may improve compliance with published guidelines.

OBJECTIVE

To investigate the response of internal medicine residents to an educational intervention regarding SUP.

DESIGN

A prospective, pre and postintervention cohort study using an educational intervention based on PBLI.

PATIENTS

Three groups of consecutively admitted patients (1 group preintervention and 2 groups postintervention) on the medicine ward at a University Hospital.

MAIN OUTCOME MEASURE

Rates of inappropriate SUP prescription and discharge with an inappropriate prescription.

RESULTS

One month after the intervention, inappropriate prophylaxis was significantly decreased (59% pre, 29% postintervention, P<.002). The rate of discharge with an inappropriate prescription also decreased, but was not significant (25% pre, 14% postintervention, P=.14). In the 6-month postintervention cohort, inappropriate SUP remained lower (59% pre, 33% postintervention, P<.007). The rate of discharge with an inappropriate prescription was also significantly lower (25% pre, 7% postintervention, P<.009).

CONCLUSION

Practice-based learning and improvement can improve compliance with published guidelines, and change practice patterns. After the intervention, both inappropriate prophylaxis and inappropriate prescriptions upon discharge were reduced. Importantly, the intervention was sustained, transmitted across academic years to a new class of interns who had not directly experienced the intervention.

An evaluation of compliance with practice guidelines on interhospital trauma transfer

STUDY OBJECTIVES

To prospectively evaluate compliance with current interhospital trauma transfer guidelines in South West Sydney, before and after an implementation programme was instituted.

METHODS

A scoring system was developed to assess compliance with the 11 main components of the guideline. Baseline compliance was measured during an initial 3-month period (pre), followed by an implementation programme to alert staff at referring hospitals to the presence of the guidelines. Following this, compliance was again measured over 3 months (post).

RESULTS

Twenty-two patients were transferred during the pre-implementation phase and 35 patients during the post-phase. Overall compliance with the guidelines increased from 62 to 67%. Mean pre-hospital compliance rose from 75 to 95%, and referring hospital compliance rose from 59 to 63%. While there was an improvement in compliance with the use of the dedicated trauma hotline (86-97%), the use of a transfer checklist (41-53%), and appropriateness of transfer (95-100%), none of these reached statistical significance.

CONCLUSION

Practice guidelines have been developed to optimise the process of interhospital trauma transfers. An implementation programme met with limited success in improving compliance with the guidelines. Further work is needed to ensure awareness of these guidelines, with ongoing monitoring to ensure best practice and optimal patient outcome.

A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals

OBJECTIVE

To assess the effectiveness of different strategies for increasing the uptake of prophylaxis for venous thromboembolism (VTE) in hospitalized patients through a systematic review of the literature.

METHODS

Literature databases and the Internet were searched from 1996 to May 2003. Studies of strategies to improve VTE prophylaxis practice were included. Studies where no policy or guideline was implemented or where the focus of the study was not VTE prevention were excluded.

RESULTS

Thirty studies were included. The quality of the available evidence was average with the majority of studies being uncontrolled before and after design and thus limited by the historical nature of much of the available data. Adherence to guidelines and the provision of adequate prophylaxis were poor in studies which relied on passive dissemination of guidelines. In general, the use of multiple strategies was more effective than a single strategy used in isolation. The most effective strategies incorporated a system for reminding clinicians to assess patients for VTE risk, either electronic decision-support systems or paper-based reminders, and used audit and feedback to facilitate the iterative refinement of the intervention. There were no studies adequately powered to demonstrate a reduction in rates of VTE. Insufficient evidence was available to make useful comparisons of strategies in terms of costs and resource utilization.

CONCLUSIONS

Passive dissemination of guidelines is unlikely to improve VTE prophylaxis practice. A number of active strategies used together, which incorporate some method for reminding clinicians to assess patients for DVT risk and assisting the selection of appropriate prophylaxis, are likely to result in the achievement of optimal outcomes.

Clinical practice guidelines on the initial assessment and treatment of urinary incontinence in women: a US focused review

OBJECTIVE

To identify clinical practice guidelines from prominent US organizations for the initial management of urinary incontinence (UI) in women and compare them with recommendations from the International Consultation on Incontinence (ICI). The challenge of implementing guidelines in the US was also identified.

METHODS

The medical literature was reviewed to identify relevant practice guidelines on the initial management of UI in community-dwelling women according to specific inclusion and exclusion criteria. Guidelines were compared with the ICI international gold standard relating to patient identification, initial therapy, and recommendation for specialist referral. Literature on programs to implement guidelines into clinical practice was reviewed.

RESULTS

There is general agreement on how females with UI should be initially managed based on guidelines, monographs, and technical bulletins from prominent US organizations. Though these recommendations are more than 5 years old, they are fairly similar to the latest guidelines developed by the ICI in 2001. Minor discrepancies are mainly related to the lack of updating US guidelines based on most recent knowledge. Implementing existing guidelines into clinical practice presents a challenge.

CONCLUSION

No evidence-based practice guidelines from prominent US organizations on the initial management of UI in women exist that are less than 5 years old, but the latest versions are in alignment with recent ICI/WHO guidelines. Although optimization of UI management may be the goal of guidances, the debate remains over whether these recommendations are actually effective in modifying practice. Simplifying and updating guidelines regularly may enhance adaptation in the initial management of UI in women.

Adequacy of evolving national standardized terminologies for interdisciplinary coded concepts in an automated clinical pathway

PURPOSE

The purpose of this analysis was to determine the adequacy of evolving national standardized terminologies with regard to coded data elements (concepts) in an automated clinical pathway designed to drive adherence with the American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for Evaluation and Management of Chronic Heart Failure.

METHOD

Concepts were identified in a previously developed automated clinical pathway and associated tools. Once identified, concepts were categorized according to the conceptual domains identified by Campbell et al. (1997). A review of evolving national standardized terminologies and coding systems was initiated to determine if the identified concepts had corresponding representation in one of these coding systems. Available codes were then evaluated for adequacy with respect to national guideline adherence measures put forth by the Centers for Medicare/Medicaid Services (CMS) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

RESULTS

The concept domain model put forth by Campbell et al. (1997) worked well for organizing concepts and for providing a useful framework for data analysis. Using our method, 260 unique pathway concepts were identified, of which, 91.9% (239) are represented by one or more of the standardized coding systems. Logical Observation Identifiers Names and Codes (LOINC) and SNOMED CT alone represented 86.2% of the concepts. Seventy percent (70%) of the clinical pathway concepts are represented using the Health Insurance Portability and Accountability Act (HIPAA) mandated national terminologies alone. Less than 50% of CMS and JCAHO guideline adherence concepts were found to have representation in the HIPAA mandated terminologies. The addition of Logical Observation Identifier Names and Codes (LOINC) and SNOMED CT improved representation up to 86.4%, but did not include representation of all concepts necessary for complete electronic monitoring of guideline adherence.

CONCLUSIONS

Evolving national standardized terminologies provided matching terms for the majority of the data elements in the automated clinical pathway. Standard clinical terminologies with granular terms such as LOINC and SNOMED CT are required to represent the depth and detail of certain procedures and guideline-based care. Gaps exist in Health Insurance Portability and Accountability Act (HIPAA) mandated terminologies for representing interdisciplinary concepts in national adherence measures.

Acute Ischemic Stroke in Hospitalized Medicare Patients

Background and Purpose— This study describes several quality indicators of care in hospitalized stroke patients in Michigan from 1998 to 1999.

Summary of Report— Median times from admission to head CT/MRI (89.5 minutes) and thrombolysis (113 minutes) exceeded recommended guidelines. Deep venous thrombosis prophylaxis was used in only 13.8% of eligible patients.

Conclusions— Timing for brain imaging and acute ischemic stroke symptom onset need to be better documented, along with more provider education for routine deep venous thrombosis prophylaxis.

[Long-term usefulness of an information programme on practices in surgical antimicrobial prophylaxis]

INTRODUCTION

In France, numerous concordant studies show that there are some discrepancies between guidelines on surgical antibiotic prophylaxis and the current practice. In a previous study, conducted in April-June 2001, we found that the rate of appropriateness of surgical antimicrobial prophylaxis was approximately 40%. An information programme was implemented and the purpose of this paper was to present the short- and long-term usefulness of this campaign.

METHODS

A total of 13 pairs of surgeons/anaesthetists participated in data collection during the three periods of the study. Prescriptions were observed in order to answer to five questions. Five variables describing practices concerning antibiotic prophylaxis in surgery were compared to national recommendations (updated in 1999): did the surgical procedure require antibiotic prophylaxis and was this carried out? Was the antibiotic used appropriate? Was the timing of the first injection optimal? Was the total duration of the treatment correct? Was the dose correct?

RESULTS

The overall compliance with recommendations was significantly improved during the third period (P = 0.0002). This improvement was particularly marked for antimicrobial prophylaxis duration.

CONCLUSION

It seems that sequential surveillance of antimicrobial prophylaxis, including numerous surgical teams, could considerably improve the practices, if it was associated to informations that allowed physicians to appropriate the procedures.

Status of practice guidelines in the United States: CDC guidelines as an example

BACKGROUND

Clinical practice guidelines have proliferated in the past several decades, starting with only a handful in the 1980s to over 1000 approved through The National Guideline Clearinghouse in 2002.

METHODS

The purposes of this article to review research related to guideline adoption and impact and to make recommendations for assessing the outcomes of guidelines, using the CDC guideline process as an example.

RESULTS

Despite the national movement toward standardization of evidence-based practice, few studies have been conducted to assess the costs of guideline development and implementation, and some practice guidelines have been implemented without concomitant assessment on patient outcomes and costs and benefits of changes in care.

CONCLUSIONS

An immediate mandate is to ensure that when guidelines are promulgated, they include an evaluation plan, developed by the implementer of the guideline, which takes advantage of existing qualitative and quantitative data and programs (e.g., patient-centered care, quality assurance, risk management) not limited to expensive and sophisticated clinical trials.

Practice guidelines and measurement: state-of-the-science

BACKGROUND

Restructuring of the health care system has exposed widespread evidence of practice variability and has highlighted the benefits associated with nurses embracing interdisciplinary, best practice solutions to health care delivery. Clinical practice guidelines have emerged as a valuable interdisciplinary evidenced-based tool.

PURPOSE

This article explores the state of the science of guideline measurement and evaluates the strengths and weaknesses of measurement approaches.

METHOD

A computerized search of Cumulative Index of Nursing and Allied Health Literature, Health and Psychosocial Instruments, Medline, and PubMed for the search term "practice guidelines" was combined with the following key words: attitudes, adherence, effect, impact, instrument, and measurement.

DISCUSSION

Measurement issues identified in this analysis are related to the manner in which guidelines are written and the lack of a standard methodology for measurement.

CONCLUSIONS

The challenge remains to establish sound measures of adherence and impact while controlling for confounding variables. Questions remain as to the format of practice guidelines to best grant autonomy while offering recommendations that are clear and measurable.

A thoracostomy tube guideline improves management efficiency in trauma patients

BACKGROUND

Thoracostomy tube (TT) placement constitutes primary treatment for traumatic hemopneumothorax. Practice patterns vary widely, and criteria for management and removal remain poorly defined. In this cohort study, we examined the impact of implementation of a practice guideline (PG) on improving management efficiency of thoracostomy tube.

METHODS

We developed a PG aimed at standardizing the management of TTs in critically ill patients admitted to a Level I trauma center. During the 9-month period before (Pre-PG) and 3 months after (Post-PG) implementation, practice parameters including prophylactic antibiotics, duration of TT therapy, preremoval chest radiographs with associated charges, and complications were evaluated. Differences between groups were assessed by Mann-Whitney rank sum and chi(2) with Yates correction.

RESULTS

There were 61 patients, 14 in the Pre-PG group and 47 in the Post-PG group. The groups were matched in age and Injury Severity Scores. The Post-PG cohort averaged 3 fewer days of TT therapy. After implementation of the PG, 21 patients did not have preremoval chest radiography, representing a $3000 reduction in radiology fees. Complication rates (retained pneumothorax, hemothorax, and empyema) were not different between the two groups.

CONCLUSION

Implementation of a thoracostomy tube practice guideline was associated with improved management efficiency in trauma patients.

Implementation and evaluation of guidelines for use of enoxaparin as deep vein thrombosis prophylaxis after major trauma

Although enoxaparin is more efficacious than many other deep vein thrombosis (DVT) prevention strategies after trauma, its routine use in trauma patients at low risk for venous thrombosis is unlikely to be cost-effective and may be deleterious if risk factors for bleeding are present. By way of consensus of opinion of trauma surgeons and pharmacists, enoxaparin DVT prophylaxis guidelines were developed, implemented, and evaluated. Fifty patients with major orthopedic or spinal trauma were followed throughout hospitalization. Enoxaparin use and frequency of DVT, pulmonary embolism (PE), thrombocytopenia, and enoxaparin-related major bleeding (overt bleeding associated with a hemoglobin decrease > or = 2 g/dl, need for > or = 2 units of packed red blood cells, or need for surgery) were recorded. All pharmacist interventions pertaining to enoxaparin prophylaxis were collected. Average patient age was 45.6+/-19.5 years, average Injury Severity Score was 19.0+/-11.2, and average length of hospitalization was 14.3+/-10.0 days. Most injuries were related to motor vehicles (52%) and falls (30%). Sites of injury were femur or tibia (52%), pelvis or acetabulum (32%), hip (20%), and spinal cord (12%). Two-thirds (72%) of patients received enoxaparin during part of their hospital stay (on average, for 53% of the duration of hospitalization). Sequential compression devices and vena caval filters were used in 86% and 10% of patients, respectively. Duplex-proven DVT occurred in two patients, and angiography-proven PE developed in one patient. Enoxaparin-related major bleeding and thrombocytopenia occurred in three and one patient(s), respectively. Pharmacists recommended enoxaparin initiation in nine (18%) patients and discontinuation of the agent in seven (14%) patients (one for bleeding; six for lack of indication). Most recommendations (78%) were accepted. Data from the 50 patients in this study showed fewer thrombotic complications but more bleeding than the frequencies found in controlled studies. It is unclear whether the large number of days that patients did not receive enoxaparin was due to fears of enoxaparin-related bleeding or other factors.