Physicians' perceptions of two ways of algorithm presentation: graphic versus text-based approach

Acute bleeding during surgery or after trauma harms patients, and challenges involved physicians. Protocols and cognitive aids can help in such situations. This dual-centre study investigated physicians' opinions regarding two ways to present cognitive aids, graphic 'Haemostasis Traffic Light' and text-based, using the example of a coagulation management algorithm to identify the strengths and limitations of both presentation modalities. Using qualitative research methods, we identified recurring answer patterns and derived major topics and subthemes through inductive coding. Eighty-four physicians participated. We assigned each half randomly to one of the cognitive aids (graphic/text-based) and determined 447 usable statements. We qualitatively deduced the importance of having a cognitive aid for physicians. Furthermore, it is noticeable that the graphic group made more positive comments (154 of 242 (64%) statements), while the text-based participants made more negative annotations (126 of 205 (61%) statements), suggesting a generally stronger approval of this cognitive aid. Practitioner summary: This qualitative study provides an overview of physicians` positive and negative perceptions regarding two presentation ways for a coagulation management algorithm. Participants perceived the graphic method created according to user-centred design principles more positively. The analysis reveals components that an ideal algorithm should have to help streamline the decision-making process.

Development and implementation of research integrity guidance documents: Explorative interviews with research integrity experts

Research integrity (RI) guidance documents often lack sufficient details on handling specific RI issues causing the lack of harmonized approaches to RI and opening the way to research misconduct and other detrimental research practices. Standard operating procedures (SOPs) are developed and implemented by organizations for ensuring the uniformity and quality of performed actions. This study aimed to explore stakeholders' opinions on SOPs for RI, factors influencing the implementation of RI guidance documents and practices, and ideas for improvements in the RI field. We conducted semi-structured interviews with stakeholders from different groups. Data were analyzed using the reflexive thematic analysis approach, and three themes were developed. The first theme addressed participants' knowledge and perceptions on SOPs for RI and their impact on RI promotion and implementation. The second theme described different factors that have a positive or negative impact on the implementation of RI and RI guidance documents and practices, while the third theme addressed needed changes and ideas for improvements in the RI field. Participants considered SOPs valuable for RI promotion. SOPs should be developed based on and consistent with more general and aspirational guidance and through the dialogue with researchers and other stakeholders, to ensure their relevancy.

Development of a comprehensive Percutaneous Dilatational Tracheostomy process model for procedural training: A Delphi-based experts consensus

BACKGROUND

Deconstructing a complex procedure improves skills learning, but no model has covered all relevant Percutaneous Dilatational Tracheostomy (PDT) procedural aspects. Moreover, the heterogeneity of techniques described may hinder trainees' competency acquisition. Our objective was to develop a PDT model for procedural training that includes a comprehensive step-by-step design.

METHODS

Procedural descriptions were retrieved after a structured search in medical databases. Activities were extracted and the adherence to McKinley's dimensions of procedural competence was analyzed. We developed a comprehensive PDT model, which was further validated through a Delphi-based consensus of Spanish-speaking international experts.

RESULTS

The 14 descriptions retrieved for analysis presented a median [interquartile range] of 18 [11-22] steps, covering 3 [2-4] of McKinley's dimensions. The Delphi panel's first model included all McKinley's dimensions, and was answered by 25 experts from nine countries, ending in the second round. The final model included 59 activities divided into six stages (51 from the initial model and eight proposed by experts) and performed by two operators (bronchoscopy and tracheostomy).

CONCLUSIONS

We have presented a PDT model that includes necessary competence dimensions to be considered complete. The model was validated by an experts' consensus, allowing to improve procedural training to promote safer patient care.

Implementation and Evaluation of a Web-Based Distribution System For Anesthesia Department Guidelines and Standard Operating Procedures: Qualitative Study and Content Analysis

BACKGROUND

Digitization is spreading exponentially in medical care, with improved availability of electronic devices. Guidelines and standard operating procedures (SOPs) form an important part of daily clinical routine, and adherence is associated with improved outcomes.

OBJECTIVE

This study aimed to evaluate a digital solution for the maintenance and distribution of SOPs and guidelines in 2 different anesthesiology departments in Switzerland.

METHODS

A content management system (CMS), WordPress, was set up in 2 tertiary-level hospitals within 1 year: the Department of Anesthesiology and Pain Medicine at the Kantonsspital Lucerne in Lucerne, Switzerland, as an open-access system, followed by a similar system for internal usage in the Department of Anaesthesiology and Pain Medicine of the Inselspital, Bern University Hospital, in Bern, Switzerland. We analyzed the requirements and implementation processes needed to successfully set up these systems, and we evaluated the systems' impact by analyzing content and usage.

RESULTS

The systems' generated exportable metadata, such as traffic and content. Analysis of the exported metadata showed that the Lucerne website had 269 pages managed by 44 users, with 88,124 visits per month (worldwide access possible), and the Bern website had 341 pages managed by 35 users, with 1765 visits per month (access only possible from within the institution). Creation of an open-access system resulted in third-party interest in the published guidelines and SOPs. The implementation process can be performed over the course of 1 year and setup and maintenance costs are low.

CONCLUSIONS

A CMS, such as WordPress, is a suitable solution for distributing and managing guidelines and SOPs. Content is easily accessible and is accessed frequently. Metadata from the system allow live monitoring of usage and suggest that the system be accepted and appreciated by the users. In the future, Web-based solutions could be an important tool to handle guidelines and SOPs, but further studies are needed to assess the effect of these systems.

Observational clinical study on the effects of different dosing regimens on vancomycin target levels in critically ill patients: Continuous versus intermittent application

Different dosing regimens for vancomycin are in clinical use: intermittent infusion and continuous administration. The intention of using these different dosing regimens is to reduce toxicity, to achieve target levels faster and to avoid treatment failure. The aim of this phase IV study was to compare safety and effectiveness in both administration regimens. The study was conducted in 2010 and 2011 in three postoperative intensive care units (ICUs) in a tertiary care university hospital in Berlin, Germany. Adult patients with vancomycin therapy and therapeutic drug monitoring were included. Out of 675 patients screened, 125 received vancomycin therapy, 39% with intermittent and 61% with continuous administration. Patients with continuous administration achieved target serum levels significantly earlier (median day 3 versus 4, p=0.022) and showed fewer sub-therapeutic serum levels (41% versus 11%, p<0.001). ICU mortality rate, duration of ICU stay and duration of ventilation did not differ between groups. Acute renal failure during the ICU stay occurred in 35% of patients with intermittent infusion versus 26% of patients with continuous application (p=0.324). In conclusion, continuous administration of vancomycin allowed more rapid achievement of targeted drug levels with fewer sub-therapeutic vancomycin levels observed. This might indicate that patients with more severe infections or higher variability in renal function could benefit from this form of administration.

Long-term effect of computer-assisted decision support for antibiotic treatment in critically ill patients: a prospective 'before/after' cohort study

OBJECTIVES

Antibiotic resistance has risen dramatically over the past years. For individual patients, adequate initial antibiotic therapy is essential for clinical outcome. Computer-assisted decision support systems (CDSSs) are advocated to support implementation of rational anti-infective treatment strategies based on guidelines. The aim of this study was to evaluate long-term effects after implementation of a CDSS.

DESIGN

This prospective 'before/after' cohort study was conducted over four observation periods within 5 years. One preinterventional period (pre) was compared with three postinterventional periods: directly after intensive implementation efforts (post1), 2 years (post2) and 3 years (post3) after implementation.

SETTING

Five anaesthesiological-managed intensive care units (ICU) (one cardiosurgical, one neurosurgical, two interdisciplinary and one intermediate care) at a university hospital.

PARTICIPANTS

Adult patients with an ICU stay of >48 h were included in the analysis. 1316 patients were included in the analysis for a total of 12,965 ICU days.

INTERVENTION

Implementation of a CDSS.

OUTCOME MEASURES

The primary end point was percentage of days with guideline adherence during ICU treatment. Secondary end points were antibiotic-free days and all-cause mortality compared for patients with low versus high guideline adherence.

MAIN RESULTS

Adherence to guidelines increased from 61% prior to implementation to 92% in post1, decreased in post2 to 76% and remained significantly higher compared with baseline in post3, with 71% (p=0.178). Additionally, antibiotic-free days increased over study periods. At all time periods, mortality for patients with low guideline adherence was higher with 12.3% versus 8% (p=0.014) and an adjusted OR of 1.56 (95% CI 1.05 to 2.31).

CONCLUSIONS

Implementation of computerised regional adapted guidelines for antibiotic therapy is paralleled with improved adherence. Even without further measures, adherence stayed high for a longer period and was paralleled by reduced antibiotic exposure. Improved guideline adherence was associated with reduced ICU mortality.

TRIAL REGISTRATION NUMBER

ISRCTN54598675.

Standard operating procedures for antibiotic therapy and the occurrence of acute kidney injury: a prospective, clinical, non-interventional, observational study

Introduction

Acute kidney injury (AKI) occurs in 7% of hospitalized and 66% of Intensive Care Unit (ICU) patients. It increases mortality, hospital length of stay, and costs. The aim of this study was to investigate, whether there is an association between adherence to guidelines (standard operating procedures (SOP)) for potentially nephrotoxic antibiotics and the occurrence of AKI.

Methods

This study was carried out as a prospective, clinical, non-interventional, observational study. Data collection was performed over a total of 170 days in three ICUs at Charité – Universitaetsmedizin Berlin. A total of 675 patients were included; 163 of these had therapy with vancomycin, gentamicin, or tobramycin; were >18 years; and treated in the ICU for >24 hours. Patients with an adherence to SOP >70% were classified into the high adherence group (HAG) and patients with an adherence of <70% into the low adherence group (LAG). AKI was defined according to RIFLE criteria. Adherence to SOPs was evaluated by retrospective expert audit. Development of AKI was compared between groups with exact Chi²-test and multivariate logistic regression analysis (two-sided P <0.05).

Results

LAG consisted of 75 patients (46%) versus 88 HAG patients (54%). AKI occurred significantly more often in LAG with 36% versus 21% in HAG (P = 0.035). Basic characteristics were comparable, except an increased rate of soft tissue infections in LAG. Multivariate analysis revealed an odds ratio of 2.5-fold for LAG to develop AKI compared with HAG (95% confidence interval 1.195 to 5.124, P = 0.039).

Conclusion

Low adherence to SOPs for potentially nephrotoxic antibiotics was associated with a higher occurrence of AKI.

Trial registration

Current Controlled Trials ISRCTN54598675. Registered 17 August 2007.

Computer-assisted decision support for changing practice in severe sepsis and septic shock

Computer-assisted decision support systems (CDSS) are designed to improve infection management. The aim of this prospective, clinical pre- and post-intervention study was to investigate the influence of CDSS on infection management of severe sepsis and septic shock in intensive care units (ICUs). Data were collected for a total of 180 days during two study periods in 2006 and 2007. Of the 186 patients with severe sepsis or septic shock, 62 were stratified into a low adherence to infection management standards group (LAG) and 124 were stratified into a high adherence group (HAG). ICU mortality was significantly increased in LAG versus HAG patients (Kaplan-Meier analysis). Following CDSS implementation, adherence to standards increased significantly by 35%, paralleled with improved diagnostics, more antibiotic-free days and a shortened time until antibiotics were administered. In conclusion, adherence to infection standards is beneficial for patients with severe sepsis or septic shock and CDSS is a useful tool to aid adherence.